Fusing Cognitive Behavioral Therapy and Therapeutic

Storytelling:Overcoming Negative Self-Esteem

Terry L. Ledford, Ph.D.

Today's Workshop:

I will share my work using therapeutic stories and metaphors to convey cognitive therapy principles with an emphasis on schema development and maintenance.

To do this we will: Review principles/techniques of cognitive therapy and schema

therapy. Review some of the stories I have found helpful. Review techniques of therapeutic story development. Practice therapeutic story/metaphor development in small

groups. Review other techniques/tools I have developed to deal with

dysfunctional schema development.

Developmento Over 33 Years of Outpatient Practice

o Wrote: “Parables for a Wounded Heart” o Developed course: “Reclaiming Your Positive Self-Esteem” for

adults and adolescents.

o Published that course as a webinar on Udemy.com.

o Developed “Finding Me” program for adolescents

o Published an eBook: “Teaching Tales for Teens.”

o Currently writing a free eBook for teachers.

o Writing a devotional book: “Seeing Myself Through His Eyes.”

Today's PresentationToday we'll do the presentation with a dual focus.

Listen with one ear for the impact on your clients.

Listen with one ear for yourself. Making a personal connection to the material will help you see how the materials will connect with clients.

The Value of a Good Story

“After nourishment, shelter and companionship, stories are the thing we need most in the world.”

― Philip Pullman “It's like everyone tells a story about themselves inside their own

head. Always. All the time. That story makes you what you are. We build ourselves out of that story.”

― Patrick Rothfuss, The Name of the Wind “The purpose of a storyteller is not to tell you how to think, but

to give you questions to think upon.” ― Brandon Sanderson, The Way of Kings

The Value of a Good Story

“You may tell a tale that takes up residence in someone's soul, becomes their blood and self and purpose. That tale will move them and drive them and who knows that they might do because of it, because of your words. That is your role, your gift.”

― Erin Morgenstern, The Night Circus

“If history were taught in the form of stories, it would never be forgotten.”

― Rudyard Kipling, The Collected Works

The Value of a Good Story

“Storytelling reveals meaning without committing the error of defining it.”

Hannah Arendt

The listener is free to take what they need and ignore the rest. It avoids resistance. There is nothing to resist. It speaks to the heart on a deeper emotional level. The principle is easier to remember. (My first teaching story: Random

Interval Schedule of Reinforcement.)

Paul Zak, Ph.D.Neuroeconomist

• The Future of Storytelling• www.futureofstorytelling.org

Cognitive Therapy• Introduced by Aaron T. Beck, MD In 1960's

Seeks to help the patient overcome dysfunctional thinking, behaviors and emotional responses.

Focus is on addressing the maintenance of dysfunctional thinking, not the development of such thinking.

Provides tools to identify and correct dysfunctional cognitions, schema/beliefs and perceptions. (Dysfunctional Thought Record, Thought Stopping, etc.)

Correcting these factors leads to improved behaviors, emotions and relationships.

Evidence-Based Therapy: Found effective in hundreds of clinical trials.

Techniques of Cognitive Therapy

Dysfunctional Thought Records Thought Stopping (e.g. rubber band technique)Validity Testing (Therapist challenges the client's thinking, and the client tries to defend it. Also, role reversal where therapist defends the dysfunctional thoughts, and the clients tries to refute.)Cognitive Rehearsal (Client recalls difficult situation. Therapist and client rehearse healthy cognitions and responses to the event.)Guided Discovery (Therapist asks the client questions to help the client discover for him/herself the error in thinking.

Techniques of Cognitive TherapyJournaling (Diary, where the client writes about events, cognitive reactions, behavioral reactions, questions and outcomes.)Modeling (The therapist role-plays the client in a particular situation, exhibiting healthy reactions, and the clients then models the behavior.)Behavioral Techniques (e.g. desensitization, positive reinforcement, relaxation training, mindfulness, exposure and response prevention)Cognitive/Behavioral Psychotherapy tends to be present-focused, with only a brief focus on childhood/formative experiences. Techniques tend to be logical, rational and intellectual and less emotive.

Schema Therapy• A variant of Cognitive Therapy• Developed by Dr. Jeffrey Young. Evidence-based.

• Concerned with the etiology of current symptoms, and not only with the factors that maintain them.

• Places a greater emphasis on the therapist-patient relationship.

• Schema = a mental structure of preconceived ideas, a framework representing some aspect of the world, or a system of organizing and perceiving new information. Schema were first introduced into Cognitive Therapy by Beck in 1972.

Schema Therapy• Schemas create life patterns of perception, emotion and physical sensation

• Focuses on changing client's negative schema

• Uses features of Gestalt Therapy as it seeks to create a “corrective emotional experience.” (e.g. empty chair

technique)

• Recognizes a set of universal needs: safety, stability, nurturance, acceptance, autonomy, competence, a

sense of identity, freedom to express one's needs and emotions, spontaneity and play, and a world with

realistic limits which fosters the emergence of self-control.

Schema Therapy• Psychological health is the ability to get one's

needs met in an adaptive manner.

• The central task of children's development is to get their core needs met.

• The central task of parenting is to help the child get those needs met.

• The central task of Schema Therapy is to help adults get their own needs met, even though these needs may not have been met in the past. (Rafaeli et al, 2011)

• Somewhat similar to Attachment Theory in this regard.

Schema

• Schema are often formed early in life, but continue to be elaborated and developed throughout life.

• Schemas operate in a way that maintains our sense of cognitive consistency, serving as shortcuts, bringing us quickly towards what we think is likely to be true and saving the need to carefully process every detail we encounter. (ex. Dog)

• While schema may have accurately captured early life experience, they are often applied to later life experiences for which they are no longer applicable.

Maladaptive Schema• Maladaptive Schema are self-defeating emotional and

cognitive patterns that begin early in our development and repeat throughout life. (e.g. Abandonment Schema)

• They emerge from toxic early experiences, where the young person's needs were profoundly not met.

• The schemas closest to the person's core generally develop from experiences with the nuclear family.

• The therapy uses “limited re-parenting” as a tool provided by the therapeutic relationship.

• It uses “empathic confrontation” where the therapist confronts the patient on his maladaptive behaviors and cognitions in an empathic, non-judgmental way. The therapist has to have genuine compassion for the client for it to work.

Strategic Family Therapy

• Founders included Milton Erickson, MD; • Jay Haley and Cloe Madanes, etc.• Erickson popularized use of therapeutic metaphors or stories, therefore avoiding resistance. He would often give an indirect answer to a direct question. (Betty Alice Erickson, my builder, Stanley)• Techniques of metaphor creation were expanded by

Stephen Lankton, M.A.• Less research evidence.

Generating a Story

Identify the concept, moral, principle or perspective you are trying to convey.

Try to tie into interests, experiences or feelings that are already in the individual's world view.

Identify the individual's level of maturity and cognitive development.

Then you can try to find or make up a story that illustrates the concept you want to convey.

You can collect stories from published sources, such as the “Chicken Soup for the Soul” books.

Must Speak to the Client from His Experience

Tailoring: Adjusting the therapy to fit the client's experiential language or focus the therapy through the client's lens.

What do they value, and how do you utilize those values.

How does the client perceive, understand and interact with the world.

Speaking From The Client's Experience

Psychotherapy should be tailored to the uniqueness of the individual, not to the procrustian bed of some hypothetical theory of human behavior.

Milton Erickson

You talk to a person in a language he understands, it goes to his head. If you talk to him in his language, that goes to his heart. Nelson Mandela

An Example of Milton Erickson

An Example of Milton Erickson

What was his goal/objective? Did he tell her how to look at her scar? How did he normalize her scar?

The young woman (my client) with the scar.

Told to illustrate perceptual distortions of physical appearance.

Concepts can be illustrated by...

A story generated by the therapist. A traditional story. A variation of a traditional story. An actual therapist experience. An experience with a former client. (HIPPA

sensitive.) An historical figure or event. Actual Research.

Concepts are remembered best if

associated with: An emotional response Schemas are most easily changed when the

client's emotions are activated in the moment. (David & Szentagotai, 2006)

A negative association A positive association Humor Surprise A common experience for the client

Stories That Stick• Emotional Coloring: Stories that elicit strong emotional

reactions (Positive or Negative)• Density of Sensory Details: Details are described vividly

stimulating the senses.• Novelty: Stories that are unusual or challenge

expectations.• Familiarity: Parts of the story are connected to familiar

names, events, images and experiences.• Powerful Resolution: The ending is meaningful and

satisfying.• No Resolution: An unfinished story can be powerful

because it isn’t satisfying.• Redemption: The ending stimulates constructive change. Kottler (2015)

An Excellent Resource

Stories Can Be Short• Quotation, a song lyric or an old saying.• “If they’ll do it with you, they’ll do it to you.”• “What’s love got to do with it?” Tina Turner• “I yam what I yam.” Popeye the Sailor

• Great authors have experimented with story presentation in six-word capsules.• “Longed for him. Got him. Shit.” Margaret Atwood.

• “For sale: baby shoes, never worn.” Ernest Hemmingway

Purpose of Stories in Therapy“Therapeutic stories are purposefully crafted to feature transformations from victim to hero.” Kottler (2015)

Isn’t that the purpose of therapy?

Metaphors to Illustrate• Like the sailing ship getting off course.

• Like the tree that sways with the wind, but doesn’t move because of its deep roots.

• Like drinking poison and expecting the other person to die.

The Depression Troll

Decrease Physical Activity

Withdraw From Others

Stop Pleasurable

Activity

Criticize Yourself

Stories To Address Self-Esteem Wounds

The Story of the Stupid Little Girl

Thoughts that Impact Self-Esteem

• EVENTS

• BELIEFS

• AUTOMATIC SELF-TALK

• SELECTIVE PERCEPTION

Stupid Little Girl Exercises

Stupid Girl Exercise Do Part A Do Part B Do Part C

What is a Wound of the Heart?

• Heart = seat of emotion or the core (as in “the heart of the matter”).

• A hurt or a series of hurts that affects: a. the person's core being b. the sense of self or self-concept.• It alters the persons perception of self.• The first wounds occur during childhood,

when the heart is most tender.

What is a Wound of the Heart (cont.)

A wound of the heart tends to redefine the victim's identity; not who they are, but who they believe themselves to be.We usually try to hide our wounds of the heart. We try to present an acceptable facade to the world.“How are you?” “Fine.”We sometimes even hide the wound from ourselves.We may realize we've been hurt, but not understand the impact of that wound.

Who am I?

Why are children most vulnerable?

Embarrassing momentsHovering teachersActually incompetent.Actually weak and helpless.College Classroom example