;

Author Archive

Developing empathy in children’s using Playing CBT

Saturday, October 20th, 2018

What is empathy?
Empathy is the capacity to understand and acknowledge the feelings, thoughts and behavior of other people. Empathy is usually characterized as an emotional reaction to other people’s emotions, usually in a state of distress. Empathy means to feel and understand other people’s personal world as if it were our world, but without losing our own selves. That is, experiencing the mental, emotional and behavioral state of another person while completely separating ourselves from that person. In other words, a person’s ability to “step into someone’s shoes” temporarily, not out of identification with them but out of an understanding of their difficulties and emotions, thus providing support.
Empathy develops on the basis of a capacity called mentalization – a social cognition that allows us to visualize the mental activity of others and of ourselves in terms of desires, feelings, needs, goals and so on. Children who grew up in a non-validating environment and were not given the opportunity to express their feelings in an open and accepting manner, and who were conveyed the message, not always consciously, that there is no place for “non-functional” emotions and thoughts, will experience difficulty in developing a capacity for mentalization, understanding their own and others’ mental states and separating emotions.

Empathy is one of the most important social skills for a person who wishes to maintain social relationships. When we are able to empathize with our friends, we can understand situations that do not necessarily correlate with our current emotional state, and in spite of this, we can still support them.
In an argument between friends, each side usually perceives the situation from their own point of view and may find it difficult to acknowledge the different thoughts and emotions of  others, especially if the subject overwhelms them emotionally.  The goal of therapy is to succeed in expanding the patient’s ability to implement mentalization even in emotionally intense situations. This is done by helping the patient to identify his thoughts, emotions and beliefs and examine how they affect his behavior, especially in emotionally overwhelming situations.

Children who experience difficulty in their capacity for empathy, often have a hard time maintaining friendships since they fail to recognize the feelings  of others and therefore can’t attain closeness and a sense of mutuality.

By using the Playing CBT cards you may practice mentalization.

For example, a 10-year-old girl who came to me due to social skills issues, with a difficulty in understanding her own inner world as well as a difficulty in understanding others.
The girl presented a situation in which she had a fight with her friend because she had disappointed her. I asked her to tell me the story using cards:

 

 

 

 

 

 

 

 

At this stage we dealt with the personal experience of the girl who received the gift. Together we examined the reason for her reaction, her thoughts and feelings. The ability to examine these elements does not come naturally to children who have difficulty with mentalization, since they have trouble identifying and examining their own inner experience. Often, when a patient finds it difficult to examine their experience, I begin with a story that enables them to dissociate from the experience and hence examine it (usually through comics). Then I let them examine their experience based on this externalization model we jointly created.

The next step in our session was to develop the ability to recognize that someone else feels differently and thinks differently.
We took the cards again and I asked her to write down the same story, but this time from her friend’s perspective.

 

 

 

 

 

Therapist: “So, now that we’re sitting here, examining this, are you able to see that your friend felt and thought differently from you?”
Patient: “Yes, now I understand that she was offended too, and I must have misinterpreted her intentions. But at that moment it was very hard for me to see it because I was too hurt.”
Therapist: “Do you remember why you were hurt?”
Patient: “Yes, because I thought that I wasn’t important enough to her and therefore she didn’t put enough thought into my present. Maybe she did put a lot of thought and effort, but I jumped to wrong conclusions and tried to run away from the situation”.
Therapist: “So, what will you do next time?”
Patient: “Wow, I’m not sure. Maybe next time I’ll be able to stop for a moment, examine my thoughts, feelings and physical sensation , take a couple of deep breaths, and remember that my thought is not necessarily true.
Therapist: “Definitely. And maybe understand that your friend has a story of her own?”
Patient: “Right…”

You may also use the quartets game (game no 11) to practice the model and teach about the different elements of the cognitive behavioral model, which will contribute to the development of the child’s ability to understand his/her personal experience as well as the experience of others.

How to help children suffering from anxiety – using Playing CBT

Wednesday, October 17th, 2018

Anxious or frightened children have difficulties understanding their experience and often react automatically and unconsciously. This article presents means to explain the cycle of anxiety to children, using the game Playing CBT. It also presents the elements of anxiety and provides a psycho-educational explanation for both children and parents about the three elements of anxiety and fear, and about behavior that intensifies fear.

 

 

 

 

 

What is the difference between anxiety and fear?

In my work with Playing CBT I spread the emotions cards on the table and ask the children to pick all the cards which depict an emotion that is similar to fear in their opinion. Children often choose the cards of fear, anxiety, panic, worry and surprise. For many children, these emotions are similar.

 

 

 

 

 

The goal of this session is to start a discussion about the distinction between different emotions and help children understand that different emotions have different roles.

The questions I ask the children are:

What is the difference between fear and anxiety? What is surprise? When do you like feeling surprised and when not so much? Are surprise and panic similar at times? What is the difference between them?

We then define the role of each emotion:
Fear – anticipation of actual danger – getting stuck in an elevator, insects, a lion, a speeding car.
Concern / anxiety – anticipation of future danger. Thoughts about the future that deal mainly with the chance of the realization of negative situations (death, failure). Children tend to use the word worry while adolescents tend to use the word anxiety which is concern at a higher intensity.
Panic – immediate alertness due to unexpected danger.
Surprise – a situation that may be pleasant or unpleasant; doesn’t trigger a physiological reaction as much if it is perceived as pleasant.

 

Psycho-educational explanation for fear:

Present the children with the cycle of fear and ask them to fill out the cycle according to their experience. This explanation allows us to discuss the elements of the experience and the effect of each part on the next.

 

The three elements of anxiety:

Cognitive – anxiety is experienced through mental processes focused on danger or threat. The thinking style of children with a predisposition for anxiety is always focused on the chances of something negative happening in the future and the difficulty in coping with it. There are many types of anxieties and phobias and many thinking styles accordingly. The thinking style of children who suffer from social anxiety and shyness, will be expressed by thoughts such as “They will laugh at me” or “I will look weird and different from everyone” and “I can’t handle this”. While a child who feels anxious about their health may fear that a spot on their skin indicates a serious illness.

Physical – anxiety is also experienced in the body; physiological arousal increases and prepares the body to fight, flee or freeze as a result of potential danger (an inherent primordial element). Children who are worried, often experience stomach aches and nausea, and children who experience fear will complain of sweating and a quick pulse – all in preparation for fighting or fleeing.

Behavior – in our daily lives we react to emotions that are designed to elicit a survival behavior. That is, when we experience fear, our body prepares to flee or defend itself from danger. When we feel disgusted, our body will be deterred from something that might be toxic. However, modern life does not involve the hazards of nature, most of us do not live around predatory animals, so we need to examine whether our emotions are in line with reality, rather than reacting with an automatic emotion-driven behavior. Anxious children often tend to avoid anything that may provoke fear. They “make sure” not to evoke fear, which then causes their fear to intensify.

It is important to note that parenting styles may also contribute negatively to the intensification of fear in these children. Parents who do not cope positively with their child’s (and/or their own) fear and let them have their way with negative behavior, prevent them from coping with their fear, and thereby let it intensify.

 

 

Stage 1 – Identifying emotions

Learning about emotions

Anxious children (but not only) find it difficult to describe their emotions and to distinguish between different emotional states. One way to examine difficulties in this issue is using the game Identifying Emotions – Game 4 .

 

Stage 2 – Identifying Sensations

At this stage children learn to identify physical sensations through the game “Associating Emotions With Physical Sensations” – game 10

 

 

 

 

Stage 3 – Identifying worrying thoughts

In this stage children learn to identify thoughts that cause them fear and worry about future events. Thus children can understand that thought provokes emotions and not events.

An enjoyable and interesting way to achieve this goal is through the Event and Emotion memory game – Game 11 in which the children are exposed to the fact that thoughts provoke emotions rather than the events. Children usually come to this understanding half way through the game when they realize that any pair can be considered a match since it is the rationalization, the thought, that creates the match between event and emotion.

 

 

 

 

 

A detailed explanation of the game can be found in the instructions booklet.

 

 

Stage 4 – Identifying thinking traps.

In this stage you will be able to get to know the children’s thinking traps; children with a predisposition for anxiety will be characterized by two major thinking traps: Exaggeration of the probability of something  and extreme negative thinking

 

 

 

 

 

 

The key to changing our emotions is belief. That is, it is important that we understand and believe that the less extreme thought is the truth – in most cases it is in fact the truth. In order to realize this, one must begin to explore their thoughts by means of questions that correspond with the thinking style of exaggeration and extreme negative thinking.

Playing CBT contains the Rethink cards. These cards are designed to help children challenge and refute their thoughts:

By examining whether a thought has ever been realized in the past, and if so, what are the chances of it being realized again? Children usually understand that the likelihood of recurrence is not as high as they initially thought it to be.

These cards allow us to examine, together with the children, how to challenge and refute automatic thoughts.

 

 

 

 

 

 

 

The next step is to use moderating thoughts. Following the understanding that a negative thought is not necessarily true, we may use a moderating thought that is better aligned with the actual truth (second wave CBT).

The Coping Thought / Negative Thought memory game from the Playing CBT kit is a creative way to learn about negative thoughts, coping thoughts and how to apply this principle.

 

 

 

 

 

 

 

Once the children have learned all these steps, you may practice exposure to fear provoking situations, and start building the children’s scale of courage.

Playing cbt – Much more then a children’s game

Saturday, October 6th, 2018


Playing CBT
was first developed in 2015. The goal was to help children to understand their emotional experience through play, and to help therapists use Cognitive Behavioral Therapy with children in a creative and enjoyable manner.

The Playing CBT game board seems like a regular game board at first glance. However, through its carefully chosen questions, it becomes much more than just a game. It is a means and a tool to facilitate meaningful discussions with patients about characters in their lives, about their thoughts, about their emotions, internalized voices and voices that they wish to internalize, about the way they cope with different situations and more.

In this article I present the concept behind each carefully selected question and how to facilitate discussions using the questions on the back of the cards.

The game board is divided into 2 stages:

Stage 1 – deals with events, thoughts, emotions and behavior without the sensations cards and moderating thoughts cards. This is based on the assumption that playing the game in the initial stages of introduction will make it easier to get to know the most basic model.

 

 

 

 

 

 

Stage 2 – enables a deeper understanding of the model through the use of the moderating thoughts and physical sensations cards. Later in the game it is also possible to form sequences using the cards for the various associations with which we deal during the game and course of therapy.

 

 

 

 

 

 

The questions on the cards were carefully chosen to help participants identify their emotional experience and those of people around them, and to understand the effect of each part of the model on the next.

In addition, the cards are also effective when providing explanations to parents. The game’s instruction manual also contains explanations specifically for parents.

What is the purpose of the questions and what conversations can you start based on these questions?

 

Event Cards – presenting different events from daily life

Question 1 – Linking an external trigger with an interpretation

The purpose of the question “If it had happened to me, I would have thought…” is to teach children, through play and discussion, about the connection between external triggers (events) and interpretations (automatic thoughts), and to get to know the way they think. For example, the event: “I went into the classroom and Vanessa didn’t say hi to me” may trigger the thought: “She doesn’t want to be my friend anymore”.

Question 2 – Identifying the emotion

The purpose of the question “If this had happened to me I would have felt…” is to recognize that any event triggers an emotion. Although often an automatic thought arises that triggers emotions, there are also cases in which children experience emotions that do not necessarily follow a thought, but rather a memory of an earlier experience that causes an emotional reaction.

Some children allow to explore the matter in a broader way; make sure you notice it. For example, an event such as “I stepped into the classroom and my best friend didn’t say hi to me”. Some children may say that they would feel fine about it since they don’t care about their classmates. Others might say that they wouldn’t be sad about it but their sibling would surely be crying, allowing us to recognize the emotional mode of that child’s environment or a part in them that is currently represented by their sibling.

Question 3 – Identifying coping styles

The question “If this had happened to me, I would have…” examines our coping style when we experience triggers in everyday life.
Children tend to share similar situations from their daily lives. This is our opportunity to identify the child’s coping style, and examine with them whether this behavior is effective in the long run or whether it is an automatic reaction disregarding future results.

Question 4 – Developing the ability to observe from different perspectives

The question “If this had happened to my friend, I would tell them…” refers to thinking from a friend’s perspective. A good technique to develop cognitive flexibility is to examine a situation from the perspective of another person. The purpose of this question is to demonstrate how easy it is for us to be flexible when it comes to a friend, while at times we tend to be more rigid with ourselves.
In therapy we will want to practice this ability until it becomes an internal “friend’s voice” to counterbalance our rigid inner self.

Question 5 – Examining other thoughts

The question “If this had happened to me, I would have thought…, and on the other hand I could have thought…” makes it possible to examine other thoughts besides our initial automatic thought.
An event like: “My best friend didn’t play with me at recess” may lead to the thought “They don’t want to be friends with me”. But they can be taught to think “Even if they’re playing with someone else, that doesn’t mean that they are not friends with me”.

Question 6 – Understanding that emotions affect thoughts and not just the other way around

Emos are pawns chosen by participants. Each Emo represents an emotion. Participants may choose the emotion according to what in their opinion corresponds to the facial expression on the circle or the matching picture on the game board. The question “If this had happened to my Emo they would say…” is about the connection between emotion and thought from a slightly different perspective. The goal is to recognize that emotions affect our thoughts and not just the other way around. A participant who chose an Emo of anger and got the event “My best friend didn’t play with me at recess”, may think: “That’s not fair” or “They are doing this to upset me”. An Emo of fear may provoke the thought “Maybe they don’t want to be friends with me anymore, and then no one will be friends with me”. While an Emo of calmness may trigger the thought “This is an opportunity to play with other children during recess”. The subject may be expanded by talking about how our emotions affect our thoughts; when I wake up happy, are my thoughts different than when I wake up sad?

 

Negative thoughts cards – dealing with automatic negative thinking

Question 1 – Realizing that we all have automatic thoughts

The purpose of the question “This thought goes through my head when…” is to understand that we all have automatic thoughts with which we interpret our reality. This question often allows participants to identify with the thoughts presented in the cards and thus we may get a glimpse of their inner speech.

Question 2 – Identifying negative thoughts and moderating thoughts

The question “A moderating thought that would work with this thought is…” deals with the connection between a negative thought and a moderating thought. A moderating thought enables us to moderate the extreme aspect of a negative thought. For example: the thought “nobody loves me” may be examined together with the participant. Is this a negative thought that may be moderated with a thought such as: “Some children like me and some children don’t”? This thought is not positive and it is important to understand that we do not intend to replace it with positive thinking, but to moderate the extreme or distorted aspect of that thought.

If participants find it difficult to moderate their thought and cling to it, referring to their pawn and not directly to themselves will enable them to apply cognitive flexibility. Barlow and Heinrich’s transdiagnostic protocol presents this technique as the primary means for thought regulation.

Question 3 – Recognizing the effect of thought on emotions

The aim of the question “When I think this way, I feel…” is to introduce the effect of thought on emotions. With this you may examine with the children whether they have similar thoughts throughout the day and what emotion do they experience.

Question 4 – Recognizing the effects of one’s environment (significant figures)

The phrase “This thought is typical of…” deals with the “voices” we hear in everyday life from people who are close to us. You may expand the discussion by examining whether the children use these voices themselves. How does this affect them?

Question 5 – Understanding that thought is not reality

The phrase “This thought is not my best friend, therefore I can…” allows us to recognize that thoughts are merely thoughts and not reality – thus we may examine them rather than believe them. This allows participants to recognize that not all thoughts are true, and that we think many thoughts that do not necessarily reflect reality (in therapy based on the CBT’s third wave we deal extensively with the ability to examine thoughts as if they were on a conveyor belt or a leaf floating down a stream).

Question 6 – Recognizing thinking traps

The objective of the phrase “This thought correlates with the thinking trap of…” is to recognize thinking traps and link thoughts to their correlating traps. For this you may use the thinking traps strip and learn to distinguish between the various thinking traps. At the right stage of therapy, you may examine with the participants which thinking traps characterize them, and what type of thinking trap correlates with the thought on the card. If the time isn’t right to introduce the children to the thinking traps, you may simply help them identify which trap they think correlates with the thought based on its name alone. In the Emotions Detectives protocol, thinking traps are introduced in session number 6.

 

Emotions cards – indicate a wide range of emotions together with a scale to determine their intensity

Question 1 – Identifying emotions

The purpose of the phrase “I felt this way when…” is to allow participants to identify their emotions. Participants share events from their daily lives and thus we get to know their emotional experiences and examine what emotions they allow themselves to feel and what emotions they don’t like to experience.
If a child says that they never feel that way, I recommend not to push for an answer and instead to let them take an alternative emotion card, and to note to yourself that they are experiencing difficulty in identifying or containing a certain emotion, and to get back to it later on.

Question 2 – Calming oneself with self-talk

The phrase “When I feel this way I can tell myself…” deals with the possibility of using appeasing self-talk, which is not necessarily focused on mental change, but on one’s ability to contain the emotion. Examples for this type of self-talk may be: “It’s just an emotion that rises and subsides”, “I don’t have to fight my emotions” or encouraging self-talk: “I love myself just the way I am”.

Question 3 – Examining needs

The phrase “When I feel this way I need…” deals with our ability to examine our needs, so that we may contain our emotions or regulate them. For example: “When I am sad, I need a hug” or even simply to remind ourselves of the sensation of a hug by a loved person.

Question 4 – Associating thoughts and emotions

The purpose of the phrase “A thought that makes me feel this way is…” is to associate thoughts and emotions and emphasize the effect of thought on emotion. Make sure that participants form associations that make sense between thoughts and emotions. For example: a thought that may be associated with anger is “they are doing this to upset me”, while associating the thought “I have no friends” with anger is not a reasonable association since it would most probably not provoke anger directly but rather provoke loneliness or sadness. Of course, a child may think that they have no friends and that everyone is picking on them, and that thought may provoke anger but in this case the thought is comprised of two elements. Children’s ability to form reasonable associations is important for their process of self-regulation.

Question 5 – Understanding the role of emotions

The purpose of the phrase “This emotion helps me understand that…” is to recognize the role of emotions. The role of emotions is to help us understand what is happening around us and how it affects us. Every emotion has a role. For example: fear is meant to inform us of the presence of danger. But one must examine whether there is actual danger or whether it is only fear. Anger is meant to let us know that someone has stepped over our lines and we want to convey that message to them.

Dealing with the role of emotions is a new concept for most children (and parents), therefore I recommend to examine with them how they would react to these emotions until now, and whether the understanding that emotions are there to inform them about something and help them – can help them contain it and not react automatically.

Question 6 – Recognize the fact that emotions may intermix

The phrase “This emotion occasionally intermixes with the emotion of…” is intended to facilitate a discussion about mixed emotions since often emotions come together and occasionally they are even contradictory. Children find it difficult to accept this confusion and this is an opportunity to legitimize the concept of mixed emotions.

 

 

Physical Sensations Cards – physical sensations experienced in the context of emotions.

Question 1 – Identifying physical sensations and their association with emotions

The purpose of the phrase “This physical sensation comes with the emotion of…” is to allow to identify physical sensations and their association with emotions. With this phrase you may facilitate a discussion about physical sensations and examine whether there are other instances in which we experience the same physical sensation other than with the mentioned emotion. Do we experience the same sensation regardless of emotions? Do we experience the same sensation with a different emotion?

Question 2 – Recognizing physical sensations as an indication of emotions

The purpose of the phrase “When I experience this physical sensation I think…” is to recognize that a physical sensation can also serve as an internal trigger, and a subsequent thought will interpret the sensation. Also, with basic (primal) emotions, physical sensations come before the cognitive processing since we are surviving beings, and our body prepares us for dangerous situations in any event in order to protect us from physical harm (such as a ferocious animal attack).

Hence it is important to recognize that physical sensations affect our emotions and sometimes even come as a sign of an emotion we’re about to experience. For example, a quick pulse may provoke the thought “I am going to have an anxiety attack”, which will then lead to fear and intensify the physical sensation.

Question 3 – Recognizing the effectiveness of moderating thoughts in regulating physical sensations

The phrase “When I feel this sensation in my body I can tell myself…” may be used to generate a moderating thought for a physical sensation as well. You may say to yourself: “It’s just a natural primordial reaction” or “This sensation tells me that I feel… but I can simply examine it and it will pass”. This is an additional technique for physiological regulation.

Question 4 – Getting to know physical sensations and their location in the body

The question “Where in your body do you feel the sensation” allows participants to get to know the physical sensations they experience and then not panic as much when they occur.

Question 5 – Remembering when we felt this way

The phrase “This sensation reminds me…” links between the sensation on the card and the sensations experienced by the child. Participants are “forced” to recall different situations in which they experienced that sensation, thus facilitating a discussion about an emotion or situation with which or in which they experienced that sensation.

Question 6 – Linking between physical sensations and emotions

The phrase “If this sensation correlates with your Emo, collect 2 tokens” allows to link the emotion represented by our pawn (Emo) and a physical sensation, thus expanding the link between sensations and emotions. Children who choose the Emo of joy or calmness often have difficulty perceiving the physical sensation that correlates with these emotions. This is an opportunity to discuss the fact that “unpleasant” emotions are mostly meant to help us survive and therefore our body prepares to fight, flee or freeze. “Neutral” emotions do not incite the body to prepare for the aforementioned actions and therefore we don’t experience the subsequent physical sensation in a significant manner.

 

 

Behavior Cards – present behavioral reactions and their associated emotions

Question 1 – Identifying the emotion that triggers the behavior

The phrase “The emotion that provokes this behavior in me is…” emphasizes the fact that emotions provoke behaviors. This phrase enables to identify the emotions that provoke the behaviors on the cards and to discuss the matter that while the purpose of emotions is to generate behavior, at times emotions may overwhelm us and we may subsequently behave in a way that does not benefit us in the long run.

Question 2 – Distinguishing between behaviors that benefit the long-term and behaviors that benefit the short-term

The phrase “If this behavior is effective for long-term move forward 3 squares” deals with the distinction between behaviors that are effective for the short-term (reducing the emotion’s intensity or avoiding it altogether) and behaviors that are effective for the long-term which help us cope with everyday emotions and situations.

Behaviors such as avoidance, that stem from the emotion of fear, for example, are not effective for the long term, but certainly improve our circumstances in the short term. However, avoidance itself prevents us from dealing with the emotion of fear and from realizing that we can actually cope with it, and that things that seem frightening and impossible are not necessarily so in reality.

Question 3 – Distinguishing between extroverted emotions and other emotions

The phrase “When I see a child behaving that way I know they feel…” was chosen based on the idea that often it is possible to identify a child’s emotion according to their behavior – a secluded child is likely to feel sad or hurt. However, occasionally behavior does not necessarily reflect a child’s emotions since children often use anger as an extroverted emotion, while feeling hurt or any other emotion they wish to conceal from their environment.
This allows us to assert the fact that we can often identify someone’s emotion by their behavior, while occasionally the extroverted emotion is not necessarily the primary emotion experienced by that child.

Question 4 – Examine the behavior in different situations

The phrase “Tell us about a time when you behaved this way” encourages participants to think of similar behaviors of their own, and facilitates a discussion about situations in which they behave this way. You may examine with the children whether this behavior reflects their emotion; Is it effective? Does anyone else in their family behave this way? This allows us to identify the child’s style of behavior and to jointly examine how this behavior serves their causes.

Question 5 – Examining the gain and loss of a behavior

The phrase “After behaving this way I feel…” facilitates a discussion about the fact that after we behave in a certain way, we experience an emotion which results from our behavior. Often, children who react violently or use bad language feel guilt or remorse, and children who avoid something out of fear will feel a sense of relief or disappointment.

Question 6 – Identifying other people’s behaviors

The phrase “This behavior is characteristic of…” helps us to recognize the style of behavior of people around us and to examine these behaviors “from a distance”, which often enables us to examine whether different behaviors are adaptive or maladaptive.

 

Coping Thoughts Cards

Question 1 – Matching a moderating thought with a negative thought

The phrase “The negative thought that correlates with this thought is…” links between negative thought and moderating thought. Children often find it difficult to think of correlating negative thoughts and tend to come up with negative thoughts that do not necessarily correlate with the suggested moderating thought. This phrase enables a better understanding of how to properly match moderating thoughts. A negative thought that would correlate with a moderating thought would be similar but more extreme in nature. An example for a moderating thought: “I can do it”, matches the negative thought: “I can’t do it”, and not the thought: “I will never succeed”.

Question 2 – Making moderating thoughts available and habitual

The aim of the instruction “Repeat this thought out loud 8 times” is to practice moderating thoughts. This is based on the understanding that reiterating a thought will make it more available to us when we need it, since recently used ideas are more available in our short term memory.

Question 3 – Matching moderating thoughts with emotions

The phrase “This thought can help me when I feel…” facilitates a discussion about what moderating thought can help me when I experience a certain emotion. That is, the thought “I am great” will most probably be ineffective when feeling disgusted, but it may be very helpful when feeling disappointed.

Question 4 – Tapping into a moderating voice

The purpose of the phrase “This thought is characteristic of…” is to allow children to identify a relative’s moderating voice. This may help you recognize the people who help the child moderate themselves thus providing a tool for them for emotional regulation.

Question 5 – Identifying a moderating thought to use before an emotionally overwhelming event

The phrase “This thought can be used before…” helps to recognize that moderating thoughts allow to regulate emotions before they are experienced at high intensities. It is important to explain to the participants that the use of moderating thoughts when overwhelmed by an emotion is ineffective. During an emotional overwhelm our ‘intelligent brain’ is inactive and our emotion-driven reactions take the lead. For this reason, it would be more effective to apply this technique before a situation that may provoke an unregulated emotion.

Question 6 – Developing empathy towards others

The phrase “I would like to give this thought to… because…” raises awareness for children’s ability to help other people regulate their emotions, since one of our goals in therapy is to develop a capacity for empathy and the ability to acknowledge other people’s emotions.

 

In summary

Playing CBT introduces children to the subject of emotional experience while linking the six stages of the process: event-thought-emotion-sensation-behavior-moderating thought.

In addition, it enables therapists to considerably expand their knowledge of the patient. The various games included in Playing CBT provide a means to apply the principles of a specific element of the CBT model, to suit any stage of therapy. All games and options are detailed in the manual. You may also download additional game instructions from our website.

How Playing cbt helps to develop emotional intelligence

Saturday, October 6th, 2018

in a world in which success is everything. We all want to be as beautiful, as successful and as smart as we can. And even more so – we want our children to be successful. From an early age, we invest and nurture them – we send them to private tutors and after-school courses, enroll them in private schools – anything that may help them succeed and realize their potential. But doesn’t this kind of success, or realization of cognitive potential, make us miss something important?!

Studies have shown that high emotional intelligence (EQ) predicts more success in life than high cognitive intelligence (IQ). Some of you may say, “That’s that then. We can stop investing all this time and money in studies and classes”. While others may still be skeptical about these studies.

I do not wish to completely dismiss the importance of the intellectual aspect. I claim that a balanced combination of all our systems will help us achieve maximum success.

So what is emotional intelligence? – Emotional intelligence consists of a number of elements:

 

Identifying emotions – children should recognize a variety of emotions. Six basic emotions to be exact (fear, anger, disgust, surprise, love, sadness and joy). The older the age, the more emotions one should know and be able to name. When we are able to identify our emotions, we are more likely to respond with self-control and emotional comprehension rather than habits that do not always lead to effective behavior.

Identifying emotions game:


• Place the emotion board at the center and the event cards at its side.
• Cover all faces with tokens leaving the names of the emotions exposed.

Take a card from the event deck and read the event aloud.
• Ask participants to look at the emotion board and choose the emotion they experience as a result of this
event; then ask them to take the token that is placed on the emotion they chose. The first participant
to grab a token and announce their chosen emotion must explain why they chose this emotion. If the
explanation makes sense and is accepted by the rest of the participants, that participant keeps the token
and the game continues.
• The game ends when there are no more tokens left on the emotion board.
• The participant with the most tokens wins the game.

 

Emotional management – our ability to know how to regulate emotions and adjust them to various situations. In other words, when we experience a high intensity emotion that does not correspond to the reality or is inappropriate for the situation, it is best to know how to reduce the intensity of that emotion and to control its behavioral expression. This way we may avoid incidents which do not benefit us in the future.

Emotion Intensity Bingo game:

Preparing the game:
• Give each child 6 emotion cards and arrange them in two rows of three cards facing up.
• Place the thought cards near you.

check whether they have a suitable emotion card. The first participant to find a suitable emotion card
from the cards they hold, calls out the emotion and indicates the intensity of the emotion, they then
receive the thought card and place it over the emotion card (as illustrated).
• The first participant to cover their 6 emotion cards with 6 thought cards wins the game.
• You may make it easier for younger children and finish the game when a participant has covered one
row (3 emotions).

 

Recognizing others’ emotions (empathy) – recognizing emotions of other people and understanding that they may experience emotions other than ours. You may have noticed that some very young children acknowledge when a peer is sad and try to comfort them, while others may continue playing right next to a crying child, seemingly unbothered. Chances are that children who are empathic to their peers will eventually develop better social relationships than other children.

 

 

Identifying Others’ Emotions game:

Preparing the game:
• Place the emotion board at the center and the deck of emotion cards at its side.
• Give each participant 3 tokens.

Gameplay:
• The first participant recounts an incident from the past week. He/She then chooses an emotion card
from the emotion deck that describes his/her feelings following that event, without showing the card
to the other participants.
• Then all other participants place one token on an emotion that they think the first participant experienced
following that event (they should wait until the first participant has chosen an emotion card and only
then place the tokens).
• Once all participants have placed their tokens on the emotion board, the first participant reveals his/her
chosen emotion card, and explains the reason for his/her choice. (note to the therapist: this explanation
is the automatic thought).
• Then, all participants explain why they chose the emotion on which they placed their token. All
participants are allowed to explain their choice. This stage is important because it presents different
emotions following the same event, and facilitates the understanding that thoughts evoke emotions – not
events, and that different people may experience different emotions following the same event.

• If a participant guessed the first participant’s emotion, he/she collects all the tokens on the board and an
additional token from the first participant. If no one guessed correctly, the first participant who presented
the event collects all the tokens, and the turn goes to the next participant.
• The game ends when one of the participants is out of tokens.
• The participant with the most tokens wins the game.

 

Behavioral control following a combination of emotional, intellectual and social comprehension. That is, a good ability to choose how to behave, and not respond from with the “automatic pilot”. This assists in coping with unpleasant situations not out of a defense mechanisms (fight; flight; freeze).

As children become familiar with their own emotional world, they are better able to express their feelings in words rather than in non-adaptive behavior. A child who is familiar with their emotions can also regulate and manage them in such manner as to fully realize their potential with friends, at school and later in their career.

 

It is a well-established fact that most school programs are aimed at academic success. We see billboards and publications advertising schools’ academic success. On the other hand, we see far fewer advertisement for programs for the development of emotional abilities, which are an equally important – if not more important – element on the road to success in life.

But schools are not the only ones to blame – let’s admit it we too are culprits in “emotional neglect.” Our busy schedule causes most of us to devote very little time for this issue. We usually try to reach solutions rather than tend to feelings. When your child tells you that they were picked at at school, do you ask them how they felt? Most of us will immediately “shower” them with solutions like, go tell the teacher, hit them back and so on.

It is important to help children identify their emotions so that they may understand what provoked their anger and behavior and thus they may better cope with similar situations in the future.

 

Dr. Nava Levitt speaks of fine tuning our systems and having a flexible brain. She claims that emotional intelligence may be developed, both in children and adults. Levitt explains that the brain is like an orchestra; when one musician is off-key, the entire music is off-key. The brain works the same; when one parts isn’t sufficiently developed – social, motor, sensory, emotional – that child will not be able to realize their potential. Therefore it is important to let children experience the world not only through computer screens, but to have them engage in all kinds of activities and social interactions in which the sensory system is fully activated. Social games stimulate the motor element while the social interaction develops emotional capabilities.

 

So what can you do?

Familiarize with emotions – talk with your child and try to see check what emotions they know. Write them down, and ask them to tell you when do they feel these emotion and add a short story about each emotion. Share about your emotions; when do you feel calm, loved and maybe angry.

Self-awareness – When turning attention to what happens inside – to one’s physiological changes, the thoughts and feelings – one may develop the ability to know themselves and their emotions. What’s more, they may develop the ability to identify with and understand others; a capability that’s becoming less and less obvious in our current digital world.

The simplest technique to direct attention to yourself is to focus on breathing. Ask your child to sit for 3 minutes (extending to longer periods over time) and pay attention to their breathing, thoughts, feelings and physical sensations without judgment. Just pay attention. Of course, it is very important that when they tell you about these thoughts, feelings and emotions, you too will react without judgment.

Teach your child to recognize the different elements of their emotions. Emotions consist of three elements: physiological reactions (body sensations), behavioral reactions and thoughts. When a child knows what they feel, when they experience a shudder, they will be able to name the emotion, contain it and control its eventual behavior. When a child recognizes a thought, they may know what emotion they experience following that thought, and understand what made them feel that way.

Help your child to name their emotions – when you see them fight with their siblings, try to understand together with them what they felt that made them behave this way, and then look for solutions.

Teach your child that emotion is a transient state – emotions and thoughts go away by themselves. If we accept emotions as a wave that comes and goes, we can cope with them without having to find an immediate behavioral outlet.

Speak about emotions – we all “transgress” with over-emphasizing solutions, texting and using emoticons, while inadequately expressing our emotions in words. Try to speak about emotions at home. Thus your children will be able to continue with this outside. Over time, they will gain better control of their behavior, and develop better communication with others around them.

Convey a message that any emotion is adaptive – the role of emotions is to explain what’s happening in our inner and external world. We all want our children to be happy and never experience sadness or anger, but it is important to understand that emotions are not “positive” or “negative.” There are “pleasant” emotions and there are “unpleasant” emotions, but they are all positive because they all play an important role. Let’s consider fear. Many of my patients come to me because they do not want to be afraid. But fear is a mechanism of protection against danger, and sometimes it is important to be afraid, so that we may be careful when necessary. Of course, one must know when to be afraid – only in the face of real danger. In other cases, fear does not serve us and may also interfere with our lives. The goal of therapy is not to eliminate fear (or anger, or sadness or jealousy), but to identify unpleasant emotions, to manage them and to control our behavior even when they “come to visit”.

Moderate use of technology – going back to Dr. Nava Levitt, it is necessary to help our children balance and adjust their systems. We must ensure that our children find themselves in real social settings (not only social media), playing and moving their body. Unfortunately, the massive use of technology so abundantly available for children and youth has an adverse effect on achieving this balance.

Do not let your child sit for hours on end in front of the TV or computer – limit the use of these devices.

Do not let your children “meet” with friends only on social media. Have them get together face to face to talk and play.

Set an example – turn your mobile phones off occasionally, talk to them instead of texting them, eat a family dinner without the TV on.

Ability to cope with frustration, anger and disappointment – the path to success goes through the ability to cope with and learn from failures (Thomas Edison). If we do not teach our children to cope with feelings of frustration and anger, they will not be able to withstand them later in life. In many cases they will attempt to avoid these emotions and therefore will never challenge themselves. A challenge is a situation in which we risk failure and frustration. If we want to manage our emotions and our lives we must learn to manage them and not let them manage us. So when our children ask us for something, we can wait a bit, we do not have to respond to any request, and not immediately. When our children come home angry about something, we may be empathic and at the same time help them cope with anger and stay with it.

Playing CBT – From the first wave to the third wave

Saturday, February 24th, 2018

Cognitive behavioral therapy is a method that combines behavioral therapy with cognitive therapy. The uniqueness of this method, developed by Aaron Beck and based, among others, on the latent conditioning model, is the understanding that cognitive processes – that is, automatic thoughts and basic beliefs – are acquired through learning processes just like behavior. According to Beck, conditioning is mostly influenced by our immediate surroundings, through people who constitute a model for us or through a significant event that took place in our lives.

 

CBT was developed following therapy work with adults who suffered from depression, and later evolved in other directions, including therapy for children. This was after it has been shown that various cognitive childhood disorders are also structured on cognitive and behavioral mechanisms and that these mechanisms can be used to reduce distress and improve functioning in children (Myers, Moore 2014).

 

Over time, additional therapy methods have evolved which rely on cognitive behavioral therapy, but perceive the cognitive and behavioral elements in a slightly different way and thus incorporate other approaches into therapy.

Three major waves currently characterize the evolvement of cognitive behavioral therapy.

 

The first wave – behavioral therapy (Skinner)

 

Behavioral therapy focuses on the relationship between stimulus and the patient’s behavioral reactions.

The idea behind it is that instead of the patient avoiding the stimulus that arouses fear, shame or any other emotion, they will be exposed to that same stimulus in the safe environment of therapy. When the patient realizes that things aren’t as bad as they seem, the association between the stimulus and the reaction will gradually dissolve, which will lead to a decrease in the intensity of the reaction.

 

 

The second wave – cognitive behavioral therapy (Ellis and Beck)

Cognitive behavioral therapy attributes great importance to thoughts as mediating factors between stimuli and emotional and behavioral reactions. Ellis and Beck considered thinking errors and irrational thinking as the stimulus for patients’ reactions. According to this model, cognitive change is the key to relieving emotional intensity, and even to bringing about emotional change that will eventually lead to emotional relief.

 

 

Third wave – spiritual teachings and Mindfulness (ACT, Schema Therapy, DBT)

The third wave introduced Eastern concepts such as mindfulness and focusing on the present, with the aim of accepting emotional experiences as they are, without arguing with one’s thoughts or trying to change the circumstances. It is assumed that non-acceptance of emotions is often the cause of emotional disorders.

In therapy based on these approaches, patients learn to observe their emotional experience without giving it the power to control their lives. Without judging their own reactions or trying to change them. Thoughts are only thoughts – thus we can observe them without identifying with them. Feelings rise and fall like waves, allowing us to use techniques of acceptance and observation. The ability to experience “pleasant” and “unpleasant” emotions is positive and healthy, even if a given experience is unpleasant.

 

The second wave’s objective is to “feel good” and the aim in therapy is to reduce the intensity of fear; whereas the third wave asserts that “it’s good to feel”, with therapy sessions aiming at helping patients to adopt an attitude of acceptance towards their feelings and personal experiences.

 

What makes Playing CBT so effective when working with children?

The dynamic approach of using games with children has many advantages:

  • Games provide a creative and indirect access to children’s inner and subconscious world.
  • Games allow children to express impulses and wishes and to understand their relationship with the people and important figures around them.
  • By controlling the game children get a sense of self-control and self-efficacy.
  • Through the game’s characters and the open dialogue, children get to know their hidden aspects.

 

As with the dynamic approach, Cognitive Behavioral Therapy recognizes, of course, all the advantages of games. But unlike this approach, in CBT there is no interpretation of subconscious elements that may be expressed during the game. In CBT, games are of course a communicative means for acquiring abilities, skills, and the expression of wishes, thoughts, feelings and behaviors – all in a not directiy way in the form of conversation during the game.
Another difference is that in CBT, games are usually goal oriented, during which the cognitive, behavioral and emotional elements are processed while being named by the therapist (Myers, Moore 2014).

In the same way, Playing CBT allows patients and therapists to express thoughts, emotions, feelings, behavior and more during therapy in an indirect manner as part of the game.

The questions presented on the cards provide access to children’s inner world and experiences, but because the conversation is happening while playing, the children do not feel intimidated and are even happy to talk about the feelings and thoughts of their pawn or character while allowing access to their personal world as well.

Playing with the three waves

Playing CBT allows therapists to combine the approach of all three waves without having to choose between them. Familiarity with all approaches by choice and without judgment allows for a personally suited therapy at its initial stages.

As a therapist with many years of experience, I like to combine all approaches: some children come ready and deal with a specific phobia, and after a psycho-educational explanation they are able to expose elements of their problem (first wave).

Some children come with physical sensations and find it difficult to identify the emotion they experience. With these children I work on identifying physical sensations and then on associating them with emotions and thoughts; after that I add techniques for cognitive and physiological regulation (second wave).

Other children come to me with general anxiety and are unwilling to “argue” with their thoughts. With these children I combine tools from the “third wave” together with specific techniques of the second wave such as distraction, channel switching and more.

The game’s cards are very effective when using the second wave’s approach and especially in facilitating cognitive change.

Combining the cards with the third wave approach in therapy will enable patients to better understand the elements of their emotional experience, to separate the different elements and act in a way that serves their goals and values.

Playing CBT – get to know the inner story

Tuesday, January 23rd, 2018

Playing CBT helps children with difficulty in emotional regulation, identify and better understand their emotions

Difficulty in emotional regulation has been identified as a major cause of many emotional disorders, some of which are expressed by non-adaptive behaviors. In many cases, the inability to cope with an “unpleasant” emotion that is experienced as emotional overwhelm generates a behavioral difficulty that is reflected in the interactions with others.

Despite an awareness of the difficulty and the great motivation to change their behavior, people tend to have little ability to understand its origin. Children and adults with emotional regulation issues display behaviors that are incongruous in nature and intensity with the event that triggered them. Thus, for example, we may witness excessive crying or outbursts of anger following a seemingly minor incident. The environment, which then finds it difficult to understand this kind of behavior, reacts harshly with anger or by punishing. This reaction gives rise to feelings of guilt, and then causes more disproportionate emotional and behavioral reactions.

A model that takes into account the emotional difficulties behind this problematic behavior may provide an explanation as to why an event that may seem minor and of little significance leads to a strong reaction that is seemingly not in congruence with what actually happened.

According to this model, a bystander, and maybe even the person themselves, sees only two parts of the following sequence: the first stage (the event) and the last stage (reaction).

Exposing inner emotional experiences

In sessions with parents and children, I explain that one of our goals in therapy is to understand the child’s inner emotional experience and how they react to it behaviorally. It is important to understand that behavior is a language through which children convey their inner world and experiences.

Therefore, in therapy sessions, I teach children and parents how to identify things that lay hidden behind reactive behavior.

The illustrated cards in Playing CBT facilitate a clear and simple presentation of the ‘inner story’ and ‘external story’, and how an external event triggers an emotional experience that consists of thought, emotion and physical sensation, which in turn trigger a behavioral reaction.

 

Let’s examine what happened to the child in the story depicted by the cards above:

  • The event: the child went outside during recess and saw their best friend playing with another child.
  • The automatic thought that came to them was “Nobody loves me”.
  • The emotion they experienced: hurt, sadness
  • Physical sensation: a lump in their throat
  • Behavioral reaction: losing it/going wild
  • The reason: the child thought it illegitimate to feel sad and hurt and did not want to show it, so they preferred to react more like a bully, in a manner that looks more “tough”.

What did the teacher see? The child going outside for recess and starting to run wild. Seemingly a child with behavioral problems. The teacher then called the child’s parents and told them that the child went outside for recess and then started misbehaving for no apparent reason. The parents, who obtained only the “external” facts without understanding the hidden part, also reacted with anger.

But if we examine the entire sequence of cards, we may understand the hidden connection between the event and the behavior. In fact, the child felt hurt and sad because they thought their best friend didn’t like them and even generalized the situation and told themselves that nobody liked them. What others saw was a repeated negative behavior and so they too reacted negatively. The child consequently feels lonely and disappointed for not being understood, which then strengthen the belief “I am not loved” and “I am a problematic child.”

This generates a vicious and endless cycle. In therapy we learn to recognize our emotional experience. Together with the child, we learn to distinguish between negative thoughts and coping thoughts; we learn about the emotions that are hidden under other emotions such as anger, as well as the physical sensation that often characterizes a certain emotion.

 

The goal in therapy is to identify the different parts of the story by using the cards that depict a sequence of the external and internal story, and then help the child create a space and leeway between the different parts of the story, and thus allow them to regulate and choose their behavioral reactions.