Introduction

Cognitive behavioral therapy (Friedberg and McClure2002; Kazdin and Weisz 2003; Kendall 2006; Knell 1993; Weisz 2004) with children is an expanding clinical and research arena. Various empirical studies, randomized clinical trials, meta-analyses, and case reports support CBT with children and adolescents experiencing a wide variety of disorders and presenting complaints (Kazdin and Weisz 2003; Weisz 2004). Family and group applications of CBT are also rapidly emerging (Christner et al. 2007; Dattilio 1998, 2001). Finally, increasing amounts of attention are directed to the therapeutic processes as well as the technical procedures associated with CBT with children and adolescents (Creed and Kendall 2005; Friedberg and Gorman 2007; Shirk and Karver 2003, 2006). Thus, CBT with children is a continually evolving and flexible system of child psychotherapy that both adheres to conventions and welcomes innovations.

Greenberg (2000, p. 164) wrote, “Rather than prescribing rigid, formulaic solutions, cognitive therapy actually offers an open-ended framework that facilitates emotional change.” Therapeutic metaphors and storytelling may be included in this flexible framework when conducting cognitive behavior therapy with children. Recently, cognitive behaviorally oriented clinicians have embraced the use of metaphors and stories in their practices (Blenkiron 2005; Friedberg 1994; Friedberg and McClure 2002; Greenberg 2000; Kuehlwein 2000; Mooney and Padesky 2000; Newman 2000; Stallard 2002a). Metaphors and stories may enliven the traditional treatment modules in CBT including psychoeducation, self-monitoring, self-instruction, rational analysis, and behavioral experimentation. This article extends the clinical and theoretical literature base on metaphors and stories in cognitive behavioral therapy by providing a theoretical rationale for their use, guidelines for their implementation, and clinical examples of metaphors/stories to augment traditional cognitive behavioral interventions.

In this paper, the importance of metaphors in CBT is emphasized. While some may argue that metaphor use is an essential part of cognitive behavioral therapy with children, this paper advocates that metaphorical techniques may be integrated into traditional cognitive behavioral therapy. Seven guidelines for incorporating metaphors and stories into cognitive behavioral therapy with children are presented. Examples of metaphors/stories are included within each guideline.

The Importance of Metaphors

Young patients typically enter CBT with firmly held and rigid beliefs, emotions, and behaviors. CBT spectrum approaches unchain fixed thought-feeling-behavior patterns. Metaphors and stories are especially appealing tools to enhance young people’s information processing systems and help them escape from entrenched patterns (Kuehlwein 2000; Otto 2000). In essence, cognitive restructuring and behavioral experiments are ultimately “creative acts” (Greenberg 2000). Therefore, using creative methods to accomplish this goal makes good intuitive sense.

Metaphors in CBT foster developmental sensitivity. They help children recall and remember information (Blenkiron 2005; Stallard 2005). Additionally, metaphors make CBT more accessible to young children who have limited logical reasoning skills. Because metaphors provide analogies to young children, they provide a simple way to understand complex reasoning techniques such as tests of evidence, reattribution, and decatastrophizing (Grave and Blissett 2004).

Creative methods like metaphors and stories fuel learning and objectivity. The more personally salient an image is for children, the more likely they will remember and use it. Newman (2000, p. 136) remarked “Creativity involves ‘packaging’ mundane information in such a way that it gives the message a more affective punch.” More specifically, metaphors and stories teach specific skills such as cognitive restructuring, cognitive rehearsal, behavioral experiments, and exposure in an engaging way (Blenkiron 2005; Otto 2000).

Handprint on your heart (Friedberg et al. 2009) is a metaphorical cognitive restructuring procedure which is based on the lyrics from the song “For Good” (Schwartz 2003). It is especially useful for children troubled by separation anxiety. The metaphor is applicable because it concretely represents enduring parental presence (e.g., handprint) which can help youngsters cope with parents’ absences. Moreover, the procedure is completed together by the parents and children.

The procedure is easy to complete. The child and parent are presented with a worksheet that includes a heart. The parent then traces their handprint over the “child’s heart.” Next, the therapist, patient, and parent develop self-instructional statements and write them on each finger of the handprint. The children are encouraged to carry the “handprint on their heart” when they are separated from the parent.

Metaphors for “bossing back” OCD (Chansky 2000; March and Mulle 1998), coping cats (Kendall et al. 1992), koalas (Barrett et al. 2000a, b), and mice (Friedberg et al. 2001) are commonplace. In fact, March and Mulle (1998) and Chansky (2000) encourage children to construct individual drawings to represent OCD as well as their counter images. Drawing or cartooning allows children to objectively name the problems and to create individually significant coping images. This practice is genuinely collaborative and encourages children to adopt an active role in confronting their challenges.

Stallard (2002b, 2005) uses the metaphor of a videotape running through children’s heads to explain intrusive repetitive visual images. Moreover, an “anger volcano” is a dramatic metaphor to represent simmering anger which eventually erupts (Stallard 2005). Mini-science kits which contain a volcano, baking soda, and vinegar can be purchased and then demonstrated to the child. Barrett et al. (2000b) counted on the metaphors of “thought invaders” and “thought commanders” to teach children to identify and respond to distressing automatic thoughts.

Blenkiron (2005) offered a litany of metaphors for general use. For example, he stated, “depression is a like a bad hair day” to illustrate the mood’s temporary and changeable quality. Additionally, he recommended a mailbox metaphor to communicate the way beliefs are often self-perpetuating and self-confirming. A mailbox cannot accept letters or parcels that are different shapes than its mail slot. The package or envelope cannot be accepted unless the opening is changed. This also applies to a child’s information processing system. Disconfirming data or experiences will not be accepted unless the filtering system changes. Finally, Blenkiron employs a hermit crab to communicate the importance of tolerating vulnerability while old maladaptive coping strategies are discarded and replaced with new more productive skills. The hermit crab essentially does the same thing as it is left vulnerable for a period of time after it sheds an old shell until a new protective shell grows. The mailbox and hermit crab metaphors make abstract concepts such as mental filtering and self-protection more developmentally accessible to young children.

The Word of the Stomach was a clinician generated metaphor to promote a young patient’s expression and identification of distressing negative automatic thoughts. This metaphor was employed with an 11 year old who presented with stomach pain so severe he went to the emergency room two times and received an MRI and colonoscopy in the process. Typically, stomach pain occurred during the wrestling season, and became more severe with each passing year. The child admitted to seeing other kids getting injured and taken away in the ambulance. He believed wrestling was a dangerous sport, but was compelled to continue the activity. The cycle was driven by the child’s belief that he must maintain his “rep (e.g., reputation).” He also held the personal myth that his “rep” protected him from “bullies.” We used the Word of Stomach as the image to give this belief (“the rep”) a voice.

A cartoon drawing of the stomach augmented the metaphor. A thought bubble popped out on top of the stomach. Since expression and modification of his beliefs would make him feel vulnerable, the word of the stomach allowed him sufficient distance. He was able to objectify his beliefs and examine them from a safe perspective. Subsequently, he caught automatic thoughts about the rep in daily situations and then evaluated their validity in a meaningful but non-threatening way. The Word of the Stomach provided this young boy with a developmentally appropriate medium to understand somatization, put words to his feelings and thoughts, and construct a series of coping statements.

Stories are a specific form of metaphorical intervention. Otto (2000, p. 167) stated, “stories tend not to evoke defensiveness as direct instructions may.” Stories permit children to express and experience prohibited thoughts and feelings with relative safety (Friedberg 1994). Stories also improve alliances with young children (Blenkiron 2005). Psychotherapy is often an unfamiliar and sometimes intimidating experience for children. Stories because they are fundamental parts of a child’s culture make the strange world of therapy more comfortable.

Metaphors and stories in cognitive behavioral therapy with children make the therapeutic methods more accessible and facilitate collaboration. As Stallard (2002a, p. 302) knowingly wrote, “Thought bubbles, cartoons, imagery and metaphors based upon the child’s everyday life need to be developed, alternative methods of conveying the concepts of cognitive behavioral therapy, through for example, play and puppetry, could be explored for use with younger children.” Stories and metaphors offer young children the opportunity to experience therapeutic concepts and procedures in a developmentally sensitive way. When treatment procedures are rendered more accessible, it is more likely children will incorporate them. The following seven guidelines offer clinicians specific suggestions for integrating metaphors into cognitive behavioral practice.

The “Magnificent Seven”: Guidelines for Integrating Metaphors into CBT with Children

Embed the Story or Metaphor in a Case Formulation

The importance of case formulation in cognitive behavioral practice is well-documented (Persons 1989, 2006). CBT is defined by its theoretical rationale rather than by its techniques or interventions (Beck 1995). Kuehlwein (2000, p. 176) wrote, “The most clever intervention fails if it is not congenial with a good individual case conceptualization.” Kraemer (2006) suggested that effective psychotherapy is based on a theory which provides boundaries, conceptual discipline, and practiced techniques. Clinicians are free to innovate, create, and take risks within these boundaries.

Case formulation includes a myriad of salient theoretical variables (Friedberg and McClure 2002). Presenting complaints are operationalized by identifying their physiological, emotional, behavioral, interpersonal, and cognitive components. Additionally, since CBT is a learning theory based approach, the behavioral antecedents and consequences which initiate, maintain, and exacerbate the problems are defined. The cognitive structures or schemata which buttress the complaints are also considered. Moreover, the developmental factors and ethnocultural variables which shape symptom presentation are integrated and synthesized.

Once the individualized conceptual foundation is laid, interventions using metaphors and stories are built. The metaphors and stories should be used to change children’s information processing. They should be precisely aimed at distorted perceptions, judgments, conclusions, images, and interpretations. Effective stories and metaphorical interventions propel behavioral experimentation and constructive problem-solving.

Metaphors and Stories Need to be Individualized to Match a Child’s Individual Circumstances, Ethnocultural Context, and Developmental Level

Case formulation leads to individualized intervention strategies which appreciate developmental capacities and ethnocultural contexts. CBT with children is more likely to succeed if it merges with children’s developmental level and gracefully matches children’s internal worlds (Stallard 2002a). A young child’s developmental level may not be a treatment limitation; rather it might represent an opportunity.

Storytelling for example is a creative cognitive behavioral way to obviate children’s heretofore developmental limitations such as egocentrism (Grave and Blissett 2004). More specifically, Grave and Blissett remarked that egocentrism is an advantage in therapeutic storytelling with children’s stories representing a reflection of their thoughts, feelings, and self-representations. Moreover, their confusion between fact and fiction facilitates their storytelling. In this way storytelling in cognitive behavioral therapy promotes youngsters’ creative and imaginative processes.

Clinicians can also rely on popular narratives to teach problem-solving strategies and other change strategies. Murphy (1996) eloquently detailed the psychotherapeutic use of the movie The Wizard of Oz. He stated that the story communicates the prototypical adolescent struggles to discover competence, love, and courage as well as the necessity of finding these qualities within one’s self. Murphy clearly links the story to adolescents’ developmental quests and to familiar cognitive behavioral tenets such as self-instruction, problem-solving, and exposure. Sommers-Flanagan and Sommers-Flanagan (1996) reported on positive use of this story with 8–13 year old treatment resistant children.

Storytelling and metaphors also appreciate children’s cultural contexts (Constantino et al. 1994). Neimeyer (1993) asserted that stories are fundamentally linked to a variety of human experiences. Stories and folk tales are ways many cultures transmit basic information about groups’ social, physical, and spiritual experiences (Murphy 1996). Effective metaphors make optimal use of children’s language and lexicons. Moreover, they should reflect children’s experiences. For instance, children who have never flown on an airplane, traveled on a train, surfed, or played tennis will not benefit from metaphors based on these events.

Metaphors Should be Concrete

In cognitive behavioral therapy, concrete interventions are preferred over abstract ones. This maxim directly applies to the use of metaphors and stories. Metaphors in cognitive behavioral therapy should be broken down into understandable components so the salient therapeutic messages are illustrated (Blenkiron 2005). Therapeutic impact is not left to chance. Metaphors and stories are not intellectual exercises. Rather, they must carry an emotional payload. A good metaphor reaches a child where they live and fits both their internal and external reality. Therapeutic metaphors fuel emotional reactions and destabilize firmly implanted beliefs. CBT explicitly connects the metaphorical meaning to the child’s challenges and circumstances.

Explicit explanation and processing is de rigeur. In contrast to traditional psychodynamic play therapy, simply juxtaposing metaphors and stories alongside children’s experiences and difficulties is not sufficient. Mindful processing via direct discussion of children’s internal states (e.g., thoughts, feelings) is pivotal. Causal connections between the story/metaphor and the child’s challenges should be clearly drawn (Russell et al. 1993). Therapists should work to insure that the children actively apply the metaphors to their emotional problems.

Thought shop is an activity based on a shopping metaphor (Friedberg et al. 1999). Negative automatic thoughts are explained as clothes that looked really good and fitted well at first glance in the store after trying them on in the dressing room. However, after you take them home and look at them in a different light, they do not fit nearly so well. Therefore, after further review, they must be exchanged.

The following example shows how Thought Shop may be explained.

Sometimes when you go to a store, the clothes you pick seem right and fit well and then when you get home and look more closely, they don’t fit so well. The same is true for the things you say to yourself. We have to see what thoughts fit well and those that do not. Then, we have to exchange the thoughts that do not fit so well. How does this sound to you?

Thought Shop may be augmented with written paper and pencil work. For instance, inaccurate negative automatic thoughts may be written on clothes cut outs which seem to be the wrong size or an unflattering coloring/style. The “clothes” then could be returned and then more accurate appraisals are recorded on better fitting clothes.

Metaphors and Stories Keep Treatment Relevant

Concrete and understandable metaphors bring CBT to life. CBT’s “aliveness” is further enhanced by its experiential focus. Children need to try things out and see what happens. Curiosity and experimentation are highly valued in CBT. When metaphors and storytelling are accompanied by experiential activities, they enter the realm of immediate awareness and are more impactful (Kuehlwein 2000). Learning in the present moment from immediate experience is a fundamental cognitive behavioral concept (Padesky 2004). Padesky (p. 434) concluded that experiential learning in CBT allows “the head and heart to reach consensus.”

Once the metaphors are introduced and understood, cognitive behavioral therapists put them to the test. Children may be invited to create a behavioral experiment or a written assignment based on the metaphor. For instance, they may become a “Worry Explorer”. Instead of avoiding experiences that induce worry, the child can become an explorer who seeks them out. This acknowledges the courage that the child needs to face their fears, and highlights the “treasure” to be found by finishing the journey. Hence, we encourage tolerance of the exposure until the anxiety diminishes. The child can think about the treasure or conquest as a coping skill during the exposure (e.g., reading aloud in front of her fourth grade class).

Proficiency in Traditional CBT Procedures Accompany Metaphorical Communication

Conventional and innovative methods are not categorically different but are two ends of the same psychotherapeutic dimension. Technical proficiency in the traditional and established procedures aids in processing metaphorical interventions. This technical proficiency is especially important when making the best of the experiential component of treatment. Skills developed by experience in Socratic dialogues with “hot cognitions” and exposure based methods serve the cognitive behavioral therapist well when applying creative methods with children. Greenberg (2000, p. 165) aptly wrote, “…the most creative acts seem to require mastery of the relevant form: if I am to compose for the violin, I had best know the potential and limitations of the instrument as well as something about composition.”

Improvisation and creativity in cognitive behavior therapy requires mindfulness, deliberateness, and allegiance to form. Skillfulness in managing session structure, assigning and reviewing homework, designing behavioral experiments, eliciting automatic thoughts, and traditional cognitive restructuring procedures enables cognitive behavioral therapists to make optimal use of metaphorical, analogic, and narrative techniques. Therapists who are proficient with traditional cognitive restructuring techniques will know how to build Socratic dialogues which foster more accurate appraisals and attributions when using innovative metaphorical procedures.

“3-D thinking” was a spontaneous metaphor offered by an extremely anxious 11 year old female patient. This patient was highly reactive to any experience she considered difficult. Due to emotional reasoning, she mistakenly believed that any difficulty or discomfort absolutely led to disaster. After we developed a series of experiments to test whether this was in fact true for her, she collected data and attempted to make a synthesizing conclusion. At this point, she glanced at the data with a look of surprise and exclaimed, “Dr. Bob, I have to start thinking in 3-D.” I then curiously asked, “What do you mean?” She replied, “You know Discomfort Doesn’t equal Disaster” and underlined the three D’s. This child initiated metaphor has subsequently been concretized into a cognitive behavioral procedure focused on decastrastrophizing (Friedberg et al. 2009).

Newton’s cradle (Friedberg et al. 2009) is a metaphor illustrating all or none thinking. Newton’s cradle is a toy based on the fundamental physics principle (Newton’s fifth law) (i.e., Everything has an action and an opposite reaction). A row of silver balls are suspended by thin cords. When one ball is pulled away and then released to connect with the previously inert other four, the ball on the opposite side jerks upward and then returns to propel its opposite. This reciprocal interaction continues until the energy is exhausted. Newton’s cradle is an apt metaphor for the cyclical nature of all or none thinking. Seeing things in only either/or categories eliminates all middle ground. One is governed by the extremes (e.g., “I’m either the greatest or I am a total failure.”) Individuals are then caught in a cycle where they bounce between these extreme poles.

Metaphors are Collaborative

Metaphors are a medium for enhanced communication. The fundamental cognitive behavioral tenet of collaborative empiricism (Beck et al. 1979) holds true for metaphor use. Patients are active partners in CBT and few things are unilaterally prescribed. Thus, before metaphors are introduced, young patients’ input should be elicited (e.g., “I’d like to try a metaphor with you. What’s your opinion about that?” How would you like to do some storytelling?).

The type of metaphor should also be a collaborative effort. Often, this is easier after learning more about the patient’s likes, dislikes, interests, and activities. For example, children who enjoy and are interested in sports are more likely to resonate to sport stories and metaphors.

There are a number of therapeutic storybooks which make use of child friendly metaphors to help children understand and cope with a variety of psychological disorders. Some of these storybooks are explicitly cognitive behaviorally oriented (Lamb-Shapiro 2000, 2001; Nass 2000, 2004; Sobel 2000; Shapiro 2004, 2006a, b; Shaw and Barzvi 2005; Wagner 2004; Waters 1979, 1980). Clinicians can read these engaging stories with children and help them apply the generic messages to their individual circumstances. Thought diaries using the main characteristics can be constructed. Coloring assignments which accompany the cognitive restructuring are good strategies. Table 1 lists some useful clinician created stories.

Table 1 CBT stories and their emphasis areas
Full size table

We have several suggestions for effective storytelling in CBT. First, attention should be directed toward identifying and communicating characters thoughts, feelings, behaviors, and problem-solving strategies (Kershaw 1994; Trad and Raine 1995). Therapeutic stories should make use of multiple sensory modalities (Lawson 1987). The central character in therapeutic stories should be a covert model for the child and therefore should appeal to the young patient (Callow and Benson 1990). Characters that transform themselves (e.g., swans, caterpillars, Dalmatians, hermit crabs, etc.) speak to children about the potential for change. Friedberg and McClure (2002, p. 149) explained, “Themes involving emotional growth and skill acquisition can be gracefully woven around narratives that detail the metamorphoses of these characters from a negative circumstance to a more sanguine situation.”

An example of a therapeutic story is illustrative. The following story was created with a 5 year old child who held the absolutistic belief that “I must always be the center of attention and the best at everything.” The patient experienced excruciating difficulty sharing attention and was painfully intolerant of others winning games. Accordingly, peer relationships were unsatisfying and she was rejected by many of her peers. The following story was used to help her shift her cognitions and behaviors.

Once upon a time, a long, long time ago in a place far, far away, there lived a princess with magical powers. Her name was Portia. She lived with her mother, father, and baby brother in a beautiful castle. The princess was able to use her magical powers to get everything she wanted. I mean everything!

Portia happily used her powers to get toys, candy, cakes, and pets. She also used her powers to make sure that everyone looked at and liked her. One day she even used her magic powers to help her win a spelling bee. Everything was going well for Portia until 1 day things changed.

And that day was horrible. Another princess named Natalie moved into her neighborhood and you know what? Natalie had special powers, too! She could do the same things with her powers that Portia could do. Now all of a sudden, Natalie was getting what she wanted and Portia felt left out and like she could never be the best and most favorite princess ever and always. Portia gave up doing things she liked. She started fights with the other princes and princesses especially with Natalie. Natalie was invited to play with all the other princes and princesses and she went to parties at their castles. Portia began not to be invited anywhere anymore.

Then things changed again! Portia’s unicorn named Webster could talk because he was sort of magical too. Webster went up to Portia and said, “Portia, you have forgotten that you have many magical powers not just the ones that get you what want.” “Really?” said Portia. “Yes,” Webster replied, “You have the power to share the attention and role of magical princess with Natalie. You just have to use it.” “Will people still see me as a princess and invite me to play and go to parties if I am not the best?”, asked Portia. “Sure they will! You just have to try out your new power,” explained Webster.

And you know what? That’s just what she did. Portia learned to share with Natalie and thought that even thought she wasn’t the only magical princess she still was a magical princess and that was good enough!

The story communicated several important cognitive restructuring messages to the young girl. First, she learned that you do not always have to be the best and center of attention to get what you want. Second, the story communicated that she had many abilities (e.g., special powers) that can help her tolerate frustration.

There are some children and adolescents who will not respond well to metaphors. Collaborative empiricism takes some of the pressure off the cognitive behavioral therapist to read patients’ minds. If a patient finds metaphorical interventions silly, stupid, or otherwise unhelpful, their reaction should be collaboratively processed and their preferences should be honored. There is little benefit to imposing metaphors on unwilling children.

Metaphors and Stories Add Fun and Increase Engagement in Treatment

The importance of “fun” in child cognitive behavioral therapy is well documented (Friedberg and McClure 2002; Stallard 2002a, b). Going to a clinic is rarely embraced by any child. They may believe they will receive a shot, be scolded, or punished. Moreover, many appointments require the child to take time away from school, friends, and/or favorite activities. In our experience, increasing the reinforcement value of the session facilitates therapeutic progress.

A 10 year old non-compliant boy who loved baseball turned the task into a fun project by using a metaphor which he called “Keepin my stats.” He encouraged his mother to rate his compliance and then compute it into a percentage like a batting average in baseball. Statistics were kept on a weekly basis on a “baseball card.” As the child became more compliant, his batting average soared. This led to the parents extending the metaphor by exclaiming, “Keep this up and you’ll make the Hall of Fame.”

A 9 year old boy diagnosed with ADHD was working on his social skills record. This youngster loved ships and boats. He began drawing a large cargo ship that would hold all the skills he acquired. As we completed the task, I (RDF) asked him what we should call the ship. He smiled wryly and replied, “let’s call it, the FRIEND SHIP!”. He then extended the metaphor by continuing, “And the skills could be the cargo.”

A very anxious 11 year old girl was having trouble acknowledging negative feelings, beliefs, and unfavorable circumstances. I (LHW) decided to create a game (like Monopoly) to help her express feelings in a meaningful way, but at enough of a distance that it was tolerable for her. She then identified various emotional hot spots for her. For instance, one spot was called The House of Sad where they served Regret Soup, Bull Burger, and Ambivalence Salad. The House of Sad was of course her home. Not surprisingly, she suffered significant conflict with her mother and painfully inhibited her unhappy feelings and dysfunctional beliefs. Simply, she engaged in considerable psychological biting of her tongue. The regret soup fixings consisted of the prohibited anger and the self-critical beliefs that held this inhibition in place (e.g. Good daughters do not get mad at their mother). Each ingredient was a thought or action that she regretted. By writing these beliefs on paper, cutting them into a food shape and tossing them into the pot, she subsequently pulled one out and evaluated how valid and useful it was. If it was accurate and productive, it went back into the pot, and if not, it was thrown into the trash.

The ambivalence salad was a smattering of mixed thoughts and feelings. For instance, beliefs associated with affiliation, achievement, autonomy, and control were tossed together. She wrote conditional beliefs such as “If I let others help me, I lose all control,” “If I get too close to people, they will dominate and suffocate me,” In order to be close to others, I must submit to their will, “and “My competence is determined by my degree of control,” were written on salad fixings. They were individually analyzed, tested, and modified before they were included in the salad.

The Family Pentagon was another spot on the board and held this young girl’s secrets. She was burdened by adults overly confiding family secrets to her. Most of these items were top secret, and she was not allowed to speak a word to anyone. She received all of these disturbing and conflicting messages and was constrained by “family (national) security.” If she landed on the Pentagon space, she would write down this disturbing information in a “top secret” envelope, and reveal them during the session.

This child also suffered from considerable performance anxiety, especially fear of negative evaluation from authority figures. She felt intense anxiety whenever the attentional spotlight fell on her. This was particularly difficult when giving a presentation in front of class or singing a solo in chorus. Therefore, she placed an Anxiety Stadium on her game board. When she landed on this space, she would picture herself in the middle of a stadium with a huge crowd watching. We took this a step further and had her be the “home team” and the visitor crowd would yell out the automatic thoughts, the scoreboard kept track of how realistic they were while the home crowd yelled out the coping statements.

Metaphors and stories are ways cognitive behavioral therapists can “play” with their young patients. They are entertaining and promote a good working alliance. Additionally, they allow difficult topics and issues to be gently broached. Through this game, the child dealt with her negative feelings and chaotic home environment. Through stories and metaphors, children can learn to view their problems from an objective perspective. At times, we have found that when children and their therapists share therapeutic stories and metaphors, the children forget they are in therapy. Consequently, they feel more comfortable processing emotionally powerful material. The board game created by the child helped transcend her inhibitions and decrease her censorship of emotional provocative material.

Conclusion

Being a psychotherapy patient is a difficult and distressing experience for most children. Entering into a collaborative treatment relationship requires children’s courage to face their challenges. Change inherently involves creativity (Mooney and Padesky 2000). Uniting both creativity and courage is fundamental in cognitive behavioral therapy with children. The use of treatment metaphors in CBT with children is a way to ignite this union. Ideally, this paper will encourage cognitive behavioral therapists to use metaphors with their young patients.

Similar to the development of other procedures and techniques in CBT, metaphor use with children will evolve with greater clinical practice, scholarly research, and robust conceptualization. Accordingly, we urge cognitive behavioral therapists to consider including metaphors in their clinical work and research. As more theoretical, clinical, and empirical research is directed to metaphors in cognitive behavioral therapy with children, the issues regarding whether it assumes a central or peripheral role can be clarified. Welcoming new ideas and embracing innovation is a historical tradition in CBT. Metaphor use in CBT with children is an exciting and potentially productive future direction which continues this tradition.