CASE REPORT

THE USE

NARRATIVE STRATEGIES BASED ON FAIRYTALES AS

INTEGRATIVE INGREDIENT IN CBT: A CASE REPORT

OF

NOVEL,

Chiara Ruini, PhD,# and Fedra Ottolini, PhD

Even though cognitive behavioral therapy (CBT) is often

the recommended treatment for mental health problems, it
may present limitations when dealing with existential or
moral issues. The aim of this case report is to describe the
introduction of narrative techniques based on traditional
fairytales in the process of CBT, in order to overcome
treatment resistances and to help the patient in dealing
with major life crises. In the case presented, the joint use
of these two techniques helped the patient to achieve

the right self-distance from her problems, allowing her to

reach a new, wider perspective and a subjective selfmaturation.

INTRODUCTION
The cognitive behavioral group of therapies (CBTs) have
ourished over the last four decades. The CBT approach
emphasizes the links between thoughts, feelings, and behaviors connected with, and responsible for, psychological
disorders. CBT is aimed at targeting the maladaptive beliefs
and biased information processing that underpin the distressing emotions and damaging behaviors associated with specic
psychological conditions. However, some research1,2 has
pointed to several problems in the application of CBT. For
instance, Goldfried1,2 noted that CBT fails in several areas.
First, even if CBT provides a micro-analysis of reactions to
specic problematic situations, it usually prevents an exploration of the big picture. Second, because CBT is based on
skills-training orientation, the therapist is most effective if he
or she serves as more a didactic teacher than as a healer.3,4
Further, although CBT has provided effective interventions
for reducing symptomatology, a comprehensive view of the
self is often lacking, leaving CBT at times not able to address
the recent call for more attention to humanism in psychotherapeutic settings.5,6
The need to integrate these rigid protocols of CBT with a
more holistic approach has recently been addressed by the
third-wave psychotherapies, which basically combine CBT
techniques with mindfulness strategies and meditation techniques, guided by some concepts taken from Eastern philosophy, such as acceptance.7,8 The need for a more humanistic

and holistic consideration of patients also dovetails with the

narrative medicine framework,6,912 which calls for a holistic
approach to the patient, involving not only his/her illness,
but his/her biography, narrative, and cognitive interpretation
of the illness.912
White and Epston13 observed that individual narratives
associated with psychological distress were often characterized
by thin and impoverished stories. They developed a narrative
therapy13 with the aims of deconstructing dominant problem
stories, incorporating previously neglected stories into the
overall life story of the person, and achieving nal enriched
life stories. The use of narrative strategies in clinical psychology and psychotherapy has a long tradition.14 Following
Jung15 and his theories on archetypes and myths, Jungian
psychoanalysts have applied these concepts in the treatment
of various emotional disorders.16 Many contemporary authors
underline the clinical value of employing myths and
metaphors included in various fairytales in the process of
psychotherapy17; Bettelheims18,19 analytic interpretations of
fairytales is one of the best known of these approaches. Some
clinicians in the psychoanalytic setting use traditional fairytales and their protagonists (hero/heroine) with their patients
in order to discuss with them their symbolic value.20
In traditional societies, fairytales have always played an
important psycho-educational role, providing ad hoc frameworks to interpret reality, to deal with personal issues and
stressful events, to encourage or warn in facing lifes adversities, and to help enter adulthood. Fairytales were aimed at
young adults more than children, and storytellers were mostly
older and well-respected members of the community who
communicated their wisdom and life experience through the
stories in their repertoires.4 Their content often deals with
several concepts that are now scientically investigated by
clinical psychology and psychotherapy research, including

Department of Psychology, University of Bologna, Viale Berti Pichat

5, Bologna 40127, Italy
# Corresponding author.
e-mail: chiara.ruini@unibo.it

& 2014 Elsevier Inc. All rights reserved.

ISSN 1550-8307/$36.00

Key words: Narrative therapy, CBT, fairytales, psychotherapy, treatment resistance

(Explore 2014; 10:121-124 & 2014 Elsevier Inc. All rights
reserved.)

EXPLORE March/April 2014, Vol. 10, No. 2 121

http://dx.doi.org/10.1016/j.explore.2013.12.003

resilience, self-realization, personal growth, forgiveness, and

meaning in life.3,4,21,22 Recently, a pilot study that used a
narrative intervention based on fairytales, told and discussed
in a group format, yielded promising results with emotionally
distressed women.23 In this preliminary group intervention,
21 women with adjustment disorders underwent a sevensession intervention conducted by a folklorist and by a
clinical psychologist. Sessions were each two hours long. In
each of the rst ve sessions (lectures) a different fairytale
(or part of it), with related topics (such as the ability to cope
with adversities and stressful situations, the use of inner
resources and personal strengths, and couple and family
dynamics), was told and then discussed with the participants.
In the two nal sessions (workshops), the women were asked
to write as a group their original fairytale, using a narrative
basic structure (based on the concept of functions developed in fairytale structuralist analysis24) and consisting of six
main phases: initial stressful event, test, tasks, help, ght,
victory, and nal reward. The therapist underlined similarities
with real-life problems, specic coping strategies adopted by
the hero/heroine of the story, and his/her emotional maturation, and these themes were discussed by the group.
The aim of this article is to describe the introduction of
narrative techniques based on traditional fairytales in the
process of CBT. Following the previously cited narrative
interventions, the authors decided to introduce this novel
ingredient in a standard CBT protocol in order to overcome
resistance to change and difculties encountered during
treatment by a patient with anxiety disorder. The patient
provided written informed consent to have her therapeutic
experience published.

CASE REPORT
S. was a 31-year-old woman, who worked as blue collar
worker in a textile factory and had gone to live with her
boyfriend a year earlier. Since that time, she had been
suffering from panic disorder and agoraphobia, according to
Diagnostic and Statistical Manual of Mental Disorders Fourth
Edition (DSM-IV) criteria. The panic attacks were quite
frequent (on average two per week) and associated with
agoraphobic situations, such as traveling, going to supermarkets, and going to cinema and restaurants. They were also
linked to gastroenterologic symptoms (nausea, stomach-ache,
and dizziness). S. sought a psychotherapeutic intervention in
order to have her panic disorder treated. A CBT program,
based on gradual exposure to feared situations, was carried
out with the patient. She was instructed to keep a diary with
automatic thoughts, error identications, and cognitive
restructuring. After six months of treatment, the panic attacks
had disappeared and she began to feel much better. At this
stage of the therapy, the therapist started to investigate other
problematic areas in the patients life, and S. reported some
difculties with her boyfriend. In her workplace she was being
courted by one of her male colleagues, with whom she had an
affair some years before. She felt she was still attracted to this
other man, but also felt extremely guilty when thinking about
her boyfriend. Additionally, in the same period, a strong

122 EXPLORE March/April 2014, Vol. 10, No. 2

earthquake happened while she was at work. No one was

injured during the earthquake, but S. described it as extremely
frightening. After that, the panic attacks reappeared and S. felt
anxious and distressed again. She started to avoid going to
work and asked for a long sick leave. She did not meet criteria
for full post-traumatic disorder, and the therapist decided not
to add antidepressant medications, but to intensify psychotherapy.25 The CBT protocol was implemented again, but
this time S. did not respond readily and anxiety levels and
somatization were very high. Subsequently, her boyfriend
received a promotion in a law rm and decided to ask her to
get married. At this stage of the therapy she reported that her
panic attacks were easy problems when compared to the
decision to get married. She felt insecure and still attracted to
her colleague at work, and consequently the emotional
distress was very intense. The therapist noted at this point
that the patient was now seeking help for dealing with
existential issues, rather than simply overcoming panic
disorder. A more holistic, integrative approach3 appeared to
be crucial at this point of the therapeutic process.
In the wake of the promising results obtained by the
narrative group intervention described above,23 the therapist
introduced a set of narrative techniques for helping the patient
to work on these moral and existential problems. S. was
invited to review her life, with particular attention to the
characteristics of previous partners and love affairs and to
discuss them during session. The therapist used metaphors and
found analogies between these various partners and similar
characters in traditional fairytales (i.e., the prince charming,
the ugly toad, and the evil ogre). At home, S. was assigned
the homework of writing a fairytale that represented her life,
using the fairytale narrative basic structure24 and imagining
its happy ending. No specic instructions were added in
terms of time settings, number of characters, or length of the
manuscript. The patient was left free to facilitate her
creativity. In the next session the therapist examined the
fairytale written by S., which was very short and simplistic.
The therapist then underlined the narrative mistakes and the
missing points: for instance, her character (the young princess)
was not sufciently characterized and was extremely passive
throughout the story. The imagined happy ending involved
her very rst boyfriend coming back and rescuing her from an
unhappy marriage with the current one, but no details were
provided on this former boyfriend, the reasons why he was
back, or their future planning. The patient was thus asked to
write again the same fairytale, correcting the mistakes, adding
details, and giving to the young princess a more active role in
the story.
In the subsequent session S. reported feeling much better.
She said that she felt she was emotionally un-blocked for the
rst time after many months, and that she nally understood
the value of her relationship with the current boyfriend.
When examining the newly written fairytale, in fact, the
happy ending was completely changed and, this time, she
identied her current boyfriend as her real prince charming.
She imagined a realistic future with him, involving a baby, a
new home in the countryside, and other positive outcomes. S.
reported that the homework of writing a structured ction

Fairytales as a Novel, Integrative Ingredient in CBT

story really helped her to examine people and situations in a

new light, with the right emotional distance, and with a wiser
perspective. She understood she already had a valuable person
and a brilliant future with him and decided to get married
to him.
After this cognitive and emotional maturation S. decided
to go back to work, to stop irting with the colleague and to
engage in organizing her wedding. Her panic attacks gradually
disappeared, with some more exposure homework that was
easily undertaken by the patient. She continued to create and
write new fairytales for addressing ongoing problems in her
daily life, such as nancial difculties, and resolving work and
family issues. S. reported that this narrative technique had
really helped her, providing a valid, symbolic framework for
interpreting reality. At a three-month follow-up visit, she was
still in recovery and happily engaged with her boyfriend.

DISCUSSION AND THERAPEUTIC IMPLICATIONS

This case report illustrates the integration of narrative techniques, based on traditional fairytales, in the process of CBT
psychotherapy. These narrative techniques consisted of various elements:
(a) Re-formulation of the patients difculties and problems in a
narrative way: The patient was guided to think about her
problems using a story plot (beginning, development of
the situation, and nal positive resolution) and using
characters and metaphors traditionally endorsed by
fairytales.24
(b) Creative writing of a new fairytale: The patient was cognitively engaged in building the plot and nding possible
positive outcomes.
(c) Sharing and discussing the fairytale with the therapist, in
session: The therapist underlined the narrative mistakes
or the lacking parts of the story, where resistance or
difculties indirectly emerged.
(d) Correction and re-writing of the fairytale, or a new one, using
suggestions and indications provided by the therapist.
The use of these narrative strategies, in a phase of CBT
where this patient was not responding to treatment and was
not able to engage in cognitive restructuring, yielded immediate benets and facilitated the abatement of resistances and
emotional blocks. Throughout the process of the fairytale
creation, the patient was able to use a metaphorical language
and exercise her building of symbolism. In the process of
writing her original fairytale, S. could work at creating
metaphors rather than just interpreting them. The working
approach was I would like to convey this characteristic or
feeling, so what action/symbol could I employ in order to do
so? rather than This event has occurred in the story: what
could it mean, what could it stand for? As a result, the
patient was able to develop her own symbolic language.
Further, the emotions were projected in a ctional, impossible setting, and this provided her the right distance from
problems, connected with a more effective cognitive engagement in problem solving. This is in accordance with White
and Epstons13 observations that a more richly described

Fairytales as a Novel, Integrative Ingredient in CBT

narrative enables the person to reposition his or her self in

relation to the problem.
This emotional distance is similar to the therapeutic
principle of cognitive defusion endorsed in Acceptance and
Commitment therapy (ACT)26 or in the Mindfulness-based
therapeutic approach.8 The emotional distance is also a
specic psychotherapeutic ingredient of Wisdom Psychotherapy, a recently validated group psychotherapy
for addressing embitterment disorders.27 Recent psychotherapeutic approaches thus suggest an important role for
helping patients to achieve the right self-distance from their
problems, allowing them to reach a new, wider perspective
and a subjective self-maturation. The narrative techniques
used with this case report yielded benets in terms of anxiety
symptoms and personal maturation, facilitating the selfhealing process.4,21 This narrative approach can help address
some of the limitations of CBT: even though CBT is an
effective treatment for mood and anxiety disorders,28 it may
have limitations when dealing with existential or moral issues,
as in our patient, probably because in CBT the role of
conictual emotions and motivations is often downplayed
and de-emphasized.3,29,30 According to Goncalves and
Stiles,31 narrative strategies could be extremely helpful in
these clinical situations because patients are provided with the
opportunity to transform true stories of problems into stories
of adaptation and meaningfulness. Psychotherapy, from this
perspective, is not only about symptom reduction, but also
about meaning, transformation,31 and self-healing.4
In conclusion, we suggest that the integration of fairytales
into psychotherapy has an important educational role and
signicant implications for helping patients to address their
emotional distress and increase their personal growth and
maturation. According to our clinical experience, fairytales
can easily support the work of psychotherapy, even improving
the value of standard CBT protocols.3,30,32 Further research,
with a larger sample, controlled design, and specic
diagnostic groups is needed in order to test and clarify the
role of fairytales in the psychotherapeutic and clinical
process.
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Fairytales as a Novel, Integrative Ingredient in CBT