Integrating the Expressive Arts Into Counseling Practice, Second Edition: Theory-Based Interventions [2 ed.] 0826177026, 9780826177025

Table of contents :
Cover
Title
Copyright
Contents
Contributors
Preface
Key Features of the Book
Share Integrating the Expressive Arts Into Counseling Practice: Theory-Based Interventions, Second Edition
Chapter 1: Introduction to the Use of Expressive Arts in Counseling
Overview of the Expressive Arts
Key Expressive Arts Modalities
Applicability of Expressive Arts Across Diversities
Conclusion
References
Section I: Theories of Counseling and Expressive Arts Approaches
Chapter 2: Adlerian Theory
Foundations of Adlerian Theory
Individual Psychology
Goals and Process of Adlerian Counseling
Multicultural Considerations
Adlerian Practice and the Creative Arts
Conclusion
References
Chapter 3: Solution-Focused Therapy
Foundations of Solution-Focused Therapy
Core Concepts of Solution-Focused Therapy
Multicultural Considerations
Efficacy of Solution-Focused Therapy
Conclusion
References
Chapter 4: Cognitive Behavioral Theory
Foundations of Cognitive Behavioral Therapy
Core Concepts of Cognitive Behavioral Therapy
Cognitions Composition
The Counseling Process
Cognitive Behavioral Therapy Techniques and Integration of Expressive Arts
Empirical Support for Cognitive Behavioral Therapy
Multicultural Considerations
Conclusion
References
Chapter 5: Choice Theory
Foundations of Choice Theory
Core Concepts of Choice Theory
Concerns Addressed by Choice Theory
Therapeutic Goals
Multicultural Considerations
Choice Theory and the Creative Arts
Conclusion
References
Chapter 6: Existential Theory
Foundations of Existential Theory
Core Concepts of Existential Psychotherapy
Concerns Addressed by Existential Theory
Multicultural Considerations
Existential Theory and the Creative Arts
Conclusion
References
Chapter 7: Feminist Theory
Foundations of Feminist Theory
Core Concepts of Feminist Theory
Concerns Addressed by Feminist Theory
Expressive Arts and Feminist Theory
Conclusion
References
Chapter 8: Gestalt Theory
Foundations of Gestalt Theory
Core Concepts of Gestalt Theory
Research Base and Efficacy
Multicultural Considerations
Gestalt Techniques and the Expressive Arts
Conclusion
References
Chapter 9: Person-Centered Therapy
Foundations of Person-Centered Therapy
Applications and Research Findings
Multicultural Considerations
Expressive Arts Perspective
Conclusion
References
Chapter 10: Narrative Approaches
Core Concepts of Narrative Therapy
Concerns Addressed by Theory
Multicultural Considerations
Narrative Approaches and the Expressive Arts
Conclusion
References
Expressive Arts Interventions
Chapter 11: Trauma-Informed Counseling and the Expressive Arts
Overview of Trauma as a Concern for Counselors
Expressive Art Therapies and Trauma
Considerations of Expressive Art Trauma Work
Conclusion
References
Chapter 12: Family Counseling and the Expressive Arts
Foundations of Family Counseling
Selected Models of Family Counseling
The Use of Expressive Arts in Family Counseling
Multicultural Considerations
Conclusion
References
Expressive Arts Interventions
Chapter 13: Integrative Theory in the Expressive Arts
Foundations of Integrative Expressive Arts
Core Concepts of Integrative Theory
Issues Adressed by Theory
Integrative Theory and the Expressive Arts
Conclusion
References
Expressive Arts Interventions
Section II: Emerging and Special Issues in Expressive Arts and Counseling
Chapter 14: Neuroscientific Applications for Expressive Therapies
Foundations of Neuroscientific Perspective in Counseling
Theory and Components
Applications of Neuroscientific Perspective
Expressive Arts and Art Therapy
Conclusion
References
Chapter 15: Clinical Supervision
Overview
Core Principles
Gestalt Approach to Supervision
Multicultural Considerations
Conclusion
References
Expressive Arts Interventions
Section III: Additional Clinical Uses of the Expressive Arts
Chapter 16: Adventure Therapy
Foundations of Adventure Therapy
Conclusion
References
Chapter 17: Animal-Assisted Therapy
Overview of Animal-Assisted Therapy
Foundations of Human-Animal Relational Theory
Common Significant Human-Animal Relational Moments
Neurobiology of Significant Human-Animal Relational Moments
Conclusion
References
Chapter 18: Child-Centered Play Therapy
Overview of Child-Centered Play Therapy
Foundations of Child-Centered Play Therapy
Core Concepts of Child-Centered Play Therapy
Healing Relationship
Issues and Concerns Appropriate for Child-Centered Play Therapy
Child-Centered Play Therapy with Diverse Populations
Conclusion
References
Chapter 19: Mindfulness in Counseling
Overview of Mindfulness
Foundations of Mindfulness in Counseling
Benefits of Mindfulness
How Does Mindfulness Work?
Developing Mindfulness
Integrating Mindfulness into Counseling
Examples of Mindfulness Practices/Interventions
Conclusion
References
Chapter 20: Sandplay Therapy
Overview of Sandplay
Materials
The Process
Conclusion
References
Appendix: Summary Chart of Expressive Arts Activities
Index

Citation preview

Integrating the Expressive Arts Into Counseling Practice

Suzanne Degges-White, PhD, LPC, NCC, is professor and chair of the Department of Counseling, Adult and Higher Education at Northern Illinois University, DeKalb, Illinois. She is a licensed counselor and her research interests include intimate relationships, family relationships, and friendships. She is the author of Friends Forever: How Girls and Women Forge Lasting Relationships; Toxic Friendships: Knowing the Rules and Dealing with the Friends Who Break Them; and Mothers and Daughters: Living, Loving, and Learning over a Lifetime. She is a featured blogger on the Psychology Today website (www.psychologytoday.com/blog /lifetime-connections) and has edited six books on counseling in the community and the schools. Nancy L. Davis, PhD, LPC, LSC, is a visiting associate professor and program director for school counseling at Purdue University, West Lafayette, Indiana. Nancy earned her master’s degree in counseling education at Long Island University, post-licensure and certificate in school counseling from Purdue University, and PhD in interdisciplinary studies from Union Institute. She has used the creative arts in her clinical work with children, adolescents, and adults in schools, clinical practice, and numerous hospice settings. Nancy’s research interests include multicultural communication and collaboration, institutional spirituality delivery, and older adult life review.

Integrating the Expressive Arts Into Counseling Practice THEORYBASED INTERVENTIONS SECOND EDITION

Suzanne Degges-White, PhD, LPC, NCC, and Nancy L. Davis, PhD, LPC, LSC Editors

Copyright © 2018 Springer Publishing Company, LLC All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, LLC, or authorization through payment of the appropriate fees to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, [email protected] or on the Web at www.copyright.com. Springer Publishing Company, LLC 11 West 42nd Street New York, NY 10036 www.springerpub.com Acquisitions Editor: Sheri W. Sussman Compositor: S4Carlisle Publishing Services ISBN: 9780826177018 Ebook ISBN: 9780826177025 Instructor’s Materials: Qualified instructors may request supplements by emailing [email protected]: Instructor’s Manual ISBN: 9780826177056 Instructor’s PowerPoints ISBN: 9780826177063 17 18 19 20 21 / 5 4 3 2 1 The author and the publisher of this Work have made every effort to use sources believed to be reliable to provide information that is accurate and compatible with the standards generally accepted at the time of publication. The author and publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance on, the information contained in this book. The publisher has no responsibility for the persistence or accuracy of URLs for external or third-party Internet websites referred to in this publication and does not guarantee that any content on such websites is, or will remain, accurate or appropriate. Library of Congress Cataloging-in-Publication Data Names: Degges-White, Suzanne, editor. | Davis, Nancy L., editor. Title: Integrating the expressive arts into counseling practice : theory-based interventions / Suzanne Degges-White, PhD, LPC, NCC, and Nancy L. Davis, PhD, LPC, LSC, editors. Description: Second edition. | New York : Springer Publishing Company, [2018] | Includes bibliographical references and index. Identifiers: LCCN 2017037021| ISBN 9780826177018 | ISBN 9780826177025 (ebook) Subjects: LCSH: Arts--Therapeutic use. | Mind and body therapies. Classification: LCC RC489.A72 I58 2018 | DDC 615.8/5156--dc23 LC record available at https://lccn.loc.gov/2017037021 Contact us to receive discount rates on bulk purchases. We can also customize our books to meet your needs. For more information please contact: [email protected] Printed in the United States of America.

Contents Contributors vii Preface

xiii

Share Integrating the Expressive Arts Into Counseling Practice: Theory-Based Interventions, Second Edition Chapter 1

Introduction to the Use of Expressive Arts in Counseling 1 Suzanne Degges-White

Section I

THEORIES OF COUNSELING AND EXPRESSIVE ARTS APPROACHES

Chapter 2

Adlerian Theory 9 Mary Amanda Graham and Dale-Elizabeth Pehrsson

Chapter 3

Solution-Focused Therapy

29

Mark Gillen

Chapter 4

Cognitive Behavioral Theory

49

Dixie Meyer

Chapter 5

Choice Theory

75

Torey L. Portrie-Bethke

Chapter 6

Existential Theory 93 Michele P. Mannion

Chapter 7

Feminist Theory 115 Heather Trepal and Thelma Duffey

Chapter 8

Gestalt Theory

137

Brian J. Mistler

Chapter 9

Person-Centered Therapy 155 Melissa Luke

Chapter 10

Narrative Approaches 187 Shawn Patrick

Chapter 11

Trauma-Informed Counseling and the Expressive Arts 209 Charles E. Myers v

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Contents

Chapter 12

Family Counseling and the Expressive Arts 221 Edward F. Hudspeth, Krystal Burks, and Keith Bowden

Chapter 13

Integrative Theory in the Expressive Arts 237 Sally S. Atkins, Keith M. Davis, and Lauren E. Atkins

Section II

EMERGING AND SPECIAL ISSUES IN EXPRESSIVE ARTS AND COUNSELING

Chapter 14

Neuroscientific Applications for Expressive Therapies 251 Jim M. Nelson and Patrick L. R. McMillion

Chapter 15

Clinical Supervision

259

Montserrat Casado-Kehoe and Kathy Ybañez-Llorente

Section III

ADDITIONAL CLINICAL USES OF THE EXPRESSIVE ARTS

Chapter 16

Adventure Therapy 287 Mark Gillen

Chapter 17

Animal-Assisted Therapy 291 Cynthia K. Chandler

Chapter 18

Child-Centered Play Therapy 299 Charles E. Myers

Chapter 19

Mindfulness in Counseling Cheryl L. Fulton

Chapter 20

Sandplay Therapy 315 Suzanne Degges-White

Appendix 319 Index

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305

Contributors

Rachel A. Altvater, MS, MA, LCPC, RPT, is a clinical psychology doctoral candidate at The Chicago School of Professional Psychology, Washington, District of Columbia Campus and a clinical psychology doctoral intern at The Children’s Assessment Center, Houston, Texas. Angela L. Anderson, PhD, LP (MO), is an associate professor of counseling at Missouri State University, Springfield, Missouri. Lauren E. Atkins, MA, MFA, is an associate professor in the Department of Theatre and Dance at Appalachian State University, Boone, North Carolina. Sally S. Atkins, EdD, REAT, is professor of counseling at The European Graduate School and professor emerita and founding director of Expressive Arts Therapy within the Department of Human Development and Psychological Counseling at Appalachian State University, Boone, North Carolina. John Beckenbach, EdD, is an associate professor in the Counseling and Guidance Program at California State University, San Bernardino, California. Paul Blisard, EdD, LPC, is a clinical assistant professor of counselor education at the University of Arkansas, Fayetteville, Arkansas. Keith Bowden, BA, is a master’s candidate in counseling at Henderson State University, Arkadelphia, Arkansas. Hannah Bowers, PhD, LMHC, is an assistant professor of counseling at Purdue University, West Lafayette, Indiana. Imelda N. Bratton, PhD, LPC, NCC, RPT-S, is an assistant professor of school counseling and clinical coordinator in the Counseling and Student Affairs Department at Western Kentucky University, Bowling Green, Kentucky. Krystal Burks, BA, is a master’s candidate in counseling at Henderson State University, Arkadelphia, Arkansas. Katherine Campbell, MAEd, LPC, is a doctoral student in counselor education and supervision at the University of Akron, Akron, Ohio. Montserrat Casado-Kehoe, PhD, LMFT, RPT, is a professor of counseling and counselor education at Palm Beach Atlantic University, Orlando, Florida. vii

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Contributors

Christian D. Chan, MA, NCC, is a doctoral candidate in counseling at the George Washington University, Washington, District of Columbia. Cynthia K. Chandler, EdD, LPC-S, LMFT-S, is a professor of counseling and higher education at the University of North Texas, Denton, Texas. Madeline Clark, PhD, LPC, NCC, ACS, is an assistant professor of counseling at the University of Toledo, Toledo, Ohio. Katrina Cook, PhD, LPC-S, LMFT-S, is associate professor and practicum coordinator for counseling and guidance at Texas A&M University, San Antonio, Texas. Savannah Cormier, MS, LPCC, is a doctoral student in counselor education and supervision at the University of Northern Colorado, Greeley, Colorado. Keith M. Davis, PhD, NCC, is an associate professor in the Department of Counselor Education at Radford University, Radford, Virginia. He is also a licensed professional school counselor in North Carolina. Nancy L. Davis, PhD, LPC, LSC, is a program director for school counseling at Purdue University, West Lafayette, Indiana. Suzanne Degges-White, PhD, LPC, NCC, is professor and chair of the Department of Counseling, Adult and Higher Education at Northern Illinois University, DeKalb, Illinois. Kristin I. Douglas, PhD, LPC (ND), LPCC (KY), NCC, BCB, ACS, is an assistant professor of clinical counseling at the University of Jamestown, Jamestown, North Dakota. Thelma Duffey, PhD, LPC, LMFT, is professor of counseling and counseling program director at the University of Texas, San Antonio, Texas. Ireon LeBeauf Dupree, PhD, is a counselor in private practice in Sparks, Nevada. Nancy Forth, PhD, LPC, NCC, is professor and program coordinator of the Counselor Education Program at the University of Central Missouri, Warrensburg, Missouri. Cheryl L. Fulton, PhD, MBA, LPC, is an assistant professor of counseling at Texas State University, Austin, Texas. Nan J. Giblin, PhD, is professor emerita of the Department of Counselor Education at Northeastern Illinois University, Chicago, Illinois. Mark Gillen, PhD, is an associate professor and chair of the Counseling and School Psychology Department at the University of Wisconsin, River Falls, Wisconsin. Mary Amanda Graham, PhD, is an associate professor of counseling at Seattle University, Seattle, Washington. Samantha Grzesik, MEd, is a graduate of the Mental Health Counseling Program at Purdue University Calumet, Hammond, Indiana, and is employed as the Human Resources hiring coordinator at JLL, Inc., Chicago, Illinois.

Contributors

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K. Hridaya Hall, PhD, NCC, is an assistant professor in clinical mental health counseling at Plymouth State University, Plymouth, New Hampshire. Jessica A. Headley, MA, LPC, is a doctoral candidate in the Counselor Education and Supervision Program at the University of Akron, Akron, Ohio. Laura Heil, MS, is an elementary school counselor in Corpus Christi, Texas. Stephanie Helsel, PhD, is a licensed professional counselor who is active in research, counseling, and teaching in the Pittsburgh area. She has a doctorate from Duquesne University and is a graduate of the Gestalt Institute of Pittsburgh. Edward F. Hudspeth, PhD, NCC, LPC-S, ACS, RPh, RPT-S, is associate dean of counseling programs at Southern New Hampshire University, Manchester, New Hampshire. Rachel L. Hughes, MA, is a doctoral student in the Medical Family Therapy Program at Saint Louis University, Saint Louis, Missouri. Flossie Ierardi, MM, MT-BC, LPC, is the director of field education for the Department of Creative Arts Therapies at Drexel University, Philadelphia, Pennsylvania. Kathryn Kozak, MEd, is a doctoral student in counseling and counselor education at Syracuse University, Syracuse, New York. Chloe Lancaster, PhD, is school counseling coordinator and counseling admissions coordinator at the University of Memphis, Memphis, Tennessee. Ileana Lane, MS, is a doctoral student at Texas A&M University, Corpus Christi, Texas. Elsa Soto Leggett, PhD, LPC-S, CSC, is an associate professor at the University of Houston–Victoria, Sugar Land, Texas. Kathleen Levingston, PhD, LPC, RPT-S, is a core faculty member of the School of Counseling at Walden University, Minneapolis, Minnesota. Sandra Logan, PhD, NCC, NCSC, DCC, ACS, is a clinical assistant professor at the University of Alabama, Birmingham, Alabama. Melissa Luke, PhD, LMHC, NCC, ACS, is professor and coordinator of the School Counseling Program at Syracuse University, Syracuse, New York. Sean Lynch, BA, CDCA, is a master’s candidate in clinical mental health counseling at Walden University, Minneapolis, Minnesota. Coresair Mack, BA, is a master’s candidate in the Department of Counseling, Adult and Higher Education at Northern Illinois University, DeKalb, Illinois. Karen L. Mackie, PhD, NCC, LMHC, is an assistant professor of counseling and human development at the Warner School, University of Rochester, Rochester, New York.

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Contributors

Michele P. Mannion, PhD, LCPC, ACS, is a licensed clinical professional counselor in the state of Maine. She is in private practice. Jamie Marich, PhD, LPCC-S, LICDC-CS, REAT, is a therapist at the Institute for Creative Mindfulness, Warren, Ohio. Beth McCabe, MS, is an elementary physical education instructor and incorporates expressive arts into her curriculum. Patrick L. R. McMillion, MEd, is a counselor in private practice at Adventure Works Counseling and a doctoral student at Northern Illinois University, DeKalb, Illinois. Christine McNichols, PhD, LPC-I, NCC, is an assistant professor of counseling and the director of the Psychology and Counseling Training Clinics at the University of Texas–Tyler, Tyler, Texas. Dixie Meyer, PhD, NCC, PLPC, is an assistant professor in the Medical Family Therapy Program at Saint Louis University, Saint Louis, Missouri. Brian J. Mistler, PhD, is director of health and wellness at Humboldt State University, Arcata, California. Teah L. Moore, PhD, is an assistant professor of counseling at Fort Valley State University, Fort Valley, Georgia. Fatima La’Juan Muse, MA, is a doctoral student in the Medical Family Therapy Program at Saint Louis University, Saint Louis, Missouri. Charles E. Myers, PhD, LCPC, NCC, NCSC, ACS, RPT-S, is an assistant professor of school counseling and play therapy director at Eastern Kentucky University, Richmond, Kentucky. Abigail Nedved, MA, is a doctoral student in the Medical Family Therapy Program at Saint Louis University, Saint Louis, Missouri. Jim M. Nelson, PhD, is a professor of psychology at Valparaiso University, Valparaiso, Indiana. Adele Logan O’Keefe, PhD, NCC, LPC, LMFT, is a therapist at Sage Counseling & Wellness, LLC, in Lexington, Virginia. Bill ‘Eli’ Owenby, MC, NCC, CCMHC, LPCC (OH), LPC-S (TX), is a doctoral candidate in counselor education and supervision at the University of Akron, Akron, Ohio. Jill Packman, PhD, RPT-S, NCC, is an associate professor in the Department of Counseling and Educational Psychology and the coordinator of the Marriage, Couple, and Family Counseling/Therapy Program at the University of Nevada, Reno, Nevada. Tina R. Paone, PhD, NCC, NCSC, LPC, RPT-S, is an associate professor in the Department of Educational Leadership, School Counseling, and Special Education at Monmouth University, West Long Branch, New Jersey.

Contributors

xi

Lucy C. Parker, MS, is a doctoral student in the Department of Counseling, Adult and Higher Education at Northern Illinois University, DeKalb, Illinois. Shawn Patrick, EdD, is an associate professor in the Counseling and Guidance Program at California State University, San Bernardino, California. Rachel Payne, MS, is a counselor at the Women’s Shelter of South Texas and has worked in the expressive and healing arts field for the past 20 years as an arts educator and massage therapist. Dale-Elizabeth Pehrsson, EdD, CLPC-S, NCC, ACS, DCC, RPT-S, is professor and dean of the College of Education and Human Services at Central Michigan University, Mount Pleasant, Michigan. Kristi Perryman, PhD, LPC, RPT-S, is an assistant professor in the Department of Counselor Education at the University of Arkansas, Fayetteville, Arkansas. Sheri Pickover, PhD, LPC, is an associate professor of counseling at the University of Detroit Mercy, Detroit, Michigan. Melina Pineda, MS, is an associate psychologist at the Corpus Christi State Supported Living Center, Corpus Christi, Texas. Melanie A. Popiolek, MA, LPC, NCC, is a counselor in private practice in Clarkston, Michigan. Torey L. Portrie-Bethke, PhD, NCC, is a core faculty member in the School of Counseling at Walden University, Minneapolis, Minnesota. Mayra Aragon Prada, MA, is a doctoral student in the Medical Family Therapy Program at Saint Louis University, Saint Louis, Missouri. Christopher P. Roseman, PhD, is an associate professor and chair of the School of Intervention and Wellness, counselor education program director, and doctoral program coordinator at the University of Toledo, Toledo, Ohio. Mardie Howe Rossi, MA, EdD, LMHC, is an adjunct instructor at Medaille College and a psychotherapist and life coach in private practice, Rochester, New York. Brittany Rotelli, BA, is a master’s candidate in counseling at Northern Illinois University, DeKalb, Illinois. Varunee Faii Sangganjanavanich, PhD, LPC, NCC, ACS, RPT, is an associate professor in the Department of Counseling at the University of Akron, Akron, Ohio. Corie Schoeneberg, EdS, LPC, is a certified professional school counselor, an adjunct faculty member in the Counselor Education Program at the University of Central Missouri, and is currently in private practice in Sedalia, Missouri. Atsuko Seto, PhD, LPC, NCC, is an associate professor chairperson of the Counselor Education Department at the College of New Jersey, Ewing, New Jersey.

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Contributors

Cheryl L. Shiflett, MS, LPC, ATR-BC, is a community faculty of the Graduate Art Therapy and Counseling Program at Eastern Virginia Medical School, Norfolk, Virginia. Allison L. Smith, PhD, NCC, ACS, is an assistant professor of clinical mental health counseling in the Applied Psychology Department at Antioch University New England, Keene, New Hampshire. HoiLam Tang, MS, BFA, is a staff therapist in South Bay Mental Health Center, Brockton, Massachusetts. Heather Trepal, PhD, LPC-S, is an associate professor of counseling at the University of Texas, San Antonio, Texas. Katarzyna Uzar, PhD, is an educationalist and assistant lecturer in the Chair of Philosophy of Education at the John Paul II Catholic University, Lublin, Poland. Katie Vena, MS, LMHC, is a licensed professional counselor in Valparaiso, Indiana. Anna Warzecha, MA, is a psychologist who completed postgraduate studies in art therapy at the Maria Curie–Skłodowska University in Lublin, Poland and works with the Polish Association for Mentally Handicapped People. Erin Wold, BA, is a master’s candidate in the Department of Counseling, Adult and Higher Education at Northern Illinois University, DeKalb, Illinois. Kathy Ybañez-Llorente, PhD, LPC-S, is an associate professor at Texas State University– San Marcos, San Marcos, Texas. Seydem Yesilada, MS, is a doctoral student in counseling and counselor education at Syracuse University, Syracuse, New York. Jasmine Young, BA, is a master’s candidate in the Department of Counseling, Adult and Higher Education at Northern Illinois University, DeKalb, Illinois.

Preface

Counseling has long been considered to be an art, as well as a science, of helping individuals grow and develop. Yet many of our theories and practices rely heavily on the role of “talk therapy” in the healing process. Although these traditional methods of engaging the client in the process are important, the use of nontraditional methods that include the adjunctive or primary use of the expressive and creative arts may actually deepen the healing process as well as expedite diagnosis, treatment, and prevention. As professionals search for productive and effective methods of care, it is important to also realize that approaching the psychological space in which clients wrestle with their concerns, their challenges, and their inner wounds may also require the use of complementary methods of healing. Engaging the client in the creation of art—whether it is visual, auditory, kinetic, and so forth—can provide a safe path for clients to follow as they explore and delve deeper into the places where words alone may be inadequate to fully explore, express, and process their experiences. Our purpose in developing this second edition is to provide counselors and counseling students with a broader awareness of the ways in which traditional theories can be supplemented with expressive arts interventions as well as to provide a clear description of the ways in which multicultural considerations can be addressed via the integration of the expressive arts into practice. This book is unique in that it provides a collection of field-tested creative interventions contributed by practicing counselors and counselor educators. These interventions are presented to the reader in chapters organized by the leading theoretical orientations under which they best fit. The infusion of the expressive and creative arts into clinical practice is enjoying a growing popularity as practitioners face what seems to be an increasingly difficult-to-reach client population. Electronic media continue to grow and offer distracting, eye-catching variety. Our culture increasingly expects “entertainment” rather than substance. Practitioners who integrate creative techniques that engage the client’s mind, imagination, and physical presence during sessions may be able to capitalize on the client’s need for novelty. Creativity and experiential interventions can be the catalysts needed to propel clients toward lasting change. However, many counselors are unaware of the numerous expressive arts interventions that may well suit their philosophical and clinical frameworks. By introducing expressive arts interventions framed within the theories that are most familiar to practitioners and students, we hope that counselors will feel more comfortable in stretching their clinical work beyond their current borders and implementing these unique techniques that may expedite client growth and development. Each chapter in this volume offers a summary of the counseling theory and an explanation of how expressive arts interventions can easily be integrated into its practice. By framing innovative and creative intervention activities within familiar theoretical constructs, we hope that all readers will feel encouraged to enliven their practices with ideas that invite clients to invest more energy, creativity, and self-exploration into the therapy hour. In summation, this book will ideally demonstrate to practitioners and students the possibility of incorporating expressive arts interventions into clinical work. xiii

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Preface

KEY FEATURES OF THE BOOK ■ ■

■ ■ ■ ■ ■ ■ ■ ■ ■

This edition includes 111 interventions for use with various clients and presenting issues, including more than 40 new expressive arts interventions! New chapters address cutting-edge areas in counseling, including the areas of: Neuroscience and counseling Trauma-informed counseling Animal-assisted therapy Mindfulness and counseling Family counseling and the expressive arts Multicultural considerations related to each major theory are explicitly addressed in relevant chapters. Interventions are presented within a framework of familiar counseling theories—narrative therapy, solution-focused therapy, cognitive behavioral therapy, feminist theory, and more. Interventions use art therapy, music therapy, bibliotherapy, drama, expressive writing, dance, puppetry, sandplay, and other modalities. Leading practitioners share their clinically proven interventions that encourage clients to move forward. Creative interventions are clearly described in a step-by-step fashion, allowing clinicians to easily put them into practice. A chapter on the use of expressive arts in supervision provides ideas for improving supervision sessions. Presented ideas will help clients and clinicians feel “unstuck” when traditional talk therapy needs a jump-start. The book serves as a toolbox for practitioners ready to tune up their clinical work and an accessible introduction for students learning about expressive arts in counseling. In support of the text, an Instructor’s Manual and PowerPoints are available. Qualified instructors can request these ancillaries by e-mail: [email protected].

1 Introduction to the Use of Expressive Arts in Counseling Suzanne Degges-White

OVERVIEW OF THE EXPRESSIVE ARTS For thousands of years, healers have integrated a variety of creative arts into their therapeutic practices. In ancient Greece and Rome, drama and comedy were “prescribed” for individuals suffering from disorders such as depression or anxiety. Tribal dances have long been used for healing individuals and the planet. Music has been used to alter mood for hundreds of years. Contemporary Navajo healers still include sandpainting and music in their healing. The expressive arts have the power to help us transcend the mundane and to connect with parts of ourselves that traditional talk therapy may not so readily offer. The arts provide a medium through which we may draw on inner feelings and the unconscious to produce a tangible product, whether a sculpture, a story, a painting, or a dance. Engagement in the expressive arts allows clients to explore their deepest and often hidden feelings, to use symbols to represent their inner feelings and conflicts, and to physically express their internal issues. This process frequently leads to a more comprehensive self-exploration and self-expression than traditional talk therapy may allow. It is the process, not the processing, of art-making that promotes client growth, which may be a novel idea for contemporary healers—that is, mental health counselors and clinicians—today. Many well-educated mental health professionals have had little exposure to the use of expressive arts interventions in their professional programs. Although very familiar with the dominant counseling theories—person-centered therapy, rational emotive behavioral therapy, cognitive behavioral therapy, and others—they are yet to learn how to successfully integrate creative arts techniques into their chosen theory of practice. Yet all of these theories can be successfully married with, and enhanced by, the introduction of expressive arts interventions. Moreover, through the incorporation of more active forms of therapeutic work, clients are frequently more invested and more motivated toward personal growth and change. The interventions included in this volume are designed to be an extension—not a replacement—of a clinician’s current practical skill set. Clinicians who are interested in energizing their work will find a collection of creative and innovative interventions in this book that fit within the theories that shape their clinical practice. And as they explore and discover the types of creative arts that best suit their styles, they are encouraged to research these specific areas more fully. Knill, Barba, and Fuchs (2004) pioneered a theory of intermodal expressive 1

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Integrating the Expressive Arts Into Counseling Practice

therapy that supports the inclusion of multiple forms of creative arts in one’s practice. As clinicians find the best fit for their own approach to clinical work, they may find themselves merging and blending multiple modes in the way they feel is most effective for their individual clients. This is the heart of intermodal expressive therapy—using the mediums that speak to the imagination and soul. KEY EXPRESSIVE ARTS MODALITIES Art takes many forms and various methods and media are used in its creation. Visual art, music, dance/movement, drama, and expressive writing are the primary expressive arts modalities used in counseling. Counselors frequently offer various arts activities to create an intermodal experience for their clients. By inviting clients to participate in a selection of diverse arts activities, counselors set the stage for multilayered self-discovery experiences for their clients. The following is a brief overview of the origin of the predominant art modalities; however, it is not the purpose of this volume to explore these modalities in depth. Rather, the goal is to raise awareness of the variety of expressive arts formats that may be used adjunctively within a counselor’s existing theoretical orientation. Each of the separate interventions included in this book includes clear instructions for successful implementation. To learn more about each of the modalities, a resource list is provided in the final chapter of this book. Visual Arts The field of visual arts encompasses many forms of art-making, a few of which are painting, drawing, sculpting, collage-making, and photography. Art therapy may also include the use of existing art pieces to stimulate self-exploration. Margaret Naumburg (1950) was an early pioneer of the use of art in therapy, bringing art to the therapeutic milieu in the 1940s. Her work with patients was very well received, and art therapy became a customary component of mental health care in treatment centers as the medical field recognized the positive effect art-making had on patients. The earliest art therapy practitioners were often psychiatrists or art teachers who entered the mental health field. Today, there are specialized therapists who earn their degrees from art therapy graduate programs, but there are a host of means by which nonspecialized clinicians can infuse art therapy experiences into their practices. The professional association for art therapy is the American Art Therapy Association (www.arttherapy.org). Music Therapy Music therapy has been a component of psychotherapeutic care in this country since the first half of the 20th century (Wigram, Pedersen, & Bonde, 2002). Musicians volunteered their time to provide musical relief in the veterans’ hospitals for those who had been injured in World Wars I and II. The curative and symptom-relieving effects of music were acknowledged by the medical staff and, shortly thereafter, musicians were then hired for the hospitals. Four areas of functioning are understood to be improved through music therapy: physical functioning, cognitive functioning, psychological functioning, and social functioning. During music therapy, clients may actively compose and create their own music, or they may be led in directed music activities by the clinician. Although there is a specific training program for those interested in being recognized as licensed music therapists, mental health counselors are all encouraged to incorporate aspects of music therapy into their clinical work with clients in private practice, agency settings, inpatient/residential treatment centers, and schools. The professional association for music therapy is the American Music Therapy Association (www.musictherapy.org).

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Drama Therapy Although drama and enactment have been present in virtually every culture for more than 2,000 years, it was in the early 1900s that Jacob Moreno led the movement to use the healing properties of these forms of self-expression in therapeutic settings in the form of group therapy. Drama therapy is a powerful and highly experiential therapeutic device. Clinicians direct the action between clients and provide a safe space in which exploration of feelings, behaviors, and thoughts may actively take place. Clients are often encouraged to play out the parts of themselves that they typically inhibit or censor. Forms of dramatic interventions encompass various activities including storytelling, improvisation, puppetry, enactment, and role-play of significant events. The professional association for drama therapy is the National Association for Drama Therapy (www.nadt.org). Expressive Writing/Poetry Therapy Expressive writing can take many different forms, including the composition of both prose and poetry. The purpose of expressive writing is to assist clients in healing and coping with psychological and physiological pain. Expressive writing typically involves the use of clinician-provided prompts for the clients. Expressive writing has been shown to be beneficial in highly diverse settings (Baikie & Wilhem, 2005). Clients coping with normative developmental tasks as well as those who have experienced significant trauma (including terrorist attacks such as the World Trade Center tragedy) and chronic and acute health problems (including terminal illness and chronic pain) have shown marked improvement in well-being via expressive writing exercises. Poetry therapy and bibliotherapy are related forms of creative therapies and involve the use of specifically chosen works for client reading. The professional association for poetry therapy is the National Association for Poetry Therapy (www.poetrytherapy.org). Dance/Movement Therapy Dance/movement therapy grew into a distinct therapeutic modality in the early 1940s, as did art therapy and music therapy (Malchiodi, 2005). The modern dance movement gave birth to a more spontaneous, expressive form of movement that dancers reported as a freeing, health-promoting experience. Marian Chace, a choreographer of modern dance, was invited to introduce psychiatric patients to this form of self-expression and did so with positive results. Dance and movement therapists attribute the beneficial effects to the integration of mind and body that occur in the movement of dance. By expressing oneself via dance and movement, it is believed that experiences that are too deep or complex for words can be communicated and processed. The professional association for dance and movement therapy is the American Dance Therapy Association (www.adta.org). APPLICABILITY OF EXPRESSIVE ARTS ACROSS DIVERSITIES The expressive arts are exceptional in their effectiveness for individuals who represent a wide array of diversities and differences. Art is universal and it finds expression in every contemporary culture. This universality supports the implementation of the expressive arts with any client, regardless of gender, ethnicity, ability, age, language, cultural identity, physical functioning, among other forms of diversity. Visual art, music, dance, dramatic enactments, and expressive communication are found in all corners of the globe and this, in itself, supports the inclusion of expressive arts with essentially any client population. By supporting the unique creative capacity of every client, clinicians are supporting the healthy development of the individual.

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The visual arts can be modified for individuals who may face physical challenges and are particularly useful with those who have limited verbal ability or when language barriers exist. Use of existing pieces of art (i.e., photographs, prints, sculptures, etc.) can be incorporated into counseling for those who lack the physical control to manipulate art materials such as paintbrushes or drawing instruments. Music therapy has been shown to be effective with many clinical populations as well as individuals and groups interested in developmental counseling experiences. According to the American Music Therapy Association (2010), music therapy is beneficial to individuals facing physical illness and age-related diseases/disorders such as Alzheimer’s disease. Music therapy is also indicated for those suffering from autism, physical disabilities, and individuals experiencing chronic pain. Individuals may generate music or enjoy receptive listening during a music therapy experience; thus, it is open to virtually all potential clients. Movement is a natural aspect of our physical presence in the world, and clients do not need to be able to leap through the air with grace and style to benefit from this therapeutic modality. Individuals with physical disabilities can benefit from movement therapy through the stretching and moving of their bodies (Horowitz, 2000). This modality does not require words or complicated explanation but can exist in the purest form of client movement, thus inviting participation regardless of verbal ability or intellectual ability. Drama therapy can be used by individuals of virtually any diversity who have the cognitive capacities to respond to prompts from the clinician and who are able to understand the difference between reality and fantasy. Expressive writing is accessible to clients who have the cognitive capacity to use verbal expression and the physical ability to put words on paper or computer keyboard. This makes it accessible to widely diverse clients. If clients are unable to write or use a keyboard, they may “dictate” their thoughts, feelings, and reflections to an aide or clinician. Because the client is not required to share his or her writing with a clinician, greater participation may occur from clients who might otherwise feel less skilled in the areas of writing fluency and ability. CONCLUSION The creative arts offer both the clinician and the client an opportunity to move beyond the expressive limits of talk therapy. Sparking the creative process often results in the discovery of innovative solutions to problems that have held clients back from achieving optimal functioning. Encouraging clients toward greater self-expression and spontaneous process can effectively break up patterns of negativistic and constricted thinking. Further, the arts can be successfully incorporated in any clinical setting, from schools to outpatient settings to residential treatment centers, and with clients of any age, from young children to older adults. Challenging yourself to incorporate expressive arts interventions into your traditional framework of practice will allow you to develop your own unique creative techniques. However, to begin a new developmental process, it is often helpful to have new ideas framed within familiar structures. To that end, this book is organized by theory with eight of the most frequently implemented counseling theories included. Within each chapter, a summary of the theory is presented as well as a clear explanation of how the theory supports the integration of the expressive arts. Each accompanying creative intervention includes step-by-step instructions for ease in adding new techniques to your clinical repertoire. As you gain confidence, you are encouraged to use these techniques merely as starting points, as you discover the modalities that best suit your style and enable you to bring the expressive arts to your personal science of counseling.

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REFERENCES American Music Therapy Association. (2010). What is the profession of music therapy? Retrieved from http://www.musictherapy.org Baikie, K. A., & Wilhem, K. (2005). Emotional and physical health benefits of expressive writing. Advances in Psychiatric Treatment, 11, 338–346. Horowitz, S. (2000). Healing in motion: Dance therapy meets diverse needs. Alternative and Complementary Therapies, 6, 72–76. Knill, P., Barba, H., & Fuchs, M. (2004). Minstrels of soul: Intermodal expressive therapy (2nd ed.). Toronto, ON, Canada: EGS Press. Malchiodi, C. A. (Ed.). (2005). Expressive therapies. New York, NY: Guilford Press. Naumburg, M. (1950). An introduction to art therapy: Studies of the “free” art expression of behavior problem children and adolescents as a means of diagnosis and therapy. New York, NY: Teachers College Press. Wigram, T., Pedersen, I. N., & Bonde, L. O. (2002). A comprehensive guide to music therapy: Theory, clinical practice, research and training. London, UK: Jessica Kingsley Publishers.

I Theories of Counseling and Expressive Arts Approaches

2 Adlerian Theory Mary Amanda Graham and Dale-Elizabeth Pehrsson

It is easier to fight for one’s principles than to live up to them.—Alfred Adler Alfred Adler’s individual psychology is a dynamic theory that offers counselors many opportunities to help clients find creative, socially focused, meaning-making, and growth-oriented strategies to heal and grow. The creative and expressive nature of Adlerian psychology not only is conducive to practice with a wide client base but is also easily integrated with expressive art approaches. This chapter discusses Adlerian theory and shows how expressive arts techniques can be used in Adlerian counseling. FOUNDATIONS OF ADLERIAN THEORY Alfred Adler (1870–1937), an early contemporary of Sigmund Freud, developed individual psychology (also referred to as Adlerian counseling). Adler practiced as an ophthalmologist, medical doctor, and psychiatrist early in his professional career. He chose this path based on several early childhood experiences. Born into a large family, Adler grew up as one of six children and suffered several emotional and physical traumas during his childhood. At the age of 3, he experienced the death of a sibling who had shared a bed with him. He spent much of his youth battling severe illnesses. These challenging experiences influenced his concept of personality development and theory (Orgler, 1963). As an early associate of Freud, Adler was intimately involved in the Psychoanalytic Society from 1902 to 1911. In 1911, Adler separated himself from Freud and from the Psychoanalytic Society because of conflicting beliefs related to human development. These included disagreements regarding biological and sexual drives, the role of the libido, social issues, and the role of the unconscious. Adler marched in another theoretical direction. However, his association and studies with Freud provided him with a foundation for his own theoretical constructs, which he expanded to develop into individual psychology. Adler, unlike Freud, believed in the power of choice. He argued that people were neither innately evil nor good and he supported the notion that people were heavily influenced by relationships and social connections.

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INDIVIDUAL PSYCHOLOGY Adlerian theory, or individual psychology, emphasizes a basic premise that supports the assertion that each individual is unique. The theory postulates that there are four core concepts that shape the nature of human existence; these address personality development, the notion of superiority, psychological well-being, and the unity of the personality. Those who base their clinical practice on individual psychology’s theory ground their interventions in social interaction, relationship, and connectedness. Adler viewed human beings as healthy individuals whose difficulties are based largely on lack of social interests, relationship connectedness, and on faulty goals. He put forward the notion that the motivating force behind an individual’s behavior rests with a desire for perfection and attainment of the ideal. Striving for perfection is integrated with an individual’s social interests and connections, which can be termed his gemeinschaftsgefühl (Adler, 1927). Adler believed people always exist and function within a social context and environment. He postulated that individuals develop feelings and beliefs of inferiority, or inferiority complexes, based on their feeling of worthlessness. In relationship to inferiority complexes, Adler identified superiority complexes as a result of individuals’ attempts to overcome inferiority by ignoring true feelings (Adler, 1927; Orgler, 1963). Adler, like Freud, stressed the influence of early childhood experiences. Both theorists believed that the personality of an individual developed early in life. Adler differed from Freud, however, in that he argued a child’s personality developed based on the early experience of the child, not of the infant, as Freud purported. This early experience was influenced by the place, role, significance, and fit within the family constellation and system of the child. Other concepts underlying individual psychology include the understanding of both the conscious and unconscious, viewing the individual’s life subjectively through the individual’s own perspective, the examination of lifestyle, position in the family, family constellation, choice, and life span growth (Adler, 1959). What follows is a list of condensed definitions of core principles of individual psychology: ■ ■

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Individual perceptions. A person’s perceptions relate to his or her view of reality. Soft-determinism. An individual makes choices in regard to how he or she feels or interprets situations regardless of whether choices are limited to biology or circumstances. Both individual choice and individual responsibility play a critical role in one’s development. Holistic. An individual must be viewed as a whole entity, not as merely parts of a whole. Understanding each facet of a person’s life as it relates to the whole person is essential within the construct of individual psychology. Lifestyle. Each individual develops a distinctive framework for his or her life path or, as Adler identified it, a lifestyle. One’s lifestyle is foundational for successfully meeting goals and overall life management. This framework is a combination of beliefs and assumptions that is used to organize and find meaning and personal reality. Family constellations. This construct addresses the relationship an individual has within his or her own family system. Influences on these familial relationships include birth order, sibling and parental roles, societal influences on the parents, cultural norms, and family experiences. The early relationships and events within a family will directly impact the development of an individual’s lifestyle beliefs. Adler gained international recognition for his work on birth order. Social interests. Individuals are driven by social relatedness. Interconnectedness and social relationships stand as core concepts within individual psychology. Behavior is purposeful and goal oriented. Behavior is a choice and behavioral choices are made to reach goals consistent with individual lifestyle, reality, and relationships. There is no automatic cause and effect relationship between behavior, heredity, and environment.

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Individuals have the ability to understand, manipulate, and generate events based on lifestyle goals. Behavior is considered to be teleological in that it is not driven by internal or external force or factors. GOALS AND PROCESS OF ADLERIAN COUNSELING The goals associated with the implementation of Adlerian therapy include relationship, assessment, insight and understanding, and reorientation and reeducation. ■

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Relationship. The relationship between counselor and client is equal, collaborative, warm, empathetic, and based on trust and on the developing relationship. The goals for client growth are based on the client’s worldview and are coconstructed with the counselor. The client and counselor engage in a mutual journey of discovery of the client’s issues related to the client’s lifestyle assessment. Assessment. Assessing or learning about the client plays a central focus in the Adlerian counseling process. Assessment occurs initially at the start of treatment but takes place throughout the counseling process as well. Adlerian counselors assess individual lifestyles, goals, relationships, individual dynamics, family connectedness and constellations, and early recollections. There are both formal and informal lifestyle assessments that Adlerian counselors use in gathering information for client growth. Insight and understanding. Individual growth in Adlerian counseling arises from gaining an understanding of one’s individual purpose. Adlerian counselors assist clients in recognizing their motivations and help clients become knowledgeable of themselves. Through counseling, they discover awareness of purpose. Reorientation and reeducation. Through insight and understanding, clients are able to become reoriented and reeducated. This is the process of putting awareness of purpose into action. During the growth stage, the counselor facilitates behavioral choices to help clients overcome the use of less well-functioning alternatives. This is consistent with the insight and understanding the client gains regarding lifestyle, purpose, and motivation.

MULTICULTURAL CONSIDERATIONS Alfred Adler paved the way for understanding and working with marginalized groups. Alfred Adler has been described as a pioneer in issues of equity, justice, and multicultural counseling. His work was a precursor to the multicultural competencies and social justice advocacy movements as they relate to the counseling field. The theory of individual psychology focuses on working individually with a client to understand his or her worldview and lived experiences. A tenet of individual psychology is the focus on various cultures, norms, and practices as they relate to the system and development of relationships of the client. Individual psychology, being holistic in nature, takes into consideration the environment, social interactions, lifestyle, beliefs, and background as they relate to the individual (Carlson, Watts, & Maniacci, 2006; Corey, 2013; Kottman, 2003). In many respects Adlerian therapy fits well with the multicultural context. The basic tenets Adler laid out honoring an individual’s beliefs and environment as developed within the context of his or her lifestyle and interactions are congruent with multicultural competencies. The Adlerian counselor operates from a lens of understanding individuals as unique beings and understanding them from their frames of reference. This focus on the uniqueness of each client provides a strong foundation for integrating the creative arts within this theoretical orientation.

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Expressive arts, specifically art therapy, play therapy (Kottman, 1999, 2003), and bibliotherapy (Kottman, 2001), fit well within the frame of individual psychology. Creative approaches provide avenues of self-exploration and understanding (Gladding, 2005). Further, these venues often provide a catalyst to insight and change and these are directly or indirectly expressed through the art activity. Through expressive and creative interventions, clients are able to gain insight, reorientation, and reeducation for growth. ADLERIAN PRACTICE AND THE CREATIVE ARTS Art and creative interventions can easily and appropriately be integrated into the counseling process (Crenshaw, 2004, 2006; Gladding, 2005; Malchiodi, 2003, 2005, 2006, 2008; Oaklander, 1988), especially when working within the framework of individual psychology (Kottman, 2001). Art and play media are tools that facilitate individual competence in communication, understanding, self-reflection, and world perceptions (Pehrsson & Aguilera, 2008; Pehrsson & McMillen, 2005). Art interventions in counseling function as avenues for individuals to recognize lifestyle, family constellations, faulty thinking, and mistaken goals (Dreikurs, 1986; Watts & Garza, 2008). The use of art therapy within individual psychology consists of four phases consistent with the stand-alone goals of individual psychology (relationship development; assessment and exploration of lifestyle, goals of behavior, faulty thinking, and maladaptive behaviors; facilitation of individual insight; and orientation and reeducation). Although most often art media is used in the assessment phase of Adlerian counseling, it should be noted that Adlerian-based counselors can and do use art media to facilitate all phases of the counseling process. The benefits of introducing art into the counseling practice include self-discovery, empowerment, understanding motivations and behaviors of self and others, social connectedness and purpose, relaxation, self-efficacy, and catharsis (Kramer, 1979; Kramer & Schehr, 1983; Rubin, 1984), all of which fit well within the individual psychology framework (Kottman, 2003). Play Therapy Client-centered play therapy (Axline, 1947; Landreth, 2002; Pehrsson & Aguilera, 2008) can easily be adapted to Adlerian premises; indeed, encouragement and self-efficiency are major components of this theory and form of therapy (Kottman, 1999, 2001, 2003). Play therapy is geared primarily toward working with children aged 2 through 12, although some counselors have successfully modified the process to serve other populations as well (Pehrsson & Aguilera, 2008). The tools of play therapy include mostly toys, art media, and role-play materials. Adlerian toys (tools), in general, that are used in the counseling playroom include those that represent nurturing and family because they promote exploration of family atmosphere and constellation. Scary tools promote exploration of mistaken beliefs and worldview. Cultural tools promote self-worth and a sense of social belonging (Kottman, 2001, 2003). Through play, counselors can assist clients in recognizing family roles, worldview and lifestyle, motivations, and mistaken goals (Dreikurs, 1986; Watts & Garza, 2008). Adlerian play therapy moves through these phases: relationship development; exploration of lifestyle, goals of behavior, faulty thinking, and maladaptive behaviors; facilitation of individual insight; and orientation and reeducation. Play used within the Adlerian framework assists individuals in the cathartic process of self-discovery and emotional release that leads to the discovery of mistaken goals (Kottman, 1999, 2001, 2003).

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Bibliotherapy Bibliotherapy is the use of literature to assist clients in dealing with severe mental health matters as well as life transitional issues. The most recognized and used model of bibliotherapy includes a three-stage approach that focuses on identification, catharsis, and insight (Shrodes, 1950). This approach is consistent with the focus of individual psychology. Through this three-stage bibliotherapy approach, the individuals identify with characters in a selected piece of literature, work through issues and experiences that then move them toward a cathartic release. The cathartic release is the avenue toward gaining insight, personal growth, and development (Hynes & Hynes-Berry, 1994; Pehrsson & McMillen, 2005; Shrodes). Bibliotherapy offers counselors a wide range of creative and experiential strategies (Pardeck, 1991, 1998; Pardeck & Pardeck, 1984, 1993; Pehrsson, 2006; Pehrsson & McMillen, 2007). Adlerian counselors can employ bibliotherapeutic interventions to facilitate clients in gaining familiarity with their personal concerns and to identify with their own personal uniqueness and their feelings. It may also be used as a therapeutic mechanism to help establish the counseling relationship, to explore lifestyle and career issues, to promote insight and awareness, and to reorient and reeducate ( Jackson, 2001). Bibliotherapy can assist clients in understanding their worldview and cultural sense of self and related connections (Pardeck & Pardeck, 1998; Pehrsson & McMillen, 2006). CONCLUSION Adler’s individual psychology accentuates the positive nature of humankind and focuses on assisting individuals to drive their own destiny through choice and change. Together, the Adlerian counselor and client build relationship, gather information on lifestyle, family, and social connectedness; gain insight; and develop goals and behaviors based on newly fashioned meaning and purpose. Further, the creative nature of individual psychology lends itself to application within a wide variety of contexts and for individuals across many cultures. Counselors practice individual psychology within school, agency, private, individual, family, group, college, mental health, and parent education settings. Individual psychology offers a rich framework for the integration of multiple expressive art techniques. Its focus on relationship, insight, growth, and social connection makes it an ideal theory for the integration of creativity by the counselor.

Expressive Arts Interventions

A STRUCTURED DISCOVERY BIBLIOTHERAPY TECHNIQUE Mary Amanda Graham and Dale-Elizabeth Pehrsson

Indications: Bibliotherapy is appropriate with clients facing family, mental health, career,

lifestyle, parenting, cultural, substance abuse, and trauma-related issues. Goal: Client identification, catharsis, insight, reorientation, and reeducation Modality: Bibliotherapy The Fit: The purpose of this activity is to expand and intensify the individuals’ understanding of their issues through the use of literature. Used within an individual or in group context, this intervention aids in developing counselor and client working alliance, trust, group cohesion, self-exploration, insight, and growth. This activity lends itself to an Adlerian approach because it promotes insight, growth, social connection, self-discovery, and change. The psychology of the six Es is used within the Adlerian bibliotherapy context (Riordan, Mullis, & Nuchow, 1996): educate by filling the basic needs and skills gap; encourage through the reading of inspirational and motivational reading material; empower through goal formation and attainment; enlighten by reading materials that increase awareness about self and others; engage the individual with the social world through social mentoring and other fictional material; and enhance by reinforcing specific points and lifestyle changes being addressed in counseling. Populations: Children/adolescents/adults; Groups/individuals Materials and Preparation: Various types of literature should be made available. Literature should be chosen based on the developmental level of the individual and presenting concern(s). The counselor needs to be mindful of complex cultural and diversity aspects when using literature with clients. Within the Adlerian framework, literature selection is often collaborative but can be selected by the client or the counselor. An Adlerian counselor always prereads and screens the literature for appropriateness prior to making it available to the client (Pehrsson & Pehrsson, 2006). Instructions: 1. Select written material consistent with the client’s developmental level and presenting concern. 2. Depending on client’s developmental level, comfortability, and book choice, you may choose to read the book to the client in session or ask the client to read the material at home prior to the session. 3. When the client is prepared for a discussion of the material, you will invite a discussion of the material in session. You may want to use some of the following questions to facilitate the discussion: What happened in the story or what are the general themes of the literature reading? Do you relate to any characters or themes in the story? How? How are these themes or characters related to your current situation? What feelings, thoughts, or memories has this story brought out? How can you take what you have identified with and make changes?

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4. Your facilitation of the bibliotherapy experience should have the flexibility to facilitate the

dialogue as it relates to characters and themes with whom the client identifies and to his or her relevant presenting problems. Each client will identify with a different theme or character, and catharsis and insight are unique to each individual. 5. The bibliotherapy experience can be facilitated in a single session or over the course of treatment using a single piece of literature or various literature choices.

LIFE MAP ACCORDION BOOK Katrina Cook

Indications: Appropriate presenting concerns include discouragement, low self-esteem,

depression, major life transitions, lack of decision-making skills, lack of coping skills, or stress. Goal: Exploration of life experiences to improve self-esteem, mood, decision making, coping, or transitional reinforcement Modality: Art The Fit: Life maps fit well within Adlerian therapy because they help clients examine early recollections, impact of experiences within their family constellation (such as birth order), lifestyle, life goals, fostering social interest, developing an action plan, and future orientation. All of these areas are a focus of Adlerian therapy (Adler, 1959). This activity allows clients to turn their life map into a book. Populations: Adolescents/adults; Groups/individuals Materials: Colored paper, cardboard, glue, old maps, scissors, markers, crayons, colored pencils, old magazines, and dowels. The client is asked to provide personal items such as photos, drawings, tickets for special events, and so forth. Instructions: 1. Help the client construct the accordion stylebook (Weintraub & Miller, 2010). The size of the book will be determined by the size of the strips of paper. Fold a strip of paper in half. Then fold the edge of one half back to the centerfold. Crease that fold and then fold it backward and crease it in the other direction. Fold this new fold up to meet the centerfold, and then fold the end to the centerfold. Repeat this folding sequence with the other half of the book. This will create an eight-page accordion fold book. Cut two pieces of cardboard the same size as the book and glue them to the ends of the pages. 2. Cut out and glue a section of a map as a backdrop. 3. Develop collages or draw significant events representing the clients’ lives or future goals. Invite the clients to process the events and mementos they placed in their books (see Figure 2.1).

Figure 2.1 View of the open book, “Where is the Earth?” 16

SEEING THE CLIENT’S WORLD THROUGH IMAGES AND COLLAGE Teah L. Moore

Indications: As with any counseling session, the practitioner should have an understanding

about the clients’ readiness to explore certain areas of their lives, relationship, or selves. Collage work may uncover unconscious beliefs or past events. Caution should be taken in regard to the selection of the area of exploration. Safety scissors should be used with clientele such as small children, clients who may have difficulty working with sharp items, or clients to whom sharp items are a concern. Goal: To provide clients with a visual and tangible image of their self-exploration and their work toward enhancement of self-awareness and communication skills Modality: Art The Fit: Collage work provides clients the opportunity to express their feelings, describe family dynamics, interactions, and themselves, which fits with a range of theories including existentialism, Adlerian, and Jungian. An existentialist orientation may lead to an exploration of self-awareness and themes of death, meaninglessness, freedom, and isolation. Adlerian counselors may use collage work as another tool by which to develop the lifestyle assessment for clients who have difficulty sharing about themselves. Collages can be a medium through which clients illustrate various relationships with others, daily life, ways of being, inferiority issues, and so forth. Jungian practitioners can assist clients in examining archetypes by building a collage of various animals, characters, or people (Frost, 2001). Populations: Children/adolescents/adults; Groups/individuals Materials: Magazines from different genres and of different audiences, such as National Geographic Magazine, Ladies’ Home Journal, men’s magazines, catalogs; scissors; glue sticks; white card stock paper (choose size appropriate for time limitations); laminating machine (if possible, not required); markers or pens Instructions: 1. Consider areas that clients will be exploring such as what aspect of themselves (clients’ emotions or feelings, themes, events, relationships, etc.) they will explore through the collage work and present these areas to them as a focus. 2. Introduce the activity to clients by discussing their knowledge about collages. Explain ways in which collage work may be used in counseling and its benefits to clients such as its use as a visual diary of counseling sessions, their lives, behaviors, family interactions, feelings and emotions, and, also, progress in sessions. If possible, have some examples for the clients to view. Inform clients that they will work independently to create a collage and that they will be invited to discuss the process and their work after its completion. Normally, collage work stays in the office and, later, can be used as a gauge for progress. 3. For the first time, provide client with a 5 3 9 size cardstock. This will help in time management. Establish a set time for the completion; if not, some clients will use more of the time in creating the collage and leave little time for discussion. 4. Allow clients to work without interruption and encourage them to work silently as they reflect and focus on their image choices.

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5. Attend to the items at which the clients pause, comments the clients make while working,

and in the way in which they approach the task and sort the pictures. 6. After the collage is complete, invite each client to share what he or she sees in the collage

and the meaning the selected images hold. 7. Connect the collage with previous sessions, such as themes, lifestyle, family descriptions,

and previous confrontations. 8. Point out use of colors, images, words, and so forth, in a tentative and nonjudgmental

way, such as, When I look at your picture I think about; this comes to mind; those colors seem to represent; you mention you would hide in the stable and I see you have horses in the picture; and so forth. 9. Prior to laminating or storing, label the back of the card with what was explored, such as an emotion, event, relationship, and so forth, and the client’s name or code. 10. Remind the client that the artwork will remain in the office and that it will periodically be explored in future sessions. Ask if the client would be willing to continue with additional collage work in future sessions. Reiterate that the work helps provide a visual diary of progress and visually gives him or her ways to discuss what is inside him or her. Variation: Some clients may need examples of collage to better understand the process. Prepared cards can be used prior to this activity. The practitioner can develop his or her own collage cards. Friends and families are a great source for developing various viewpoints, pictures, themes, and inner thoughts. The already prepared cards can be used to do some prework. Clients select which cards “speak” to them. From these selected cards, the session can focus around the pictures, words, themes, and so forth.

SEMISTRUCTURED EARLY RECOLLECTION DRAWING TECHNIQUE Sean Lynch and Jessica A. Headley

Indications: This intervention is appropriate for diverse clients who are seeking counseling

services for encouragement in life circumstances, such as adjustment to life transitions, relational issues, mental health and substance use issues, and discrimination and oppression. Goal: Connection and interpretation through self-exploration and self-discovery Modality: Visual art The Fit: The purpose of this technique is to help clients uncover their lifestyle and gain increased awareness of the ways in which personally held beliefs, motives, and behavioral patterns relate to the presenting issue. The early recollections technique is frequently used by Adlerian therapists at the beginning of therapy as a means to uncover how clients perceive themselves, others, and life events (Pomeroy & Clark, 2015). Through engagement in a creative art process with the counselor, the clients are able to visually represent early recollections; explore the meaning of their work; and identify ways in which early recollections influence their thoughts, feelings, behaviors, and experiences related to presenting issues. Populations: Older children/adolescents/adults; Individuals Materials: Paper or canvas, writing utensils (e.g., oils, colored pencils, paints, crayons, markers), and a flat writing surface (e.g., table, lapboard) are necessary. Additional materials (e.g., glitter, popsicle sticks, paper cutouts of shapes) can also be utilized to promote creative expression. Instructions: 1. Invite the client to participate in the early recollection drawing technique, and provide an overview of the purpose and process of the technique as well as its potential benefits. 2. Provide the client with the materials needed for the activity and deliver the following prompt: “Think back to your childhood, to one of your earliest memories. Focus on the important details of your memory such as the people and surroundings. When you are ready, please take your time and represent your memory using the art materials.” 3. Track the client’s process and provide support as needed, using reflective statements (e.g., I see you’re switching to the orange now, giving the drawing some added color. You are engaged in your work.). 4. Process and analyze the visual representation once the work is finished. During this phase, invite the client to provide an overview of the specific memory (e.g., Tell me about your experience.); discuss the experience of creating the visual representation (e.g., What thoughts, feelings, or experiences emerged for you during this exercise?); and explore how the visual representation relates to the presenting problem (e.g., How does this past experience relate to your present issue?). 5. Demonstrate appreciation and acceptance to the client following completion of the activity.

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SHOW ME YOUR FAMILY IN THE DOLLHOUSE ACTIVITY Mary Amanda Graham and Dale-Elizabeth Pehrsson

Indications: This intervention can be used with clients facing any challenges of life and transition

as it provides a window into the origin of the client’s worldview, lifestyle, and family atmosphere. Goal: Client identification, self-awareness, understanding family constellation, and assessing family atmosphere Modality: Play therapy The Fit: The concepts and principles of child-centered play therapy are easily married to Adler’s theory. In Adlerian play therapy, the counselor’s main role is to observe the client within the playroom and through the play process, to understand the child’s lifestyle, worldview, and the life situation he or she presents. It is through observation and synthesis of this information that the therapist gains understanding of the child. Strong emphasis is placed on understanding the child and his or her role within the family context. Adlerian play therapy builds on the premise that children are inherently social and have a need to belong. Children are creative beings who seek experiences that enhance their own lifestyles and they demonstrate behavior that is purposeful. Maladjustment results when children fail to connect with others. The counselor relies heavily on the use of encouragement and, thus, shows unconditional acceptance, demonstrates faith in the child’s abilities, recognizes the child’s effort, and focuses on strengths. Additionally, the counselor demonstrates interest and accepts and even models the courage to be imperfect while providing opportunities for social belonging. Populations: Adolescents/adults; Groups/individuals Materials: Dolls of all shapes, ages, sizes, colors; dollhouse (or a large box with cardboard glued to designate different rooms can be used); dollhouse furniture appropriate to the kitchen, dining area, bathroom, garage, bedroom, and living room; food, baby bottles, telephones, clocks, bathtub, toilet, stoves, televisions, and computers. Cultural artifacts that pertain to the counselor’s client population are critical (Gil & Drewes, 2005). Instructions: 1. Invite and guide the client to create his or her family in the dollhouse (i.e., state Show me your family in the dollhouse.). 2. If the client is hesitant, ask the client to create a scene of a typical day in his or her home or a make-believe day. Tell him or her that he or she can use many things in this room and place them inside or around the dollhouse. 3. Once the family scene is created, invite the client to tell you about the scene (i.e., Tell me about this scene or Tell me what is going on in the house right now). 4. Follow the client’s cues and probe as needed. If the client is more reserved, move from general information gathering to more specific probes; invite the client to discuss each figure and what each of them is doing, saying, thinking, and feeling. Suggested processing statements or questions might include, Tell me more about this family, what are they doing now? If this family were to sing a song together, what would that song be? (This can also be changed to watch television show, read a book, play a game, go to a movie, or do something together.) In this family, show me what happens when people are happy, sad, mad, and quiet. Show me what

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happens when there is a birthday and celebration. Show me what happens when someone is in trouble. Show me this family working on a project. 5. When the processing has reached an end, thank the client for participating using statements that encourage the client and acknowledge the client’s efforts. Summary: Adapting play therapy to Adlerian principles provides the counselor a rich opportunity to understand the client and the client’s state of self-awareness, the family constellation, and family atmosphere. Through strategically chosen toys (tools), the use of a structured activity within the dollhouse, the counselor can build the relationship and, at the same time, explore with the client by assisting him or her in gaining insight and ultimately moving toward reorientation and reeducation.

STRUCTURED MULTIPLEDOMAIN FAMILY DRAWING TECHNIQUE Mary Amanda Graham and Dale-Elizabeth Pehrsson

Indications: This intervention is appropriate for clients facing transitional, family, mental

health, career, lifestyle, parenting, identity, cultural, violence, poverty, substance abuse, and trauma-related issues. Not all individuals are comfortable communicating their concerns verbally or without some form of structure (Crenshaw, 2004, 2006; Malchiodi, 2003, 2008). This procedure allows for a relatively nonintimating process for clients to express their ideas regarding their family dynamics using the medium of visual art. This technique provides a guided process and minimal structure for the client and the counselor to follow and allows for expression of thought and feeling through verbal and nonverbal methods (Kramer, 1979). The technique also provides for some choice making, nondirective, and creativity within the drawing process. These matter to clients as they move through the exploration process (Malchiodi, 2005; Oaklander, 1988). 1. This procedure serves to create discovery, self and family awareness, and insight. 2. The counselor encourages the client to draw a picture representing a family activity. The counselor’s stance and prompts apply encouragement. The message to the client is “You are the expert of what your family does.” 3. The client is empowered to create and explain the picture. 4. The client becomes enlightened regarding family dynamics and his or her place within the family structure. 5. The client becomes engaged within the therapeutic relationship. 6. The counselor enhances the client’s self-awareness and family roles by reinforcing specific points and family dynamics discussed as the picture is processed. Goal: Client self-identification and insight Modality: Art The Fit: The purpose of this activity is to expand the individual’s understanding of his or her current life issues and roles he or she plays within the family through the use of drawing. This drawing activity is used for the purposes of exploring the client’s home environment and the client’s family dynamics and it promotes the use of verbal and nonverbal skills in the reflective and counseling processes. The procedure also provides distancing and something of a safety net to talk about complex and painful concerns. This technique is a modification of the original diagnostic and projective assessment procedure created by Burns and Kauffman’s Kinetic Family Draw Technique (Burns & Kaufman, 1972). The counselor prompts the client to draw and through additional writing, drawing, and talking, the counselor encourages the client to explore and discuss the picture; thus, investigating several domains (cognitive, verbal, affective, and behavioral) as these relate to the client’s family structure and dynamics that are contained within the drawing. Populations: Children/adolescents/adults; Groups/individuals Materials: Paper and pencil, as a minimum; other art materials, if desired. Additionally, this can be applied to modified sand tray work, sculpture, or other forms of media other than paper and pencil.

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Cautions: Counselors must know their art media and understand the provocative nature of art

and what art and art materials can elicit from clients (Kramer, 1979; Kramer & Schehr, 1983; Malchiodi, 2005, 2008; Oaklander, 1988; Rubin, 1984). Some clients have a fear of drawing, poorly developed motor skills or injuries, an expressive writing disorder, or other related ability limitations that may make art an inappropriate therapeutic choice (Malchiodi, 2003, 2006). Instructions: 1. Provide an appropriate work area with minimal distractions. 2. Explain to the client that the activity will assist in getting to know one another better. The counselor can state, People can communicate about their worldviews, daily lives, and families through drawing and talking. It is important to let the client know that it is not a test and that there is no grade or right or wrong way of doing the exercise, especially when working with school-aged youth. 3. Instruct the client to draw (i.e., Draw a picture of you and your family doing something; it can be real or imaginary). 4. After the client has completed the picture, invite the client to discuss the picture. Move from the general (what the family is doing) to the specific details of the drawing (placement of persons and objects and related specifics). 5. Ask the client, What would each person in the picture be saying if he or she were talking? Inviting the client to draw speech bubbles is also helpful. Suggest that the client draw a bubble out of each person’s mouth or hands if that person uses sign language. 6. Ask the client, What would each person in the picture be thinking about but not really saying? Invite the client to draw a thought bubble. 7. Prompt discussion by asking the following question, What would each person in the picture be feeling inside? Drawing a heart-shaped bubble in which the client can write feelings is often useful. 8. Ask this final question, What would each person in the picture be doing next or planning to do? Invite the client to draw an action arrow. 9. When the client indicates he or she is finished, pause and ask, Is there anything else you want to erase or add to the picture that you may have forgotten or now seems important? This allows for closure, provides additional invitation to add that which might be hidden, important, and/or valuable information and allows for undoing of embarrassing or emotionally difficult information.

TISSUE PAPER COLLAGE Nan J. Giblin

Indications: This activity works well for clients who may have difficulty expressing their

feelings and for children and adults who may be unsure about their ability to make art because there are no “right or wrong” methods of completing the activity. It is appropriate for clients who have suffered abuse, lack verbal skills, or have secrets that they do not want to verbalize or for those who suffer from impatience and anger. Goal: Expression of feelings and increased self-awareness Modality: Art The Fit: Adlerians have long used art as a means of helping clients. Sadie Dreikurs (1986), wife of Rudolph Dreikurs, was the first to introduce Adlerians to the power of art as a therapeutic tool. Creative artwork is viewed as an extension of the client. Art allows for emotional catharsis and the free expression of feelings, and also provides a verbal and nonverbal means for the client to connect with the therapist. Adlerians believe in the right of individuals to express themselves through various methods. Populations: Children/adolescents/adults; Groups/individuals Materials: 11 3 14 canvas, plywood, or heavy art board (size may vary); various colors of tissue paper; glue (1 cup white school glue and 1 cup water); 1-in. inexpensive paint brush; gesso (optional); paper towels; newspapers or coverings for protecting desks and tables Instructions: 1. Begin the session with a discussion about ways that people can express their feelings through art. Assure clients that tissue paper collage is a method of artistic expression at which everyone can succeed. 2. Prepare canvas by applying a layer of gesso to the canvas or art board and allow it to dry (preparation of canvas may be omitted if time is short). 3. Invite clients to choose the pieces of tissue paper that they wish to use. Each person should choose at least six different colors and cut or tear the tissue paper into smaller pieces. Reassure clients that they may or may not create a plan for their collage. 4. Apply a layer of the glue mixture to the canvas. 5. Using a brush, let clients cover each piece of tissue paper with the glue mixture with pieces of torn or cut tissue paper and affix them to the canvas using lighter colors first. 6. Allow clients to repeat the process as many times as desired as they add layers of tissue paper (at least six) to the canvas. 7. Allow art to dry and then invite the clients to share their artwork and to describe their collage. Invite processing with questions such as, Tell me about your collage(s). Did you have a plan for making it? How did you actually do it? How did you choose the colors? How do you feel about how it turned out? What does the collage mean to you? What does the collage say to you? If more than one collage was created, ask, How are the collages related? Keep the focus on the client’s interpretation or reaction to the activity and allow group members (if present) to offer only nonjudgmental feedback. Possible Variations: Include substitution of materials or upgrades or combination with other media such as ink or magic markers. 24

TRANSFORMING LIFESTYLE WITH DANCING MINDFULNESS & THE EXPRESSIVE ARTS Jamie Marich

Indications: This activity is best suited for clients who possess a modicum of experience with

distress tolerance and the ability to work with potentially difficult emotions. It is designed to help clients identify and process a variety of cognitive distortions that may be at the root of depression, anxiety, specific phobias, posttraumatic stress, substance abuse and other addictive disorders, and eating disorders. This activity is not recommended as a first-line intervention; rather, it is important that a client be sufficiently prepared to work with processing emotions through exercises like grounding, breath work, and other practical coping skills before attempting this exercise. In a group where clients may present with various levels of engagement, remind people that they can opt out of this exercise at any time. In opting out, they may consider coming back to one of their existing coping or distress tolerance skills, or simply witness others in the group move through their process. If the dance/movement component of the exercise, which is the primary modality, proves to be the biggest challenge, clients may decide to take part in the other expressive arts invitations by reflecting on the experience of opting out (see step #11). Goals of the Activity: (a) To assist clients in identifying the negative cognitions or core beliefs that inform elements of their lifestyle that they may most desire to change; (b) To invite clients into moving in a mindful, expressive way in order to share the story of how these negative core beliefs developed and allowing the movement to help them process the emotions and bodily experiences inherent in these stories; (c) To suggest how trusting the process of the movement may help clients to bring a new story, and thus a new lifestyle pattern, into existence after engaging in the holistic processing; (d) To offer outlets for fusing other expressive art forms (e.g., writing, visual art making, music) into a client’s continued work with the concepts of lifestyle after the formal intervention concludes. Modality: Primarily dance and mindful movement, drawing on some elements of drama; suggestions for incorporating more of a multimodal experience for clients as they continue with the work invited in this exercise The Fit: Although now a common expression used in the English language, the word “lifestyle” traces back to the writings of Alfred Adler in the late 1920s. Alfred Adler’s concept of the lifestyle refers to “an individual’s characteristic way of overcoming or compensating for feelings of inadequacy” (VandenBos, 2007; p. 536). In Adlerian psychology, lifestyle is synonymous with the psyche and personality, as these lifestyle patterns tend to develop before the age of 9. Adler, who contended that lifestyle originated in childhood, described lifestyle as the pair of eyeglasses through which every individual saw her world (Mozak, 2000). Carrying this metaphor a step further, to bring about change in those aspects of lifestyle that cause problems for an individual requires a new pair of glasses—or at least an adjustment on the existing prescription. A major mechanism of change in Adlerian psychology is recognizing that one’s inferiority can inspire one to “movement and action;” to bring about this change, persons must have a clear goal or vision for how they would like to manifest change in their style of living (Adler, 1929, pp. 98–100). In this exercise, clients are literally encouraged to use movement to help them identify the patterns and move with them into a vision of change and growth for the future. This movement is clinically directed by inviting a process of dancing mindfulness. The working definition of “mindfulness” in this exercise is noticing any activity (in this case, 25

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expressive movement) without judgment, inviting one’s attention back to the activity at hand even if awareness should drift (Marich, 2015; Marich & Howell, 2015). Population: Although written for adults, the exercise can also be used with adolescents and children as long as the practitioner guiding the exercise has extensive experience working with these populations and is able to developmentally modify the language of the exercise. Individuals/Group: The exercise is written for a group platform although it can be modified for individual work. Individual work may be preferred with certain cases where more intensive support may be needed due to low distress tolerance. Materials: Sufficient space for movement proportional to the size of the group; can be done in an office with little space if being done individually. For the supplementary expressive arts fusion, you may want to have paper and pens on hand (clients can also use their own journals), in addition to some other art-making materials (e.g., markers, crayons, collage pieces, glue). Instructions: 1. Begin an informal discussion with the group about the word lifestyle. Ask your group members how they would define lifestyle based on their lived experiences. You do not need to take long for this process; ensure that everyone is heard. 2. Give the group a brief history of how the word lifestyle that we commonly use today traces back to a psychologist (naming Adler if you wish) who believed that our lifestyle or style of living was the series of behaviors and patterns that we develop in response to early childhood inferiority, or not feeling good about ourselves. You can also use the metaphor of the glasses needing a prescription adjustment if this would work for the group. 3. Have the group take a moment to ground in silence and take some breaths. 4. Ask them what, if any, negative self-beliefs are areas of struggle. Ask how these are connected to inferiority. Allow approximately a minute for silent reflection. 5. If appropriate for your group, elicit a brief verbal discussion about what they came up with during silent reflection. 6. Encourage your group to come to their feet and take an impromptu stretch. Invite them to move in whatever way may feel good to their body after sitting. This organic stretch process, and the rest of the exercise, can be done seated for members of your group who are unable or unwilling to stand. 7. Invite the group to begin dancing a story of how their negative core self-beliefs developed and how they show up in their lives today. The amount of time you give the group for this part of the exercise is at your discretion, although 3–5 minutes is recommended. This can be done silently or with music. Choose whatever music you feel appropriate; instrumental music is generally recommended as are pieces that incorporate some type of tempo or rhythm that elicits movement. Avoid gentle, floating, relaxation music for this part of the exercise. Pieces that incorporate piano, violin/strings, or drums are generally good fits. 8. For the next segment of the exercise, select another piece of music and encourage the group to envision a goal for the future—how would they like to see their old patterns change? Note that some group members may need to visualize their goals before they can express them through movement. Others may be more comfortable proceeding directly into the movement and others may choose to just stay with the visualization while others are moving. 9. You may choose to repeat Step #8 for one or two more songs and integrate encouraging statements as you see fit. Remind your clients to avoid self-judgment or judgment of the process. Remind clients to allow the movements to flow organically to allow their stories of transformation to unfold. You may also let them know that even if the new story doesn’t feel totally “real,” the purpose of the intervention is to visualize the goal and dance it into existence. That may happen today or it may take several rounds of this dance over a period of time to bring about that change.

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10. After the final song, encourage the group to come to a place of stillness, either sitting or

standing. Invite several focusing breaths and then ask the group to be present and aware of what they are noticing. You can ask the questions, “What are you learning today about your strength? superiority (which Adler saw as the opposite of inferiority)? potential for growth?” 11. OPTIONAL: If time and supplies permit, you can invite your group members into a period of 5–10 minutes of individual reflection with another expressive art form before coming back to the group. Writing (journaling/free writing, poetry, other prose) or other art making (drawing, making a collage, gush or free-form art) are nice options for a contained group setting. As an option, group members can also sit in silent meditation or continue with some gentle stretching and movement. 12. Bring the group back together for a closing-process piece. The length of this discussion about the experience can vary due to the time you have, although at least 10 minutes for closure is recommended. It’s also important during this closure process, particularly if someone had a distressing experience with the exercise, to come up with a plan of action for continued self-care and honoring of their experience. You may ask the group to consider how they can safely engage in this movement practice on their own, or how they might bring in other expressive arts (e.g., writing, art making, listening to or making music, photography, sculpting, knitting) to assist the process. REFERENCES Adler, A. (1927). Understanding human nature. Garden City, NY: Garden City. Adler, A. (1929). The science of living. New York, NY: Garden. Adler, A. (1959). Understanding human nature. New York, NY: Premier Books. Axline, V. M. (1947). Play therapy. London, UK: Churchill Livingstone. Burns, R. C., & Kaufman, S. H. (1972). Action, styles, and symbols in kinetic family drawings (K-F-D). New York, NY: Brunner-Routledge. Carlson, J., Watts, R. E., & Maniacci, M. (2006). Adlerian therapy: Theory and practice. Washington, DC: American Psychological Association. Corey, G. (2013). Theory and practice of counseling and psychotherapy (9th ed.). Independence, KY: Cengage. Crenshaw, D. A. (2004). Engaging resistant children in therapy: Projective drawing and storytelling techniques. Rhinebeck, NY: Revelstoke Community Forest Corporation. Crenshaw, D. A. (2006). Evocative strategies in child and adolescent psychotherapy. Lanham, MD: Rowman & Littlefield. Dreikurs, S. E. (1986). Cows can be purple: My life and art therapy. Chicago, IL: Alfred Adler Institute. Frost, S. (2001). SoulCollage. Santa Cruz, CA: Hanford Meade. Gil, E., & Drewes, A. (2005). Cultural issues in play therapy. New York, NY: Guilford Press. Gladding, S. T. (2005). Counseling as an art: The creative arts in counseling (3rd ed.). Alexandria, VA: American Counseling Association. Hynes, A. M., & Hynes-Berry, M. (1994). Biblio-poetry therapy, the interactive process: A handbook. St. Cloud, MN: North Star Press of St. Cloud. Jackson, S. A. (2001). Using bibliotherapy with clients. The Journal of Individual Psychotherapy, 57, 289–297. Kottman, T. (1999). Integrating the crucial C’s into Adlerian play therapy. Journal of Individual Psychology, 55(3), 288–297. Kottman, T. (2001) Play therapy: Basics and beyond. Alexandria, VA: American Counseling Association. Kottman, T. (2003). Partners in play: An Adlerian approach in play therapy (2nd ed.). Alexandria, VA: American Counseling Association. Kramer, E. (1979). Childhood and art therapy. New York, NY: Schocken Books. Kramer, E., & Schehr, J. (1983). An art therapy evaluation session for children. American Journal of Art Therapy, 23, 3–12. Landreth, G. L. (2002). Play therapy: The art of the relationship (2nd ed.). New York, NY: Brunner Routledge. Malchiodi, C. A. (Ed.). (2003). Handbook of art therapy. New York, NY: Guilford Press. Malchiodi, C. A. (Ed.). (2005). Expressive therapies. New York, NY: Guilford Press. Malchiodi, C. A. (2006). Art therapy sourcebook (2nd ed.). New York, NY: McGraw-Hill.

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Malchiodi, C. A. (Ed.). (2008). Creative interventions with traumatized children. London, UK: Jessica Kingsley. Marich, J. (2015). Dancing mindfulness: A creative path to healing and transformation. Woodstock, VT: Skylight Paths. Marich, J., & Howell, T. (2015). Dancing mindfulness: A phenomenological investigation of the emerging practice. Explore: The Journal of Science and Healing, 11(5), 346–356. Mozak, H. M. (2000). Adlerian psychotherapy. In R. J. Corsini & D. Wedding (Eds.), Current psychotherapies (pp. 54–98). Belmont, CA: Thomson Wadsworth. Oaklander, V. (1988). Windows of our children. Highland, NY: Gestalt Journal Press. Orgler, H. (1963). Alfred Adler: The man and his work: Triumph over the inferiority complex. London: Sidgwick & Jackson. Pardeck, J. T. (1991). Using reading materials with childhood problems. Psychology: A Journal of Human Behavior, 28, 58–65. Pardeck, J. T. (1998). Using books in clinical social work practice: A guide to bibliotherapy. New York, NY: Haworth Press. Pardeck, J. T., & Pardeck, J. A. (1984). Bibliotherapy: An approach to helping young people with problems. Journal of Group Psychotherapy, Psychodrama, & Sociometry, 37(1), 41–43. Pardeck, J. T., & Pardeck, J. A. (1993). Bibliotherapy: A clinical approach for helping children. (Vol. 16). Langhorne, PA: Gordon and Breach Science Publishers. Pardeck, J. T., & Pardeck, J. A. (1998). An exploration of the uses of children’s books as an approach for enhancing cultural diversity. Early Child Development and Care, 147, 25–31. Pehrsson, D.-E. (2006). Fictive bibliotherapy and therapeutic storytelling with children who hurt. Journal of Creativity in Mental Health, 1, 273–286. Pehrsson, D.-E., & Aguilera, M. E. (2008). Play therapy: Overview and implications for counselors (APAPCD-12). Alexandria, VA: American Counseling Association. Pehrsson, D.-E., & McMillen, P. (2005). Bibliotherapy evaluation tool: Grounding counseling students in the therapeutic use of literature. Arts in Psychotherapy, 32, 47–59. Pehrsson, D.-E., & McMillen, P. (2006). Competent bibliotherapy: Preparing counselors to use literature with culturally diverse clients. Vistas 2006. Alexandria, VA: American Counseling Association. Pehrsson, D. E., & McMillen, P. (2007). Bibliotherapy: Overview and implications for counselors (ACAPCD-02). Alexandria, VA: American Counseling Association. Pehrsson, D.-E., & Pehrsson, R. S. (2006). Bibliotherapy practices with children: Cautions for school counselors. Journal of Poetry Therapy, 19, 185–193. Pomeroy, H., & Clark, A. J. (2015). Self-efficacy and early recollections in the context of Adlerian and wellness theory. Journal of Individual Psychology, 71(1), 24–33. Riordan, R. J., Mullis, F., & Nuchow, L. (1996). Organizing for bibliotherapy: The science in the art. Individual Psychology, 52(2), 169–180. Rubin, J. (1984). Child art therapy. New York, NY: Van Nostrand Reinhold. Shrodes, C. (1950). Bibliotherapy: A theoretical and clinical-experimental study (Unpublished doctoral dissertation). University of California–Berkeley, Berkeley, CA. VandenBos, G. R. (Ed.) (2007). APA dictionary of psychology. Washington, DC: The American Psychological Association. Watts, R. E., & Garza, Y. (2008). Using children’s drawings to facilitate the acting as if procedure. Journal of Individual Psychology, 64, 113–118. Weintraub, D., & Miller, K. (2010). Accordion fold book. Retrieved from http://198-172-203-93.ga.verio .net/pix/accordionbook.pdf

3 Solution-Focused Therapy Mark Gillen

The use of solution-focused therapy (SFT) has increased in all areas of counseling, popularized both by its flexibility and focus on client’s strengths. Williams (2000) reported that SFT energized staff and increased staff confidence and optimism when working with clients. Proponents of SFT claimed that it yields rapid change, enduring change, a higher frequency of single session cures, and a high degree of client satisfaction (Stalker, Levene, & Coady, 1999). FOUNDATIONS OF SOLUTIONFOCUSED THERAPY Steve De Shazer, Insoo Kim Berg, Eve Lipchik, Alex Molnar, Jane Peller, and others developed SFT at the Brief Family Therapy Center in the 1980s. This ideographic, strategic therapy model emphasized brevity, clearly defined goals, and the use of interventions with clients (Stalker et al., 1999). De Shazer (1982) described how Milton Erickson, and others, influenced SFT. According to De Shazer (1982), Erickson took the learning that people already had and assisted them in applying this information to new situations. This method of interaction with clients was based upon Erickson’s three principles: (a) meet the clients where they are, (b) modify the outlook of the client to gain control, and (c) allow for change that meets the needs of the client (De Shazer, 1982). Aspects of Erickson’s principles have been intertwined in SFT. For instance, solution-focused therapists utilized the miracle question in order to determine how life would be different for the client if the problem were miraculously solved (Stalker et al., 1999). Erickson also contributed his description of the counselor’s role in client resistance; referred to as Erickson’s First Law, it states, “as long as clients are going to resist, you ought to encourage them to resist” (De Shazer, 1982, p. 11). The concepts of isomorphism, cooperation, and paradoxical intent were also described as basic to solution-focused work (De Shazer, 1982). De Shazer (1982) reported that he and others at the Brief Family Therapy Center were influenced by Bateson’s concept of isomorphic change as a central component of family therapy. Bateson’s description of prior learning, which stated that an idea that had been used successfully would be used again, and Festinger’s idea of social-group support, where a social group strengthened ideas that were demonstrably false, also influenced the solution-focused theorists (Molnar & Lindquist, 1989).

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CORE CONCEPTS OF SOLUTIONFOCUSED THERAPY Solution-focused therapy is based on the assumption that solutions are to be found through the process of changing interactions and the creation of new meanings for clients’ problems as well as the client solving the problems and overcoming habit patterns (Gillen, 2005; Stalker et al., 1999). Littrell, Malia, and Vanderwood (1995) described the assumptions of solution-focused therapy as (a) setting a concrete goal to elicit ideas for change, (b) the existence of exceptions to any problem, (c) clients already have the resources to change, and (d) the use of a clinical team can be used to develop compliments and clues. These assumptions supported the underlying precepts that (a) small changes lead to changes in the system as a whole, (b) change is constant, and (c) clients should be encouraged to see themselves as “normal” with the counselors at their side (Littrell et al.; Stalker et al.). The various components of solution-focused therapy have been built over time. The miracle question, a major therapeutic component, originated with Milton Erickson’s work with hypnosis, and it emphasized coconstruction of solutions gathered through the use of Socratic questioning between the therapist and the client, as well as visualization of prior and future successes (Franklin, Biever, Moore, Clemons, & Scamardo, 2001). The consulting break began when a Brief Family Therapy Center trainee disagreed with a phone-in suggestion and left the room to consult with the team and the compliment originated when a client asked the observers for feedback (de Shazer, 1982). The model has also evolved from simply attempting to change client behavior directly to a process of mutuality, whereby the counselor and the client accept each other’s worldview and employ a conversation counseling model to determine an appropriate intervention (Stalker et al., 1999). Molnar and Lindquist (1989) have described solution-focused therapy as being ecosystemic, thus it intended to impact problem behaviors in various social setting. They further offered insights on the creation of an ecosystemic view that included (a) asking questions that reoriented the client to the problems, (b) searching for clues that revealed how others perceived the problem situation, and (c) noticing changes. However, although some theorists described a close relationship between problems and solutions, known as problutions (Selekman, 1997), this contradicted the solution-focused concept that solutions are not directly related to problems (de Shazer, 1988). MULTICULTURAL CONSIDERATIONS SFT is based upon a socially constructed reality dependent upon the client’s perspective, communicated through the client’s language and using the client’s frame of reference (Meyer & Cottone, 2013). Meyer and Cottone (2013) noted that because the therapist utilizes the client’s understanding of the situation and worldview, SFT can be culturally sensitive. DeJong and Berg (1998) agreed that SFT was a theoretical orientation beneficial for diverse populations including Latinos, White Americans, African Americans, Asians, and Asian Americans. Franklin and Montgomery (2013) supported this contention. The authors reviewed the work of social workers and found that when providing therapy for Asian populations, social workers may consider using solution-focused behavioral therapy (SFBT) since studies suggested that SFBT was being successfully applied in diverse Asian countries, such as Taiwan, China, Japan, and Korea, with promising results. Meyer and Cottone (2013) examined the cultural efficacy of SFT with American Indians and found that some components of SFT may need to be adjusted when working with this population; however, in general, the assumptions and techniques utilized by solution-focused therapists align with the client’s worldview. Chaudhry and Lee (2011) examined the efficacy

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of SFT with Muslim Americans and, while there are many different communities of Muslims in the United States with different practices and lifestyles, the authors stated that SFT’s focus on current needs/goals and short-term change decreases the opportunities for cultural conflict. Since SFT relies upon the stated goal or problem as the actual problem, without evaluation and reinterpretation by the therapist leading to short-term goals and plans by the client, in collaboration with the counselor this style can create less concern for clients who might be anxious about seeking support outside of their family and community (Chaudhry & Lee, 2011). SFT supports cultural sensitivity by utilizing five elements: (a) collaboration, (b) context, (c) critical consciousness, (d) competence, and (e) community (Chaudhry & Lee, 2011). Specific SFT techniques also support cultural sensitivity including (a) problem free talk, (b) pre-session change, (c) goal setting, (d) competence seeking, and (e) the miracle question (Chaudhry & Lee, 2011). EFFICACY OF SOLUTIONFOCUSED THERAPY The literature is filled with anecdotal reports outlining the success of SFT (Corcoran & Stephenson, 2000); however, in a meta-analysis of published studies examining SFT, Stalker et al. (1999) reported that there was no empirical evidence to support the claims of success made by solution-focused advocates, since no methodologically sound studies had been conducted. Some studies were constrained by the solution-focused assumption that the client was considered the person most knowledgeable about whether he or she had reached the goal of therapy; thus client feedback was the primary focus of research (Littrell et al. 1995). Other studies suffered because they utilized some components of SFT, but did not employ all of the characteristic features including (a) the miracle question, (b) scaling questions, (c) the interview break, and (d) client compliments and homework. These studies were not included in the Stalker et al. study since the counselors being observed were not practicing solution-focused counseling. In 2000, Gingrich and Eisengart conducted systemic qualitative review of 15 SFBT outcome studies and found that due to limited research designs and other factors, there was not enough empirical support for SFT. Franklin et al. (2001) stated that the solution-focused model has not been established using experimental methods, and that outcomes of the studies that have been done are simplistic. Coady, Stalker, and Levene (2000) warned that most experimental research into SFT has not utilized control groups. Studies that have employed control groups must be also viewed with caution because of the small number of participants, stringent criteria for participation, and little information about intervention protocols (Coady et al., 2000). Kim (2008) conducted a meta-analysis of 22 studies and found small positive treatment effects for SFT when providing support on externalizing behavioral problems, internalizing behavioral problems, and family and relational problems. The analysis showed positive effect with depression, anxiety, self-concept, and self-esteem (Kim, 2008). Results from a review of SFT studies related to work with children and adolescents also found that it may be useful for certain outcomes, for example, working with at-risk students with behavioral problems including conduct problems, hyperactivity, and substance abuse (Kim & Franklin, 2009). More recently, Bond, Woods, Humphrey, Symes, and Green (2013) reviewed 38 SFBT studies from 1990 to 2010. The authors found that despite methodological weakness in most of the studies, there is tentative support for SFT. The authors did identify five high-quality research studies, especially in the areas of internalizing and externalizing childhood behavior and early interventions in both school settings and with families. Gingerich and Peterson (2013) reviewed 43 studies and found that 74% reported positive benefits when using SFT. The authors also analyzed randomized only studies and found positive benefits in 83% of the studies suggesting the better designed studies provide stronger support for the use of SFT.

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Implications for Counseling Solution-focused counselors have claimed that this method provides rapid, enduring change, and a high degree of client satisfaction (Stalker et al., 1999). Research into SFT has found that this method is strengths oriented, collaborative, and represented a promising addition to a counselor’s repertoire (Bond et al., 2013; Gingerich & Peterson, 2013). Some have argued that methods such as SFT are merely vehicles that contribute to change (Williams, 2000). Recent research has also provided support for the use of SFT across cultures (Chaudhry & Lee, 2011). While research studies provided a glimpse into the effectiveness of SFT, there are instances where solution-focused methods should not be used, for example, in crisis situations, with certain clients with severe problems such as trauma, and where a prescribed policy must be followed, as in the case of abuse or neglect (Coady et al., 2000; Molnar and Lindquist, 1989; Stalker et al., 1999). CONCLUSION One of the key foundational beliefs of Solution-Focused Brief Therapy is that clients have the power to envision a different way of behaving and to generate different outcomes than they have in the past. The focus on imagining a new way of being aligns clearly with the introduction of the expressive arts into counseling practice. Clients are encouraged to “think outside the box” and explore how their lives can be different, thus encouraging creative expression throughout their treatment.

Expressive Arts Interventions

DISCOVERING SOLUTIONS IN THE SAND Charles E. Myers

Indications: Appropriate for a wide range of presenting concerns, including loss, divorce,

depression, and trauma, this activity can also be used in personal growth, visualizing what the client wants to obtain. Goal: To help the client to envision solutions Modality: Sand tray therapy The Fit: The purpose of this activity is to help clients shift from a problem-focused, past-oriented perspective to a solution-focused, future-oriented perspective. Clients often can become “stuck,” or mired in their problems, unable to visualize a better future. This activity is a modification of De Shazer’s (1988) “miracle question,” with roots in Erickson’s (1954) “crystal ball” technique. The therapist asks the client to envision a world without his or her problem, how would it be different, and what he or she can do to help make that change. This process helps the client to develop well-defined goals (Sklare, 2005) and interventions the client is likely to commit to and to follow through. Built on the belief that all people have the resources to find their own solutions, this technique allows the therapist to tap into those resources. The goal of the miracle question is to shift the client’s focus from the problem to the solutions (Murphy, 1997), instilling hope that his or her circumstances can change and that he or she has the power to make change happen. The use of solution-focused, brief, and sand tray therapies together provide clients a positive and empowering approach (Taylor, 2009). Populations: Children/adolescents/adults; Couples/individuals Materials: Sand tray (ideally 20 in. wide, 30 in. long, and 3 in. deep with inside bottom and walls painted medium blue); dustless sand to fill the tray about 2–3 in. deep; and eclectic collection of miniatures in prescribed categories (Homeyer & Sweeney, 1998) Instructions: 1. Begin with having the client become acquainted with the sand with prompts such as Place your hands in the sand, notice how it feels, how it moves and responds to your touch. Invite the client to share any sensations or observations. This has both the effect of accustoming the client to the medium as well as having a grounding effect. 2. Say to the client, Think about the_______________ (the presenting problem). What does it look like in your life, what feelings does it bring up? 3. Say to the client, Now, keeping in mind_______________ (the presenting problem), choose as few or as many miniatures as you like and create your world (a picture) as it is now on the left half of the sand tray. Note: as in reading, time in expressive arts often moves visually from left to right. 4. The client creates the world without disruption as the therapist observes and honors the process and provides a safe space in which the client may create.

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5. Process the first half (problem side) of the tray with the client. Ask the client first to explain

the tray globally, then gradually move to more specific parts of the tray. 6. After processing the “problem” side of the tray with the client, ask the client the miracle

question: Imagine it is 6 months from now and your problem no longer exists. Think about how your world, your life will be different. How will it look, how will you feel? Now on the right side of the tray I would like you to create your world (a picture) of how it will be in 6 months when the problem no longer exists. As the client creates the “solution,” simply observe and honor the process in silence. 7. When the client has completed the right half (solution side) of the tray, ask the client, What is different in the second half. What changed? How do you know the problem is gone? How can others tell the problem is gone? Questions like these help the client to define how things will be different, which is useful in creating goals for therapy. These questions also help the client to see that his or her life can change for the better, which is useful in instilling hope. Write down and acknowledge the goals that are created through the processing of the sand tray. 8. Ask the client, What can you do to get from the left half of the tray to the right half? What is in your power to change? These questions tap the client’s inner resources and elicit potential interventions from the client. As the ideas originate with the client, the likelihood of client buy-in and follow through is increased. 9. Take a digital photo of the sand world. Photos of sand tray can be used to help the client see change and to develop a common metaphorical language between the client and the therapist. (i.e., Remember the dragon you used to represent your anger over the breakup of your marriage, and the swimming dolphin as freedom to become yourself. Are you more the dragon or the dolphin today?)

DRAWING A SOLUTION Elsa Soto Leggett and Kathy Ybañez-Llorente

Indications: This activity is especially appropriate for clients who may have limited vocabularies,

difficulty expressing complex concepts, or for whom their primary language is not English, or who may be reluctant to engage in talk therapy. It is recommended for clients who express a sense of hopelessness about present or future situations. Goal: To provide concrete expression of abstract questions that explore exceptions to problems, the miracle question, and goal setting Modality: Art The Fit: Solution-focused therapy (SFT) uses signature questions to keep the focus on how clients can change. These questions are designed to allow the counselor to listen to clients’ words and absorb the meanings before formulating the next question by connecting clients’ key words and phrases. This process helps the client establish the groundwork for new thinking while co-constructing with the counselor new and alternative meanings that move the client toward change and solutions (Trepper et al., 2008). The miracle question is a technique often used in SFT (De Shazer, 1988). Through this activity, clients create a visual reminder of how their lives could be and the goals they aspire to achieve. To facilitate the verbal and nonverbal expressions of thoughts, feelings, and behaviors of a client, it may be necessary to utilize a combination of talking and playing (Gladding, 2005; Orton, 1997). Naumberg (as cited in Orton, 1997, Leggett, 2009) described drawing as a means to view into the unconscious, gain insight into the process of counseling, and allow the client to bring in his or her own interpretation. Malchiodi (2005) asserted “self-expression is used as a container for feelings and perceptions that may deepen into greater self-understanding” (p. 9). Through the visual art of drawing, a client can manipulate paper and crayons to represent the problem or situations (Chesley, Gillett, & Wagner, 2008), or in the case of SFT, to explore the exceptions to a problem or discover the details of a miracle. The purpose of this activity is to allow the client to reveal thoughts, feelings, and hopes in a tangible format. Populations: Children/adolescents/adults; Groups/individuals Materials: Art supplies such as plain paper or drawing paper of various sizes, pencils, crayons, markers, pastels, or colored pencils. (An older client may feel more comfortable with a drawing tablet or notebook to chronicle his or her drawings.) Instructions: Depending on the stage of the counseling relationship, the counselor can use any of the five following prompts to complete the drawing activity. 1. Describing the problem and establishing goals 1.1 Ask the client, What brings you here today? This initiation step invites the client to tell his or her story. The client identifies what he or she wants to be different or to change, which can lead to establishing a goal. The goal should (a) fit the client’s needs; (b) be relevant, meaningful, and specific to the situation; and (c) be concrete, behavioral in nature, and measurable. Sometimes a client has difficulty explaining or expressing the problem being faced. 1.2 Provide art materials and ask the client to draw a picture of the situation that is most troubling and allow the client time to fully complete the picture at a high level of detail. 35

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1.3 Invite the client to describe the details of the picture. The use of solution-focused

2.

3.

4.

5.

relationship questions and not-knowing questions will facilitate the processing of the drawing while providing important information about what and who is important to the client (see 5). Miracle question. The miracle question helps the client look beyond the present and into the future. It helps the client to visualize how life will be different when the goal is achieved. This step can prove to be the most difficult for young clients, because of developmental level and the complexity of the question. 2.1 Ask the client, If a miracle happened tonight while you were asleep and when you woke up tomorrow the problem that brought you here today was solved by magic, what would be the first small thing you would notice that told you this miracle has happened? or Imagine that tomorrow was a perfect day and the problem you are having today was gone. What would that perfect day look like? 2.2 Ask the client to draw a picture of the miracle or the perfect day and allow the client time to fully complete the picture at a high level of detail. These details, specifically those that are different from the previous day, should be discussed and enriched with SFT relationship questions and not-knowing questions. Exploring for exceptions. This technique includes the search for times when the problem is not happening or is less severe. This can also include time in the past similar to the miracle picture—when things have been better. The use of follow-up questions provides insight into who did what to make the exceptions happen. Was it the client? Was it a parent, a teacher, or a friend? The drawing allows the client to carefully examine even the smallest exception to the problem. 3.1 Ask the client, Can you think of another time when you did not have a problem with_________? 3.2 Ask the client to draw a picture of a time when the problem was not happening and allow the client time to fully complete the picture at a high level of detail. As the client is encouraged to consider exceptions, the drawing may enable the client to consider actions or behaviors contributing to the exception. If a client has difficulty with this request, ask the client to consider a time in the recent past when a small part of the perfect day or miracle was experienced. For some young clients it may be simplest to concentrate on only one exception rather than the exploration of several. Scaling questions. These questions can be used to assess the baseline or to evaluate progress of the presenting concern. 4.1 Ask the client, On a scale of 1 to 10, with 10 meaning you have every confidence that this problem can be solved and 1 meaning no confidence at all, where would you put yourself today? 4.2 Ask the client to draw a picture of what the number looks like. Visual representations of the scaling question can help make the evaluation of progress more concrete (Nims, 2007). The format of the question may be altered to fit the focus of the scaling question. An example of such rewording might be, On a scale of 1 to 10, with 10 being your miracle picture or perfect day, and 1 being the worst day, where would you say you are today, right now? Relationship questions and not-knowing questions. These questions allow clients to take ownership and expertise regarding their presenting concerns. Questions include, What tells you that this is a problem? Who would notice that this is a problem for you? Can you tell me more about what you have drawn? What do you mean when you say______? When this problem is solved, what will you notice different? Who else will notice that things are different? What differences will they notice?

EVERY LITTLE STEP YOU TAKE Sandra Logan

Indications: This activity can be used with clients to identify how they currently view their interpersonal relationships with others (i.e., peers, teachers, parents) and identify how they can take small steps toward improving or changing their behavior for better interpersonal relationships. Goal: To allow individuals to assess how they currently view their relationship and interpersonal communication, and identify how things could improve and what it would look like. Modality: Collage The Fit: As Bannink (2010) has described, solution-focused theory includes using the technique of scaling questions to focus on an individual’s progress, motivation, and confidence. In this activity, the intention is to get individuals to think about how relationships currently function and consider what improvement would look like. Population: Best suited for adolescents in an individual setting Materials: Magazines, newsletters, newspaper, or other visual media outlets scissors; glue/ glue stick; markers/pens Instructions: 1. Counselor focuses on the client verbally describing how the client currently sees the relationship with another individual of interest/conflict (e.g. a peer, teacher, parent). 2. Counselor asks the client to numerically describe where he or she perceives the relationship with the other individual to be, using a 0- to 10-point scale. 2.1 It may be useful to ask whether the client understands what a scaling question looks like. 2.2 Consider providing an example: If __________ (the goal you would like to reach) is a 10 and the moment when things were at their worst is a 0, where on that scale are you now? How did you manage to come to this number? 3. Counselor encourages the client to now visually represent what he or she has just verbally described, using the collage materials provided. This could include single words, quotes, inspirational messages, pictures, photographs, and more. 4. After the client has created the collage of where the current functioning of the relationship is perceived, ask the client to verbally describe how he or she would like to see the relationship with this other person in the future. 5. Counselor asks the client to numerically describe where he or she would see the relationship with the other person. 6. Counselor asks questions that focus on progress, such as: 6.1 What would one point higher look like? 6.2 What would you be doing differently? 6.3 How would you be able to move up one point? 6.4 What is needed for you to do that? 6.5 What else?

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7. Counselor encourages the client to now visually represent what he or she has just verbally

described, using the collage materials provided. This could include single words, quotes, inspirational messages, pictures, photographs, and more. 8. Counselor encourages the client to reflect on the differences between collage 1 and collage 2 and consider what the client is willing to do to change the current situation. 9. Counselor asks questions that focus on what the client needs, such as: 9.1 How would you be able to move up one point? 9.2 What is needed for you to do that? 9.3 What else? 10. Activity wrap-up could include identifying multiple small steps that the client could take, which could also be depicted in a collage and could be used as visual cues/reminders for the client to actually carry out what he or she described could be done to improve the situation. Counselor emphasizes that every little step the client is willing to take will get him or her closer to the goal of what was described/depicted in collage 2. Example: A client might describe the relationship with both parents as volatile and wounded. The typical mode of communication is yelling at one another at a 10 on a scale of 0 to 10. Counselor could facilitate conversation and reflection on how the client currently sees the situation. For example, the client might say, “I would like it if the yelling in the family was at a 6 instead of a 10.” The counselor could explore what a 6 would look like to the client and have him or her depict that in the collage. Next, the counselor could facilitate reflection with the client on how he or she would like to see the family relate and communicate, and then repeat the steps for the preferred family relationship.

FAMILY SUPER POWERS Savannah Cormier

Indications: This intervention can be used with families that are struggling with excessive or unhelpful focus on problems that impede development and growth. Families that are stuck in a problem-focused, blaming, or critical mind-set often have a difficult time noticing and appreciating each other’s strengths and contributions to the family. By focusing solely on problems, members may be unable to recognize potential preexisting solutions. This intervention is designed to help family members acknowledge the ways in which each member’s strengths contribute to the family and make it a stronger system. Goal: To shift family members’ focus of treatment away from a problem-focused lens to a more strength-and solution-focused lens; to focus attention on individual strengths, family strengths, what is working, and work toward appreciation and better connection among family members Modality: Art, drawing The Fit: SFT grew out of Steve De Shazer and Insoo Kim Berg’s work with families at their Milwaukee Brief Family Therapy Center (Trepper, Dolan, McCollum, & Nelson, 2006). This intervention is geared primarily to work with families and couples, though it can be adapted to work with individuals and other groups. As implied by the name, a main tenet of SFT is shifting attention away from problems to focus more on strengths clients already possess and future solutions. Another aspect of SFT is the notion that small changes lead to big solutions. This intervention promotes the belief that each family member already possesses strengths and inner resources, called “superpowers,” that when combined with other family members’ superpowers, create a unique family system and superhero team. Another important aspect of SFBT is the decision as to where to place the focus—on the problem or on the solution. Using the creative modality of art, with the familiar concept of superheroes, family members learn a new way of seeing and thinking about their world and the people in it. Population: Families and couples; Children, adolescents, adults; Families and groups Materials: Art supplies such as paper, pencils, crayons, markers, colored pencils, paint, etc. Post-it notes optional. Instructions: 1. Open the activity with a discussion that addresses the belief that every person has strengths and weaknesses. If appropriate, normalize this concept with self-disclosure of one of your own identified strengths and weaknesses. For example, you might share something to the effect of: One of my weaknesses is that, at times, I can be a perfectionist and will focus so much on doing something perfectly that I procrastinate starting. However, I also have several strengths. One of my strengths is that I genuinely care about people and tend to be a very good listener. It is important to note the use of language here. Our strengths and weaknesses are described as something that affect us at times or as something we tend to be or do, not all encompassing ways we are. Stating strengths and weaknesses in this way models to our clients that there are always exceptions; nothing is ever only one way. 2. After normalizing the idea that everyone has strengths and weaknesses, introduce the concept of strengths as unique superpowers and weaknesses as a character nemesis or “kryptonite.” 39

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Figure 3.1 Mom’s strengths as “superpowers.”

Tell the family members that they are each going to draw themselves as a superhero with special powers and weapons of resource (Figure 3.1). To balance this, they will also draw their weaknesses, but externalized as something separate from themselves: their nemesis or kryptonite (Figure 3.2). It may be helpful to tell your clients a specific number of strengths and weaknesses to find to ensure that they focus on and include more strengths than weaknesses. 3. Once everyone has completed their superhero drawing and nemesis, ask them to share both with the rest of the family. As a family member is sharing, the rest of the members are actively listening. Once finished, each member gets a turn to share with that person either (a) which strength is most meaningful to the member, what they heard that person say about their strength, and how they feel that person’s strength contributes to the family; or (b) a strength of that person that they did not include on their superhero drawing, what is meaningful about it, and how they feel that strength contributes to the family. If adding a strength, members may draw a symbol and write it on a post-it note to stick on the drawing. 4. After everyone has had a chance to share and respond to each family member’s drawings, tell the family that they have the opportunity to come together as a team to fight their nemeses and other problems that try to affect their family. Together, come up with positive, observable, realistic goals that are meaningful to the family and involve family interaction. Ask the family what superpowers they can make use of to achieve these goals.

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Figure 3.2 Weaknesses externalized as a separate character, the nemesis.

5. The superhero drawings can be taped together, or a separate drawing of the superheroes

together can be created and placed in a visible area in the family’s home to remind them to see the unique strengths of each family member. Adaptations for Individuals or Groups: While this intervention is geared toward families, it can also be adapted to work with other groups or to work with individuals. In using this intervention with groups, you would follow the same steps as above; however, instead of focusing on family connection, the focus would be on the therapeutic group factors of instillation of hope, universality, imparting information, altruism, the corrective recapitulation of the primary family group, development of socializing techniques, imitative behaviors, interpersonal learning, group cohesiveness, catharsis, and existential factors (Yalom & Leszcz, 2005). Group members experience these therapeutic factors in sharing their strengths, hearing others’ strengths, giving and receiving feedback, and working with others to achieve their goals. In a different way, this intervention could also be used with individual clients. Clients would follow the above steps; however, instead of sharing their superhero drawing and nemesis with their family members in session, they would share it with the therapist. You as the therapist now have the option of giving the client feedback on your perception of their strengths and how you see these strengths being helpful and meaningful in life.

“IF IT DOES NOT CHALLENGE YOU, IT DOES NOT CHANGE YOU”: INSPIRATIONAL QUOTES FOR MOTIVATING CHANGE Bill Owenby

Indications: Through the use of inspirational quotes, clients perceive circumstances in a

different lens, allowing them to identify different methods and strengths in a more realistic and approachable manner. Goal: To identify new strengths and old skills through inspirational quotes. By identifying with and creating meaning from inspirational quotes, the client is able to identify options for promoting change. Modality: Visual/Writing Art The Fit: Solution-focused brief therapy (SFBT) identifies a person’s strengths through reframing questions and techniques, as well as identifying and applying previously used but forgotten skills toward newfound challenges. Inspirational quotes provide a creative perspective for identifying possible solutions from the past rather than focusing on the presenting problem. Inspirational quotes assist in promoting the client’s hope by validating the gap between the presenting problem and his or her goals. As the client identifies this difference, the counseling process may continue identifying the client’s abilities to move forward based on the connection to the quote’s message and internalized meaning (De Shazer et al., 2007; George, Iveson, & Ratner, 2015; Jones-Smith, 2014; Simonton, 2009). Population: Children, adolescents, and adults; Individuals and groups Materials: Obtain multiple inspirational quotes from online, books, magazines, or any other location where they may appear; tailor to the client’s need, focus, age appropriateness, or your clinical judgment. Another option is to have the client identify meaningful quotes and bring them to the session for application, review, and processing. Instructions: 1. After establishing rapport and an understanding of the client’s presenting concerns and goals in counseling, the counselor will find inspirational quotes for the upcoming session. These quotes can pertain to a particular topic on which you are working with the client (e.g. trauma, substance use, or life struggles in general), but are open to the counselor’s discretion and or client’s need. Find enough from which the client(s) can choose. For example, if engaged in individual counseling, have about five to ten quotes; use more within a group setting as this allows for a sufficient amount of quotes to be chosen. 2. The counselor will either type them up or handwrite them on individual pieces of paper (if typed, print and cut into strips). Next, the client will choose a bag or box to hold the papers. Quotes may be chosen intentionally or randomly by the counselor or client; sometimes the quotes picked by the client can be more powerful and representative of the client’s circumstances thus allowing for deeper meaning. 3. This technique could be used in the beginning of the session as a way to approach the topic that will be discussed, or could be used at the end of the session as a way to build motivation, identify strengths, or areas of improvement toward positivity for the clients after they leave. 4. For an individual, have the client choose the quote either from the bag/box or from assigning the homework task; for groups, walk around for each client to choose a quote. It works best 42

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7. 8.

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for only one client to choose a quote at a time so that his or her reaction is authentic and off the cuff opposed to being rehearsed. Once the client has a quote, have him or her read the quote out loud and explain how he or she relates and/or identifies with the quote, or what it means to him or her and his or her circumstances. This allows the client to shed light on his or her problem from a different perspective and opens the doors for discussion of how the client reacted at different times, such as before scheduling for counseling, currently in the session, and how the client may respond after the session. This is considered the initial brainstorming within the counseling session. To engage the client further, have him or her discuss possible options for obtaining his or her goals based on the discussion and processing of the quote to his or her circumstances. This is where one may incorporate the miracle question and identify new/different thoughts, behaviors, or beliefs in order to increase his or her score to the next level. Further process the summary of the discussion and the quote in order to encourage the client to try “experiments” with these newfound options. Continue this intervention as necessary for future sessions in order to promote the client’s progress and movement; change as necessary to further inspire the client’s progress and success.

NEW CHAPTER PAMPHLET STITCH BOOK Katrina Cook

Indications: Appropriate presenting concerns can include, but are not limited to, physical

abuse, sexual abuse, verbal abuse, low self-esteem, depression, eating disorders, substance abuse, or major life transitions. Goal: To enhance self-awareness and establish goal setting Modality: Art and/or writing The Fit: The miracle question is a technique often used in SFT (De Shazer, 1988). The pamphlet stitch book provides clients with opportunities to shift their focus from current problems to a future life that is open to positive opportunities. The pamphlet stitch book has one signature, or chapter, that represents the client’s answer to the question: If a miracle happened and the problem you have was solved overnight, how would you know it was solved, and what would be different? Through this activity, clients create a visual reminder of how their lives could be and the goals they aspire to achieve. This intervention is especially appropriate for clients experiencing a transition. Populations: Adolescents/adults; Groups/individuals Materials and Preparation: Stiff paper for the book cover, softer paper for the text pages, sturdy thread, and sewing needles, old magazines, ink stamps, and ink pads, any client-chosen personal items such as photos, drawings, poems, letters, or journal entries You may elect to create the signatures before meeting with the client so the client can focus his or her energy on the collage. To create signatures, fold sheets of paper and tear the sheets at the fold until you have sheets at the desired size, with a fold crease in the middle. Stack the pages on top of each other on the fold, creating a peak shape (Miraker & Peyton, 2009; Smith, 1999). Include three to five sheets in each peak, depending on how many pages the book will contain. Instructions: 1. Begin the session by collaborating with the client to identify the presenting problem; ask the client the miracle question; and ask the client to write a response to the miracle question. 2. Give the client one of the peaked signature/chapters and the cover sheet, and demonstrate how to sew the pages together inside the cover sheet. 2.1 Fold the cover sheet and place it on top of the peaked sheets. Use a clothespin or a paper clip to keep the pages together. 2.2 With a needle, pierce three holes along the fold—one in the center, one 1 in. from the top, and the other 1 in. from the bottom. 2.3 Measure and cut a thread that is three times as long as the book and thread it on the needle. 2.4 From the inside of the book, bring your needle and thread through the center hole, while holding the tail of the thread in the inside of the book. 2.5 Bring the needle and thread to the top hole and thread from the outside of the book to the inside. 2.6 Bring it back to the center hole on the inside of the book and bring the thread through this hole again. Continue to hold the tail securely. 44

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2.7 Bring the needle to the bottom hole of the book and thread through the outside of the

3. 4. 5.

6.

book back to the inside. Then bring the needle and thread back to the center hole and tie a knot with the tail. Think of the sewing as if you are creating a figure 8 (Miraker & Peyton, 2009; Smith, 1999). Ask clients to write or collage images that represent their answers to the miracle question. Ask clients to create a title for their books and write or collage it on the covers. After completion of the books, facilitate a discussion focusing on the visual and written representations within the books. Possible discussion questions include, Tell me about the title of your book. What does that title mean to you? Show and describe each page of the book and explain what it means to you. What story does this book tell about you? How does this chapter of your life end? Encourage clients to carry their books with them as a visual reminder of how their lives might be.

RACE CAR IDENTIFICATION Sheri Pickover

Indications: Appropriate presenting concerns may include, but are not limited to, extreme emotional reactions, attachment disorders, impulsive or aggressive behavior. Goal: To increase range of emotion and increase self-awareness Modality: Art The Fit: The purpose of this activity is to provide the client with a metaphor for extreme emotional reactions that are not appropriate to the arousing situation; for example, a client who flies into a rage over an insult or a client who worries excessively over a quiz. This activity is appropriate for either group or individual counseling and is designed to be used after a client has developed the ability to identify a wide palette of emotions. This intervention derives from the theoretical view that clients who struggle with affect regulation have a developmental deficit resulting from an insecure attachment style and therefore respond to social situations with impulsive and aggressive behavior (Bowlby, 1988). This theoretical view assumes that the client struggled to develop adequate affect regulation skills in early childhood and this intervention works to build these needed emotional developmental skills. Populations: Children/adolescents/adults; Groups/individuals Materials: Markers, crayons, pens and the like, paper, and age-appropriate scissors Instructions: 1. Open the session with a description of the analogy, such as, How do we react to different situations? Emotions are like a race car. All feelings are valid, but sometimes we go 0 to 150 miles per hour even in the wrong situations. How fast do you go in the following situations? 2. Ask the client to draw a race car without offering assistance or guidelines. 3. Review relevant scenarios with the client and ask the client to put a speed on the emotions (i.e., 50 miles per hour angry or 80 miles per hour anxious). Scenarios might include such times as the following: (a) neighbor insults family member, (b) starting a new job, or (c) friend makes fun of your clothes. Write down the client responses to maintain a written record of progress. 4. Discuss scenarios that would justify 150 miles per hour angry or 130 miles per anxious, as well as scenarios that would not justify as strong a response. 5. Invite the client to create “speeding tickets” with the art materials available. The tickets should include a space for the client to either write or draw the situation (depending on developmental level), a space for the client to mark the speed, and a space for an “I feel” statement/ drawing. Ask the client to cut out the tickets and then review the “I feel” statements in session. 6. Give the client the tickets with the following directions: For the next week, see if you can catch yourself speeding. Every time you run into a situation that makes you feel angry (or anxious, etc.), ask yourself if the level of emotion is appropriate to the situation. Remember, feelings are not wrong, but if the intensity does not match the situation, you are speeding. Give yourself a speeding ticket each time you catch yourself speeding. Review the results in future sessions and create more speeding tickets, if needed. Use the metaphor to identify client strengths by pointing out times the client either showed awareness of speeding or demonstrated the ability to prevent speeding. Continue to refer to this intervention throughout the counseling process as a check-in and to monitor progress. 46

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REFERENCES Bannink, F. (2010). 1001 solution-focused questions. New York, NY: W. W. Norton. Bond, C., Woods, K., Humphrey, N., Symes, W., & Green, L. (2013). A practitioner review: The effectiveness of solution-focused brief therapy with children and families: A systemic and critical evaluation of the literature from 1990 to 2010. The Journal of Child Psychology and Psychiatry, 54(7), 707–723. Bowlby, J. (1988). A secure base: Clinical applications of attachment theory. New York, NY: Basic Books. Chaudhry, S., & Lee, C. (2011). Is solution-focused brief therapy culturally appropriate for Muslim Americans? Journal of Contemporary Psychotherapy, 41, 109–113. Chesley, G. L., Gillett, D. A., & Wagner, W. G. (2008). Verbal and nonverbal metaphor with children in counseling. Journal of Counseling & Development, 86(4), 399–411. Coady, N., Stalker, C., & Levene, J. (2000). A closer examination of the empirical support for claims about the effectiveness of solution-focused brief therapy: Stalker et al. respond to Gingerich. Families in Society, 81(2), 223–230. Corcoran, J., & Stephenson, M. (2000). The effectiveness of solution-focused therapy with child behavior problems: A preliminary report. Families in Society, 81, 468–474. De Shazer, S. (1982). Patterns of brief family therapy: An ecosystemic approach. New York, NY: Guilford Press. De Shazer, S. (1988). Clues: Investigating solutions in brief therapy. New York, NY: W. W. Norton. De Shazer, S., Dolan, Y., Korman, H., Trepper, T., McCollum, E., & Kim Berg, I. (2007). More than miracles: The state of the art of solution-focused brief therapy. Philadelphia, PA: Haworth Press. DeJong, I., & Berg, I. (1998). Interviewing for solutions. New York, NY: Brooks/Cole. Erickson, M. H. (1954). Pseudo-orientation in time as a hypnotic procedure. Journal of Clinical and Experimental Hypnosis, 2, 261–283. Franklin, C., Biever, J., Moore, K., Clemons, D., & Scamardo, M. (2001). The effectiveness of solution-focused theory with children in a school setting. Research on Social Work Practice, 11, 411–434. Franklin, C., & Montgomery, K. (2013). Does solution-focused brief therapy work? In J. S. Kim (Ed.), Solution-focused brief therapy: A multicultural approach (pp. 14–32). Thousand Oaks, CA: SAGE. George, E., Iveson, C., & Ratner, H. (2015). Solution-focused brief therapy. In E. S. Neukrug (Ed.), The SAGE encyclopedia of theory in counseling and psychotherapy (pp. 946–950). Thousand Oaks, CA: SAGE. Gillen, M. (2005). Providing efficacy for Solution-Focused Theory in school counseling programs. Journal of School Counseling, 3(2). Retrieved from http://www.jsc.montana.edu/articles/v3n2.pdf Gingerich, W., & Eisengart, S. (2000). Solution-focused brief therapy: A review of outcome research. Family Process, 39, 477–496. Gingerich, W. J., & Peterson, L. T. (2013). Effectiveness of solution-focused brief therapy: A systematic qualitative review of controlled outcome studies. Research on Social Work Practice, 23(3), 266–283. Gladding, S. T. (2005) Counseling as an art: The creative arts in counseling (3rd ed.). Upper Saddle River, NJ: Pearson. Homeyer, L. E., & Sweeney, D. S. (1998) Sand tray: A practical manual. Canyon Lake, TX: Lindan Press. Jones-Smith, E. (2014). Strengths-based therapy: Connecting theory, practice, and skills. Thousand Oaks, CA: SAGE. Kim, J. S. (2008). Examining the effectiveness of solution-focused brief therapy: A meta-analysis. Research on Social Work Practice, 18, 107–116. Kim, J. S., & Franklin, C. (2009). Solution-focused brief therapy in schools: A review of the outcome literature. Children and Youth Services Review, 31(4), 464–470. Leggett, E. S. (2009). A creative application of solution-focused counseling: An integration with children’s literature and visual arts. Journal of Creativity in Mental Health, 4, 191–200. Littrell, J., Malia, J., & Vanderwood, M. (1995). Single-session brief counseling in a high school. Journal of Counseling and Development, 73, 451–458. Malchiodi, C. A. (2005). Expressive therapies: History, theory, and practice. In C. A. Malchiodi (Ed.), Expressive therapies (pp. 1–15). New York, NY: Guilford Press. Meyer, D., & Cottone, R. (2013). Solution-focused therapy as culturally acknowledging approach with American Indians. Journal of Multicultural Counseling and Development, 41, 47–55. Miraker, C., & Peyton, S. (2009) Sewn pamphlets. Retrieved from http://www.bookmakingwithkids.com/ wp-content/uploads/2009/07/sewn-pamphlet-instructions.pdf Molnar, A., & Lindquist, B. (1989). Changing problem behavior in schools. San Francisco, CA: Jossey-Bass. Murphy, J. J. (1997). Solution-focused counseling in middle and high schools. Alexandria, VA: American Counseling Association.

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Nims, D. R. (2007). Integrating play therapy techniques into solution-focused brief therapy. International Journal of Play Therapy, 16, 54–68. Orton, G. H. (1997). Strategies for counseling with children and their parents. Pacific Grove, CA: Brooks/Cole. Selekman, M. (1997). Solution-focused therapy with children: Harnessing family strengths for systemic change. New York, NY: Guilford Press. Simonton, D. K. (2009). Creativity. In C. R. Snyder, & S. J. Lopez (Eds.), The Oxford handbook of positive psychology (2nd ed.). New York, NY: Oxford University Press. Sklare, G. B. (2005). Brief counseling that works: A solution-focused approach for school counselors and administers (2nd ed.). Thousand Oaks, CA: Corwin Press. Smith, K. A. (1999). Non-adhesive binding: Books without paste or glue. Rochester, NY: Author. Stalker, C., Levene, J., & Coady, N. (1999). Solution-focused brief therapy: One model fits all? Families in Society, 80, 468–477. Taylor, E. (2009). Sand tray and solution-focused therapy. International Journal of Play Therapy, 18(1), 56–68. Trepper, T. S., Dolan, Y., McCollum, E. E., & Nelson, T. (2006) Steve de Shazer and the future of solution-focused therapy. Journal of Marital and Family Therapy, 32(2), 133–139. Trepper, T. S., McCollum, E. E., DeJong, P., Korman, H., Gingerich, W., & Franklin, C. (2008). Solution focused therapy treatment manual for working with individuals: Research Committee of the Solution Focused Brief Therapy Association. Retrieved from http://www.sfbta.org/Research.pdf Williams, B. (2000). The treatment of adolescent populations: An institutional vs. a wilderness setting. Journal of Child & Adolescent Group Therapy, 10, 47–56. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy. New York, NY: Basic Books.

4 Cognitive Behavioral Theory Dixie Meyer

Many cognitive behavioral therapy (CBT) goals and techniques are in alignment with an expressive arts perspective. In both CBT and the expressive arts, the common goal is for the client to achieve behavioral change. CBT is known for using techniques such as journaling, role-play, and guided imagery—techniques commonly used in expressive arts approaches. This chapter further explains how the expressive arts can be integrated into CBT. FOUNDATIONS OF COGNITIVE BEHAVIORAL THERAPY CBT is an amalgam of rational emotive behavior therapy (REBT; Ellis, 1998, 1999), behavior therapy (BT; Lazarus, 1971), and cognitive therapy (CT; Beck, 1967, 2005; Beck, Rush, Shaw, & Emery, 1979). What makes this theory different from other kinds of therapy is the emergence of behaviors and cognitions into one integrated, comprehensive theory. Historically, REBT developed during the 1950s (Ellis & Jaffe Ellis, 2014). Despite prior exploration into behavioral interventions, it was not until the 1950s when BT developed into a manner to treat psychological issues (Antony, 2014). Dr. Aaron Beck’s work in the cognitive model closely followed the development of these other theories and in the 1960s the writings of Beck emerged into CT (Beck & Weishaar, 2014). Beck’s theory began as he was investigating depression. Because BT often leaves out the cognitive and affective component, and because of brevity, this chapter will focus on Beck’s cognitive model with limited comparison to Ellis’s REBT. CORE CONCEPTS OF COGNITIVE BEHAVIORAL THERAPY When assessing any theoretical orientation, it is important to begin with the unique theoretical view of human nature. From a CT perspective, humans are viewed as neither good nor bad, but the focus is concerned with how individuals adapt to their social environment and the application of learning (Beck, 1976). REBT is similar in the neutral perspective of the view of human nature, but the REBT perspective posits individuals are capable of thinking rationally and thus, rational thinking is the focus of therapy (Ellis, 1998, 1999). Although both focus on cognitions, the difference between CT and REBT is CT’s focus on previous experiences in cognitions. CT follows that experiences form beliefs. Therefore, a CT counselor will more readily focus on the past and the REBT counselor will stay focused on the present. With both CT and REBT, the emphasis in counseling is on the clients’ beliefs. Integral to CT, beliefs may 49

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be categorized as core, conditional, or compensatory beliefs (Beck, Freeman, & Davis, 1994). Core beliefs are automatic and typically reflect views of oneself. Conditional beliefs assign meaning to experiences and operate from the if-then principle. If an event happens, then the individual will often assign a label to himself or herself. Compensatory beliefs are often based on core beliefs and help individuals define the core belief. An individual may have a certain core belief about himself or herself and then the compensatory belief indicates to the individual how he or she should act. In CT, all beliefs (core, conditional, and compensatory) are organized into schemas or patterns of assumptions developed out of experience (Beck et al., 1979). All information is processed through schemas and this determines thoughts about new experiences and how individuals respond. Schemas can be either adaptive or dysfunctional dependent on the outcome on the mental health of the individual. Collections of schemas are called “modes” and modes organize the client’s perspective of reality (Beck et al., 1979). Modes may be primitive, often operating with a more extreme response and thinking in absolutes, or mature, operating with more flexibility in the thought process and able to integrate situational information (Beck et al., 1979). COGNITIONS COMPOSITION Unlike Ellis, who assessed for irrational thoughts, Beck was known to assess for dysfunctional thoughts. What often happens with individuals is patterns emerge from their negative thoughts, typically called “cognitive distortions.” In CT, Beck (1967) and Beck et al. (1979) described common cognitive distortions: ■ ■ ■ ■ ■ ■ ■ ■ ■ ■

Arbitrary inferences occur when the client makes a conclusion without confirmatory evidence or when contradictory evidence is present. Selective abstraction occur when a client elects to focus on one or a few details present and disregards the broader circumstances. Overgeneralizations occur when the client comes to a generalized conclusion from one event. Magnification and minimization occurs when the client either contributes too little or too much significance to an event. Personalization occurs when the client views unrelated events as a reflection of himself or herself when no relationship exists. Dichotomous thinking occurs when a client interprets an event as either all good or all bad. Catastrophizing occurs when the client views the event as worse than what actually happened. Mind reading occurs when the client assumes that he or she knows the intentions of or what someone else is thinking. Fortune telling occurs when the client imagines the worst will happen. Labeling occurs when a client defines himself or herself based on a singular event or applies a negative label to himself or herself without objectively describing the event.

Ellis (1999) had a theoretical explanation for the individual’s thoughts: the ABC model. The A represents the activating event. The B represents an individual’s belief about the activating event and the C represents the emotional or behavioral consequence based on the belief of the event. Thus, it is not the emotions, behaviors, or the event that disturbed an individual, but his or her beliefs about the event (Ellis, 1999). Throughout the course of counseling, a counselor may review common cognitive distortions with a client or have the client dissect his or her responses to an event to investigate his or her beliefs about the event. Cognitive restructuring activities help the client work toward more adaptive thought processes or more rational thinking. For example, Ellis would work with the client to examine his or her irrational thoughts, whereas Beck would work with a client to develop adaptive or flexible thought patterns.

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THE COUNSELING PROCESS REBT integrates emotions and cognitions into behaviors (Ellis, 1962). Comparably, CT postulates individual responses involve behavioral, cognitive, and affective components (Beck, 1976). Thus, both an REBT and a CT counselor examine the client’s belief system during the counseling process. Although Ellis noted irrational thoughts cause disturbances, Beck had a more neutral response to thoughts. Beck found that the outcome of the thoughts defined the thoughts not as irrational or rational, but rather adaptive or maladaptive. In terms of pathology, CT considers each disorder to have cognitive themes of dysfunctional thoughts (Beck et al., 1994), whereas REBT views pathology in what the client considers is something he or she should or must have or do and how he or she incorporates these musts and shoulds into his or her beliefs (Ellis, 1998, 1999). Remember from the CT perspective, within the behavioral, cognitive, and affective responses are a series of schemas or core beliefs that influence how an individual will respond. In counseling, the schemas or core beliefs are converted to testable hypotheses (Beck et al., 1979). Clients are asked to test their hypotheses or look for evidence to either confirm or deny their core beliefs. The process of using the scientific method to test the client’s beliefs is called “collaborative empiricism” (Beck et al., 1979). The other strategy that directs the course of CT counseling is a process called “guided discovery.” Guided discovery looks for themes in present dysfunctional thoughts and links the themes to previous experiences (Beck et al., 1994). During the guided discovery process, the counselor and client seek to uncover the origins of his or her thoughts and uncover his or her cognitive distortions. It is important for the client to recognize his or her automatic thoughts and determine if the automatic thoughts are negative or dysfunctional (Beck et al., 1979). Following this, the client will be able to understand how cognitions influence behaviors and feelings (Beck et al., 1979). The counselor works with the client to help him or her deactivate his or her dysfunctional thoughts (Beck et al., 1979). To deactivate the thoughts, the counselor aims to loosen the power the thoughts have over the client and help the client become less sensitive to the dysfunctional thoughts (Beck et al., 1979). Once this process is underway, the counselor can help the client modify his or her current beliefs. Remember, this model of therapy closely follows the scientific model; thus, the counselor works with the client to help the client assess the evidence in support of or against the automatic thoughts (Beck et al., 1979). Dependent on the outcome of the evidence search, the counselor works with the client to help him or her develop cognitions founded in reality (Beck et al., 1979). Subsequently, the counselor adapts new beliefs or modes to help the client uncover new, healthier cognitive thought patterns. Together, the CT counselor and the client examine dysfunctional beliefs to adjust them into functional beliefs. The counselor fully integrates this process with the client (Beck et al., 1979). Thus, the client will be able to detect dysfunctional thoughts, alter these thoughts to be more objective and, therefore, the client’s thoughts will no longer distort his or her experiences. COGNITIVE BEHAVIORAL THERAPY TECHNIQUES AND INTEGRATION OF EXPRESSIVE ARTS The term “CBT” is designated for combining the cognitive model of therapy with behavioral interventions (Beck, 2005). The outline of CBT techniques often is in alignment with the use of the techniques from an expressive arts perspective. In both CBT and the expressive arts, the common goal is for the client to achieve behavioral change. During a counseling session after the execution of any intervention, both in CBT and in counseling using the expressive arts, time is set aside for processing the intervention. During this time, the use of questioning, reflection,

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and learning from the intervention occurs. From a CBT perspective, the goal may be focused on cognitive restructuring. It is important to note, however, that even if the term “cognitive restructuring” is not used in expressive arts modalities, this does not mean that change in the client’s thought process does not occur. Through both the CBT and the use of expressive arts in counseling, changes in thoughts and behaviors can be expected. The uses of the expressive arts are often already included in CBT techniques or could easily fall into a category of a behavioral intervention. For example, CBT is known for using journaling to chart progress and explore current thoughts and feelings. From the expressive arts perspective, writing and poetry are common modalities often already used for this purpose. CBT is also known for the inclusion of role-play. Role-playing involves practicing new behavioral skills or preparing the client for a difficult social situation by practicing the situation in counseling. In drama therapy, role-playing is frequently used. Dance therapy could also be used to role-play through movement. Aside from cross-utilized techniques, other techniques could easily be adapted into expressive arts techniques. The CBT technique of guided imagery is already commonly used in drama therapy. Guided imagery is the process of allowing the imagination to guide the client toward healing. The counselor will often tell a story or direct the client to imagine what the counselor is saying. Guided imagery is often used to aid in relaxation or helping the client to imagine a time when he or she will have the quality of mental health he or she desires. The inclusion of music could enhance a guided imagery, thus making the technique a music therapy intervention as well. CBT includes the technique of reprocessing memories to uncover the etiology of cognitive distortions. This could easily become an art therapy invention. The client could draw the memory of when the distortion began. Then, the client could paint over the picture to change it to a more adaptive memory. Thus, the client could have a physical representation of a healthier thought process. EMPIRICAL SUPPORT FOR COGNITIVE BEHAVIORAL THERAPY Beck believed that mental health disorders could be categorized by common thought processes. Beck is a prolific author and often writes about the thought processes of certain mental disorders while creating guidebooks for helping others counsel clients with various mental health disorders. He has written books over such disorders as working with depression, anxiety, personality, bipolar, schizophrenia, and substance abuse while creating a model for treating individuals with these disorders. The evidence-based practices movement is strongly influencing the counseling profession. Several key components of this movement are knowing when, how, and with whom to use which theoretical orientation. The structure of CBT allows this orientation to be researched; thus, there are numerous studies supporting its use with various populations, psychological issues, and settings. In 2012, a meta-analysis of meta-analyses examined empirical support for CBT across psychological conditions (Hofmann et al., 2012). Results from numerous studies reviewed in the article reported using CBT may produce efficacious outcomes when working with individuals with depressive disorders, anxiety disorders, bipolar disorders, substance abuse issues, psychotic disorders, sleep disorders, obsessive-compulsive disorder, posttraumatic stress disorder, eating disorders, somatoform disorders, anger management, personality disorders, and health concerns (e.g., chronic pain). Despite Beck’s development of CT for use with depression, Hofmann et al. acknowledged that CBT may be most effective for stress, anxiety disorders, somatoform disorders, anger management, and eating disorders, but symptom reduction is expected across other disorders. The use of CBT may also be helpful with youth and elderly. Separate meta-analyses also reported efficacious results to treat posttraumatic stress disorder

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(PTSD) with depressive symptoms (Sijbrandij, Kunovski, & Cuijpers, 2016), marital distress (Butler, Chapman, Forman, & Beck, 2006), and sexual dysfunction both in person and online (Andersson, Cuijpers, Carlbring, Riper, & Herman, 2014). Much of the research included in the meta-analyses were well designed studies using randomized controlled trials. This suggests the findings are valid representations of CBT effectiveness and that using a CBT orientation in counseling may be beneficial for clients of all ages with most disorders and behavioral concerns. Not all disorders or behavioral concerns have been investigated with a meta-analysis. Other conditions that may improve after CBT intervention include hoarding (Kellett, Matuozzo, & Kotecha, 2015), factitious disorders (Borojeni, Zaheriany, Borojeni, & Bidaki, 2011), and dissociative disorders (Gillig, 2009). Although without randomized clinical trials testing symptom reduction, using CBT to treat the aforementioned conditions should be applied with caution. Although randomized clinical trials support CBT for many personality disorders (e.g., antisocial, avoidant, borderline, obsessive-compulsive), counselors should be advised when working with clients with paranoid, narcissistic, histrionic, schizoid, and schizotypal personality disorders where randomized clinical trials were not found to have been conducted (Bamelis, Evers, Spinhoven, & Arntz, 2014; Matusiewicz, Hopwood, Banducci, & Lejuez, 2011). It is important to note, however, that no studies were found assessing for treatment of cognitive disorders. Therefore, counselors should be cautious about applying CBT when working with clients facing dementia. MULTICULTURAL CONSIDERATIONS Given the impeccable empirical support for CBT across disorders, it may be tempting for counselors to apply CBT with all clinical cases without consideration if this is the best model for all clients. When using CBT it is important to take a postmodern approach that considers the client’s worldview. Therefore, the counselor will not want to take a one-size-fits-all approach; instead, the counselor should be sensitive to the unique needs of the client. Being sensitive to the individualistic nature of clients leads a counselor to question what populations may benefit from CBT intervention. For example, a meta-analysis examining CBT effectiveness for treating substance abuse with Whites compared to Blacks and Hispanics found that while CBT was beneficial, it was consistently more effective for White populations (Cambraia Windsor, Jemal, & Alessi, 2015). The lack of consistency across populations could be attributed to limited empirical studies exploring CBT effectiveness with racial (Wilson & Cottone, 2013) and sexual minorities (Craig, Austin, & Alessi, 2013). Counselors need to examine when CBT may be more or less helpful with clients. An area of concern is implicit bias. CBT does not necessarily attend to implicit racism, heterosexism, or social economic status bias. When counselors are confronted with client-reported implicit bias, CBT counselors may ask for tangible proof of the bias or justification for the mental health distress experienced by clients. However, when clients feel judged based on the color of their skin, their sexual orientation, or their income, the person delivering the oppressive messages may not be sending an overt message. Instead, the bias comes from the way clients are being looked at, not promoted at work, or similar experiences. When a CBT counselor asks the client for evidence or support suggesting the client is the target of oppression, it may not be possible to demonstrate evidence that the client is disliked or was not promoted because of his or her minority status. Instead of providing support to the client facing the injustices, the CBT counselor may tell the client that the thought patterns are not functional or are catastrophic. The messages that the counselor sends through using terms like “maladaptive” or “irrational thoughts” continue to subjugate the client instead of validating legitimate concerns. A CBT counselor needs to acknowledge that covert messages are just as valid as overt messages in supplying evidence for the adverse events the client may be facing. When CBT counselors become as sensitive to implicit messages as they are to explicit messages, they can began to develop multiculturally sensitive relationships with clients.

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CONCLUSION There is strong empirical support for the use of cognitive-based therapy for a range of client concerns, which makes it a frequent choice for many clinicians. The successful practice of this form of therapy requires counselors to help clients intentionally identify and explore the faulty beliefs that they hold and actively work to change these. The expressive arts provide multiple methods of exploring clients’ connections between thoughts and action and the following are multiple examples of how CBT can be integrated with creative expression.

Expressive Arts Interventions

A THOUSAND WORDS: COGNITIVE BEHAVIORAL PHOTOTHERAPY Savannah Cormier

Indications: The focus of this intervention is on working with clients who are experienc-

ing significant concerns in life due to difficulties or struggles in personal (family, romantic, friendships, etc.) and/or professional relationships. Clients facing difficulties in relationships or struggles in connecting with others may experience issues in identity and self-concept, self-esteem, anxiety, depression, and more (Duru, 2008; Haslam, Cruwys, Haslam, Dingle, & Chang, 2016; Jaremka et al., 2012; McWhirter, 1990; Yalom & Leszcz, 2005). These issues can stem from a variety of sources including recent transitions, ineffective social skills, lack of boundary setting, poor communication skills, trauma, and attachment issues. Using the creative modality of photos and photography, this intervention provides clients with a familiar, yet novel, way of communicating their perceptions of themselves in various relationships. Through photographic images, either taken by themselves or collected from other sources, clients are able to reflect upon, explore, and discuss their beliefs about themselves, relationship dynamics, and perceptions of social connectedness. Goal: To assist clients in reflecting on and exploring their beliefs and perceptions of themselves in relationships and work toward new behaviors that will promote interpersonal effectiveness and experiences of social connectedness Modality: Photography, Collage-making, Art The Fit: This intervention fits with a cognitive behavioral approach in its focus on exploring perceptions, beliefs, and cognitive distortions and then adapting these to promote new behaviors that will help clients achieve their goals. While different therapists may approach the cognitive counseling theories from a variety of angles, a primary focus in cognitive behavioral therapy is exploring beliefs and perceptions, as well as their impact on current behavior, in order to help clients achieve behavioral change. For clients to improve their relationships and ways of connecting with others, it is important to first examine current beliefs, perceptions, and behaviors that clients may not be aware are impeding their ability to connect. For some individuals, diving directly into these explorations can feel intimidating and can immediately increase client anxiety, fear, and defensiveness. Using photographic images as a means of exploration can bypass those anxieties and defenses by providing a creative and novel way of examining their beliefs and perceptions of how others may experience them (Ginicola, Smith, & Trzaska, 2012). With these lowered defenses and reduced anxiety clients are more open to examine cognitive distortions and how they may be affecting their relationships. Furthermore, photos can often represent something greater than merely the image. A photo that symbolizes an experience for the client can unlock additional information he or she may not have had the insight to articulate without the means of the image, as in the common saying, “A picture is worth a thousand words.” Using this approach, explorations into beliefs, perceptions, and their impact on behavior often deepen exponentially. When this intervention is done with couples, families, or groups, an additional layer of feedback can be incorporated, with live opportunities to try out new behaviors in relationships in the here and now. 55

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Population: Children, adolescents, adults, individuals and groups, couples and families Materials: Collection of images. These can be collected with a client’s personal camera

(including phone camera), a camera borrowed from the therapist used specifically for therapy, images from the Internet, social media images, magazines, or therapist’s collection of images. A printer to have hard copies of the images is optional. Instructions: 1. An optional opening to this intervention is to share with your client one of the popular Internet memes “What People Think I Do/What I Really Do” (see www.knowyourmeme. com/photos/251963-what-people-think-i-do-what-i-really-do for an example) leading to a discussion on how different people and groups have perceptions of things, including us. Included in this discussion can be a brief explanation of cognitive behavioral therapy and how our thoughts and beliefs shape our perceptions of reality and how we respond to the world. While we can’t directly change others’ perceptions of us, we indirectly change them by adjusting how we respond to them. Similarly, we can change our behaviors if we change the thoughts that lead us to feel and act in a certain way. 2. Explain that you would like your clients to create a similar meme in which they will take or collect images to express their perceptions of how others see them in relationships. 3. Brainstorm with your clients to come up with three people or groups of people with whom they interact on a regular basis. These may include categories such as friends, significant other(s), family members, parents/children, siblings, coworkers/school peers, boss/teacher, coach/teammates, supervisor, or other significant relationships. At least one of these people or groups of people should be one that a client feels is a challenging relationship that significantly impacts his or her quality of life. 4. Using materials you and your client have agreed upon (see above section on materials), ask the client to collect images that represent how the client feels that different persons or groups perceive the client. Also tell them that you would like for them to include a fourth person: themselves. In addition to collecting images for others, they are to also collect images to reflect how they perceive themselves (their relationship with themselves, both positive and negative). 5. Once the images have been collected, ask your clients to go through and share each one for the first category, focusing less on the superficial content of the image (see Figure 4.1; e.g., “This is a picture of shoes.”) and more on what the image represents and its meaning and significance (e.g., “In this picture all of the shoes are the same except this one pair. It reminds me of how I think people at work see me—as someone who is different than the rest of the team; someone who just doesn’t fit in with the rest of the staff; someone who snuck into a group of professionals but doesn’t belong.”) As you are processing each image together, ask them how each of these perceptions impacts how they respond to that particular group or person. Using the previous example, clients might discover how perceptions of feeling different led them to isolate themselves from others at work, take less risks in order to not stand out, or other behaviors that further perpetuate this feeling and perception. Once you have gone through each image in the first category, continue to the rest of the categories, saving their perceptions of themselves for last. 6. After going over each image, move into talking about the options of changing them, keeping them the same, or adjusting them slightly. Ask your clients which images they would like to change, what is it about those images/perceptions/beliefs that they feel are not helpful, and what they would like to have instead. Continuing, ask them which images they would like to keep the same and what it is about those images/perceptions/beliefs that they feel are helpful. Role-play scenarios in which clients hold their now intentionally chosen beliefs and perceptions and how these beliefs influence how they respond to others.

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Figure 4.1 Example of collection of images under the category “People at Work” representing clients’ perceptions of how boss and coworkers see them.

7. Process with your clients what this experience was like. Discuss what each step of the activity

was like for them, including what it was like to collect the images for each category, share them with you, talk about which ones are helpful versus which ones are not, and begin working to change their beliefs, perceptions, and behaviors. Adaptations for couples, families, and groups: This intervention can be adapted in several ways in order to work with multiple people such as with couples, families, or groups. One adaptation includes prompting members to collect images that represent their beliefs on how the other members see them, as well as selecting images for how they see the other members. In this adaptation, family or group members share their images to the extent they feel comfortable while the remaining members listen. Once finished, the other members share what they heard that person say, checking in after to see if they missed anything significant. Members then have the opportunity to provide feedback in the form of their images and how they perceive that member. This adaptation provides the additional layers of feedback, opportunities for live practice of new behaviors, and opportunities for social connectedness with group members in the moment.

ACTING OUT: PARADOXICAL INTERVENTION Dixie Meyer

Indications: This activity may be used with clients who are fearful of their own reactions,

emotions, or possible responses to client-specific stimuli. It can be helpful for clients who allow their fears or apprehensions about people or events to keep them from experiencing things they would like as in cases of phobias or obsessive-compulsive disorder. Goal: To allow a client to play out his or her fears in a safe environment to give him or her a sense of control over debilitating fears and anxieties Modality: Drama The Fit: There is a creative essence to CBT. Many of the techniques used from this theoretical orientation allow the counselor to use his or her imagination in the process. One such inventive intervention is the paradoxical intervention. Paradoxical intervention asks the client to act out exactly what he or she fears (Burns, 1989). The client would be encouraged to physically or behaviorally act out what he or she is afraid might happen. The individual then, via his or her behaviors, tries to go crazy. This may include the client talking gibberish, throwing a tantrum, or pounding his or her fists. In this manner, clients are able to see that what frightens them may not actually be so fearful. In addition, by the client being able to act out this behavior, he or she is also admitting control over the behavior. Populations: Children/adolescents/adults; Individuals Materials: No special materials are required. Caution: It is important for the counselor to be mindful of the fears of the client and to avoid encouraging unethical or dangerous behavior by the client. Do not encourage clients to behave in ways that may harm themselves or another. It is essential that the client initially practice this intervention in the counselor’s presence before trying this without the counselor present. Instructions: With any counseling, the client’s safety is a concern; thus, the client may initially be encouraged to try this behavior with the counselor present. However, once the client is able to feel comfortable with the intervention and the counselor is not concerned the client will harm himself or herself, the client may also implement this activity at home. 1. Begin the practice enactment by demonstrating what the client is being asked to perform (Burns, 1989). 2. Invite the client to execute the behaviors that are feared. Encourage the client to perform his or her own behaviors and feelings rather than mimicking your demonstration so that the client can feel connected with his or her behavior. 3. During the client’s enactment, verbalize encouragers (i.e., It is okay to pound your fist or throw yourself into this activity). Encouragement from you may help the client release any anxiety associated with acting out the behaviors or help the client feel more comfortable with his or her feared behaviors and feelings. 4. After an in-session enactment, encourage the client to use this activity outside of the office on an as-needed basis, allowing the behavior to become intrinsically reinforced. If the client uses this technique with others present, it may be best if the client informs them that it is a therapeutic technique.

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CATASTROPHE COMIC BOOK Rachel L. Hughes and Dixie Meyer

Indications: The focus of this activity is to reduce automatic negative thoughts resulting from

catastrophization. For example, when hearing something negative about one’s behavior, clients may assume the other individual does not like them or that their relationship is in danger. In reality, the other individual could be trying to help. This activity will target negative thought patterns to uncover where counselors can help their clients develop more adaptive thought processes. Goal: To help clients identify when they may predict negative outcomes to provide an opportunity to reframe stressful situations as less threatening Modality: Art and Writing Therapy The Fit: This activity aligns with the interconnection of cognitions, behaviors, and emotions by addressing catastrophizations (Beck, 1967). Catastrophizing is a common cognitive distortion addressed by CBT that interprets the situation as worse than it actually is (Beck, 1967). During this activity, the clients practice interpreting the situation in a positive context through contrasting, reimagining, and creating past “catastrophes” in an objective light. Population: Children, adolescents, adults; Individuals and groups Materials: Pens, markers, colored pencils, or crayons, white paper, stapler, other decorative items such as glitter, sequins, stickers, cardboard cutouts of animals or objects Instructions: This activity offers clients a creative perspective on common cognitive distortions. Creating a comic book allows clients to recreate what they thought was a terrible scenario and instead to provide an alternative interpretation of the event. 1. Give clients four pieces of white paper and invite the clients to fold the papers in half. Staple the papers together at the crease, forming a book. 2. Explain the process of catastrophization to clients, giving an example: 2.1 Sometimes we interpret events as much worse than they actually are. Let’s say you called your friend a “jerk,” and you think to yourself, “I’m so mean. My friend will stop talking to me for sure.” Catastrophizing makes everything a worst-case scenario and can lead to self-pity or hopelessness about a situation. Today you’ll have the opportunity to be the star in your own comic book and start your journey of combating these thoughts by comparing them with an objective interpretation of these “catastrophes.” 3. Invite clients to title their comic books and create cover images using the materials provided. For example, a client could title the book, “Super Rachel and the End of Doomsday,” and draw a picture of herself battling automatic negative thoughts. Once cover pages are designed, allow clients to draw out three or four personal examples of catastrophization, including drawing themselves, the exaggerated situation, and speech bubbles describing the negative thoughts about the situation in great detail. The drawings should fall on the left-hand side of the booklet pages, leaving the right-hand side open for reinterpretation. 4. Once clients complete drawing their “catastrophes,” invite clients to share examples and display their initial interpretations of the event. If in a group, allow group members to offer alternative perceptions of the “catastrophe.” The therapist may do this in an individual format if the client is struggling. 59

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5. Invite clients to draw on the right-hand side of the pages how they might reimagine a less

exaggerated, objective interpretation of the “catastrophe” with corresponding thought bubbles. 6. At completion of the reinterpreted drawings, invite clients to share the drawings of the

positive reinterpretations of the event. Facilitate group conversation around the difference in cognitive and emotional content between contrasting images. For example: How did your feelings change as a result of the positive interpretation? What behaviors could you change to match your new outlook? How do you think catastrophizing certain events may impact your mood throughout the day?

COGNITIVE BEHAVIORAL THERAPY DRAMA IN TWO ACTS Dixie Meyer

Indications: This activity is especially appropriate when a client is developing ways to expand

his or her behavior repertoire or when a client is preparing to face a challenging or potentially emotionally charged social situation or seeking to stretch personal boundaries. Goal: To prepare a client to successfully manage an upcoming personal interaction Modality: Drama The Fit: Drama therapy seems to be the expressive art modality most easily in alignment with CBT. With the strong emphasis on behavioral change and practicing new behaviors prior to real-life execution, both CBT and drama therapy are similar in application. For example, one technique frequently implemented in both CBT and drama therapy is the role-play. Role-play is a form of skills training in which the client is able to act out a social situation of his or her choice. Populations: Children/adolescents/adults; Couples/families/groups/individuals Materials: No special materials are required. Instructions: The following technique will focus on executing a role-play while encouraging the client to expand his or her behavioral repertoire. This technique may be executed as a typical role-play with one adjustment. Act I: 1. Ask the client to focus on the upcoming challenging interaction. 2. Ask the client to initially try the role-play of the difficult situation behaving and speaking in his or her normal manner. 3. Process the role-play and ask the client to focus on the emotions that arose out of the experiences, what was expected and unexpected in the role-play, what he or she thought about the process, and his or her likes and dislikes about the role-play. Act II: 1. Ask the client to think about a character from a movie or play that he or she would like to emulate in real life, in general, and the upcoming situation, in specific. Character of choice may be someone who has survived despite impossible odds such as Dieter Dengler, the only prisoner of war taken in combat during the Vietnam War who successfully escaped; his story is told in the movie Rescue Dawn. A client may want to portray a selfless individual such as George Bailey from the movie It’s a Wonderful Life. A client may also choose to portray an individual who never gave up his or her hopeful attitude such as Anne Frank, the young Jewish girl who lived in hiding during World War II; her story is told through her book, The Diary of Anne Frank. 2. Ask the client to execute the role-play again personifying the admired character. 3. After playing out the new role in the familiar situation, invite the client to explore what he or she would like to take from the role-play and to incorporate into his or her thought, affect, and behavioral repertoires. Curtain Call: At the follow-up session after the actual interaction has occurred, ask the client to share the ways in which he or she emulated the character and ask him or her to “play the character” as he or she gives his or her assessment of the interaction. 61

A DAY IN LIFE WITHOUT THE DISORDER Abigail Nedved and Dixie Meyer

Indications: Eating Disorders, Depression, or Anxiety Goal: To allow clients to consider how their lives would change if they quit being weighed

down by their disordered thoughts, behaviors, or emotions Modality: Art and Drama Therapy The Fit: The intervention is composed of a two-step intervention with both art and drama therapy. The art therapy component utilizes the ABC model of cognitive behavioral therapy to help restructure cognitive processes (Ellis, 1999). The drama therapy component provides the clients the opportunity to role-play their new day, a common CBT technique (Hamamci, 2006). Counselors guide the intervention while asking clients how their thoughts and behaviors affect their emotions throughout engaging in the art project and role-play. Population: This intervention is suitable for all ages: children, adolescents, and adults; individuals and groups. Counselor–client interactions should reflect a developmentally appropriate line of inquiry. Materials: Paper, paint, paint brushes, crayons, colored pencils, magazine clips, mod podge, glue, scissors, etc. Instructions: During this activity, clients are asked to artistically create a day without their disorder followed by making the artwork come to life during a role-play. 1. Clients are initially asked to create what a day would look like without their disorder using various art supplies (i.e., draw, paint, collage, etc.). 2. Once clients have created their pictures or collages, the counselor will process the artistic creation using the ABC model of cognitive behavioral therapy. To process the activating event, example questions could be: What was going through your mind before doing this project? Did you notice any anticipatory feelings before beginning this project? or What motivated you to do this? To process the beliefs held by the clients, example questions could be: What aspects of the picture do you believe you are able to attain? What were your thoughts while completing this project? or What keeps you from achieving this day? To process how the consequences affect the client, example questions could be: How would you be affected if this day happened? What from your artistic creation are you currently working toward? or How could you progress to this day? 3. After the counselor and clients have processed the artistic creation, the counselor will ask the clients to step into the picture. The counselor may want to use the following directions: Now I would like for you to try out the new behaviors you created in your picture. The clients will be asked to role-play using the help of the counselor or other group members as needed to create their miracle day. As the clients role-play their day, the clients are able to model new behaviors and assess how their thoughts have changed. 4. After the role-play, the counselor will process the role-play with the clients. The counselor may inquire through questions related to how their behaviors in their role-play are different from their typical behaviors. The counselor might ask, What are their new thoughts as they are executing the behaviors? 5. The final step is to examine what a day without the disorder cumulatively feels like for the clients. The counselor will ask how the clients feel differently executing these behaviors as a result of not having the disorder. The counselor will then ask what parts of this day the clients are able to begin to execute now. 62

FELTING WITH FAMILY Cheryl L. Shiflett and HoiLam Tang

Indications: Children and adolescents with an autism spectrum disorder and their families

may benefit from the collaborative, manipulative, and tactile dimensions of this art intervention. Goals: To promote cooperative and reciprocal interaction with siblings, to promote sensory integration, and to develop communicating choices Modality: Art The Fit: The purpose of this activity is to expand the client’s tolerance of tactile and kinesthetic exploration of art materials, provide opportunities to select and communicate color choices, and to promote cooperative and reciprocal interactions with siblings. Used in a group of siblings, this motivating activity facilitates a primarily nonverbal method to build meaningful interactions with family members while empowering the client with opportunities to make choices about materials and to safely and actively explore those materials with touch. This activity lends itself to a cognitive behavioral approach because it promotes social learning through observation of other siblings’ social interactions and imitating behaviors demonstrated by the therapist or counselor. According to Bandura (1977), human behavior is learned and modeled based on observation. By shaping desired behavior to interact with art materials, prompting continued engagement, and by reinforcing the interaction between client, sibling, and material, the client’s perception of a successful experience provides a conceptual reference for repeating interactive and engaging behaviors in novel circumstances (Kazdin, 2001). The felting material and felting process provide tactile sensory nourishment, a primary building block for sensory integration and ultimately developing academic readiness and more complex cognitive skills (Kranowitz, 1998). The authors have used this activity in a sibling art therapy group for children diagnosed with an autism spectrum disorder and with their sibling(s) in a sibling art therapy group. Additionally, this activity has implications for enhancing familial relationships by including parents and caregivers in family art therapy. This technique has also been found to promote attention to task, following directions, turn-taking, and other prosocial behaviors with children attending an alternative school setting because of oppositional defiant behaviors. Populations: Children/adolescents/adults; Families/groups Materials: 20-oz assorted colored merino wool (basic primary and secondary colors); a 0.5-gal thermos filled with warm soapy water; a second 0.5- to 1-gal thermos container filled with warm, clean water; several small measuring cups; working mat (a 12-ft-round solar bubble cover or a large durable plastic bubble sheet); two or three water trays; a few small sponges; five to seven pieces of big towels; and a couple of pieces of felt cloth samples Instructions: 1. Lay down the solar bubble cover in the center of the activity room. You can stand in the middle of the solar bubble cover and invite your clients and their siblings to explore the environment together. Allow 4 to 6 minutes for your clients to get familiar with the environment and ask them to find a comfortable spot to sit on the solar bubble cover with their siblings. 2. After your clients become comfortable with the environment, a brief sensory experiment will take place by inviting your clients and their siblings to touch and feel the wool supply. Put the wool against your cheeks or between your palms; encourage your clients and their 63

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siblings to follow your actions. Ask them to identify feelings from touching the materials. Encourage them to describe their sensory feeling (e.g., soft, comfortable, ticklish, warm, itchy). For clients with limited verbal communication, incorporate communication devices or a prepared picture card choice board. As they describe their feelings, explore with them what kinds of sensory feelings they like the most. 3. Following the brief sensory experiment, pass several pieces of small felt samples for your clients to touch. Describe to them that today they are going to play with the wool and transform the wool into felt. Demonstrate the dry felting techniques to your clients by placing small pieces of wool against each other. Use two different colors and blend them together during the dry felting process. 4. Next, announce to your clients that they are going to pick their favorite colors to create a piece of soft felt with their siblings. Ask your clients and their siblings to learn each other’s favorite colors. Ask your clients and their siblings to select their favorite color from the wool supply bin. 5. Then, assist them with the dry felting technique by placing small pieces of wool against each other. Emphasize to each sibling team the importance of connecting their wool on the flat solar bubble cover. Encourage them to interact with each other by working the colors together. 6. Give approximately 5 to 8 minutes (depending on time constraints) for them to lay three to four layers of the dry wool together to make a piece of woven wool. Demonstrate wet felting technique by pouring a one-half cup of warm soap water on the center of a piece of dry woven wool. Demonstrate with the sibling pair how to use their hands to slowly spread the soapy water outward and gently to rub the wet wool. Exhibit different movements (e.g., pulling, twisting, squishing). Try mixing the wool with your feet and toes. Invite siblings to lead your clients to explore different movements with the wet wool. Also, ask each team to observe other teams’ movements and try out new movements from others. 7. After 5 to 10 minutes of wet felting, provide each team with a sponge to absorb the excessive soap. Examine with each pair if the wool has successfully transformed into a piece of felt. Then, pour about 0.5 gal of warm water in the water trays. Ask each team to use the warm water to clean their felt cloth. 8. After they use the clean water to clean their felt cloth, demonstrate a catch-and-throw game with your cofacilitator. Ask each team to follow your demonstration and play throw and catch several times with the felt cloth to dry their wet felt cloths. If any client does not want to play the catch-and-throw game, ask him or her to lift the wet felt above his or her head and drop it on the solar bubble wrap many times with his or her sibling so that they can extract excessive water from their felt. 9. After the throw-and-catch game, give each team a towel. Invite each team to use the towel to clean up the working area and roll up the solar bubble cover together. 10. Using communication devices, line drawings, or images for communication when appropriate, invite responses to questions such as, How did the dry wool feel? How did the wet felt feel? What was your favorite part of felting? What was it like to make felt with your sibling? What have you learned from your siblings?

MENTAL HEALTH TOOLBOX Katherine Campbell

Indications: This technique is appropriate for clients who verbalize that they have coping skills to combat mental health symptoms or substance use disorders, but are not using them to their full advantage outside of sessions. This technique would allow the clients to have a tangible “toolbox” for all the tools/coping skills learned within a group or individual setting to increase self-resilience and reliance. Goal: To physically create a toolbox for ongoing care and immediate intervention for mental health maintenance and stress management. If the clients cognitively associate change and coping with tangible items, then they may increase their behavioral use of these mental health skills. Modality: Visual Art The Fit: The mental health toolbox is a physical form of behavioral activation, cognitive restructuring, and refutation. Through the identification of physically represented items within one’s toolbox, the client is able to improve his or her daily mastery over stress, increase confidence in the ability to change and cope, as well as realize he or she can refute irrational thoughts and unhealthy coping skills with the presence of appropriate physical tools (Ellis, 2015; Prochaska & Norcross, 2014). Population: Children, adolescents, and adults; Individuals and groups Materials: Any box would suffice (e.g., old shipping boxes, shoe container boxes, or whatever the client prefers to hold his or her tools), art supplies including markers, scissors, glue, magazines, as well as any other items of significance brought from the client’s home/life to include in the box. Instructions: 1. Introduce the activity and rationale for it in order to increase client buy-in and utilization of this intervention. 2. Have all initial materials prepared and ready for the clients prior to beginning the technique. 3. Explain to the clients the discrepancy between what is said or utilized within a session (i.e., they say they have coping skills) but they report not using them or knowing of coping skills outside of the session, particularly when needed and appropriate. 4. Let clients choose whatever box suits their needs. 5. Have clients decorate the outside of the box to their desire. These may be things that make them happy, calm, inviting, how they want to see themselves, or decorate it like an actual toolbox to give that “utilitarian” feel. 6. Once this toolbox is created, allow them to fill the toolbox with physical items and representations of their coping skills. These may include relaxation items such as music or a small journal, support group name, number, locations, day/time of meetings, a friend’s contact information, or a picture of a runner to signify going for a walk; this is where the clients (as well as the counselor) become creative in the process and personally tailor and take responsibility for treatment and symptom management. In general, these representations can either be the words written on a piece of paper, physical items for appropriate use, or representations of the words such as pictures or symbols possibly cut out from magazines. Depending on time, this may have to be broken up into multiple sessions (i.e., first introducing the idea and letting them decorate the outside of the box as well as allowing them to prepare items from home to include in the box for next session). 65

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7. While they are completing the toolboxes, it may be best to have relaxing/concentration/

soothing music on in the background or, if in a group setting, to have tables set up with enough personal space in which to allow discussion and bonding with other group members for support and ideas. 8. Once they have completed their boxes, it is time to present them. I find it best if, in a group setting, each group member stands up and presents his or her box at the front of the room. This promotes their individuality and increases the clients’ ownership of their coping styles. Further, this presentation provides a chance for others to hear about coping skills that they may not have thought of before but may be appropriate for their needs. In an individual setting, standing up as well to present the box to the counselor shows ownership of his or her work and increases the promotion of a responsible use of coping skills, that is, his or her tools. 9. Engage with the clients via your own style of processing as to what the experience was like for them, and ask the significance of these tools in their toolboxes as well as in their own recovery and maintenance. Remind clients that these tools are always available for them to use when needed and should be kept close and easily accessible. 10. Have clients take toolboxes home to use for future and ongoing needs. Possibly assign homework such as having the clients add to the box, whether creating the outside or adding tools to the inside. They should bring their toolboxes in for presentation and review next session.

REVERSAL MOVES FOR PROBLEMATIC THINKING Suzanne Degges-White

Indications: This activity is useful for clients who are embedded in unproductive patterns or who feel unable to come up with a new way of looking at a problem. Goal: To help clients find new ways of addressing issues that have them stuck Modality: Art and visualization The Fit: Clients often get stuck in negative patterns because of personal belief systems or schema that effectively lock them into predictable patterns. Through this activity, clients are encouraged to first write out their problems or presenting issues in the normal way in which they perceive events in their lives. Then, they are encouraged to let go of their preconceived perspectives or expectations through a revision of their thought processes to allow for innovative and less structured thinking. Populations: Children, adolescents, adults; Groups/individuals Materials: Two writing instruments (ideally, one regular pencil/pen and one colorful or unique marker/pen/crayon); ruled paper and drawing paper Instructions: 1. Give clients a piece of ruled paper and invite the clients to take out a pen/pencil (or provide one). Invite them to take a few moments to write out a brief description of the problem, issue, or concern that brought them to counseling. 2. After they have completed the writing exercise, ask them if you may read aloud their description. 3. Before reading the clients’ writing, communicate the following, paraphrasing into your own natural speech: 4. We often look at problems with just the “dominant” side of our brain. For left-handers, we use the right side and for right-handers, we use the left side. Both hemispheres do some really unique things. The right side is visual, and processes information in an intuitive and simultaneous way. The left side is primarily verbal, and processes information in an analytical and sequential way. Sometimes a problem needs an intuitive solution and sometimes it needs a logical solution. Yet a lot of times when we get “stuck” in a problem, it means that we’ve exhausted our dominant side’s ability to come up with a solution. By inviting the “other side” of our brain to take over, we can sometimes see a solution where there wasn’t one beforehand. 5. Read the clients’ descriptions aloud and then invite them to close their eyes or soften their gaze. Invite them to let their minds drift past the problem issue and to allow their “nondominant” hemisphere to take over and visualize a solution or a part of the solution to their concern. You can tell clients to imagine that the written words become blurry and the letters shift from spelling out words to becoming an image of the solution to their problem. Ask the client to watch the letters and words transform into a picture of the answer. Have the client tell the words that they need to solve the problem so the problem can be unraveled. 6. After giving them a few moments to let their minds engage in a new way, invite the clients to hold on to their developing solutions as they open their eyes or come back to focus. Place in front of them a sheet of drawing paper and a unique or different marker, pen, or crayon. Invite them to take the pen into their nondominant hand to transfer the new ideas 67

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generated by their nondominant brain hemisphere onto the paper. Assure them that they can use whatever form of creative processing they would like to use, such as visual images, words, symbols, phrases, self-directives, and so forth. 7. After clients have transferred their imagined solutions onto the paper, invite them to share with you their newly developed ideas about working their dilemma. 8. Process how it was for clients to imagine letting go of their dominant way of looking at things as well as to use their nondominant hand to draw/write. Does their tendency to “look at things in only one way” ever get in the way of their problem solving or interactions with others?

THE TEAPOT TRANSITION Nancy L. Davis

Indications: This activity is directed at individuals with some block to change when facing transitions. Goal: To assist clients in developing action plans for handling upcoming transitions Modality: Expressive writing The Fit: This activity fits with the cognitive behavioral emphasis on the connection between our thoughts and our behaviors. By creating and stating plans for future action, we are changing our future behavior through thoughtful planning. Populations: Older children/adolescents/adults; Groups/individuals Materials: Paper, writing instruments Instructions: 1. Print out a picture of a teakettle to represent the need to let ideas “simmer” and “brew” until ready for action. Print out the prompts on surface of choice (a chalkboard, paper, small pieces of papers in an envelope, etc.) 2. Each participant will receive a small envelope with the following phrases to complete. Phrases inside the make-believe teapot: With some planning, I can . . .; In the past, when I was stuck, I tried . . .; I have confidence that I will start . . .; One person who can help me is . . .; Three baby steps I can accomplish include . . . 3. Explain the challenges of making progress over obstacles using this script: When individuals meet obstacles in their lives, they often find themselves floundering. Some might say they feel that they are “stuck.” The emotional impact of this condition can restrict the behaviors that would enable positive movement. Stopping for a cup of tea can afford some reflective opportunities. In your make-believe teapot, you will find some phrases to help you start thinking of ways to overcome the obstacles you’re facing. With the phrases you find, complete sentences addressing your specific problem. Example: If the phrase says, “With some planning, I can . . .” then you would write something like this: “With some planning, I can contact a counselor, make an appointment, and begin work on my addiction.” 4. After each participant has had time to come up with some action plans, invite the group to share their ideas and to help those who are still stuck in the process of developing ideas.

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TUCKED AWAY Mayra Aragon Prada and Dixie Meyer

Indications: This activity is useful for clients who feel stuck. For example, a client may be working a position without career advancement and the client may be unable to generate a new way of looking at the situation. Goal: To reevaluate a current situation to generate a new outlook that allows clients to see the situations through a different lens; to help clients find the positive components and outcomes that are tucked away in those difficult/stuck situations Modality: Art The Fit: Clients are often stuck assessing a situation through one lens, their negative/ dysfunctional thought patterns, and forget all situations can be assessed through multiple perspectives. This activity encourages clients to try to find something special tucked away in a wrinkled piece of paper. The wrinkled piece of paper symbolically represents the current negative situation faced by the clients. At first glance, it no longer looks as nice as a brand new piece of paper but then clients are encouraged to look beyond the wrinkles and start to see the lines left behind, changing their perspective through finding what image is tucked away in what could be a discarded piece of paper. This can help the client deactivate his or her dysfunctional thoughts (Beck et al., 1979). During and after the activity, clients are encouraged to explore current thoughts and feelings about the paper and relate them to their lives. By using art in therapy, there is a greater emotional commitment to target (Barahal, 2008) altering dysfunctional emotions, behaviors, and thoughts. This activity targets individual’s reasoning, questioning and investigating, observing and describing, comparing and connecting, finding complexity, and exploring others’ viewpoints (Barahal, 2008). When this activity is done with multiple individuals/family members, clients learn from each other that there is more than one way to see a situation (in this case what image is tucked away). Population: Children/adolescents/adults; Couples/families/groups/individuals Materials: Pencil, markers, crayons, or colored pencils and drawing paper Instructions: 1. Start off by establishing the basis for the “Tucked Away” activity by indicating there is something beautiful in everything, even in a piece of crumpled paper and that the piece of wrinkled paper contains images to find. 2. Give clients a piece of drawing paper, ask them to roll up the piece of paper, crumble it up into a ball, and then ask them to smooth it out. 3. Once the clients have smoothed out the paper, ask them to observe the wrinkle lines. Encourage clients by describing objects that have been found in crumbled paper such as faces, shapes, or houses in the wrinkles. 4. Give the clients a pencil, colored pencils, or another drawing tool to add more dimensions to the lines. 5. Ask the clients to share their results after 10 minutes. After participants have had time to discover what is tucked away in their papers, invite the group to share their ideas, and to help those who are still stuck or unable to see what is tucked away.

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6. After everyone has shared the surprises in their papers, invite them to take a few moments

to write out a major problem or situation that is bothering them or brought them into therapy. Ask the clients to try to look at their situations in the same manner as they did the lines in the wrinkled paper. If a person is unable to come up with something, encourage others to help him or her out.

YES, AND YOU UNDERSTAND Fatima La’Juan Muse and Dixie Meyer

Indications: This activity may be used with couples or families seeking to improve com-

munication. It is helpful for those who feel that their thoughts or feelings are unheard and misunderstood. This activity may be helpful for those unresolvable problems couples face from the mundane of which way the toilet paper should be placed on the roll to in-law challenges. Goal: To promote an effective communication cycle; to create a space for exploration and understanding of communication patterns through lighthearted fun, although it is possible this activity could lead individuals to change their perspective on a topic of disagreement Modality: Drama Therapy The Fit: A primary goal of CBT is to challenge maladaptive thoughts through exploring new ways of thinking and behaving. This is often accomplished through Socratic questioning (Treadwell, Kumar, & Wright, 2002). This activity will utilize improvisation to explore new thoughts, feelings, and behaviors. As written dialogue and plot are absent, improv theater allows for freedom of thought and process (Goldie, 2015). The “Yes, And You Understand” game challenges maladaptive and unproductive thoughts by restricting “No, but” comments and requiring acceptance/validation through “yes” as well as creativity/exploration through “and.” Quite often in arguments, communication breaks down and misunderstandings arise. This intervention offers a twist to conventional Socratic questioning. Clients are encouraged to refrain from countering their loved one’s statements with a “yes, but” and instead clients use the truthful statements made by their partner as an exploration tool in order to reply with a supportive “yes, and” statement. In this manner, clients are able to communicate more effectively while having fun. Population: Adolescents/adults; families/couples; Groups of two or more clients Materials: A buzzer or a bell is needed to ding clients if they use outlawed language. Instructions: Similar to improv theater where a topic is selected by the audience, the counselor chooses a subject that is a point of contention between the clients. The counselor then selects who is the lead and who is the supporting player. The lead player begins with a statement related to the topic that addresses his or her thoughts or feelings on the subject. The supporting player responds with an affirmative statement, “yes, and,” to demonstrate support for the thoughts and feelings of the lead player. If one partner uses the words, “yes, but,” the counselor will sound a buzzer or bell saying he or she used a phrase that is not allowed in the conversation. The activity ends when the lead player truly believes that the supporting player understands the lead player’s stance on the topic by saying, “Yes, and you understand!” 1. This activity is almost completely self-directed by clients after the counselor introduces the scene (point of disagreement). 1.1 Counselor: “Welcome to The Play Room and we hope you enjoy this scene entitled, ‘But the lamp is on your side of the bed.’ SCENE!” 1.2 Lead Player: “It frustrates me when you go to sleep and leave the lamp on because it always wakes me up.”

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2. The supporting player may be uncomfortable initially as he or she is being asked to speak

against his or her interest. The counselor may need to remind clients to use a “yes, and” statement in order to add new information and move the scene along. 2.1 Supporting Player: “Yes, and you don’t enjoy being frustrated before going to bed.” 2.2 Lead Player: “Yes, and I feel guilty if I wake you up to turn it off, so quite often I get out of bed and walk to the other side to do it myself.” 2.3 Supporting Player: “Yes, and when you get out of bed to turn off the lamp you sometimes have a difficult time falling back asleep.” 3. At this point, the counselor may notice that one or both of the clients are beginning to get excited. They are each experiencing a deeper level of understanding as well as being understood. 3.1 Lead Player: “Yes, and quite often I am not able to fall back asleep so I toss and turn all night.” 3.2 Supporting Player: “Yes, and you already have a difficult time falling asleep because of your insomnia so leaving the lamp on probably makes it worse.” 4. Both clients are showing signs of communicating effortlessly and may even begin nodding their heads in agreement while smiling or even laughing. 4.1 Lead Player: “Yes, and it causes me to skip making breakfast in the morning because I’m so exhausted.” 4.2 Supporting Player: “Yes, and breakfast is your favorite meal of the day! If I turned off the lamp at night you’d be happier in the mornings and we would have breakfast together more often!” 4.3 Lead Player: “YES, AND YOU UNDERSTAND!” 5. The activity has ended and the counselor can then use this time to process with the clients what the experience was like, what connections they made, and how they might apply the concept outside of therapy. For example: What was it like to say the words, “Yes, and you understand?” What are some other situations you are facing to which you can apply this conversation at home? How did your partner validate your feelings? REFERENCES Andersson, G., Cuijpers, P., Carlbring, P., Riper, H., & Herman, E. (2014). Guided internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: A systematic review and meta-analysis. World Psychiatry, 3(3), 288–295. doi:10.1002/wps.20151 Antony, M. (2014). Behavior therapy. In D. Wedding & R. Corsini (Eds.), Current psychotherapies (10th ed., pp. 193-229). Belmont, CA: Brooks/Cole. Bamelis, L. L., Evers, S. M., Spinhoven, P., & Arntz, A. (2014). Results of a multicenter randomized controlled trial of the clinical effectiveness of schema therapy for personality disorders. American Journal of Psychiatry, 171(3), 305–322. doi:10.1176/appi.ajp.2013.12040518 Bandura, A. (1977). Social learning theory. Upper Saddle River, NJ: Prentice Hall. Barahal, S. (2008). Thinking about thinking: Preservice teachers strengthen their thinking artfully. Phi Delta Kappan, 90(4), 298–302. Beck, A., & Weishaar, M. (2014). Cognitive therapy. In D. Wedding & R. Corsini (Eds.), Current psychotherapies (10th ed., pp. 231–264). Belmont, CA: Brooks/Cole. Beck, A. T. (1967). Depression: Clinical, experimental, and theoretical aspects. New York, NY: Harper & Row. Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York, NY: International Universities Press. Beck, A. T. (2005). The current state of cognitive therapy: A 40-year retrospective. Archives of General Psychiatry, 62, 953–959. Retrieved from http://archpsyc.ama-assn.org/cgi/content/abstract/62/9/953 Beck, A. T., Freeman, A., & Davis, D. D. (1994). Cognitive therapy for personality disorders: A schema-focused approach (Rev. ed.). Sarasota, FL: Professional Resource Press/ Professional Resource Exchange. Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). Cognitive therapy of depression. New York, NY: Guilford Press.

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Borojeni, B., Zaheriany, S., Borojeni, N., & Bidaki, R. (2011). Münchausen’s syndrome in the form of factitious vomiting in a young female. Iranian Journal of Psychiatry Behavioral Science, 5(2), 146–149. Burns, D. D. (1989). Feeling good handbook. New York, NY: Plume/Penguin Books. Butler, A. C., Chapman, J. E., Forman, E.M., & Beck, A. T. (2006, January). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17–31. Cambraia Windsor, L., Jemal, A., & Alessi, E. (2015). Cognitive behavioral therapy: A meta-analysis of race and substance abuse outcomes. Cultural Diversity & Ethnic Minority Psychology, 21(2): 300–313. doi:10.1037/a0037929 Craig, S., Austin, A., & Alessi, E. (2013). Gay affirmative cognitive behavioral therapy for sexual minority youth: A clinical adaptation. Clinical Social Work Journal, 41, 258–266. doi:10.1007/s10615-012-0427-9 Duru, E. (2008). The predictive analysis of adjustment difficulties from loneliness, social support, and social connectedness. Kuram ve Uygulamada Egitim Bilimleri, 8(3), 849–856. Ellis, A. (1962). Reason and emotion in psychotherapy. Secaucus, NJ: Citadel Press. Ellis, A. (1998). How to control your anxiety before it controls you. Secaucus, NJ: Caroll Publishing Group. Ellis, A. (1999). Reason and emotion in psychotherapy: A comprehensive method of treating human disturbances. New York, NY: Citadel Press. Ellis, A., & Jaffe Ellis, D. (2014). Rational emotive behavioral therapy. In D. Wedding & R. Corsini (Eds.), Current psychotherapies (10th ed., pp. 151–191). Belmont, CA: Brooks/Cole. Ellis, D. J. (2015). Rational emotive behavior therapy. In E. S. Neukrug (Ed.), The SAGE encyclopedia of theory in counseling and psychotherapy (pp. 848–853). Thousand Oaks, CA: SAGE. Gillig, P. (2009). Dissociative identity disorder: A controversial diagnosis. Psychiatry, 6(3), 24–29. Ginicola, M. M., Smith, C., & Trzaska, J. (2012). Counseling through images: Using photography to guide the counseling process and achieve treatment goals. Journal of Creativity in Mental Health, 7(4), 310–329. Goldie, A. (2015). The improv book: Improvisation for theatre, comedy, education and life. London, UK: Oberon Books. Hamamci, Z. (2006). Integrating psychodrama and cognitive behavioral therapy to treat moderate depression. The Arts in Psychotherapy, 33(3), 199–207. doi:10.1016/j.aip.2006.02.001 Haslam, C., Cruwys, T., Haslam, S. A., Dingle, G., & Chang, M. X. (2016). Groups 4 health: Evidence that a social-identity intervention that builds and strengthens social group membership improves mental health. Journal of Affective Disorders, 194, 188–195. Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36, 427–440. doi: 10.1007/ s10608-012-9476-1. Jaremka, L. M., Andridge, R. R., Fagundes, C. P., Alfano, C. M., Povoski, S. P., Lipari, A.M. et al. (2013). Pain, depression, and fatigue: Loneliness as a longitudinal risk factor. Health Psychology, 19. Advance online publication. doi: 10.1037/a0034012. Kazdin, A. E. (2001). Behavior modification in applied settings (6th ed.). Belmont, CA: Wadsworth/Thomson. Kellett, S., Matuozzo, H., & Kotecha, C. (2015). Effectiveness of cognitive-behaviour therapy for hoarding disorder in people with mild intellectual disabilities. Research in Developmental Disabilities, 47, 385–392. doi:10.1016/j.ridd.2015.09.021 Kranowitz, C. S. (1998). The out-of-sync child: Recognizing and coping with sensory integration dysfunction. New York, NY: Berkley Publishing Group. Lazarus, A. A. (1971). Behavior therapy and beyond. New York, NY: McGraw-Hill. Matusiewicz, A., Hopwood, C., Banducci, A., & Lejuez, C. (2011). The effectiveness of cognitive behavioral therapy for personality disorders. Psychiatric Clinics of North America, 33(3), 657–685. doi:10.1016/j .psc.2010.04.007 McWhirter, B.T. (1990). Loneliness: A review of the current literature, with implications for counseling and research. Journal of Counseling and Development 68, 417–422. DOI: 10.1002/j.1556-6676.1990.tb02521.x. Prochaska, J. O., & Norcross, J. C. (2014). Systems of psychotherapy: A transtheoretical analysis (pp. 226–227). Pacific Grove, CA: Brooks-Cole. Sijbrandij, M., Kunovski, I., & Cuijpers, P. (2016). Effectiveness of internet-delivered cognitive behavioral therapy for posttraumatic stress disorder: A systematic review and meta-analysis. Depression and Anxiety, 33(9), 763–791. doi:10.1002/da.22533 Treadwell, T. W., Kumar, V. K., & Wright, J. H. (2002). Enriching psychodrama through the use of cognitive behavioral therapy techniques. Journal of Group Psychotherapy, Psychodrama & Sociometry, 55(2/3), 55–65. Wilson, C., & Cottone, R. (2013). Using cognitive behavior therapy in clinical work with African American children and adolescents: A review of the literature. Journal of Multicultural Counseling and Development, 41, 130–143. doi:10.1002/j.2161-1912.2013.00032.x Yalom, I. & Leszcz, M. (2005). Theory and practice of group psychotherapy. New York, NY: Perseus Book Group.

5 Choice Theory Torey L. Portrie-Bethke

Choice theory is short term, action based, and focuses on the resolution of problems in the present; it is a creative therapeutic process that entails exploring mental images in our minds known as “quality worlds.” This chapter will explain the history and basic tenets of choice theory, and then discuss how expressive arts techniques can be integrated within it. FOUNDATIONS OF CHOICE THEORY Choice theory (1998), an expansion of reality therapy (1965), was originated and authored by William Glasser, a board-certified psychiatrist. His therapeutic vision began in 1962, when he created a theory focused on personal responsibility and choice. Although Glasser’s theoretical beliefs do not emphasize exploring past experiences, it is important to recognize a few of his critical life experiences that he attributes to the development of this theory. William Glasser was born May 11, 1925, in Cleveland, OH; he was raised by parents who he describes as being loving toward him and incompatible with each other (Glasser, 1998). At an early age, Glasser recognized the struggle for power and control, relationship disconnect, and lack of fun present in his parents’ partnership. The brief information provided by Glasser highlighting his past childhood gives insight into the development of this theory that emphasizes personal connection in relationships, choice and responsibility, consideration of others, and compatible basic needs in partnerships. In addition to observing relationships that led to his understanding of personal choice and needs, Glasser was a dedicated student; his educational journey entailed earning three challenging degrees. He began his professional career by earning a degree as an engineer, and he spent 1 year employed as a chemical engineer. This profession did not fulfill Glasser’s basic needs and as a result, he chose to enter a doctoral program in clinical psychology. Consistent with Glasser’s belief of reevaluation and purposeful planning, after earning his master’s degree in clinical psychology, he then continued to earn a medical degree in psychiatry. At the age of 28, Glasser completed his medical degree and began the development of what would become reality therapy and later, choice theory. Glasser developed this theoretical construct from the writings of Powers (1973) on control system theory (Seligman & Reichenberg, 2010). Glasser interpreted control system theory as a way of understanding how individuals are controlled by an inner control system in the brain that guides and regulates emotions and behaviors to meet individual needs (Seligman & Reichenberg, 2010).

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Further development of Glasser’s theory shifted the focus from external control of the brain to internal control of choice. Therefore, reality/control theory later became choice theory with an emphasis on individuals’ choices of thoughts and feelings leading to more fulfilling lives. The connection among all three labels to this theory holds that the brain as a control system relates information from the external world to the present reality of what individuals want and what is currently experienced (Seligman & Reichenberg, 2010; Wubbolding, 2000). The process of discovering the gap between what an individual has and what he or she wants guides development of choice theory. Glasser (1998) chose to educate himself and live his theory in a manner that led to the advancement, development, and perfection of an internationally practiced theory that embraces present choices and honors the quality of relationships. Choice theory contributes to the counseling process by embracing the quality of relationships in the present to assist clients’ interpersonal–intrapersonal growth. This process enhances clients’ understanding of their genetically encoded needs of survival, love and belonging, power, freedom, and fun (Glasser, 1998). Although each of these needs is important and drives our choices in life, its relative strength may vary over time. CORE CONCEPTS OF CHOICE THEORY Human Nature As human beings, we are described by Glasser (1998) as genetically programmed to attempt to satisfy five psychological needs: survival, love and belonging, power (or achievement), freedom (or independence), and fun (or enjoyment). The attempts made by individuals to fulfill these psychological needs are considered the individuals’ best choice given the persons’ circumstances, experience, and energy at the time the choice was implemented (Glasser, 1998; Purkey & Schmidt, 1990; Zeeman, 2006). The methods individuals use to satisfy the inherently driven needs serve as instructions for how life is lived and fulfilled (Glasser, 1998). Glasser (1985) identifies five means for satisfying psychological needs (Archer & McCarthy, 2007; Seligman & Reichenberg, 2010; Sommers-Flanagan & Sommers-Flanagan, 2004): 1.

2.

3.

4. 5.

Fulfilling the need to belong by loving, sharing, and cooperating with others. Belonging is also satisfied by the give and take of loving relationships; having emotional contact, connections, interactions, and valued relationships with people. Fulfilling the need for power by achieving, accomplishing, and being recognized and respected. Power/achievement is also satisfied by feeling successful in achieving accomplishments and competence, self-worth, success, and control over one’s own life. Power may also be achieved in connection and collaboration with others to redefine and refine skills necessary to succeed in life. Fulfilling the need for freedom by making choices in our lives. Freedom and independence are also satisfied by the ability to make choices that best serve personal needs and those of others and to live without unnecessary limits or constraints. Freedom is also the ability to cope effectively with our environment and potentially limited choices. Fulfilling the need for fun by laughing and playing. Fun and enjoyment are also satisfied by asserting the ability to play and explore the world, and by appreciating being human. Fulfilling the need for survival. Life survival is also satisfied by experiencing the essentials in life, similar to Abraham Maslow’s hierarchy of needs. As humans, we strive for good health, food, shelter, air, medicine, sexual pleasure, safety, security, and physical comfort. Survival may be viewed as the desire to work hard and gain a sense of security.

All life circumstances and experiences result in differing degrees to which individuals choose behaviors to fulfill and satisfy psychological needs. These behavioral choices are based on the

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pictures created in individuals’ minds to capture the most pleasurable moments, experiences, and people within those events. The pictures created and recreated to capture our relationships with life are termed “quality worlds” (Glasser, 1998). Quality Worlds Quality worlds are created by small groups of pictures that represent individuals’ unique reality and perceptions of relationships and events. Generally, these pictures represent the moments of time when life experiences support basic needs or represent the life individuals most desire, filled with the people with whom individuals want to be, surrounded by acquired or earned possessions, depicting experiences individuals would like to have, and encompassing the ideas and beliefs valued. Glasser (1998) describes three categories these pictures portray: (a) the people with whom we most enjoy spending our time, (b) the material items and belongings we most want to own or experience, and (c) the thoughts, dreams, or values of belief that govern much of our behavior. As individuals develop a clearer perception of their basic needs through a collaborative counseling environment, they may gain a new awareness that their quality world needs to be reevaluated and restructured to satisfy their basic needs to lead a more fulfilling life. The counseling process is a therapeutic environment that fosters a collaborative counseling relationship to explore aspects of individuals’ quality worlds that they are able to control and where they may satisfy pleasurable desires. The motive driving this behavior to alter the true reality is a continual force to instill a pleasurable feeling in place of a not-so-pleasurable life experience. As individuals begin to view their quality worlds with untruthfulness and discrepancy regarding needs, they begin to lose sight of fulfilling basic needs. If individuals continue to choose pictures that are not realistic to their current life experiences, then they may feel disappointment and anger. As individuals engage in the counseling process and become more aware of their needs and the discrepancies in their quality worlds, it becomes more possible for them to make wiser, more realistic choices, have a greater sense over the decisions in their lives, and satisfy their basic needs (Glasser, 1998). The nonjudgmental atmosphere of the counseling relationship affords individuals the opportunity to process and explore relationships and habits. The collaborative counseling process helps hold individuals accountable for the changes in behaviors/habits in their lives they chose to make. Choice theory addresses the need for individuals to create supportive habits for their personal growth; these are termed the “seven caring habits.” Caring habits are embraced by individuals as internally controlled behaviors. These include supporting, encouraging, listening, accepting, trusting, respecting, and negotiating differences. External control is experienced as having dominant controlling behaviors over others. Individuals who believe they are dominated by external control are convinced that they know what is best for everyone including themselves. These behaviors are known as the “seven deadly habits” exhibited by individuals who are choosing external control and are disconnected from relationships by choosing to behave in a way that is criticizing, blaming, complaining, nagging, threatening, punishing, bribing, and/or rewarding to control. Both the caring and deadly habits listed previously are explored in the counseling process in regard to individuals’ total behavior. Mental Health Mental health professionals may say that Glasser’s view on mental health is extreme and possibly reckless given his assertive view that individuals choose and are responsible for behaviors, emotions, and physical problems (Sommers-Flanagan & Sommers-Flanagan, 2004). At times, this concept may seem insensitive to clients and their presenting issues; however, when implemented correctly, these techniques to transition an experience from being depressed to depressing are empowering for clients (Sommers-Flanagan & Sommers-Flanagan). The idea to use verbs in place of adjectives and nouns encourages individuals to interpret their

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emotional, physical, and mental pain in terms of choice. Glasser (1998) identifies two purposes behind this method in gaining awareness: (a) individuals purposely choose how much energy they exert when complaining, and (b) they are more aware and attuned with how their choice impacts experiences to make better choices to eliminate complaints (Archer & McCarthy, 2007). Given that Glasser’s concept of mental illness is drastically different than the mainstream view of medical models of disease, it is important to conceptualize accurately his stance for empowering individuals. Directly related to empowering individuals, the overarching tenets of the counseling profession are to empower clients to access their resources, acknowledge and embrace life transitions across the life span, support and honor individual differences, and foster positive growth and wellness. Consistent with this view, Glasser embraced an alternative empowering view to assist individuals in directing their lives. Mental illness in choice theory terms is the result of individuals’ failure to meet their five basic needs in pleasurable, effective ways (Glasser, 1998). Rather than conceptualizing problems as mental illness, choice theorists view the five basic needs as unbalanced and unmet. This failure may be viewed in five encompassing ways based on emotional difficulties: ■ ■ ■ ■ ■

loneliness and isolation loss of control and power—rather than empowerment and success illness or deprivation—rather than freedom, safety, and security monotony and depression—rather than fun and creativity irritation, rebelliousness, and inhibition—rather than freedom and mindfulness (Seligman & Reichenberg, 2010)

Effectively satisfying the five basic needs is a result of individuals being mindful of the choices made regarding thoughts, behaviors, and emotions. As counselors shift clients’/individuals’ focus from the symptoms to identifying the purpose of motivating the psychological behavior and question what goals are accomplished, they are able to assist clients/individuals in addressing positive effective strategies within their value system to meet the five basic needs in balance. Wubbolding (2000) suggested that counselors work to express empathy and validation of clients’ experiences when identifying the clients’ methods for meeting their five basic needs. Providing clients with a phenomenological experience may enhance the clients’ perceived connection and security with the counselor when venerable issues and needs are explored. CONCERNS ADDRESSED BY CHOICE THEORY Total Behavior Behavior is more directly defined and elaborated through Glasser’s (1998) view regarding choice theory. His view of theory focuses on four expansions of the word “way” as in the way of conducting oneself. Glasser describes the four inseparable components that, as a whole, make up the “way” we conduct ourselves: Activity is the first component. This involves walking, talking, playing. Thinking is the second component. This involves the thoughts and images we create. Feeling is the third component. This is described as the emotions we experience based on our behaviors. 4. Physiology is the forth component, and this includes the reaction to doing and living (heart pumping, lungs contracting and retracting, and the neurology associated with our brain functioning). 1. 2. 3.

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Considering the impact of all four components of behavior working simultaneously, Glasser (1998) expands the single word “behavior” to the two words “total behavior.” The concept of adding the word “total” preceding “behavior” refers to the four components (acting, thinking, feeling, and the physiology) associated with all our actions, thoughts, and feelings that constitute total behavior. Choice theory postulates that individuals can choose to control thinking and acting components and by doing so, they indirectly gain control over their physiology and emotions. As counselors engage clients in this process, they encourage clients to focus on changing their actions first. Changing actions and thinking is conceptualized as the beginning point for changing feelings and physiology. This concept of total behavior has been described by Wubbolding (2000) using the car analogy, where the front two wheels are the individuals’ action and thinking and the rear two wheels that follow along are the feelings and physiology (Archer & McCarthy, 2006). Given that cars are led by the front two wheels and the rear wheels follow, it is clear to see that the best driving results are when the front wheels lead. This directly applies to individuals’ choices to change action and thinking patterns first and as a result, emotions and physiology behaviors are changed and are assumed to provide an overall benefit to individuals. WDEP System Robert E. Wubbolding, another significant figure in the development, implementation, and promotion of reality therapy and its progression as choice theory, developed a system for evaluating decisions and actions. His creative strategies enhanced therapeutic outcomes by integrating the WDEP system. This delivery system was designed to enhance the theories’ practicality by Wubbolding. The WDEP system includes four main components: Wants, Direction and Doing, Evaluation, and Planning. These components may be used interchangeably and at the discretion of the counselor and clients’ needs for the more effective therapeutic process. This process is described by Wubbolding (2000) as follows: W—Wants: This process is the counselor’s and clients’ exploration of the clients’ wants and perceptions. Examination of the clients’ perceptions involves identifying what they want from relationships and the world and how hard they are willing to work to fulfill these wants. Wubbolding (1995) identified two filters through which perceptions travel when assisting individuals in making decisions of wants. These two filters are called the “lower level filter” and “upper level filter.” ■ ■

The lower level filter (total knowledge filter) recognizes and names clients’ perceptions. The upper level filter (valuing filter) appraises perceptions.

The phenomenological approach, which counselors assume while processing with clients in how they use their perception filters, fosters development of the clients’ awareness to better evaluate how their choices are fulfilling their needs. Wubbolding (2007) identified a five-level model for counselors to collaboratively assess with clients their commitment to change. The levels assist counselors in empowering clients to move from lower levels of commitment change to higher levels of change: (a) “I do not want to be here,” (b) “I want the outcome but not the effort,” (c) “I’ll try; I might,” (d) “I will do my best,” and (e) “I will do whatever it takes.” ■

Therapeutic questions to process: How do you perceive your wanting to meet your needs? How do you perceive your wanting_____to assist you in meeting your goals? How hard do you want to work?

D—Direction and Doing: Counselors and clients collaboratively explore self-talk and choices. This process enhances clients’ understanding of how they perceive themselves in the

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world and how they view aspects of their lives they are able to control and are not able to control. The focus is on what clients are doing and does not focus on specific behaviors and actions. ■

Therapeutic questions to process: What choices and actions best satisfy your basic needs? Is what you are doing getting you what you want? What self-talk comments best satisfy your motivation to make choices that fulfill your needs? Where are your current choices taking you? What were you doing the last time you felt really well?

E—Evaluation: Self-evaluation is the process in which counselors assist clients in assessing their role and the ramifications of clients’ choices to fulfill goals, actions, and perceptions. ■

Therapeutic questions to process: Is what you are doing helping or hurting you? Is what you want realistically attainable? Does your self-talk help or impede your need for satisfying choices? Are you committed enough to get the desired results? Is what you are doing getting you what you want?

P—Planning: Counselors and clients establish and reevaluate the short- and long-term goals established during the therapeutic process. The plans are a result of self-reflection, changes in wants, and the clients’ reevaluation of their total behavior. ■

Therapeutic questions to process: How will you hold yourself accountable in evaluating and completing your role in meeting this goal? How will you explore your perceptions of your wants in fulfilling your basic needs? What skills will you implement in meeting your basic needs? What behavior/s will you need to modify to have the greatest control? If you follow through with your plan, how will your life be better? How will you be living a more need-satisfying life? What will you have that you do not have now?

As counselors provide clients therapeutic questions to explore their ability to fulfill their basic needs, they are instilling a lifelong skill of personal responsibility for evaluating choices. The questioning techniques listed earlier are used in the counseling process to question and reevaluate plans to meet basic needs. This will assist clients in transferring learned skills from the counseling process to their lives. Transference of personal choice and responsibility from the counseling relationship to other relationships is an overall goal of counseling. THERAPEUTIC GOALS The counseling goals and outcomes for choice theory are described as individuals’ ability to access personal freedom and choice and to have great control over their lives by making more satisfying choices that benefit not only themselves but also others. As counselors work with clients to identify patterns in actions, they assess clients along five therapeutic goals (Sommers-Flanagan & Sommers-Flanagan, 2004): 1.

Human connection—Are clients’ personal relationships becoming more fulfilled by the connections with people in their quality worlds? ■ Identify how the counseling process provides clients access to explore their quality worlds to reflect on their innate needs and wants. ■ Explore how clients are choosing to form and maintain rewarding, fulfilling, and respecting relationships.

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Understanding total behavior—Are clients willing to recognize that their actions and thoughts are directly chosen, and are they able to recognize that their actions and thoughts lead their feelings and physiology? ■ Explore how clients are able to create successful identities. ■ Explore how clients’ actions are respectable of their core values. 3. Counseling—Are clients gaining from the counseling process? ■ Address with clients the aspects of the counseling relationship that are supportive in their process. ■ Explore the aspects of the counseling relationship that assist the clients in effectively making choices to meet their basic needs. 4. Using choice theory—Are clients able to implement the core concepts of choice theory within their relationships and are they able to let go of efforts to control others? ■ Assess the degree to which clients make choices that are respectful of others. ■ Explore how their actions impact themselves and others in their quality worlds. 5. Developing effective plans—How effectively are clients developing and implementing plans for satisfying basic needs? ■ Explore how clients’ plans assist them in maintaining active, healthy lifestyles. ■ Determine if the elements of clients’ plans are simple, attainable, measurable, immediate, involving, controlled, committed, and consistent for clients to obtain. 2.

Overall, counselors and clients work collaboratively to obtain and reach the counseling goals. Counselors encourage, support, and challenge clients to change actions and thoughts and to find a positive balance in meeting basic needs. To reach these goals, counselors educate clients on the main tenets of choice theory and the process of personal responsibility and choice for satisfying relationships. MULTICULTURAL CONSIDERATIONS Applying choice theory to diverse populations seems fitting given that the theory has a phenomenological focus used to identify individuals’ worldviews and quality worlds. Choice theory empowers clients by focusing on personal patterns and choices unique to each individual rather than assuming that all individuals fit into a specific plan. Glasser (1998) describes the five basic needs as universal needs. By incorporating needs viewed as universal to all human beings, it appears that choice theory honors the decisions and needs of the individuals receiving counseling services. Many of the concepts within this theory appear to be empowering to clients. Counselors work to empower clients by the encouragement of a successful identity, power of choice, emphasis on personal responsibility, and balance of basic needs (Seligman & Reichenberg, 2010). Counselors applying the principles of choice theory provide a framework that honors and embraces the needs of diverse and disenfranchised individuals through a humanistic process of questioning. Overall, this process is respectful of others’ choices while providing challenging considerations for personal choice and change. CHOICE THEORY AND THE CREATIVE ARTS Given that choice theory is short term, action based, and focuses on the resolution of problems in the present, it seems appropriate for diverse needs and issues of the client. In addition to the theory’s emphasis on the empowerment of individuals’ choice and responsible behavior, it

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employs a creative therapeutic approach to enhance personal fulfillment relationships. Choice theory is a creative therapeutic process that entails exploring mental images in our minds known as “quality worlds.” Any image of a quality world or new way of living our lives is representative of the relationships and experiences we desire to have or maintain to fulfill our basic needs. Capturing honest perceptions of basic needs is an important component for making effective, empowering choices in creating our quality worlds. CONCLUSION Choice theory is built on the belief that clients choose their behaviors and have the ability to make different, more effective choices in their lives. The theory encourages clients to visualize the life that they desire and it encourages clients to feel free to make choices that will better help them reach their goals. The dual focus on possibility and choice supports the integration of creative expression within this theoretical orientation.

Expressive Arts Interventions

CHOICE MOBILE ACTIVITY Rachel Payne, Chloe Lancaster, Laura Heil, and Melina Pineda

Indications: This activity is appropriate for clients who are conflicted about past choices or fearful about making the wrong choice in an upcoming situation. Goal: To assist clients in understanding choices based on volition Modality: Drama The Fit: During this activity, clients explore their total behavior by reenacting a choice they have previously made. According to Glasser, total behavior always includes four distinct yet interrelated components: acting, thinking, feeling, and physiology (1992, 1997, 1998). Acting involves all those behaviors that are discernable from the outside, such as walking, jogging, and talking. Thinking relates to our perceptions and voluntary beliefs that inform the choices that we make. Feelings are the emotive reactions we experience internally in response to external stimuli. Feelings may include anger, anxiety, and depression. Finally, physiology refers to the physical reactions that occur in our bodies, such as sweating, headaches, and other psychosomatic symptoms. Choice theorists contend that we choose our total behavior because we are able to choose how we think and how we act. The car analogy has often been used to describe how these four factors influence our total behavior (Glasser, 1992, 1997, 1998). In this depiction, the motor is the basic need, the steering wheel represents the direction we choose to pursue, and the wheels are the acting, thinking, feeling, and physiology constituents. Although all four wheels influence the path taken, thinking and acting are more dominant, as they determine the choice that is made. We can choose how we think and how we act, therefore thinking and acting represent the front wheels as they steer the direction of the car. By contrast, our physiology and feelings neither are chosen nor have to determine the choices that we make. Feeling and physiology are the back wheels, as they work in tandem with the front wheels, yet do not steer the direction. Populations: Children/adolescents; Groups Materials and Preparation: Choice mobile poster constructed from poster paper and markers prior to the session. On poster board, draw a bird’s–eye view outline of a car. Label one rear tire Feeling and the other Physiology. Label the passenger’s side front tire Thinking and the driver’s side front tire Acting. Write Acting steers on the steering wheel. Arrange four chairs for four participants. Instructions: 1. Invite clients to discuss problems that they have experienced in the previous week. Using a WDEP lens (Wubbolding, 1996), encourage clients to evaluate their choices in relation to how they are meeting their needs. 1.1 After clients have shared, introduce the clients to the poster of the choice mobile and explain and process the four components of choice making (acting, thinking, feeling, and physiology). Inform the clients that they are to perform a live enactment of a choice that has been made by one of the group members. Allow the group to decide which choice will be played out. 83

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2. Ask clients to place their chairs in the configuration of a car: Two chairs in the back seat

and two in the front seat. Each client represents a component of the choice-making process: Physiology and feelings occupy the back seat whereas thinking and acting occupy the front. 3. Ask the members to interpret their response to the problem from the perspective of their assumed roles. Emphasize the importance of describing multiple feelings and describing the physiological symptoms in detail. The more information generated by the back seat passengers will enhance the decision-making capacity of the front seat occupants. Likewise, the front seat passenger who represents thoughts should be encouraged to consider multiple options and generate a range of possible consequences. 4. The driver will execute the action. If the choice mobile has been effective, all group members will begin to understand that they are in control of their choices and are not compelled to think or act simply in terms of a prominent feeling and/or psychosomatic symptoms. This activity will help generate multiple options around a single scenario and illuminate the variety of choices available. 5. Process the activity with questions such as these: Describe the type of road your choice mobile is on. Bumpy roads are often a sign of trouble. How would the road surface influence the reactions of the passengers in the back seat? Brainstorm how the backseat cues provide important information for making informed choices. Identify a time that you have acted on your back seat cues. What do your choices look like when they are driven only by the back seat passengers—feelings and physiology? Identify times when it would be useful to consider thoughts and actions independent of their feelings and physical reactions.

“FASHION STATEMENTS ARE A FASHION CHOICE” ACTIVITY Samantha Grzesik and Katie Vena

Indications: This activity is appropriate for clients experiencing maladaptive self-image/

self-esteem body image distortions, or struggles with identity issues. Goal: To develop new perspectives on distorted thinking and decision making through analysis of personal perceptions of the world versus one’s quality world. As a result, clients will gain an insight into how their basic needs are not being met, and how this contributes to their maladaptive self-image and identity issues. Modality: Visual art The Fit: The purpose of this activity is to assist clients in understanding the ways in which negative thinking and self-talk drive them to perceive their self with distractive appreciation. Choice theory is based on the notion that external events do not motivate individuals to make poor choices, but rather their own internal expectations (Glasser, 1998). As adolescents work through Erikson’s stage of development identity versus role confusion, many young women face distortions between the media’s portrayal of ideal appearance and their own reality. This may lead to identity crises, poor self-image, and low self-esteem. By inviting young women to use clothing choice and fashion as a medium of expression, the counselor is providing a vehicle through which they can express their individuality and their self-image. Through the integration of choice theory, clients will be encouraged to move from a discussion of fashion style to what other choices in their lives signify. Dressing the self is a strong focus for many adolescents as they grow in their awareness of body image and the visual expression of their identity through their appearance. Populations: Adolescent females, 13 to 19 years old who are struggling with self-image/ self-esteem and/or identity issues Materials and Preparation: Mannequins (one thin, one average, one plus size) and large plastic bins filled with pants, sweaters, tank tops, shorts, and T-shirts that represent a range of fashion styles (i.e., preppy, hippie, emo, conservative, sexy, etc.) and brand names. These items can be purchased at garage sales, thrift stores, and so forth. Instructions: 1. Instruct the client to choose his or her “ideal outfit” from the clothing collection and to lay the clothing out on the floor. Invite the client to process the clothing choices with questions such as: What is it about this image that makes it “ideal” to you? Tell me more about the specific items of clothing (i.e., conservative top, ripped-up jeans, etc.) chosen, and what it represents to you. What do you think some of the clothing you did not choose would say to others about you? 2. Ask the client to choose and dress the mannequin he or she feels best represents his or her own body. Process this choice with questions such as: What is it about this mannequin that you feel represents you? How is this choice different from how others might see you? 3. Invite the client to move into a deeper processing of the activity and his or her self-image with questions that lead deeper into identity issues such as: What do your clothing choices say to others about you? How do you feel when you look at the outfit you chose? What is it about

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the image that expresses what you want and/or need in your ideal world? How might this image affect your self-esteem or self-image? What are some of your basic needs that you might have trouble being met based on your choices? What areas on your body do you like the most? What areas on your body do you like the least? 4. Instruct and encourage the client to verbally provide three positive affirmations about himself or herself.

FLORAL ARRANGEMENTS DEPICTING QUALITY WORLD Torey L. Portrie-Bethke

Indications: Floral arrangements signify beauty, love, loss, encouragement, acceptance, adventure, and relationships. Through creating a floral arrangement to signify intrapersonal and interpersonal relationships within clients’ quality worlds, clients will be encouraged to explore how their relationships are satisfying their basic needs of survival, love and belonging, power, freedom, and fun right now and how they plan to continue satisfying these needs in the future. Goal: To gain personal insight into their life experiences, relationships, values, and belongings through the dimensions of choice theory and the main premises of personal needs and responsibility Modality: Floral art The Fit: Exploring clients’ quality worlds will bring insight into choices and relationship needs. Encouraging clients to explore how choices are made regarding relationships will enhance clients’ abilities in determining how people, events, and dreams are within their control. Ascertaining what is within clients’ control will enhance their vision of their quality world. Populations: Children/adolescents/adults; Groups/individuals Materials: Floral arrangement materials including the holder Instructions: 1. Invite clients to select flowers that best represent themselves and those they picture in their quality worlds. 2. Ask clients to arrange the flowers to best represent their relationships with others in their quality worlds. Clients are to self-select the flowers and container for displaying the arrangement. 3. After the floral arrangements are finished, clients will process the experience with the counselor. Possible processing prompts may include: Describe how your needs of survival, love and belonging, power, freedom, and fun are met within your quality world. 4. What aspects of your needs can you control? Describe aspects of your quality world that do not meet your basic needs. Based on your current choices, identify ways you will change what you want and what you are doing. How have you built relationships that meet your basic needs? What aspects of relationships are most important to you? Describe how you give to your relationships. What aspects of your relationships provide you with the caring habits of supporting, encouraging, listening, accepting, trusting, respecting, and negotiating differences? What aspects of your relationships do you allow to be controlled by the seven deadly habits of criticizing, blaming, complaining, nagging, threatening, punishing, and bribing/rewarding to control? What control do you have over your role in these caring and deadly habits? Identify and describe your process in creating your floral arrangement. Describe what each flower or filler represents and how you decided on its place in your floral arrangement. Explore if clients represented themselves within their quality worlds.

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THE PEER PRESSURE COOKER “TAKING A STAND” Beth McCabe

Indications: This activity is helpful for youth who are dealing with peer pressure and are

unsure how to manage their choices in life. Goals: To acquire personal awareness of one’s freedom to choose and one’s responsibility in choosing; to attain personal acceptance of the given consequences in relation to one’s choices; to explore one’s motives for decision making and conscious awareness of how peer pressure can influence one’s decision-making process; to develop mental images as cues to making choices congruent with one’s self-concept Modality: Movement The Fit: The purpose of this activity is for the student/client to become aware of his or her personal freedom and responsibility in making behavioral choices independent of others’ negative influence that conflicts with who they are as an individual. A simulation of peer pressure is derived with the given activity, evoking the internal and emotional tension felt between one’s need to belong to a group and the need to be true to one’s self. Two follow-up movement activities use a tug-of-war rope and a parachute help to “paint” a visual picture of how this conflict physically feels until a decision is made that is congruent with one’s own value system. Populations: Children/adolescents; Groups Materials and Preparation: Three orange cones with “YES/TRUE,” “MAYBE/NOT SURE,” and “NO/FALSE” written on them; copy of peer pressure statements (created by you or volunteered by the group); tug-of-war rope with bandana tied at its center; four cones to mark the area that each team must cross to win the physical challenge; whistle for signal to stop; parachute (All mentioned items can be purchased from Palos Sports Sporting Goods Store in Alsip, Illinois (800) 233-5484). Instructions: Stage 1 1. Place the “MAYBE/NOT SURE” sign in the center of the other two signs with at least 20 feet of space between the other two signs placed at each opposing end. 2. Inform the students that a statement will be read that might be controversial in nature. After the statement is read, tell the students that each one must choose what “stand” they will take as their choice of response and they must make the choice without talking to other group members. They may choose to move to the YES/TRUE, MAYBE/UNSURE, or NO/FALSE marked cone. Inform the group that they will be allotted 30 seconds in which they may change their mind and move to a different position. 3. Because it is difficult for one to make decisions without fearing rejection from peers, gentle reminders should be expected and normal reactions such as talking to each other, looking where others are moving before deciding, chiding others for their decisions to stand alone, and requesting friends to follow them in their decision verbally or by physical gestures, should be viewed as “teachable moments” for future discussion. Adults can be assigned specific groups of individuals to observe and document their behaviors as well, to add to a more meaningful discussion during the debriefing period.

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4. Read the pressure cooker statements to the group of students. Reinforce the afore-

mentioned rules as needed. Document student observations by using the pressure cooker statements and writing their name and behaviors elicited next to each statement for group discussion following the activity or private discussion during individual therapy sessions in the future. 5. The following are examples of pressure cooker statements: ■ Teenagers should not be allowed to ride their skateboards on public sidewalks. ■ There should be an age limit for buying a pack of cigarettes or for smoking. ■ Recreational use of marijuana should be legal. ■ Because 18-year-olds can go to war, they should be able to drink at 18 in Indiana. ■ If I found a wallet with $50 and a driver’s license in it, I would return it to the owner with the money in it. ■ If I did not have time to study for a test, cheating on it is okay. ■ It is not my fault for being truant. ■ If a friend asked me to bully someone else, I would do it because of our friendship. ■ I would not “tag” another friend’s house if my best friend asked me. ■ It is okay to skip school because I stayed up until 2:00 a.m. playing computer/video games. ■ I would never wear my favorite shirt, which my friends made fun of, again. ■ The decisions I make today will affect my future tomorrow. ■ My family should make a curfew for me only on weekdays. ■ I should not have any curfew. ■ I have “snuck” out of the house at night. ■ Blondes are dumber than brunettes. ■ Redheads have a bad temper. ■ Girls gossip more than boys do about other people. ■ Boys have no feelings. ■ It is always the teacher’s fault if I do poorly in a subject. ■ It is always a bad idea to cut math class to skip a test. ■ Country music is “the bomb.” ■ Lying to my family is never a good idea. ■ Boys can swear, but girls should never do it. ■ Hawaiian shirts are in style. ■ A girl should be 16 before she pierces her ears. ■ I would never get a tattoo. ■ Having sex makes me cool. ■ Being in a gang is awesome. 6. After all of the statements are read, move into a debriefing session. This can be done first in small groups with mentors (seniors with juniors/sophomores with freshmen, college with high school or middle school students), or split between coleaders (counselor and cofacilitator/teacher). If a counselor is a lone facilitator, students can be divided into small groups and a leader from each group can be assigned to debrief the activity using some of these debriefing questions: What made this activity difficult for you? What topics were difficult? Did you feel uncomfortable telling the truth in front of adults? What about mentors? How about each other? What were some of the behaviors that you noticed? (Answers may include standing alone, watching others, following others). What makes a person give in to peer pressure? (Answers may include: need to fit in and belong; do not want to lose friendships; need to be liked, to avoid being made fun of/bullied.) What are some examples of positive peer pressure? (You may need to suggest some responses such as learn how to play a new game; become an ally with a friend to be kinder to someone who is in the “out” group.)

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Stage 2 Divide the students in half between each end of the tug-of-war rope. For safety, students should alternate left and right on each side of the rope. Each team is told to face the other. Inform the teams that when the whistle blows, all activity should stop. The signal to begin is ready, set, and go. Students compete for the championship by winning two out of three challenges. If there are more students than room provided on the rope, more groups can be formed. Groups can name each other and compete against all other groups to become the champion team of the school. Upon completion of this activity, ask groups to discuss how the tugging of the rope can relate to a friend being pressured into conforming to actions of a group that are not congruent with his or her self-concept. Share the metaphor that the rope symbolizes the person’s inner struggle to “fit in” by changing behaviors, dress, or ideas that conflict with one’s moral, cultural, sexual values, body image, or self-concept. Students are informed that the symbol of the rope can serve as a mental image of the pressure that is placed on someone’s heart when he or she is trying to make others conform. It can also serve as a mental reminder for checking one’s soundness in making decisions on one’s own. The “sick feeling” in the stomach can serve as an indicator for self-check in the monitoring of one’s decision. Stage 3 Introduce the final activity of parachute play. The parachute should be spread out on the ground so that it is entirely open. Students are told to walk to the parachute and sit cross-legged by one of the colors of the parachute. They are informed not to touch the parachute until all instructions are given. Students are told that they may never go under or on the chute and never trap anyone under the chute. Inform students that the goal of this activity is to cooperate with one another to achieve all tasks. Use a raised arm to begin activity and an index finger (pause sign) to stop all activity. A whistle can also be used if it is more comfortable. Students are instructed to grasp the parachute with two hands. Various parachute activities (sitting, kneeling, or standing) are listed below: ■ ■ ■ ■ ■ ■ ■

■ ■

■

Ripples—Wave wrists up and down. Waves—Raise arms higher and lower. Tidal waves—Half of chute stands, other half squats down, alternating movement. Merry-go-round—Students perform locomotion of choice as a group in a clockwise or counterclockwise direction switching on signal. Umbrella—All lift the chute at the same time keeping arms up until chute deflates. Shake the bugs off the rug—Students jump up and down shaking the parachute vigorously. Inside the mountain/on top of the mountain—Students hold onto the edges, make an umbrella, take three steps inside of the chute, pull the chute under their bottom and sit on it; Students make an umbrella and pull the edges of the chute down to the ground, kneeling on it. Shake the mountain—Inside the mountain, students push their backs against the chute bouncing their bodies back and forth. Colors—One of the four colors of the chute is called as students raise the umbrella and switch colors by going under to the other matching color (Can be done under or over the chute by crawling to the other side). Cat and mouse—Two students are chosen as mice and go under the chute. Two are chosen as cats and are on top of the chute. All other students shake the chute. The cats must attempt to catch the mice by crawling on top of the chute and tagging them. All players are given a chance to be a cat or a mouse.

Upon completion of parachute play, inform the students that the calmness felt while cooperating with one another is a feeling that they should have when their decisions are sound

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and when they feel acceptance for who they are in their group despite their choices. Inform students that with friendship comes power of influence. Peer pressure can be used in positive ways for the good of individuals, as well. REFERENCES Archer, J., & McCarthy, C. J. (2007). Counseling theories: Contemporary applications and approaches. Upper Saddle River, NJ: Prentice Hall. Glasser, W. (1985). Control theory: A new explanation of how we control our lives. New York, NY: Harper & Row. Glasser, W. (1992). Reality therapy. New York State Journal for Counseling and Development, 7(1), 5–13. Glasser, W. (1997). Teaching and learning reality therapy. In J. K. Zeig (Ed.), The evolution of psychotherapy: The third conference (pp. 123–133). New York, NY: Brunner/Mazel. Glasser, W. (1998). Choice theory: A new psychology of personal freedom. New York, NY: HarperCollins. Powers, W. T. (1973). Behavior: The control of perception. Chicago, IL: Aldine. Purkey, W. W., & Schmidt, J. J. (1990). Invitational learning for counseling and development. Ann Arbor, MI: ERIC Counseling and Personnel Services Clearinghouse. Seligman, L. W., & Reichenberg, L. W. (2010). Theories of counseling and psychotherapy: Systems, strategies, and skills (3rd ed.). Upper Saddle River, NJ: Prentice Hall. Sommers-Flanagan, J., & Sommers-Flanagan, R. (2004). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques. Hoboken, NJ: Wiley. Wubbolding, R. E. (1995). Integrating theory and practice: Expanding the theory and use of the higher level of perception. Journal of Reality Therapy, 15(1), 91–94. Wubbolding, R. E. (1996). Reality therapy: Theoretical underpinnings and implementation in practice. Directions in Mental Health Counseling, 6(9), 4–16. Wubbolding, R. E. (2000). Reality therapy for the 21st century. New York, NY: Brunner-Routledge. Wubbolding, R. E. (2007). Glasser quality school. Group Dynamics: Theory, Research, and Practice, 11, 253–261. Zeeman, R. D. (2006). Glasser’s choice theory and Purkey’s invitational education: Allied approaches to counseling and schooling. Journal of Invitational Theory and Practice, 12, 46–51.

6 Existential Theory Michele P. Mannion

If a man wishes to be sure of the road he treads on, he must close his eyes and walk in the dark.—Saint John of the Cross, Dark Night of the Soul Through the lens of multiple considerations, existential psychotherapy speaks to the larger questions of human existence and experience. Via key themes such as freedom, isolation, death, and meaninglessness, the existential clinician engages clients to contemplate how they understand their world, their lives, and the choices they make. The creative process and art making can serve as a vehicle to explore existential themes and assist clients in identifying their own purpose and meaning, with art serving as a source of connection to clients finding their own relevance within their world. FOUNDATIONS OF EXISTENTIAL THEORY Existential psychotherapy focuses on the nature of human existence via a spectrum of concerns such as freedom, responsibility, anxiety, and authenticity. Born initially out of the writings of European philosophers such as Kierkegaard, Nietzsche, Heidegger, and Sartre, existential philosophy spurred the development of existential psychotherapy by influencing European clinicians, including Ludwig Binswanger (1957) and Viktor Frankl (1959). Existential psychotherapy concepts were introduced to the United States via the writings of Rollo May (1958) and James Bugental (1965). The emphasis shifted from a skeptical and restrictive view of the human condition (based on a European existential emphasis) to one that is based on “expansiveness, optimism, limitless horizons, and pragmatism” (Yalom, 1980, p. 19). As noted by Yalom, given the historical European experiences of war, death, and ensuing uncertainties over life, such a viewpoint is inherent to a European perspective of existential psychotherapy; however, existential perspectives from a U.S. framework were bound to reference tenets particular to the United States (such as potential and individuality). Given the grounding of existential psychotherapy in philosophical thought, an existential orientation is transformed into a therapeutic approach relatively free from technique. This is one perception that has contributed to the approach being viewed as the misunderstood stepchild of psychotherapy orientations. An additional oft-cited view of existential psychotherapy is that the approach is best suited for the “worried well,” those clients who have the luxury to “intellectualize” and explore the larger complexities of life. Such perspectives, however, fail to grasp the commonalties existential psychotherapy has with other therapeutic approaches such 93

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as humanistic, cognitive behavioral, and narrative therapies. Norcross (1987) suggests that the “core existential concepts—such as meaning, freedom, responsibility, and choice—have been incorporated into most contemporary systems of psychotherapy” (p. 42). Additionally, the importance of attention to the worldview of clients was noted decades ago by human beings and can be best summed up by the concept of “being-in-the-world” (Lebenswelt) as one of the key purposes of the therapeutic encounter. In essence, the focus of existential psychotherapy centers on the common experience of being human and can be best summed up by the questions: Why am I here? and How do I choose to lead my life? CORE CONCEPTS OF EXISTENTIAL PSYCHOTHERAPY The avenues to explore “Why am I here?” and “How do I choose to lead my life?” occur via the existential themes of death, freedom, isolation, and meaninglessness (Yalom, 1980). In many respects, these themes can be considered broad based or umbrella themes, as other clinicians have noted the exploration of additional existential themes, such as intentionality and individuality (Norcross, 1987), myth (May, 1991), or suffering (Frankl, 2000). For purposes of this chapter, Yalom’s themes are referenced. Although Yalom’s conceptualization presents as seemingly pessimistic, there are mirror truths to each existential theme, and these themes serve as points of examination with clients in exploring the fundamental truths about existence. Freedom As part of our human experience, we are free to choose how we will live our lives, but that freedom entails the ensuing responsibility of directing our lives through the larger lens of freedom, responsibility, and choice. It is the clinician’s task to assist clients in increasing their awareness about their responsibility, including their awareness of multiple possibilities and decision options. This increase in awareness is not without ensuing anxiety, because there are no assurances of avoiding pain or tragedy resulting from any decision; hence, as suggested by Rollo May, freedom is “the mother of anxiety” (May, as transcribed by Mishlove, 1995). Death For the existential clinician, the denial of death places constraints on one’s ability to live fully and effectively. Denial is connected to not taking responsibility for life’s ultimate truth—that we are finite. Avoidance of death can be best summed up by Woody Allen, the director known for existential themes in his films: “I don’t want to achieve immortality through my work . . . I want to achieve it through not dying” (Schoel & Stratton, as cited in Bauman & Waldo, 1998, p. 16). Increasing awareness about death and attempts to come to terms with life’s ultimate truth can trigger a number of defense mechanisms such as repression, avoidance, and regression. Yalom (1980) delineates two specific defense mechanisms in avoiding anxiety: an irrational belief in being special and the belief in an ultimate rescuer. Both of these defense mechanisms circumvent the ability to see the ultimate reality of death. Working through the anxiety, however, allows us to be and to take action where we need to in life. Isolation From an existential perspective, we are all ultimately separate, and isolation is considered a given of the human condition. By not confronting our individual separateness, our human nature will defensively dictate paths to assuage the anxiety of aloneness, such as over identification with others or retreating into isolation. Although the recognition of ultimately being alone in

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the world can be overwhelming and disturbing, recognition can serve to identify sources of connection and relatedness with others, which is a real human need. Hence, the task of the existential clinician is to assist clients in negotiating apprehensions about their aloneness, with the responsibility of creating functional and meaningful relationships in life. Meaninglessness In existential psychotherapy, the client is asked to address the question: How do I make meaning in a world where nothing makes sense? The theme of meaninglessness is embedded in a world that frequently presents as random, full of chaos, and indifferent. To make sense of such a world, existential psychotherapy posits that all humans demonstrate a need for meaning. This view is associated mostly with Viktor Frankl (1959). Frankl’s experiences in a Nazi concentration camp served as the impetus behind the development of logotherapy, a psychotherapy approach grounded in existential principles. Frankl wrote of the human need to find meaning in the world rather than within oneself. He referred to this need as “the self transcendence of human existence” and noted that, “being human always points, and is directed, to something, other than oneself—be it a meaning to fulfill or another human being to encounter” (p. 115). Lack of meaning in life has been described as an “existential vacuum” by Frankl, and it contributes to a sense of emptiness and a lack of purpose in life. One task of existential psychotherapy is to assist clients in reconciling the harsh nature of the world with their potential for purposefulness and hope. The Link to Anxiety, Authenticity, and Guilt Anxiety Underlying each existential theme is anxiety—the existential anxiety of being human. Existential anxiety is not viewed as unconstructive; however, it can be used effectively to help identify specific existential concerns, link the client to awareness, and assist in the development of an authentic life. Existential anxiety is not specific to any one existential theme, given that “an individual may experience existential anxiety from the need to choose alternatives with uncertain outcomes, from recognition of one’s ultimate aloneness, and from the inevitability of death, which may occur prior to self-actualization” (Kitano & LeVine, 1987, p. 405). As we become aware of existential concerns, we rely on defense mechanisms, in a non-dysfunctional way, to cope with these concerns. In contrast to existential anxiety is neurotic anxiety, which relates to avoidance and the inability to take responsibility for one’s life. It is nonadaptive and restricts one from living a full life. Avoidance of life’s realities (the existential themes) ultimately leads to an inauthentic life and contributes to neurotic anxiety. With neurotic anxiety, the task is movement toward existential anxiety, to the greatest degree possible, because the presence of neurotic anxiety and symptoms reflective of avoiding life’s realities are linked. Authenticity As noted by Norcross (1987), “authentic people are aware of themselves, their relationships, and their world; recognize and accept choices and decisions; and take responsibility for their decisions, including full recognition of the consequences” (p. 52). It is through authenticity that we become fully human. Our sense of being human is linked to the responsibility for our potential and our awareness of that potential. Existential Guilt Existential guilt is another subtheme within an existential perspective. Yalom (1980) delineates between real guilt and neurotic guilt. The latter is associated with perceived grievances toward the self, whereas the former represents actual wrongdoings, socially or toward others.

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Neurotic guilt may occur when we are not attentive to our own needs, ignore options related to choices, or diminish our experiences with self-condemnation. The degree to which clients can condemn themselves via previous or current decisions can be especially powerful, because guilt is associated with not living up to personal potential. As Yalom notes, however, guilt can be a motivating force to assist clients in connecting to personal responsibility and recognition of personal potentiality rather than a compulsion to live in regret. CONCERNS ADDRESSED BY EXISTENTIAL THEORY As noted previously, the practice of existential psychotherapy is not technique driven and this is consistent with an existential openness to worldview and perspective. Because of this openness, no one set of techniques could possibly address the uniqueness of each client. In general, existential clinicians do not view a lack of techniques as problematic, because most believe techniques oversimplify human nature and needs. However, a lack of a systematic approach to the theory has led to a deficiency of empirically supported data on the effectiveness of existential psychotherapy. Norcross notes that the lack of empirically supported outcome data has contributed to the marginalization of the theory itself (1987). Criticism, notwithstanding research, has consistently demonstrated that it is the therapeutic relationship itself that has the most significant and most positive outcome for therapy (Beutler, Crago, & Arizmendi, 1986; Hubble, Duncan, & Miller, 1999; Lambert & Barley, 2001). Existential psychotherapy does not focus on psychopathology because diagnosis is perceived as a barrier to the relationship that can create a power differential in the client–clinician relationship. Symptoms are framed in terms of understanding their meaning to the client, in the context of the client’s world and experience. Although the manifestations of neurotic anxiety can lead to psychopathology, severe mental health concerns are framed within an adaptive perspective and link to the avoidance of life’s existential themes. An existential principle shared with humanistic perspectives on psychotherapy is the importance of the client–clinician relationship in facilitating client awareness and change. In a study of clinical practice among existential psychologists, Norcross (1987) found that respondents had the highest mean scores on a scale denoting relationship-enhancing behaviors. Norcross noted “the relative avoidance of psychological tests, overt structure, and direct guidance coincide with the themes of uniqueness and freedom, as well as the inherent burdens of choice and responsibility” (p. 61). In effect, existential clinicians indirectly translate existential themes into the practice of existential psychotherapy; central to this is how an existential clinician views the therapeutic relationship. Yalom (2002), for instance, identifies himself as a “fellow traveler, a term which abolishes distinctions between ‘them’ (the afflicted) and ‘us’ (the healers)” (p. 8). The clinician–client relationship conveys the existential theme of authenticity and facilitates a genuine understanding of the worldview of the client, enabling the clinician to connect and engage with the client on relevant existential concerns. Because several existential concerns can be overwhelming to process, the means to process those concerns are dependent on the traits of the existential clinician and the strength of the therapeutic relationship. The practice of existential psychotherapy is present oriented, both conceptually, in terms of client change, and literally, in the here-and-now moment with the client. Conceptually, the past serves only as a connection to what occurs in the present. A focus on the past detracts from the ways in which the client currently experiences his or her world while also preventing him or her from taking responsibility within the present. Figuratively, existential clinicians focus on the “here and now” with clients, linking to the client’s inner world to help the client achieve greater self-understanding and awareness in the moment.

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MULTICULTURAL CONSIDERATIONS Existential psychotherapy is especially relevant in working with multicultural clients because existential themes are present and relevant across all cultures. Corey (2001, in citing Vontress, 1986) indicates that existential psychotherapy is probably the most useful approach in working with multicultural clients, given the focus on shared human experiences and eventualities. These shared human experiences include “mystery, uncertainty, and suffering (which) are our eternal companions” (Epp, 1998, p. 3). To counter arguments that existential therapy is relevant only to upper class, European clients, Vontress contended that experiences such as love, death, and meaninglessness are themes encompassing “a universal philosophy of humankind” (Epp, p. 7). Nonetheless, counselors need to be cognizant of cultural insensitivity as an expression of culturally held values. For instance, different client communication patterns, interpreting client “resistance,” and Western notions of client labeling (e.g., using the term “enmeshment” to describe a client’s sense of connection) are all examples of counselor blind spots that may contribute to cultural insensitivity and misunderstanding. However, existential themes such as individuality, while often viewed as a limitation (wherein a client’s choice may be restricted by factors out of his or her control), can be approached by engaging clients in contemplating the totality of their world experience. The theme of cultural alienation, for instance, can expand on how clients experience and make sense of their world and may open options not previously contemplated. In attending to multicultural considerations, existential counselors need to balance the uniqueness of each client, yet allow the similarity of human experience to guide the process. EXISTENTIAL THEORY AND THE CREATIVE ARTS The use of art therapy as a therapeutic modality is well established (Kramer & Gerity, 2000; McNiff, 1981; Ulman & Dachinger, 1975). The basic premise of art therapy is that certain emotional states that cannot be expressed in words are best expressed in images (Naumburg, 1966). In effect, art serves as a point of reflection when words cannot readily translate or communicate that which therapeutically needs to be conveyed. The therapeutic use of art is not meant to be entered into lightly. Artists who historically contributed a great deal to the use of art therapeutically have long recognized the power of symbolic images and the recovery of unconscious material as translated through art. Clients may often be caught off guard by the emotional responses elicited through art making, and this requires the clinician to be prepared for such experiences. Gantt (1979) cautions against using art materials indiscriminately without clearly understanding their therapeutic nuances, because doing so can result in either spinning one’s wheels, “or at the worst, courting disaster” (p. 18). Additionally, Hammond and Gantt (1998) point out ethical and legal considerations specific to the use of art therapeutically, including how confidentiality, documentation, and ownership need to be considered. Identification of Existential Themes It is no accident that existential theorists have written about art and the creative process (Heidegger, 1971; May, 1994; Yalom, 1980). Artistic processes are especially well suited to exploring existential themes, given the range and encompassing nature of existential themes relating to human experience. Malchiodi (2003) notes the views of Frankl on the creative process: that the “courage to create” and “the creative process is an expression of the self and the

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dilemmas of human existence” (p. 59). Additionally, given the importance of remaining flexible within the practice of existential psychotherapy, the inclusion of art-making activities provides additional opportunities to explore existential themes in a non-prescribed manner. As noted by Robbins (1987), “therapy cannot be stamped out in predictable form. There will always be leftover dough. What to do with that dough is the task of the creative therapist” (p. 72). The use of art within an existential framework can enhance a client’s understanding of existential themes and increase a sense of client relatedness to his or her own world and experiences. CONCLUSION Facilitating a client’s search for a meaningful existence is the goal of existential counseling, which is founded within humanistic theory. The client is given space to contemplate purpose in life as well constructs such as isolation, freedom, death, and meaninglessness. As this theory does not rely on specific, theory-based techniques, the use of the expressive arts as vehicles to understand oneself and one’s purpose provides a means to explore difficult-to-articulate concepts and beliefs. Following are a selection of interventions that are appropriate for existential theory–oriented counselors to introduce into their practice.

Expressive Arts Interventions

BRIDGING THE GAP OF SELFAWARENESS Imelda N. Bratton and Christopher P. Roseman

Indications: This activity is appropriate for use when group members have reached the termi-

nation stage because it provides an opportunity for group discussion regarding the individuals’ personal experiences. Goal: To provide group members with an opportunity to reflect on their attitudes and beliefs relating to multicultural issues through drawing Modality: Art The Fit: This activity relates to three existential ultimate concerns as described by Yalom and Leszcz (2005): freedom, meaninglessness, and isolation. Freedom relates to the construction of worldviews. Human beings have a choice to determine how we view ourselves in relation to others. The initial prompt given in this activity asks participants to reflect on their previous prejudices and biases. This allows an opportunity to construct a representation of their previous prejudices and biases that they held toward various multicultural groups. Participants have a choice to determine if they would like to continue to maintain those worldviews. Meaninglessness is described as the act of relating and interacting with others. This is explored in the second prompt by having participants represent their personal journeys from their previous worldview to their current worldview. Isolation refers to the ability to work with and relate to others in a multicultural world. The final drawing task asks participants to represent their current prejudices and biases. Participants may choose to continue to maintain their previous worldviews or bridge the gap and connect with others. Populations: Adolescents/adults; Groups Materials: Markers, crayons, or colored pencils; large sheets of paper for each group member. It is recommended that group members have a table or hard surface for the drawing activity. Caution: This may be an emotional activity for some group members. Allow ample time for additional processing, if necessary. Instructions: 1. Introduction to activity. 1.1 Invite group members to reflect on their own prejudices and biases toward different cultural groups they may have had as a child, adolescent, or young adult. 1.2 Allow a moment for clients to visualize and reflect on their experiences. 1.3 Ask group members to consider their current beliefs and prejudices toward those cultural groups. 1.4 Again, allow a moment for group members to visualize and self-reflect on their experiences. 1.5 Inform the group that the activity that they will be doing relates to the reflections that they just visualized. (If some group members ask to verbally share their experiences at this point, encourage them to wait until the end of the process time, if possible. Remind 99

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the group that this time is intended for self-reflection and the time to process and share will be provided at the end.) 2. The activity. 2.1 Ask clients to use the right-hand side of the paper to draw an image that represents their attitudes, prejudices, and beliefs on different cultural groups that they have held in the past (either before entering the group or before a significant experience). This image may be created in any way clients believe that reflects the attitudes and beliefs they held at that time. 2.2 Ask clients to use the left-hand side of the paper to draw a representation of how they see themselves in the present. Ask them to visually represent their current attitudes and beliefs they now hold after learning about multicultural issues. 2.3 Between the two drawings, ask clients to make a bridge that represents their personal journey from their previous belief system to their current belief system. Ask them to let the bridge be a symbol of the process they encountered while becoming more knowledgeable about multicultural issues. Provide group members with ample time to illustrate their drawing and encourage them to create their self-representations as they wish. The focus is on the process of the activity rather than the product of the drawing. 3. Processing questions. When group members are finished, allow them the opportunity to share their drawings, either in small groups or to the whole group, depending on group size. Use some of the following questions to help clients process the activity: What resonated with you during the activity? What were the most notable differences between the drawing on the right side and on the left side? What are your reactions to the differences? What feelings do you have when you see your picture? Where did you place yourself in relation to the bridge? Have you completed the journey across or are you still on the bridge? Can you describe specific incidents that helped you cross your bridge? Is there anything that you would like to be different? What have you learned that you will take from today’s activity?

COLLECTING MEANING: THE SHADOW BOX AS EXISTENTIAL REFLECTION Michele P. Mannion

Indications: Depression (lack of purpose, direction, motivation), grief, physical illness, best suited for clients whose motivation is not substantially impaired (i.e., severe depression) Goal: To assist clients in connecting to the existential theme of meaning Modality: Art The Fit: This activity provides an action-oriented activity to assist in identifying themes of meaning and meaning potential for clients and is especially well suited to clients who have difficulty in acknowledging or recognizing purpose in their lives or to clients who lack a sense of connection. This activity allows the client to explore specific existential themes of meaning and responsibility. Populations: Children/adolescents/adults; Individuals Materials: Cardboard 13 3 16 in. (for a completed box, 9 3 12 in.); trim (for box edges); glue gun (in trimming edges of box); Mod Podge (glue/gloss medium); paint (in painting the cardboard); construction/collage paper strips (to cover cardboard instead of paint and for trim); assorted brushes for glue and/or paint; art materials such as tissue paper, clay, pipe cleaners, paint, and so forth. The client should provide small found objects, images, and any printed materials (quotes, poems, etc.). Instructions: 1. Prior to client session, create the 9 3 12 in. box: score a line 2 in. from every edge all the way around the edge of the cardboard (this will create boxes in each corner). Cut out corners of cardboard. At scored lines, fold edges up to form box. Use wide masking tape to tape box together. 2. Invite the client to explore and identify sources of meaning and connection. Exploratory questions may include: Who, and what, has been important to me in life? How have I made a difference in my life? How can I make a difference in my life and in the lives of others? How do I create meaning via love, relationships, play, and work? How can I create new meaning in my life? 3. Convey to the client the purpose of the shadow box activity—to explore and identify sources of meaning and meaning potential. Clients can begin the activity at the point of taping the box together or with a preconstructed box (this saves time). After the box is made, spend time with the client discussing considerations for the box based on how the shadow box can assist in conceptualizing meaning (items, colors used, etc.). 4. Assign the client homework to collect items for the shadow box. These items should represent previously explored existential themes. (Time saver: It is often useful to have a variety and substantial number of pre-cut images from magazines.) 5. Review the client’s items that he or she has selected for his or her shadow box. Are there missing gaps in found objects? If so, examine with the client how missing gaps can be translated into feeling states via symbolic art made by the client during session. For instance, the lack of a photograph may translate to the client’s need for made art. 6. Explore with the client the completeness of the shadow box. Typically, clients intuitively know when their shadow box is complete. Encourage the client to discuss how the shadow 101

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box is associated with the theme of meaning. (In general, the shadow box activity can be completed in three to five sessions, depending on client needs.) 7. Process the activity using questions such as the following: How does the overall design of your box reflect who you are? What does the outside of the box, versus the inside of the box, communicate? What is meaningful in the box environment, which can be translated to your life? How have you identified taking responsibility for making meaning in your life? How does the juxtaposition of any images convey meaning? Has the box activity identified any voids in your life, and how can you fill them?

FEELINGS LANDSCAPE Mardie Howe Rossi and Karen L. Mackie

Indications: Appropriate for clients who have difficulty identifying or expressing feelings or are overwhelmed by feelings. It is also indicated with clients who have experienced loss and trauma as well as with those who are stuck, are in transition, or desire personal growth. Clients must be willing to finger paint. Some clients will not like the feeling of paint on their hands, and these clients can use a brush or Cray-Pas. It is appropriate for clients who are open to exploring their feelings and thoughts through finger painting. Goals: To encourage full experience without reserve (May, 1969); to move deeply into experience (Knill, Levine, & Levine, 2005); to develop avenues for healing and self-understanding, including common traits such as empathy, unconditional positive regard, and genuineness (Rogers, 1993) Modality: Art The Fit: Identifying and expressing feelings through finger painting allow clients to focus on their feelings and listen to what their feelings may be trying to tell them. Accessing and processing feelings are important avenues to healing and self-understanding with the existential and the expressive arts therapeutic frameworks. Both theoretical orientations share common traits such as empathy, unconditional positive regard, and genuineness (Rogers, 1993). Finger painting can be used across the life span for the exploration and expression of feelings. Clients who are uncomfortable in painting or drawing may feel more comfortable with finger painting because there is less pressure to create something precise or realistic. Populations: Children/adolescents, adults; Individuals/groups Materials: Finger paints (primary and black), large finger paint paper or coated paper, or poster board; paper plates for the paint; and wet towels to wipe off the finger paint between colors. Instructions: Activity (45–60 minutes) 1. Describe the feelings landscape as a picture of all the clients’ feelings and let the clients know that to create the landscape, they will use colors to represent their feelings. Explain that the size, shape, texture, and design of the colors can depict and differentiate their feelings. 2. Give clients the permission to make their paintings a unique expression of their own feelings and remind them that their paintings do not have to be artistic or to look like anything recognizable. 3. Ask that the painting be completed in silence so that clients have the opportunity to be aware of their process. Remind them to pay attention to their thoughts and feelings as they work. 4. Allow 45 minutes for painting and remind the clients that they have 5 minutes left after 40 minutes. 5. Invite the clients to process their paintings and to put their feelings into words by speaking from the colors (e.g., I am yellow and I feel ashamed. I am very big and am always here.). 6. Ask clients to process the experience with questions such as How did it feel to make their experience visible? Was there anything they learned about themselves?

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IDENTITYBYNUMBERS Brittany Rotelli

Indications: This intervention is designed for adolescents who identify within a minority

population such as the LGBT community. Goal: To assist clients who may be experiencing existential isolation and help them manage the anxiety associated with it and find meaning in life. Modality: Art The Fit: By building a self-accepted identity, this activity provides a way for clients to use distancing to safely feel and overcome the anxiety that comes from processing the difficult concepts of isolation and the meaning of their lives and relationships. Viktor Frankl stated that one way we can find meaning in life is “by experiencing something—such as goodness, truth, and beauty—by experiencing nature and culture or, last but not least, by experiencing another human being in his very uniqueness;—by loving him” (2006, p. 111). Through this activity, clients can safely explore their personal meaning in various ways including creating, beauty, and experiences with others, their uniqueness, and love. Clients are asked to identify those they see as members of their support system and use their alliance to build skills to effectively work and relate to others both in session and in personal reflection. Self-awareness and acceptance of the client’s individual identity will help the client connect with others and also to build healthy coping mechanisms. The end result will create an intervention that the clients can use on their own while being reminded of positive identity and meaning while minimizing anxiety and building relationships by having the colors picked out previously with members of their support system. Populations: Adolescents; Individual counseling Materials: First part of the activity: A piece of 8 3 10 white paper, a pencil, an eraser, and a black marker. Second part of activity: Copy machine, an array of colored markers, crayons, or pencils and a black marker. Third part of activity: Copy machine, 20 pieces of 8 3 10 white paper, and an array of colored markers, crayons, or pencils. Important Consideration: Use this activity after a strong rapport has been built with the client and you can identify healthy members of the client’s support system. Instructions: I. Part One 1. Begin processing with the clients about things that they appreciate about themselves.

Characteristics to consider are physical appearance, personality attributes, and hobbies. It is important that the clients include things that they are proud of, things that make them stand out as individuals, and things they enjoy doing. 2. Have the clients use the pencils to create a line drawing of themselves that incorporates all of the aspects that were identified in the processing. 3. Once finished and satisfied with the drawing, outline all of the pencil with a black marker to make the picture look like an uncolored coloring book page.

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II. Part Two 1. Ask member(s) of the client’s support system to come to a session for processing. Also,

have two copies of the drawing, one in which to color and one on which to place numbers. 2. Together as a team begin to color in the picture while being mindful of the colors used and

things they represent. 3. When the picture is fully colored in, create a legend for the picture and have the client assign

numbers to every color and place the numbers in corresponding sections of the picture that are not colored in. III. Part Three 1. Create 20 copies of the picture of just numbers and give the copies to the client. 2. Have the client color in a picture while processing the following questions. 2.1 Processing questions: 2.1.1 What pieces of the picture are sticking out to you while coloring? 2.1.2 What memories of creating the picture are coming out while coloring? 2.1.3 What ideas are you having about yourself that are being reinforced? 2.1.4 When would you color in another picture on your own? 2.1.5 What would you change about the picture?

INTERPERSONAL JENGA Savannah Cormier

Indications: This intervention is geared toward groups of individuals experiencing impairment

in, or a lack of social connectedness and meaningful relationships in their lives. This could include, but is not limited to, groups of individuals who are struggling with taking personal responsibility for creating meaning in their lives, thus negatively impacting their relationships. It is particularly appropriate for groups with a common goal of receiving feedback from one another in order to improve interpersonal effectiveness and increase authenticity. Prompts can be tailored to work with specific needs of the group and to a particular stage in group development. Goal: To assist group members in increasing self-disclosure and appropriate risk-taking in relationships, authenticity, interpersonal effectiveness, perspective-taking and compassion, taking responsibility for life choices, and enhanced self-concept. Modality: Game The Fit: This intervention lends itself to an existential approach with its focus on personal responsibility, meaning-making, Yalom’s therapeutic factors of group psychotherapy (Yalom & Leszcz, 2005), and authentic living in the here-and-now. Existential psychotherapy posits that life is full of meaninglessness and isolation; therefore, it is our responsibility as human beings to face life’s meaninglessness and ultimate aloneness and work to create our own personal meaning, connections with the world and others in it, and meaningful interpersonal relationships. Essentially, it is our responsibility alone to choose how we are going to live our lives. Throughout this intervention, clients encounter opportunities to take risks, be vulnerable, witness the impact of another’s vulnerability in both themselves and others, and experience deep meaningful connections with other group members. Merely being in the game would not necessarily create personal meaning and connections, but rather clients learn that their active participation and choices to engage are what cultivate meaning and connections. Throughout the various themes, regardless of the specific prompt, the focus is on the disclosure and what is taking place between the group members in the here-and-now. Of particular importance is the presence of Yalom’s therapeutic factors: instillation of hope, universality, imparting information, altruism, corrective recapitulation of the primary family group, development of socializing techniques, imitative behavior, interpersonal learning, group cohesiveness, catharsis, and existential factors. Collectively, these factors have enormous therapeutic impact on each group member, leading to meaningful changes in how the members understand, relate to, and engage with others in life. Population: Children, adolescents, adults; Groups Materials: Wooden block game set, such as Jenga®, and a large enough area on the floor or a table where all members can sit in a circle making each member visible to the rest of the members. Each block should have a number that corresponds with a list of prompts. Optional themes for prompts include: prompts to ask others about themselves, prompts to help others know you, questions that prompt others to be vulnerable, opportunities to be vulnerable about yourself, and sharing reactions to group members. Author’s prompts are included (see Table 6.1) but may be adapted as necessary. Removable colored circle labels are optional. 106

Table 6.1 Prompts by Theme. Prompts Should Be Adjusted to Meet the Needs of Each Group and Their Stage in Group Development Optional Interpersonal Jenga Questions by Theme (for Adults) Helping others know you

Questions that prompt others to be vulnerable

Opportunities to be vulnerable about yourself

Sharing reactions to group members

1. Choose someone else in the group and ask how the person thinks his or her closest friends would describe him or her.

11. For what in life are you most grateful?

21. Ask someone else to describe a time he or she felt left out.

31. Describe a time you had to admit you were wrong in a relationship.

41. Tell the person to your left a quality you admire about him or her.

2. Ask someone else to describe his or her favorite childhood memory.

12. If you could have any superpower, what would it be and why?

22. Ask someone else about a time he or she was talking to someone, but didn’t feel “heard.”

32. If you could change one thing about the way you were raised, what would it be?

42. Share a meaningful moment you’ve had with the person to your right.

3. Ask someone else to share the bravest thing he or she has ever done.

13. Who is someone you look up to and what is it about them?

23. Ask someone else what would be helpful for you to do/say to him or her when you think he or she might be upset.

33. Share something people do that makes you want to pull away from them.

43. If the person to your left and right were superheroes, who do you think they would be and why?

4. Ask the person across from you what he or she wishes more people knew about him or her.

14. What is something you wish more people knew about you?

24. Ask someone else what quality about self he or she does NOT want to pass on to children or others in their lives.

34. If you knew in one year you would die suddenly, what would you change about the way you’re living now?

44. Share your first impression of the person to your right and how it has evolved the more you get to know him or her.

5. Ask someone else about the greatest 15. What is something you value gift he or she has ever gotten. highly?

25. Ask someone else what he or she has a hard time accepting about self.

35. What is the hardest thing about being you?

45. What is something you wish you knew about the person across from you?

6. Ask the person to your left to share 16. If you could have a theme song what value he or she wants children or for every time you walked in a others to learn from him or her. room, what would it be?

26. Ask the person to your right to tell about a time he or she felt insecure.

36. What was a time you were trying to share something, but didn’t feel “heard”?

46. Share a time you felt intimidated by someone in the group.

7. Ask the person across from you what characteristic he or she admires most in others.

27. Ask someone else to share his or her first impression of you and how it has evolved the more he or she has gotten to know you.

37. Share a time you accidentally 47. Share a time you felt really or purposefully made someone else understood by someone in the feel bad. How has it changed how group. you interact with people now?

17. What characteristic do you admire most in others?

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Table 6.1 Prompts by Theme. Prompts Should Be Adjusted to Meet the Needs of Each Group and Their Stage in Group Development (continued ) Optional Interpersonal Jenga Questions by Theme (for Adults) Opportunities to be vulnerable about yourself

Sharing reactions to group members

8. Ask someone else what he or she 18. What do you think makes you thinks makes him or her a good friend a good friend or person? or person.

28. Ask someone else what he or she is working on about self.

38. How do you resolve conflicts in relationships?

48. Share a time you felt judged or misunderstood by someone in the group.

9. Ask someone else how he or she wants to be remembered.

19. What is the bravest thing you’ve ever done?

29. Ask someone else what is something he or she admires about you.

39. Share something you struggle with in your relationships.

49. To whom do you feel closest in the group? What is it about him or her?

10. Ask the person across from you what someone can do to make him or her feel special?

20. Share something you think people would be surprised to know about you.

30. Ask the person across from you 40. Share something about what he or she wishes to know about yourself you are working on. you.

51. Ask someone else what he or she values most in a friendship.

52. What did you want to be when 53. Ask someone else what makes you were younger? him or her want to pull away from people.

Helping others know you

54. Share how someone would know you were hurting.

50. To whom in the group do you feel least close and want to get to know more? What can you both do to get closer? 55. Choose someone in the group and share which of the seven dwarves you think he or she embodies and why or give him or her a new dwarf name.

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Questions that prompt others to be vulnerable

Getting to know others

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Instructions 1. Prior to the group meeting, adapt the list of prompts (see Table 6.1) to best fit your group

2.

3.

4.

5.

6.

needs, goals, and appropriate stage of group development. If helpful, removable colored circle labels can be attached to the blocks that correspond with the prompt’s theme. The wooden block tower is built for the group with the numbers and optional colored labels facing down or inward so that group members cannot see what they are pulling. Instruct the group that each member is going to take turns selecting a block to pull from the tower and responding to the prompt elicited by the number written on the block. As one member is having his or her turn, the other members are listening, or, depending on the prompt, responding as well. After the first person’s turn, they may choose if the circle continues to the left or to the right. As members are selecting and responding to prompts, allow for helpful/useful discussion to continue as long as the members wish. Use follow-up questions to deepen discussions as necessary, link members together, and prompt others to share what they are hearing from members. Optional follow-up questions during the game include: 3.1 Do you feel safe sharing? What is contributing to that feeling? If not, what do you need from the group to help you feel safe? 3.2 What did you hear (member) say? 3.3 Does (member)’s answer surprise you? What about it surprises you/does not surprise you? 3.4 Who can relate to her/his answer? How so? 3.5 How difficult was it for you to share that? What helped you feel safe enough to share? If it wasn’t difficult, what stopped you from sharing something more vulnerable? What do you need from the group to help you take a risk when sharing? Members are never forced to answer any prompts but have the choice to “pass” and offer it to a member who would like to answer or the therapist who then has a chance to model appropriate self-disclosure. If in the course of the game the tower falls, the group gets to choose how they would like to continue. They may choose to end the game or continue to choose questions from the pile. After the game is done, allow time to process the experience of playing. Optional post-game process questions include: 6.1 How was playing interpersonal Jenga? 6.2 What was it like for you to share personal information about yourself? How was it to ask someone else to share personal information? 6.3 What question felt the easiest/most difficult to answer? What was it about that question? 6.4 What were you most surprised to learn about someone? 6.5 What question do you wish would have been included but wasn’t? 6.6 What questions would you like to ask someone now? 6.7 What are you taking with you after this experience?

MUSICAL DIALOGUES Anna Warzecha and Katarzyna Uzar

Indications: This intervention is indicated for individuals who are new to group techniques and who may need assistance in merging into a group. It is best suited for exploration and communication of self, particularly in relation to others. Goal: Self-adjustment to a group, broadened self-consciousness, capability of giving and receiving the feedback, internalization of received information that enables multidimensional personal development, and overcoming one’s own limitations Modality: Music The Fit: The aim of the activity is to present oneself and as a result, to overcome one’s own fears, such as mental stereotypes connected with perception of a person by the others. The important focus of this activity is to excavate the real view of oneself. Its mechanism is based on the attribution of one’s own, often unaccepted, actions and feelings to the other person. Using the musical instrument enables clients to increase the distance and present the real self-picture. It also allows for a wide spectrum of feedback. To develop meaning, each participant has the opportunity to express one’s own opinion and judgment, while the person receiving the information has the chance to reflect, reconsider the way of thinking of oneself, analyze one’s own experiences, interiorize the information that supports self-development, and break stereotypes concerning oneself. Populations: Adolescents/adults; Groups Materials: A set of simple percussion instruments such as the Orff Instrument Set Instructions: 1. Develop the group contract, respected by every participant, which concerns the following: group confidentiality—to assure the feeling of safety; judgment issues—not to judge the statements, expressions, and feelings of the other participants; forms of address—directly or formally; mobile phones—to keep them on silent mode during the session; and so forth. Invite group members to discuss the contract using questions such as: Does signing the contract improve my participation in the group? Do I have a greater feeling of safety? Does the contract stimulate my openness and trust of other people in a group? Does the awareness that I won’t be laughed at, judged by the others, or receive unpleasant feedback make me feel more accepted? 2. Have members choose an instrument. Invite members to process their choices using questions such as: Which instrument have I chosen? Why this one? How does the choice of instrument correlate with my personality? Does it in any way describe or define me? Does the choice of instrument express my hidden emotions and needs? 3. After the choice of the instrument, every participant prepares a performance. One after the other, group members play their planned musical performances. They play their own works to indicate their unique presence in the group—who they are and how they are. Invite members to process the experience using questions such as: How did I use my time for presentation? Was the time of presentation long (I want to express myself thoroughly, to show who I really am) or short (I don’t want to bother the other people with my presentation)? What is the sound of the chosen instrument—is it resonant or quiet? How does it sound in comparison

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with other instruments? What is the instrument made of (wood or metal)? Does it reflect in any way who I am? Does my piece have a structured melody, is it planned, or do I play spontaneously what comes to my mind? Is my work dynamic or calm? 3.1 The therapist may help to identify these qualities, but it is important for members to try to identify, verbalize, and give meaning to their work. All group members may share in feedback. After the presentations, participants can enter into a dialogue with each other. 4. The next activity is a duet between two randomly matched members. The important thing is to find oneself in playing, in relation to the other person. Most of all, the manner of playing is interpreted here. It may happen that during playing in pairs, one person loses one’s own beat or melody. The strength of a member’s ego (one should keep the pace, pulse, and volume when playing together) can be observed during this activity. Playing music with another person allows clients to find out who dominates whom and who is submissive to the other person (it happens that, after some time, one person starts to play the same melody as the partner, although initially the melodies were different). Processing questions may include: Does how I play help or disturb me? Do I lose my own rhythm, melody? Am I more, less, or maybe equally important in relation to my partner? Do I play all the time in the same way; do I get my melody quieter to hear my partner; or maybe I play louder because I feel drowned out by him or her? 5. The next step to enter into relation with group (society) is an orchestra. All group members are to create a unified group or orchestra and play one mutually created musical piece. Discussion questions may include: How important is my role in the orchestra? Do I feel a part of the whole? Do I play in one of the sections (e.g., triangles) or do I have an instrument that anyone else has (e.g., cymbals)? Am I heard in the orchestra? Do I feel better playing in an orchestra? What kinds of emotions arise from playing the role of conductor versus orchestra member? Have I seized the opportunity to improvise in the background of the group? Have I taken up that kind of challenge?

REFRAMING WITH MAT BOARDS Kristin I. Douglas

Indications: This activity is appropriate for clients having challenges with reframing difficult and painful experiences. Goal: To increase clients’ awareness of ways in which their chosen focus on a situation contributes to the meaning made of their experiences Modality: Art The Fit: The purpose of this creative approach is to help clients choose to reframe the meaning of difficult and painful experiences. Frankl (2000) believed that we can choose our attitudes, in any circumstances, regardless of how grim those circumstances may be. He emphasized that no matter how involved suffering is, we still have the capacity to choose how we will see the world around us. Populations: Adolescents/adults; Groups/individuals/couples Materials and Preparation: Colored pencils, paper, and various small art mat boards (e.g., different sizes, colors, textures) used to frame artwork or photos; artwork for client use or client-supplied artwork/photographs. Instructions: 1. Using appropriate timing in session, discuss existential issues of freedom, choice, and accountability, emphasizing that what we choose to focus on, contributes to the meaning we make of our experiences. Invite the client to choose a specific piece of artwork for exploration. 2. Using the photo or artwork as an example (whether it is on the wall or one that a client brings in session), take the different mat boards and place them up to the artwork. Ask clients what jumps out for them in the picture when different mat boards are used. Circulate through four to five mat boards. Discuss together how different mat boards bring out something different in the picture. 3. Using this exercise as a metaphor for the client’s experiences, ask the client: How do your viewpoints and perspectives make it hard for you to reframe or make meaning of your current challenges? 4. Ask the client to discuss possible goals for growth and invite the client to create an illustration of how a new perspective might facilitate growth. 5. Invite the client to use a small mat board and a colored pencil to trace/outline a frame onto a sheet of paper. Inside the framed picture just created, have the client draw or describe one of the steps necessary for reaching the new goal. 6. Ask the client to use a larger mat board to draw another frame encompassing the first and to illustrate how this one outlined change will influence other changes (hence, helping to create new perspectives). This may be repeated depending on the mat sizes chosen. 7. Process the new insights and perspectives the client has gained from seeing how each action/experience may be reframed through a new perspective.

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RESTORING AND LINKING MEANING IN LIFE Michele P. Mannion

Indications: Depression (lack of purpose, direction, motivation), grief, physical and/or terminal

illness; addiction; life transitions; best suited for clients whose motivation is not substantially impaired (i.e., severe depression) Goal: To assist clients in reviewing life roles, experiences and/or values and life review Modality: Art The Fit: This activity focuses on how clients can integrate experiences in order to gain more purpose and meaning in life. Ideally, this activity helps clients to internalize their experiences and connect to a greater sense of groundedness and bond to their experiences. For those clients who lack meaning, this activity can assist with diminishing “ahistoricity,” or lack of ties to tradition and historical perspectives (Moon, 2009). Populations: Adolescents and adult clients Materials: Precut lightweight, fairly pliable cardboard (cereal box cardboard can often be used)—at least 2.5 in. wide and 10 in. long; a wide variety of decorative art paper (available at specialty art stores or on the web) and/or magazine imagery; pen; scissors; clear tape; mini stapler; glue (such as a permanent glue stick) Instructions: 1. Convey the purpose of the activity to the client: to identify how and why experiences have significance and how they contribute to meaning in life. Have the client select assorted papers for this activity—based on imagery, texture, color, and so on; the paper should have some significance for the client. During the selection process, the counselor should process each selection of paper with the client. 2. On the back of each piece of precut cardboard, instruct the client to write one word or a short phrase to describe the significance of the selected paper—this could include reference to feelings, memories, people—anything that links the paper selection to the experience of the client. Here, the focus is on “infusing” the selected paper with specific meaning based on one’s experiences. 3. The paper is then applied to the precut cardboard—this works best by wrapping the cardboard as if it were a gift (this process also links to a physical practice of “wrapping” experiences; the paper needs to be larger than the precut cardboard). The paper is affixed to the cardboard with tape or glue. 4. Fold the cardboard/paper to make a circle/link and use a staple to secure the link. After one link is made, continue the process, but insert the flat paper-covered cardboard into the first link and then fold this paper into a circle/link, so that now two links are formed. Continue assisting the client with making additional links (at least 10). The links can be discussed individually before adding to the chain, and the chain can either link the links randomly or by linking specific links (either decision can be processed with the client). 5. The chain can be left open in a garland style or closed in a necklace style. To close the links, be sure to have an odd number of links before securing one final, flat piece of cardboard/paper through each end of the garland. The decision to keep the chain open in garland style or closed also can be processed with the client. For instance, what does an open or closed chain represent? 113

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REFERENCES Bauman, S., & Waldo, M. (1998). Existential theory and mental health counseling: If it were a snake, it would have bitten! Journal of Mental Health Counseling, 20, 13–27. Beutler, L. E., Crago, M., & Arizmendi, T. G. (1986). Research on therapist variables in psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change (3rd ed., pp. 257–310). New York, NY: Wiley. Binswanger, L. (1957). Being-in-the-world. London, UK: Souvenir Press. Bugental, J. F. T. (1965). The search for authenticity. New York, NY: Holt, Rinehart and Winston. Corey, G. (2001). Theory and practice of counseling and psychotherapy (6th ed.). Stamford, CT: Brooks/Cole. Epp, L. R. (1998). The courage to be an existential therapist: An interview with Clemmont E. Vontross. Journal of Mental Health Counseling, 20(1), 1–12. Frankl, V. E. (1959). Man’s search for meaning. Boston, MA: Beacon Press. Frankl, V. E. (2000). Man’s search for meaning (4th ed.). Boston, MA: Beacon Press. Frankl, V. E. (2006). Man’s search for meaning. Boston, MA: Beacon Press. Gantt, L. (1979). The other side of art therapy. National Association of Private Psychiatric Hospitals, 11(2), 14–19. Hammond, L. C., & Gantt, L. (1998). Using art in counseling: Ethical considerations. Journal of Counseling and Development, 76, 271–276. Heidegger, M. (1971). Poetry, language, thought. New York, NY: Harper Collins. Hubble, M. A., Duncan, B. L., & Miller, S. D. (1999). The heart and soul of change: What works in therapy. Washington, DC: American Psychological Association. Kitano, M. K., & LeVine, E. S. (1987). Existential theory: Guidelines for practice in child therapy. Psychotherapy: Theory, Research, Practice, Training, 24(3), 404–413. Knill, P. J., Levine, E. G., & Levine, S. K. (2005). Principles and practice of expressive arts therapy: Toward a therapeutic aesthetics. London, UK: Jessica Kingsley. Kramer, E., & Gerity, L. A. (2000). Art as therapy: Collected papers. London, UK: Jessica Kingsley Publishers. Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, 38(4), 357–361. Malchiodi, C. A. (2003). Humanistic approaches. In C. A. Malchiodi (Ed.), Handbook of art therapy (pp. 58–71). New York, NY: Guilford Press. May, R. (1958). Contributions of existential psychotherapy. In R. May, E. Angel, & H. F. Ellenberger (Eds.), Existence: A new dimension in psychiatry and psychology (pp. 37–91). New York, NY: Basic Books. May, R. (1969). Love and will. New York, NY: W. W. Norton. May, R. (1991). The cry for myth. New York, NY: W. W. Norton. May, R. (1994). The courage to create. New York, NY: W. W. Norton. McNiff, S. (1981). The arts and psychotherapy. Springfield, IL: Charles C. Thomas. Mishlove, J. (1995). Rollo May: The human dilemma. In C. A. Malchiodi (Ed.), Thinking allowed: Conversations on the leading edge of knowledge and discovery (pp. 117–123). Tulsa, OK: Council Oak Books. Moon, B. L. (2009). Existential art therapy. Springfield, IL: Charles C. Thomas. Naumburg, M. (1966). Dynamically oriented art therapy: Its principles and practices. New York, NY: Grune & Stratton. Norcross, J. C. (1987). A rational and empirical analysis of existential psychotherapy. Journal of Humanistic Psychology, 27(1), 41–68. Robbins, A. (1987). The artist as therapist. New York, NY: Human Sciences Press. Rogers, N. (1993). The creative connection: Expressive arts as healing. Palo Alto, CA: Science and Behavior Books, Inc. Ulman, E., & Dachinger, P. (Eds.). (1975). Art therapy in theory and practice. New York, NY: Schocken Books. Vontress, C. E. (1986). Existential anxiety: Implications for counseling. Journal of Mental Health Counseling, 8, 100–109. Yalom, I. D. (1980). Existential psychotherapy. New York, NY: Basic Books. Yalom, I. D. (2002). The gift of therapy. New York, NY: HarperCollins Publishers. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.

7 Feminist Theory Heather Trepal and Thelma Duffey

Feminist theory is often described as an approach, or lens, through which counselors view themselves, their clients, their clients’ concerns, and the world. Through this lens, much attention is paid to issues of adherence to gender roles, issues of power and privilege, and the role of advocacy. Inherent in this approach is the use of personal power. This chapter discusses the development and core concepts of feminist theory and then show how expressive arts techniques can be used within the context of feminist therapy. FOUNDATIONS OF FEMINIST THEORY Development of Feminism Like many traditional theories, feminist theory is a product of historical context. Feminism has been described as occurring in waves and with each wave comes a new and broader scope of influence (Hannam, 2012). For example, the initial wave was built on the suffrage movement because it related to securing voting rights for women. During the second wave between the 1960s and 1970s, women challenged inequities in systemic concepts. Although both waves had an effect on all women, the early movements were by-products of and related to the efforts of educated, middle-class White women (Hannam, 2012). Alternatively, the third wave supports the current definition and is broader in scope. Mills and Mullany (2011) defined feminism as “. . . a political movement which focuses on investigating gender, that is, the way women and men come to construct themselves, their identities, and their views of others . . . which has the overall emancipatory aim of redressing gender inequalities” (p. 2). This definition includes the modern feminist scope of attention to men as well as women, and to people of all races, classes, cultures, and sexual orientations. With personal power as a central tenet of this approach, it is often conceptualized as “the ability to access personal and environmental resources to affect personal and/or external change” (Worell & Remer, 2003, p. 78). Development of Feminist Theory in Counseling Because of her focus on developmental thinking, Anna Freud has been cited as an early leader in feminist orientation in the counseling profession. She established methods of working with clients that directly opposed the theory and approach of her father, Sigmund Freud (Seligman & Reichenberg, 2010). Sigmund Freud was criticized for working with 115

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women through analyzing men and for contributing to the pathologization of women. Thus, pioneering, primarily female theorists (e.g., Karen Deutsch, Karen Horney) contributed to the construction of the feminist approach as a developmental approach that countered the psychological theories that had been derived solely from a male’s perspective (e.g., Sigmund Freud, Alfred Adler, Seligman & Reichenberg). More recent prominent feminist writers and theorists in the counseling field include Jean Baker Miller, Carol Gilligan, and Irene Stiver. Differences Between Feminist Theory and Traditional Theories of Counseling The differences between feminist theory and traditional counseling theories are threefold. First, although feminist theory is conceptualized as a “theory,” it has also been consistently used as a philosophy or theoretical lens from which counselors can conceptualize and work with clients. Second, many traditional theories are practiced and associated with a theory-specific set of techniques such as the use of the “empty chair technique” within Gestalt therapy. In feminist theory, there are few codified techniques. However, feminist theory is associated with an increased examination of gender roles (i.e., gender role analyses) as well as increased attention to advocacy and personal or political power. More importantly, traditional theories place the root of psychological health and distress within the individual, whereas feminist theory argues that sociopolitical forces are responsible, thus constituting an interactionist approach (Scholz, 2010). This distinction is vital. Although many traditional counseling theories contend that individual clients should challenge and change their thoughts and behaviors, feminist theorists suggest just the opposite. According to this approach, although society has positive benefits, it has also created institutions and social mores that can be oppressive and limiting; these oppressive social effects can then be internalized by the individuals affected by these limiting constructs ( Jordan, 2010). These effects can be further complicated for persons belonging to marginalized groups. CORE CONCEPTS OF FEMINIST THEORY Gender Roles The terms “sex” (whether one is born biologically male or female or intersex) and “gender” (societal constructions of behaviors associated with males and females) are often used synonymously in counseling and in research (Trepal, Wester, & Shuler, 2008). However, within feminist approaches, attention to biological sex is not as important as the effects, both positive and limiting, of traditional gender role socialization. Gender roles and socialization play a prominent role in feminist theory. Examining a client’s world through a feminist lens often results in increased attention to socialization and, specifically, to gender role socialization in the client’s life. For example, a male client who is a stay-at-home father and is experiencing symptoms of anxiety or depression may be encouraged to examine his life from a gender role perspective. He may consider the influence of family of origin, societal and environmental factors, and other related issues on his current situation. A counselor functioning from a feminist perspective may encourage the client to examine issues of gender role strain, particularly in areas where his beliefs and experiences may be in conflict. Gender Role Analysis The U.S. Agency for International Development (USAID) defined gender role analysis as a method for examining unique ways in which individuals are socialized to conform to culturally prescribed gender norms (2011). This analysis also considers the myriad ways in which gender

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role socialization affects their lives. For example, in traditional Western society, women are often socialized to believe they are judged or given unearned power based on their appearance. A counselor using a gender role analysis might work with a female client to examine messages related to women and their appearance while exploring any internalized messages, both positive and limiting, about her appearance. This is particularly salient given that these messages related to our appearance can influence how we feel about ourselves, our ability to trust in and invest in relationships with others, and the degree of personal power we feel in relation to others. Power The issue of power is paramount in feminist theory. According to Brown (2006), “Feminist therapy requires its practitioners to think in a complex and nuanced manner about how power and powerlessness are roots of distress” (p. 17). From a feminist approach, society can be seen as supporting factions—some groups are given more power or status than others. Some variables, such as wealth, heterosexuality, and youth, can be perceived to carry more power and this hierarchy can create oppressive social institutions and structures. Conversely, other variables, such as poverty, homosexuality, old age, disability, and culture, can be seen as holding less power. A feminist approach to counseling incorporates an examination of the role of power in a client’s life. Issues of Oppression and Marginalization (Intersections of Multiple Identities) Powerlessness can lead to issues of oppression and marginalization. Brown (2006) argued, “When feminist therapists speak of the politics of the personal, we speak of the experiences of power and powerlessness in people’s lives, experiences that interact with the bodies and biologies we bring into the world to create distress, resilience, dysfunction, and competence” (p. 17). Feminist counselors maintain that individuals live at the intersection of multiple identities. For example, a counselor might be a woman, a lesbian, a mother, a middle-class U.S. citizen, an African American, and college educated. Each of these identities and its collective constellation produce situations in which the counselor can have power or privilege in society and potentially be an oppressor as well as produce situations in which she holds less power or privilege and experiences oppression or limited functioning. For example, the counselor might be given power or status with other parents at her children’s school because she is a working mother. However, once her lesbian identity is revealed, others may then deny her access to some of the same conversations and resources that were once open to her. Working With Hierarchies in Counseling and Psychotherapy Another important factor related to the issue of power in feminist theory is the hierarchical relationship between the counselor and the client. In feminist theory, issues surrounding the hierarchy are brought out within the counseling relationship. The theory takes into account the power inherent in an “expert–client” relationship, and counselors functioning within this perspective attend to these issues. For example, feminist counselors are likely to use self-disclosure as a means to reduce the power differential in the therapeutic relationship (Henretty & Levitt, 2010). The counselor’s goal for self-disclosure is not to meet her own needs, but rather to reduce the power or hierarchy within the counseling relationship. Feminist counseling focuses on relationships. Another important challenge to both power and hierarchy is the feminist notion of reframing or reimagining traditional diagnoses. For example, a feminist counselor may challenge the traditional diagnosis of eating disorders and reimagine a client’s issues with eating as a response to societal expectations or a way of coping with unbalanced social norms for body image. As

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such, the counselor challenges traditional ways of examining psychological health. Feminist counselors support the belief that it is society and oppressive institutions and the internalization of these basic structures that are responsible for psychological distress (Travis, 2014). Advocacy Counselors who employ a feminist orientation focus on societal change; in particular, change that leads to the eradication of patriarchal systems that support a “power over” culture. In effect, these counselors practice from a cooperative and relational model (Frey, 2013). Feminist models often call for a challenge to oppressive structures (Mills & Mullany, 2011). Feminist counselors traditionally challenge clients to make their personal issues political and to combat oppression. This position holds that personal change can occur vis-à-vis political advocacy. As Brown (2006) exerts, “Feminist practice, however, continues to be one of only a handful of therapy domains in which therapists are called upon to acknowledge as central the politics of practice and the impact on practice of the politics of gender, power, and social location on the lives and work of all of us” (p. 17). CONCERNS ADDRESSED BY FEMINIST THEORY Philosophy, Rather Than Techniques or Tools Because it is philosophically grounded, feminist theory can complement other theoretical approaches in counseling. This interaction between feminist theory and other approaches and techniques continues to receive attention in the research literature (Duffey & Haberstroh, 2014; Duffey, Haberstroh, Ciepcielinksi, & Gonzalez, in press). Research Base and Efficacy The focus on gender issues, power, and context in feminist therapy complements many common concerns that clients bring into counseling. Importantly, Hill and Ballou (2011) maintain that as opposed to the current evidence-based climate, which favors measurable behavioral outcomes, feminist counselors often address issues that are less able to be measured but are important to overall functioning, such as self-esteem and empowerment. Research into feminist approaches includes treatment of eating disorders (Braverman, 2013) and advocacy-based programs (Brady-Amoon, 2011). However, one potential limitation to feminist theory is the need for more outcome research supporting its efficacy with diverse client concerns. Some of the approach’s philosophical tenets have been criticized as difficult to operationalize (Sommers-Flanagan & Sommers-Flanagan, 2012) and research. For a critique supporting the strong relationship between feminist counseling and evidence-based practice, the reader is encouraged to see Richmond, Geiger, and Reed (2013). EXPRESSIVE ARTS AND FEMINIST THEORY Flexibility as a Core Concept of Both Expressive Arts and Feminist Theory Flexibility is a core concept of both feminist theory and the use of expressive arts in counseling. Feminist theory–based counselors selectively attend to the client and societal issues based on what is occurring in the moment and within client context rather than basing practice on a

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standard set of principles or on a standard template. Similarly, counselors who use expressive counseling techniques are also free to be flexible, to experiment, and to choose the approaches best suited to each client’s unique concerns. Encouraging a client’s creativity can do much to support overall client development. Counselors using experiential techniques are called to the same ethical standards as their more traditional counterparts. Whitten and Burt (2015) describe the myriad ways counselors can effectively use creative arts techniques in their work. Duffey (2005a) and Duffey, Haberstroh, and Trepal (2009) describe how creativity and innovative practice can support client growth and relational development when used responsibly. Although counselors are encouraged to use innovative strategies when working with clients, they must be mindful of the limits of their experience and training and thoughtfully consider how to effectively use creative counseling techniques in their work (Whitten & Burt, 2015). Exploration of Multiple Identities via the Expressive Arts In addition to remaining flexible and informed, counselors operating from a feminist perspective also consider an individual’s multiple identities as central to feminist theory. This focus on identity complements the expressive arts perspective in that both allow us space to examine ourselves and our life experiences. In combination, feminist theory and expressive arts approaches facilitate creativity and the development of an expanded worldview. Multicultural Considerations The feminist and multicultural movements both focus on such issues as gender, class, power, and culture. They each (a) highlight the role of power and hierarchy and its effects on those who do not belong to the dominant society, (b) call for an end to oppression and exploitation, and (c) advocate for mutuality and equality. In her groundbreaking text, Toward a New Psychology of Women (1986), Jean Baker Miller addressed the issues of multiculturalism and feminism, and their impact on mental health. Miller’s works brought heightened awareness to concepts that frame the groundwork of relational cultural theory (RCT). RCT is grounded in both feminist theory and multiculturalism, and gives voice to issues of power and privilege and their impact on women and minorities (Duffey & Somody, 2011). CONCLUSION Feminist theory is an approach to counseling in which counselors and clients are encouraged to examine issues of gender, power, and privilege both in their individual lives and within the counseling relationship. The counseling focus is relational and incorporates an intent to lessen the counselor–client hierarchy to empower the client. Personal advocacy and empowerment are emphasized.

Expressive Arts Interventions

A MUSICAL CHRONOLOGY AND THE EMERGING LIFE SONG Thelma Duffey and Heather Trepal

Indications: Grief and loss, life review, and relationship concerns Goals: To help clients connect with and identify their beliefs about themselves and others; to

help clients understand the mitigating factors that influence their experiences and to consider their lives within the context of larger social circumstances; to provide a forum for clients to identify and process experiences that lead to disempowering perceptions and life scripts; to help clients recognize the effects of these perceptions and relational patterns on present relationships; and to assist clients to deconstruct disempowering perceptions and reauthor their lives through the use of music Modality: Music The Fit: Feminist theory describes how societal messages shape our perceptions of ourselves and others and challenges us to advocate for more growth-fostering perceptions. This intervention illustrates Becvar and Becvar’s (1996) and White and Epston’s (1990, 1992) position that clients can create an alternative perception, even though a dominant perception may be culturally sanctioned. When working from a feminist perspective, it can be important for clients to reconsider messages they now perceive as truth. Clients are encouraged to consider how societal influences impact their perceptions and help perpetuate circumstances that do not promote their greater good. Schuhmann and Sools (2014) also propose ways to help clients reauthor their lives in ways that promote personal agency. They refer to this as a therapeutic sharing ritual between client and therapist. This is consistent with the feminist theory focus on relationship. Additionally, when coming from a feminist theory perspective, clients consider the sociopolitical impact on their perceptions, and reframe pejorative self-statements and relational perceptions. This intervention can be used to promote this process. Langer (1951) posits that “because the forms of human feelings are more congruent with musical forms than with forms of language, music can reveal the nature of feelings with a detail and truth that language cannot approach” (p. 199). Other researchers also note how music provides a venue for making sense of life experiences (Aigen, 2014; Argstatter, Grapp, Hutter, Plinkert, & Bolay, 2015; Hanser, 2016). In that spirit, this intervention is designed to help people connect with their feelings surrounding important life events (Duffey, 2005b; Bruscia, 2012). The chronology process is used to help clients identify meaningful life experiences and consider the unproductive perceptions they carry about these experiences, especially when these interfere with how they live life. This intervention is used to help people connect with their feelings and experiences while considering a larger perspective that takes culture, gender, power, privilege, and other salient factors into account as they navigate a reauthoring process (Duffey & Haberstroh, 2013; Duffey, Lumadue, & Woods, 2001). This process serves as a musical scrapbook that facilitates revisiting experiences and the meanings we give them (Duba & Roseman, 2012; Duffey, 2005b; Duffey et al., 2001). Populations: Adolescents/adults; Groups/individuals 120

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Materials and Preparation: Paper, writing instruments, and access to music recordings, song

lyrics, and recording software are required. This activity is based on the following assumptions: (a) Music is a common means for some men and women to connect with their life experiences; (b) music and lyrics can contribute to clients’ perceptions of themselves in relation to others; these perceptions are often influenced by societal norms, the media, and other social influences; (c) if our perceptions lead to disempowering and unsupportive thoughts and feelings, they can lead to challenging life experiences; and (d) music is one vehicle by which we may form, maintain, or alter disempowering self-perceptions. Instructions: A musical chronology is a four-stage process. Basic to this work is an understanding that clients internalize negative and shaming messages and often accept these messages as truth about themselves. Revisiting these messages, while considering the context in which they are relayed, is integral to this work. Stage I: Counselor and client use music to revisit memories and develop an autobiographical scrapbook. Stage II: Clients identify songs that have been important to them or that remind them of important life events. They compile a list of songs, and if they wish, lyrics, and arrange them chronologically. This part of the process is designed to help clients mentally organize their experiences. Clients are often surprised to discover patterns with respect to language and messages that color and inform their experiences and expectations. Clients and counselors compile a playlist using digital technology. Stage III: Together they play the music and discuss client thoughts, memories, and associations. This leads to a “revisiting” of historical events. Stage IV: Client and counselor work collaboratively to help clients become aware of any disempowering perceptions and to create the possibility for alternate perspectives. Clients find and play a song that represents their current beliefs, values, and convictions. Finally, clients find and play a song that represents their hopes for the future. In doing so, clients identify a song that represents personal strength and an empowering perspective. Given the societal messages that can either promote or impede a person’s functioning in the world, this song is selected as a reminder of the challenges and victories that can come with self-compassion and an understanding of the impact of societal contexts on our lives.

ALTERED BOOKS AND CHANGED LIVES Katrina Cook

Indications: Appropriate presenting concerns can include, but are not limited to, physical abuse, sexual abuse, verbal abuse, low self-esteem, depression, eating disorders, or major life transitions. It is best completed over a series of sessions. Goal: To facilitate self-awareness and foster empowerment of clients Modality: Art The Fit: N. E. Downing and K. L. Roush proposed a five-level developmental model of feminist identity that charts development from passive acceptance of traditional gender roles toward active commitment to feminist ideals and an egalitarian society (1985). Clients in the embeddedness-emanation, synthesis, or active commitment stages of feminist identity development (Downing & Roush, 1985) could benefit from this intervention. As clients develop new ways of thinking and feeling about themselves, the altered books can represent their new realization and understanding of themselves. If unfamiliar with altered books, review the website listed in the references for descriptions and examples. Populations: Adolescents/adults; Groups/individuals Materials and Preparation: Old books in any condition and those that describe stereotypical gender roles are particularly useful. Also needed are glue, scissors, markers, crayons, colored pencils, paint, paint brushes, ink stamps, ink pads, old magazines, wrapping paper, and any other decorative devices, whether they are two dimensional or three dimensional. Ideally, clients will provide personal items they would like to include such as photos, drawings, poems, found objects, or other memorabilia. Basically, anything goes with altered books, and the finished product may have no resemblance to the original book at all. Instructions: 1. Ask clients to reflect on their lives and presenting concern, such as major life transitions, changes in self-perception, or changing relationships. 2. Share with clients some photos or examples of altered books and ask the clients to consider how they might depict an aspect of their lives through the medium of altering books. 3. After choosing a book, invite clients to change the book in any way they would like. Examples could be gluing the pages together, cutting into the book to make shadow boxes or hidden compartments, adding envelopes that contain messages or letters, or sewing images into the pages. Reassure the client that there are no limits and that the final product does not have to resemble a book. 4. Assist the clients while they recreate their books and ask them about the meaning of the items they are using or the messages they include in their books. 5. After all clients complete their books, each client describes what the altered book represents to him or her. 6. Examples of questions to facilitate a process discussion could include: What is the title of your altered book and what does that title mean to you? What message about yourself do you believe your book conveys? What does the [object added to the book] mean to you, and what were your reasons for including it? I see that you altered the book—glued pages together, cut into your

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book, and more. What does that change represent to you? To other group members, ask: What is your reaction when you see this book? What do you observe? What stands out to you the most? Figures 7.1 and 7.2 offer two examples of altered books.

Figure 7.1 Messages from the moon.

Figure 7.2 Love among the ruins.

PHOTOVOICE MAPPING: EMPOWERMENT THROUGH A VISUALDEVELOPMENTAL HISTORY Christian D. Chan and Melanie A. Popiolek

Indications: Trauma, sexual/affectional identity development and consolidation, gender

identity development and consolidation, depression, anxiety, poor self-esteem, interpersonal violence, bullying, life transitions, abuse, addictions, sex offenders’ issues Goal: This activity has two specific goals; these are (a) to engage in a consciousness-raising activity designed to help the client to develop awareness of the development of personal strength, resiliency, and authenticity throughout his or her life span; and (b) to teach the client how to use photovoice as a tool for future coping through self-expression and the identification of strengths Modality: Photovoice (Visual Arts) The Fit: Photovoice is a digital photography and storytelling collaboration centered around a significant social problem that requires attention and action. Targeted issues are brought to the forefront through multimedia projects aimed at affecting change in the region where the problem exists. The use of a nonverbal, artistic method of communication such as photovoice can allow counselors to compensate for the inherent privilege present within verbal language and communication; this results in this intervention being adaptable to clients at all levels of communicative/verbal ability (Povee, Bishop, & Roberts, 2014). Multiple scholars identify that photovoice has increased utility when combined with the social justice implications connected to its outcomes, especially in the essence of social justice and feminist research (Ponic & Jategaonkar, 2012; Robinson-Keilig, Hamill, Gwinn-Vinsant, & Dashner, 2014; Sanon, Evans-Agnew, & Boutain, 2014; Warne, Snyder, & Gådin, 2013). Given the power differentials imposed in counseling relationships between counselors and clients/students, it is beneficial to emphasize that within the helping relationship, clients or students are allowed to express themselves freely and authentically (Ponic & Jategaonkar, 2012; Rolbiecki, Anderson, Teti, & Albright, 2016). With knowledge of the inherent power differential, attending to social position in power differentials and the subsequent comprehension of differences in positionality between counselor and client/student is necessary. In addition, counselors must be aware that there is a consistent message sent to clients and students who originate from marginalized and oppressed populations. Historically, counseling, although radically based in humanism, multiculturalism, and social justice, continues to grow paradigmatically toward embodying tenets, especially within the most recent force of social justice. Considering the historical trajectory, counseling theoretically has many roots folded into privileged identities, where counseling practices align specifically for members of historically privileged identities (e.g., White, heterosexual, cisgender, male, upper class). Utilizing an intentional process with knowledge of negotiating privilege and oppression in counseling relationships, a substantial component of the counseling process focuses on building rapport and empathically responding to allow clients to rise as their own change agents and engage particularly in empowerment, self-actualization, community change, and social change. This philosophy consistently emerges within the auspices of feminist theory, given that marginalized and oppressed populations often lack a sense of safety and face institutional and social barriers. These obstacles often lead to a reduction in help-seeking. When making sense of privilege and oppression, photovoice can reify particular interactions of the privilege attached to language. Language offers a launching point for clients and students 124

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to enrich their narrative and discourse with the counselor, but the major issue associated with a privilege of language is its reinforcement of a power differential, where a counselor can lead in a session with a client. This position and dynamic operate in a contrary manner to the lens of feminist theory, particularly when feminist theory emphasizes a counselor’s critical examination of power. Additionally, feminist theory holds to values of equality in counseling relationships in a subtle manner to match clients’ and students’ positioning. Population: Children/adolescents/adults; Individuals/groups (note: when using this intervention with children, depending on age it may be more appropriate to use pictures drawn by the client in the place of photos). If using for groups, counselors should critically examine intentionality and care about exposure of photo expression to entire group as opposed to individual settings. Materials: Posterboard, string, printed photographs taken by the client, glue sticks Instructions: Creating a photovoice map generates an organized perspective and context on photos utilized to illustrate representations of the clients’ and students’ lives, especially as they are captured in moments of time. Photovoice allows for clients to speak in their own voices utilizing visual media to depict forms of expression in their own unique language. 1. As you process with clients about their earliest stages of seeking help, begin building a collaborative relationship to emphasize safety and to dismantle power differentials. 2. When introducing this activity, request the permission of clients to integrate the activity into their counseling work. 3. Collaboratively determine the area of the clients’ lives that should be the focus of the photovoice project. For example, you could begin with photos dating back to the clients’ birth up to the present. Alternately, you and the clients may decide to focus on particular time periods that hold substantial significance to the clients; this can be particularly useful in conceptualizing and addressing current presenting issues. 4. Invite clients to take photos of their lives that represent their current identities and experiences. The photos can include descriptions tied to current states, feelings, and issues. Photos can also become illustrations of strengths and resilience depending on the overall purpose, intention, and instructions of the counselor. Instruct these clients to bring photos to counseling sessions. 5. Ask clients to retrieve prior photos from previous points in their lives. Alternatively, clients can also take new photos that describe previous salient moments in their lives. 6. When clients bring photos into session, engage clients in discussing the meaning attributed to each photo and message through which clients are attempting to communicate. It is helpful to connect the discussions of the photos to client plans for goals and counseling. 7. After discussion, ask the clients to draw a single line across a specific medium (e.g., paper, canvas) detailing a specific time period. This time period can focus on the entire life span— beginning with birth and moving to the current stage—or distinct pieces of the life span. 8. Clients will place photos on the line, corresponding to relevant time periods, to express more detail about the time periods in their lives. 9. Provide clients both the space and time in counseling to reflect on this method. After working with clients together to assemble the photos onto a line representing time periods in the life span, explore the following areas with clients: strengths, resilience, themes, changes, and hopes for change.

THERAPEUTIC COMMUNITY DRUM CIRCLE Flossie Ierardi

Indications: This intervention may be used to build a sense of community in group settings at different stages of group development. Goal: To reinforce a sense of safety and belonging within the group community Modality: Music The Fit: Bath (2008) discusses a three-pronged approach to trauma-informed care, including safety, connections, and the expression of emotions, which the editors believe to be congruent with feminist-centered counseling. The drum circle in a therapeutic milieu can be perceived as a safe place if the participants’ rhythmic responses are accepted as valuable contributions. Community building and a sense of belonging are known outcomes of the drum circle experience and music contains elements that allow for nonverbal expression and communication. Although the therapeutic community drum circle is not a substitute for the therapeutic relationship that is necessary in addressing trauma, it can reflect an environment that is consistent with trauma-informed care. Bloom (2010) integrates the three components of trauma-informed care when she identifies the importance of cooperation and creative expression in environments that are socially safe. Perry (2013) discusses the effect of trauma on neurodevelopment and states that patterned sensory experiences, including rhythmic stimulation, are successful in helping to reorganize or repattern brain stem systems for improved impulse control and affect modulation (i.e., a calmer state). Populations: Older adolescents/adults; Groups Materials: Drums and percussion instruments (shakers, bells, claves, and other world music instruments) that do not require previous musical training; a diverse combination of large and small percussion instruments allows for maximum flexibility of expression and musical roles. The following instructions are intended as guidelines and will likely be adjusted based on the facilitator’s observation of the group’s need for structure, which will likely decrease as the participants gain experience with this activity. This activity is not a substitute for clinical improvisation methods and techniques as implemented in group therapy by a music therapist. Instructions: Chairs should be arranged in a circle with instruments in the center so that participants may switch instruments as desired after the playing begins. Participants may be invited to experiment with various instruments before making a choice. If the population consists of persons with impulsive behaviors, the facilitator may wish to provide fewer choices and less access to the entire instrumentarium. 1. Welcome and introduction of experience. Introduce the drum circle as a safe environment for self-expression and interaction. Remind participants that there is no “right” or “wrong” within the drum circle experience. You may suggest group norms, such as respect for instruments, listening to each other, making efforts to blend with the group sound. If the experience is not new to the group, a participant or participants may lead a brief discussion of group norms. Orient group members to the instruments, noting their origin and noting that each instrument, no matter how large or small, will add a unique tone quality to the overall sound and texture (with a number of instruments playing at a given time). 126

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2. Invite each group member to make a statement related to the purpose of the drum circle

(e.g., personal goal for the upcoming session, end-of-week summary statement if applicable, or affirmation). 3. Rhythmic focus and vocabulary. The goals of this phase are to orient the participants to the rhythmic experience and to introduce a vocabulary of expression on the instruments in the drum circle, through the use of a call-and-response experience, with musical imitation or “echo.” This phase sometimes transitions without pause to an ongoing pattern with improvised rhythms. For imitated rhythm patterns, some basic examples follow: ■ The rhythm associated with a “cha cha” sound is often a good start. The facilitator may recognize the following pattern (see Table 7.1). This pattern contains four musical beats, the third of which is divided into two equal parts. The group plays the pattern immediately after the facilitator. You may choose to repeat this and subsequent rhythms to create a sense of grounding or stability. ■ The following rhythm is slightly more complicated and includes a word chant that may help in understanding the pattern (accented or stronger notes are in bold; see Table 7.2). ■ A third example for imitation may be the following popular rhythm in a rock style, again including a word chant (see Table 7.3). Word chants help facilitate the learning of rhythm patterns for inexperienced group members. In smaller groups, ask each group member to say and play his or her name in a repetitive rhythm fashion. Although these rhythms are very basic and familiar, some participants may have difficulty reproducing the patterns correctly. This stage helps determine the interventions that will be used later in the session. If the group is unable to keep a shared beat, you may wish to use only the vocal chants for the imitation task and proceed to drum circle activities requiring less rhythmic accuracy. 4. Musical gathering and introduction of expressive musical elements. Depending on the group and your experience, this musical introduction can be implemented in several ways, either with a recording or independently. The goal of this section is to provide a safe and welcoming environment for rhythmic expression and interaction. ■ For an opening recorded groove, the author suggests a basic four-beat feel, such as Track 1 from the CD included in The Art and Heart of Drum Circles (Stevens, 2003). This track is basic, but energetic and inviting. It is also a good model for your personal practice. Participants can be encouraged, at first, to play softly to continue hearing the recording. At some point, the recording will become inaudible and even unnecessary. You may wish to play the basic pulse (1-2-3-4) on a loud instrument, such as the cowbell, to help keep all players in time together. Table 7.1 Example 1 1 2 Cha Cha Cha

Table 7.2 Example 2 +

1

SWEET PO

2

+

TA

TO FRENCH

3

4 FRIES

Table 7.3 Example 3 1

+

2

3

+

4

PUMP KIN PIE PUMP KIN PIE

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When you determine that the group members are able to play ongoing patterns within the basic presented pulse, begin to give cues for expanded expression through the use of musical elements, such as volume and texture. The group may become accustomed to following facilitation cues, such as raising one’s arms to increase the volume and lowering for decreasing volume. ■ Textural differences can be achieved through cues for part of the group to stop playing, or play softer, whereas one section of the circle, or one instrument type such as shakers, receives a cue to play louder and is thus emphasized. Please see Hull (1998, 2006) and Kalani (2004) for additional explanation and illustration. 5. Expanded expression and interaction. Thus far, the drum circle has incorporated safety through the acceptance of participants’ musical responses. Group members also may experience awareness of connections with others through the experience of musical synchrony, whether through pulse, musical dynamics, or volume, or simply through the simultaneous expression of sound versus silence. Interaction may be further emphasized through several options depending on the degree of musical structure needed by the group as evidenced by their ability to attain rhythmic synchrony in the preceding experiences. With all options, it is advisable for you to initiate or support an opening rhythm pattern in a familiar style. In addition to the basic four-beat feel, an example is the “6/8 Groove,” Track 2 on the CD in the Stevens (2003) publication. Give the group a brief warm-up using this new rhythm through repetition and emphasis on simple patterns in this new meter. 5.1 More structure. Continue with cues for volume and textural changes. In the most structured approach, the group may need continued instructions because they may need to develop an appropriate expressive repertoire. The nonverbal experience of affective musical elements will generate increased expressivity through cues from you. 5.2 Moderate structure. Depending on group size, you may use an approach whereby the participants make verbal suggestions regarding the execution of this phase of the session. Group members may decide, based on their experience thus far, which person or instrument type will begin, volume level, speed or pace, and how it will proceed until the end. The instructions will be written on a board that is viewable by all participants. Although there will still be improvisational options, this approach encourages the group to work together to create a visual representation of their expressive choices for the upcoming experience. 5.3 Less structure. Begin with a basic rhythmic pattern or encourage a group member to do so. To introduce this experience, you may encourage the group members to become aware of the rhythms of one or more participants and to respond through matching the person’s rhythm or interacting by playing similar rhythms. Participants can also be encouraged to independently vary their volume to add various expressions, to stop playing for brief periods to listen to the group, and to contribute to textural changes. 6. Supportive musical experience as transition to verbal expression of closure. Return to a familiar rhythm as a nonthreatening means of closing the expressive experience and transitioning to verbal closure. Using a vocal melody can be effective in incorporating musical structure at this point in the session; these may be basic familiar melodies or songs from other cultures in call-and-response style. Become familiar with uncomplicated songs that can be added to a rhythmic groove. Using melody helps to contain the expressive rhythmic experience by giving an accompaniment role to the instruments of the drum circle. If the facilitator does not wish to use melody, another possibility for imposing structure is to return to the rhythmic call-and-response style or imitation/“echo” that opened the session. This choice will give the experience of a more literal recapitulation or return to the earlier theme of the session. Musically, this session can be compared to a musical composition that contains an introduction (as in the building of rhythmic vocabulary), statement of theme (musical gathering), ■

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development of theme (increased musical expression), recapitulation (return to earlier rhythms and themes with introduction of vocal closure), and coda (as in the verbal expression of closure discussed next). 7. Verbal expression of closure. Although the therapeutic community drum circle is not intended to uncover and explore deeper memories of trauma, the association of musical (i.e., nonverbal) perceptions with various feeling states may allow participants to safely identify emotions with distance and objectivity. Ask group members to reflect on their opening statement and to articulate a brief summary phrase or word about the drumming experience to close the session. Depending on the group and the setting, the closing verbal directive may be to express a positive statement about the experience, an affirmation of self, or a word of encouragement for self and peers. Suggestions for groups where rhythmic synchrony is a challenge include the following: ■ Pairing visual and vocal cues with rhythm patterns may be more effective than rhythm patterns alone. ■ When rhythmic synchrony is not yet feasible, the facilitator can use an approach such as that described in the Moderate Structure intervention discussed earlier. Using a visual “score” of few instructions and clear gestural cues, the facilitator will help the group achieve a sense of connectedness within musical elements of volume, texture, and timbre (instruments of like tonal quality playing together). ■ The group may be able to create a musical version of an extramusical association, such as a thunderstorm or a particular setting, such as a busy intersection. ■ Occasional group tremolos, where everyone plays loud and fast producing a rumbling effect, can focus the group as a unit. You can give easy and fun cues for increases and decreases in volume, in unison as well as in group subsections (Kalani, 2004). Note: Adults with a history of typical development are generally able to synchronize pulse whether or not they have had musical training. This may be interrupted by brain trauma, psychiatric disorder, and in some cases, anxiety about a new experience; however, it is quite rare for a group to be unable to achieve a sense of rhythmic synchrony. One notable experience by the author occurred with a group of adults with severe physical disabilities. Despite the lack of basic pulse in the overall sound, their motivation for interactive expression and connection was an overriding factor in the success of the drum circle.

WOMAN CRAFT EMBROIDERY HOOP Rachel Payne

Indications: Body image, stifled creativity, externalized base of knowledge, eating disorders,

bereavement, loneliness, low self-esteem, depression, stress, major life transitions, feelings of disconnection, feminist identity development, ethnic or racial identity development, and wounded family ties Goal: For women to explore a subjective knowledge of history to create connections with the women of their past and establish a new context for themselves and their circle of women in the future Modality: Visual arts The Fit: This specific craft activity reflects the historical handiwork of women and serves as a means of connecting women to their ancestral heritage so as to understand the cultural context of our past (Sebba, 1979). It simultaneously allows each woman to claim and create a symbol of self-identity that may facilitate a shift in her relationship with the current sociocultural context. This activity uses a group setting, a preferred feminist approach, to facilitate a sense of connectedness, or “mutual empathy,” between the women participants (Stiver, Rosen, Surrey, & Miller, 2008). Paired with this framework for communication is the exploration of each woman’s inner way of knowing (Belenky, Clinchy, Goldberger, & Tarule, 1986). Participants are invited to connect with original female ancestors who exist beyond the distress of current or recent cultural shaping. The project uses the ancestors’ untainted perspectives to assist the client in revisioning the past with the hope that she may heal the women who have lived through it, herself, and those women to come. The feminist approach provided in the woman craft embroidery hoop assists clients to explore multiple areas of gender and self-knowledge. These include the social construction of meanings about women in the past; ways in which being a woman might have been different before society created “truths” about women; ways in which a woman can create her own truth; ways in which connections are fostered by the women within the women’s group; the idea that their bodies might be instruments of knowing; beliefs surrounding their own personal creativity; internalized judgments about creativity, body labels, and gender roles; ownership, honor, and pride in the crafts that generations of women have used as expressions of creativity and womanhood; and the wounds of the more recent generations of their woman-kin. Populations: (Female) Children/adolescents/adults; Groups/individuals Materials and Preparation: 8 in. embroidery hoops and 1 sq ft of opaque, nonstretch fabric (wool, velvet, heavy cotton, linen) in white, beige, or black for each woman; various colors of embroidery floss; embroidery needles; scissors; thin ribbons, small beads, and charms (optional) Instructions: 1. Begin the activity with a discussion of what life might have been like for the groups’ female ancestors. Assist clients in identifying the sociocultural influences present. 2. Explain to the group that they will be engaging in an activity that many of the women of their past may have used as a creative outlet, for decorating their homes, commemorating times of difficulty, or marking the occurrences of a significant rite of passage such as baptism or marriage (Sebba, 1979). They will be creating a kind of self-portrait showing a hidden quality of the circle of womankind to which they belong. Share that there is no right or 130

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wrong way to approach this activity. Assure participants that they are free to learn to use the materials as they go and that they may even share with each other what they learn to expand the group’s pool of knowledge. Their level of skill need not determine the quality of the process. Stitches can be complex or straight and simple. Distribute a hoop, fabric square, and needle to each woman. Place the remaining materials in the center of the group. Stretch material onto the hoop by loosening the screw at the top and separating the outer and inner rings. Center the material on the inner circle and slip the outer over it so that the material is pulled taunt. Tighten the screw to secure. Explain that the group will be doing a guided imagery. Ask them to take their hoop with them as they find a place to sit or recline. Lead the group in this visualization: (Directions to the counselor are given in italics and are not meant to be shared with the group. The following script is intended as a suggestion and may be altered to fit the specific needs of your group. For optimal effect, speak in a relaxed voice with a slow cadence.) As we prepare to explore your inner world of stories and images, allow yourself to settle into the spot you have chosen. (Wait a moment while each person gets situated.) Remembering that each cell of your body is created by the line of ancestors who existed before you, let yourself begin this visualization by relaxing your body. Invite your attention to rest with your breath. Notice how it moves in and out of your body. Notice the rise of inhalation, and the gentle giving in of exhalation. (Allow yourself to inhale and exhale, so you can be in connection with the group’s experience.) Notice, if you will, the movement of your heart within your chest, (pause) and how the breath creates a slight sensation of rocking there. Perhaps, it might feel as if your heart is being cradled by your chest; (pause) rocking to and fro, in a gentle, relaxing rhythm. (pause) It is this same kind of rhythm that has been used to soothe loved ones for generations. Perhaps your body has a small inkling of having been soothed in this way some time in the past and can be comforted once again by this age-old invitation to let go and relax. As you move deeper and deeper into a state of relaxation, let your heart reach out to that line of loved ones who has soothed and been soothed by the presence and thoughts of one another, perhaps recalling your own mother or father and the ones who cared for them. Allow your mind to drift through the circle of family you have known or about whom you have heard stories. Drift further down your line of loved ones to the family members who are just on the edge of being forgotten. Then, drifting even further allows your heart to connect with the far-reaching fringes of your ancestors. There, in the distant past, settle yourself at the edge of your family’s existence. And turning slowly, allow yourself to look across time to the present, past this day, and into the years and generations to come. These are your people. And you are one of them. Invite them, if you wish, to gather around you like a great hoop that circles around the fabric of your existence. Here in this special place between now and then, make a request to have one woman from your family circle come forward to share with you something about being a woman that might have been lost or diluted in the passing of time. She is here to tell you about the essence of womanhood. Invite her to gift you with this wisdom. It may come in the form of a word or story, an image or symbol, or perhaps it may appear as a feeling or an inner knowing. Take a few moments to visit with this wise woman, to listen her, and to connect. (Give the group a few minutes to process their interaction.) As you prepare to bring your visit with the wise woman to an end, you might consider thanking her for her part in your life. Notice, too, that as you have received your message from her, all the ancestors, female and male, of the greater circle have stood witness to and been changed by, perhaps even healed by, the wisdom you have been willing to seek out. This is a new day for all of you. Now, begin preparing yourself to return to the room. Bring with you the wisdom you have received. Paying attention once again to your heart rocking in your chest, to your

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breath, and to the sounds in the room and beyond. And when you are ready, you may open your eyes. (Once everyone has opened their eyes.) Now, allow your hoop to represent that circle of family that witnessed and supported you today. Using the thread provided, create with stitches a clue to the gift you received. It may be a symbol, a word, a self-portrait, or anything of your own creating. 7. As the women begin to sift through the floss, share with them that the six strands are sometimes split into two sets of three to allow them to be more easily pulled through the eye of the needle. As they work, they might imagine their hands drawing out knowledge, like a thread, which is anchored in the distant past with the woman in their visualization. As they pull, they may bring to mind the lineage of wounded women in their recent heritage, as if to carry the newfound realizations of womanhood through them and into the present. Simultaneously, reaching into the future, they can offer the women who are to come a taste of their untainted heritage. In this way, the three threads make the symbolic pulling together of the past, the present, and the future physical. 8. As they stitch, encourage each woman to share her realization and awareness and facilitate empathy by the group for her personalized knowledge and experience. 9. Depending on each woman’s vision for her image, the crafting time for the group may vary. The group may decide to finish and process the next time they meet or take the project home to complete. Invite participants to explain the intention behind their work and assure them that they may bring the finished pieces back later to share. Suggested discussion and questions include: What does your symbol mean to you? What story does your symbol tell? How might this symbol change your perception of yourself as a woman in our present society? What are some of the examples of empathy that you observed or experienced during the activity? What was it like to share this experience with other women? What are the common threads in your stories? 10. Once the symbols or self-portraits are completed, they may be framed, made into a pillow or badge, or left in the hoop with the excess material pulled tight, trimmed, and anchored with glue to the back. Figures 7.3 and 7.4 offer examples of woman craft hoops.

Figure 7.3 Woman craft embroidery hoop focusing on self-efficacy entitled “Trees of Life.”

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Figure 7.4 Woman craft embroidery hoop focusing on renewal called “Grace Garden.”

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Balancing safety and action: Ethical protocols for photovoice research with women who have experienced violence. Arts & Health: An International Journal of Research, Policy and Practice, 4(3), 189–202. doi:10.1080/17533015.2011.584884 Povee, K., Bishop, B. J., & Roberts, L. D. (2014). The use of photovoice with people with intellectual disabilities: Reflections, challenges and opportunities. Disability & Society, 29(6), 893–907. doi:10.1080/0968 7599.2013.874331 Richmond, K., Geiger, E., & Reed, C. (2013). The personal is political: A feminist and trauma-informed therapeutic approach to working with a survivor of sexual assault. Clinical Case Studies, 12(6), 443–456. Robinson-Keilig, R. A., Hamill, C., Gwinn-Vinsant, A., & Dashner, M. (2014). Feminist pedagogy in action: Photovoice as an experiential class project. Psychology of Women Quarterly, 38(2), 292–297. doi:10.1177/0361684314525580 Rolbiecki, A., Anderson, K., Teti, M., & Albright, D. L. (2016). “Waiting for the cold to end”: Using photovoice as a narrative intervention for survivors of sexual assault. Traumatology , 22(4), 242–248. doi:10.1037/ trm0000087 Sanon, M., Evans-Agnew, R. A., & Boutain, D. M. (2014). An exploration of social justice intent in photovoice research studies from 2008 to 2013. Nursing Inquiry, 21(3), 212–226. doi:10.1111/nin.12064 Scholz, S. (2010). A third kind of feminist reading: Toward a feminist sociology of biblical hermeneutics. Currents in Research, 9(1), 9–32. Schuhmann, C., & Sools, A. (2014). Theorizing the narrative dimension of psychotherapy and counseling: A big and small story approach. Journal of Contemporary Psychotherapy, 44(3), 191–200. doi:10.1007/ s10879-014-9260-5 Sebba, A. (1979). Samplers: Five centuries of gentle craft. New York, NY: Thames & Hudson. Seligman, L., & Reichenberg, L. W. (2010). Emerging approaches emphasizing emotions and sensations. In L. W. Seligman & L. W. Reichenberg (Eds.), Theories of counseling and psychotherapy (pp. 219–240). Upper Saddle River, NJ: Pearson. Sommers-Flanagan, J., & Sommers-Flanagan, R. (2012). Counseling and psychotherapy theories in context and practice: Skills, strategies, and techniques (2nd ed.). Hoboken, NJ: Wiley.

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Stevens, C. (2003). The art and heart of drum circles. Milwaukee, WI: Hal Leonard. Stiver, I. P., Rosen, W., Surrey, J., & Miller, J. B. (2008). Creative moments in relational-cultural therapy. Women & Therapy, 31(2–4), 7–29. doi:10.1080/02703140802145631 Travis, C. B. (2014). Women and health psychology: Mental health issues. New York, NY: Psychology Press. Trepal, H. C., Wester, K. L., & Shuler, M. (2008). Counselors’-in-training perceptions of gendered behavior. The Family Journal, 16(2), 147–154. doi:10.1177/1066480708314256 U.S. Agency for International Development. (2011). Tips for conducting a gender analysis at the activity or project level. Retrieved from https://www.usaid.gov/sites/default/files/documents/1865/201sae.pdf Warne, M., Snyder K., & Gillander, G. (2013). Photovoice: an opportunity and challenge for students’ genuine participation. Health Promotion International, 28(3), 299–310. Retrieved from https://www.ncbi.nlm.nih .gov/pubmed/22419620. doi: 10.1093/heapro/das011 White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York, NY: W. W. Norton. White, M., & Epston, D. (1992). Experience, contradictions, narrative, & imagination: Selected papers of David Epston & Michael White, 1989–1991. Adelaide, Australia: Dulwich Centre Publications. Whitten, K. M., & Burt, I. (2015). Utilizing creative expressive techniques and group counseling to improve adolescents of divorce social-relational capabilities. Journal of Creativity in Mental Health, 10(3), 363–375. doi:10.1080/15401383.2014.986594 Worell, J., & Remer, P. (2003). Feminist perspectives in therapy: Empowering diverse women (2nd ed.). New York, NY: Wiley.

8 Gestalt Theory Brian J. Mistler

Some have called training in Gestalt therapy a “creative license” (Lobb & Amendt-Lyon, 2003). For many, this is true. Almost every Gestalt therapist I have known supports creative expression in themselves and their clients. I hope that after reading this chapter and the entire book, you will feel even more licensed to be creative whatever your training and orientation are. Of course, you do not have to be a Gestalt-oriented therapist to make creative use of the arts; however, there does seem to be natural support for incorporating expressive arts interventions in the Gestalt theoretical model itself. FOUNDATIONS OF GESTALT THEORY Gestalt therapy emphasizes wholes, the therapist–client relationship, and awareness of the ongoing present, while combining phenomenological, existential, and behavioral approaches to therapeutic intervention. Its initial formulation is credited primarily to Frederick (Fritz) Perls (1893–1970), and collaborators Laura Perls and Paul Goodman beginning in the 1940s (Perls, 1947, 1969b; Perls, Hefferline, & Goodman, 1951). Fritz Perls was trained in psychiatry and worked for a time with Karen Horney and Wilhelm Reich. Early writing on Gestalt therapy was influenced strongly by the Freudian psychoanalytic tradition in which many at the time were trained. The term gestalt was derived from the focus that this approach places on wholes, patterns, configurations, or gestalts, in contrast to other more reductionist approaches. The term also makes reference to Gestalt therapy’s application of principles investigated by Gestalt psychologists (Kohler, 1992) such as understanding that organisms will tend to try to complete incomplete things, the importance of figure-ground (i.e., foreground–background) shifts, and the role of attention and personal and/or social construction of meaning involved in perception. CORE CONCEPTS OF GESTALT THEORY Gestalt therapy takes a Reichian perspective on mind–body unity and attends to the importance of bodily tension and nonverbal behavior (Perls et al., 1951), which makes it especially well aligned with expressive arts. Central to Gestalt therapy is a focus on direct experience, a humanistic belief in the innate movement of organisms toward equilibrium, and existential contact, characterized by mutuality and inclusion. Because the person of the therapist and his or her ability to be in contact with the client is so central to client growth, great emphasis 137

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is placed on the development of the counselor as a whole person. An individual who has worked on his or her own “unfinished business” is less reactive, more present, and has more available energy in facilitating the client’s work than a therapist who has not addressed his or her own issues. This suggests the importance of expressive arts not only for the client but also for the therapist. Gestalt therapy is also deeply aligned with an Eastern, nonAristotelian philosophical approach, embracing multivalent logic (i.e., both/and as opposed to either/or), field theory (i.e., people and their environment are a related system in constant change), process (e.g., being genuine and present in the ongoing now, rather than focusing on abstract structures and conceptualizations), and a paradoxical theory of change or fostering the natural Taoist “flow” of being who one is, rather than pushing toward an ideal (Beisser, 2004; Mistler, 2009b). Believing “nature heals” (Goodman & Stoehr, 1977), Gestalt-oriented counselors often look forward to developing awareness of clients’ existing processes and the ways in which even the distressing symptoms can be understood as an expression of creativity. Once the person in distress reconnects with his or her creativity through a deeper experiential awareness of the processes and resists his or her connection to present awareness, the side effects (i.e., the client’s symptoms) will begin to go away. There are six primary patterns of disconnection also called “channels of resistance.” An individual may employ one or several together. Introjection is the indiscriminate acceptance of something outside oneself without “chewing on it” first; at its core, this is passively accepting another’s ideas about how we should be, what we should do, and how we should see the world. Projection is the reverse of introjection. In projection, the tendency is to make the environment responsible for what actually begins in oneself or ascribing one’s disowned power to someone or something in his or her environment. Encouraging the projector to experiment with “I” language can often be helpful in re-owning disowned projections. Confluence occurs when the individual feels no boundary between himself or herself and others. Confluence often leads to what are commonly called “psychometric problems,” and clients stuck in confluence often demand likeness of others to themselves and are intolerant of differences. Retroflection involves doing to oneself what one would like to do to something or someone in the environment. This involves the creation of a boundary drawn sharply inside one’s own self in which an individual splits himself or herself into two parts that war against one another. Expressive techniques can be especially helpful in helping to parse these parts out and to bring integration. Deflection occurs when individuals distance themselves from opportunities for healthy contact. Examples may include avoiding eye contact, overly polite phony behaviors, or talking about things other than the present self. Lastly, egotism is an excessive concern with one’s own internal processes, so prominent that the individual does not recognize possibilities for contact (Mistler, 2009; Van De Riet, Korb, & Gorrell, 1980). Gestalt therapy aims to help the individual’s transition from being stuck in these selfdefeating patterns to experience a more creative interaction with the environment—an interaction that offers more quality contact and satisfaction of the individual’s needs. Through various clinician-led experiments, the individual may have experiences during the therapy session that offer opportunities to complete “unfinished business,” which has previously prevented healthy contact. Because such impasses, or blocks, are certain to interfere with the individual’s ability to maintain contact and stay in the now, a Gestaltian patient history will elaborate only what is already present in the moment. And because the important gestalts, or wholes, will emerge in the process of trying to make contact, attention to the obvious in the present is the pathway to completion. To facilitate this awareness, the Gestalt therapist attempts to direct the individual’s ongoing awareness to the present by providing support through the therapeutic relationship, attending to breathing as needed to stay with anxiety, and frustrating attempts to escape the present.

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RESEARCH BASE AND EFFICACY Gestalt therapy can be an effective treatment for a range of issues for both individuals, couples, and families (Kempler, 1973) and even those with personality disorders including narcissistic and borderline (Yontef, 1993). Studies have also demonstrated effectiveness within a range of specific issues such as conflict resolution and depression (Strümpfel, 2004; Strümpfel & Goldman, 2002), as well as being more effective at long-term maintenance of the gains (Ellison, Greenberg, Goldman, & Angus, 2009). A review of studies found directive experiential approaches like Gestalt to be more effective than cognitive behavioral therapy (CBT; Greenberg, Elliott, & Lietaer, 1994). Because Gestalt therapy focuses on process, a Gestalt approach can be used and adjusted to fit the needs of almost any patient population (Yontef & Jacobs, 2008). However, clients with profound difficulties in verbalization may require special adjustments by the therapist. Importantly, “Gestalt Therapy does not advocate a cookbook of prescribed techniques for specialized groups of individuals,” (Yontef & Jacobs, 2008, p. 253) but rather encourages development of the therapist as a person allowing for his or her genuine contact with each individual client. MULTICULTURAL CONSIDERATIONS Gestalt therapy is often regarded as an early proponent of multiculturalism, though some methods have a reputation for their directive nature (Mistler, 2015; Mistler & Brownell, 2015). It is important in all cases to consider the culture and context before applying and when introducing a specific intervention. One area where understanding Gestalt theoretical foundations is especially helpful in improving multicultural tolerance is the area of Tolerance for Ambiguity. Early research into Tolerance for Ambiguity demonstrates the relationships between intolerance of ambiguity to “intolerance of diversity among people” (McLain, 1993, p. 184), and to being ethnically prejudiced (Bochner, 1965; Furnham & Ribchester, 1995). More recent studies have also confirmed this relationship, finding ambiguity tolerance to be negatively associated with supporting diversity interventions (Chen & Hooijberg, 2000) and connected to both humor and higher-order thinking (Mistler, 2009a). A situation is likely to be perceived as more or less ambiguous depending on the amount of uncertainty, change, stability, and/or the degree to which it confronts the individual with problems that do not fit into existing viewpoints or ways of thinking (Dermer, 1973; Duncan, 1972; Ho & Rodgers, 1993). However, individuals do not all react the same when confronted with ambiguous situations or stimuli. Individual differences in this arena are important for working across cultures and critical for those who do not conform to traditional models within a society including those under the trans-umbrella (Lennon & Mistler, 2010, 2014; Mistler & Lennon, 2011). Gestalt therapy and the techniques that follow within this chapter are especially adept at increasing tolerance for ambiguity. GESTALT TECHNIQUES AND THE EXPRESSIVE ARTS A Gestalt therapist may use a number of techniques in his or her practice. What is most important is that each technique is approached with an experimental attitude, not as an assessment, but with an openness to a range of outcomes, and a radical respect for clients and their process; hence, the interventions are typically termed “experiments.” Although many techniques are shared with other orientations, a number of specific themes for techniques have grown out of Gestalt theory itself, such as dialogue (the empty-chair technique being the

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classic model), present awareness, revisiting unfinished business in the present, giving voice to bodily sensations, and exaggeration (which helps awareness of the “obvious”). Expressive arts interventions can be used quite creatively in the service of helping the client to elucidate the internal dialogue, to be more aware of what is happening in the present, to revisit unfinished business, and to even give a voice to bodily sensations or exaggerate something in a creative way. The expression of “creative formative power in every person” (Perls et al., 1951, p. 288) is core to Gestalt therapy and life. Importantly, good (satisfying) contact is not seen as more or less creative than bad (unsatisfying) contact (Margaret Korb, as quoted in Mistler, 2009b). Indeed, the term “creativity” is usually not found as a separate noun in itself but most often is in its adjectival form in terms like “creative adjustment”; highlighting it as an inseparable part of the field of experience. Antonia Sichera (2003) writes, “Creativity is not defined in Gestalt Therapy; but it is implicitly stated that all that ‘happens’ in the field, in relation to the contact, is in itself ‘creative,’ because without the creative contribution to the subjects involved there is no contact, no experience, no relationship” (p. 93). Something quite similar may be said about the term “expression.” Every act is expressive, but not all intentionally so. Not all expressions are owned expressions of oneself; many expressions are not owned and are expressions of things that come from anywhere but oneself. Often, they are introjected from the environment, having been taken in—and swallowed whole—at some point earlier in life without fully being processed. This is seen in children who express strong feelings about a political or religious belief about which they know nothing, but who have introjected the idea from their parents. Expression may also be projected; such as when we “put words in others’ mouths” that they have not actually communicated. The very notion of self in Gestalt therapy refers to an ongoing process of creative contact with the environment (Perls, Hefferline, & Goodman, 1994), and meeting one’s needs requires spontaneous expression in response to what is perceived in the environment. Within the Gestalt perspective, perception and expression are not fundamentally different as both are creative acts. Creative expression is more than a technique—it is, if understood in a deep, holistic way, nearly synonymous with health. Korb (as quoted in Mistler, 2011, p. 130) writes that “creativity is not the province of ‘the Arts,’ artists, or any select stratum of society or discipline. Nor is it an achievement. It must ultimately be embraced as a birthright and an existential constant; whether we learn to use it consciously, responsibly, and proactively or not. The active word is awareness. It is the intrinsic role of the Gestalt therapist to provide the appropriate environment . . .” (np). A therapist who models and supports the incorporation of expressive arts interventions into his or her practice lays the foundation for creating such an environment. CONCLUSION One of the key elements of Gestalt therapy is the encouragement of clients to try out new ideas or ways of being as evidenced by the utilization of experiments in the counseling session. This emphasis on innovative approaches makes Gestalt therapy the perfect foundation for a diverse client population as well as the introduction of the expressive arts into clinical work. Creating the environment in which clients are comfortable breaking their prior self-defeating patterns of behavior is the goal of the therapist and this focus provides a path for clients to engage in new ways of engaging with their environment and the individuals with whom they have relationships.

Expressive Arts Interventions

“EMPTY BEAR” TECHNIQUE: USING PUPPETS WITH ADULTS Brian J. Mistler

Indications: Any presenting issue that is creating conflict and needs to be given voice Goal: To help clients express and work through inner conflicts and defenses Modality: Puppetry and drama The Fit: Gestalt therapy is characterized by an attitude of atheoretical experimentalism rather

than conceptualizations and techniques (Naranjo, 2000). Nevertheless, a few specific techniques for experimenting have been developed that are especially effective and consistent with the Gestalt therapy approach. Perhaps the most iconic of these is the empty-chair technique. Using empty chairs is actually just one application of a broader technique called dialog in Gestalt (Mistler, 2009). The aim of dialog is to help increase an individual’s awareness of two or more parts that are in conflict. By using external objects, such as chairs as placeholders, a person is often able to better separate the voices. And by moving from chair to chair, the person can alternatively experiment identifying with each voice, increasing the opportunity to assimilate a disowned projection, or reject an unhelpful introject. Although puppets are often used in play therapy with children (Cassell & Paul, 1967), they also have a great potential for use with university students and even older adults. Using puppets can be helpful for clients with natural theatrical bent as well as those who are not used to being expressive. Indeed, puppets can be helpful for a range of presenting concerns including depression, anxiety, and even trauma and protracted grief (Bernier, 2005; Cassell & Paul, 1967). Using, and even choosing, a puppet both encourages initial development of projections and can help some people reconnect with their imaginations, who may be hesitant to speak with imaginary people in other chairs. Populations: Adolescents/adults; Groups/individuals/couples Materials: Multiple puppets. Ideally there should be at least three or four puppets per client from which to choose. A range of choices from bears and other animals, to humans of various genders and skin colors is nice. For a beginning collection, at least one male and one female are probably important. Eventually, it is nice to have some young and some old, some “scary” and some “friendly.” Just about any kind of real or imagined creature can work. If possible, the puppets should be appropriately sized so that the person can control the movements of the puppets’ mouths in some way. Being able to move at least one of the puppet’s limbs, even from outside the puppet, can help people engage even more in the beginning. Any sort of puppets will work—from homemade sock puppets, to tiny hand dolls, and to more professional puppets. Full-body puppets offer the most versatility in using them as puppets as well as putting them in another chair so that the clients may address them.

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Instructions: Preselection. The activity begins the moment you introduce the idea of using puppets, a

suggestion that is best approached with an experimental attitude. You may begin to develop client awareness at this point by asking questions, for example, of a person reluctant to engage: Therapist: What’s stopping you? Client: That’s silly. Therapist: You mean if you do it, you will be silly? Client: Yes. I’m a grown-up girl. I shouldn’t do silly things. Therapist: Is there also a part of you that wants to be silly? Client: Yes. But, I don’t let her come out much. Therapist: Maybe those two parts could have a conversation . . . Therapist’s Use of Puppets Without Client. Much of what determines whether a client will

participate in an intervention with puppets is your, the therapist’s, own attitude. If a client senses hesitation from you, the client will be reluctant to join in. In contrast, if you model commitment to the value of the activity, the client often readily participates. You may also encourage the client’s participation by grabbing a puppet and simply starting the interaction. This lowers the inhibition of the client to select and give voice to his or her own puppet. You may use a puppet to project two sides of a concern—a kind of therapeutic good cop–bad cop. For example, you may instigate a serious conversation with a client who swears he or she has not touched a drop of alcohol this week, whereas a therapist-selected puppet takes the role of a disbeliever saying, “Bologna!” Like a classic ventriloquist act, you can apologize for the puppet’s behavior and support the client while still communicating both important sides of the message. Selection. Much work can be done in the selection of puppets. It is important to remember, however, that this is an experiment and not a projective test. Refrain from verbalizing your analysis of choice. Rather than stating explicitly your own interpretations of puppet selection, explore them experientially. Ask the client to have a dialog between puppets selected to represent various individuals in the client’s life, starting with one asking the other, Why didn’t you choose me? Top Dog–Underdog. One of the classic patterns of dialog in Gestalt is called “top dog– underdog.” This describes a pattern wherein one part of the self oppresses the other part (which, in some way, is complicit). When you ask a person to select two puppets, one may emerge as the “Shut up and do what I say—I know what’s best for us” voice (the top dog) and the other as the “I’ve learned I’m not worth that much, but I still feel I want to be heard” placating voice (underdog). Noticing and exploring this pattern can be helpful. The outcome may be a client rejecting one of the voices as an introject or negotiating a compromise between the two, allowing both voices to be heard, understood, and appreciated for their acting in the person’s best interest. Emphasis on Ownership. Invite a client to speak to a puppet that represents a placeholder for an important individual in the person’s past or present. Then invite the client to speak for this person (i.e., pick up the puppet and speak for or from it, not just to it). Encourage ownership of feelings by reminding the person to speak using “I” language—this is helpful when a person talks about the puppet, as well as when the person uses second-person or third-person language, such as the following: Client: I don’t like to think about that, it’s depressing. Therapist: Can you say “I am depressing”? Client: I am depressing. I don’t want to be depressing . . . to be depressed, but I am. Therapist: What do you want to be? Client: I want to be pretty and happy all the time!

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Therapist: Is there a puppet over there that you think is pretty? Client: Yes, the one in the dress. I’m sure she’s always happy. Therapist: Ok. Go get her, and let’s find out about her life. Integrating With Therapy. Transitioning to and from puppetry can be challenging, but it does

not need to be. As with the start, you may consider “skipping” the transition step (or, at least, making it go by more fluidly and quickly). You can just put the puppets aside and go on with your next intervention. You can also make the transition itself as an intervention. One way to finish the experiment is simply to ask if they feel finished with it, for now. If not, ask them what else they would like to say to help them feel finished. This can involve them saying “goodbye” to the puppet for now. They might want to apologize to a puppet to whom they did not pay enough attention or to whom they were “too mean”. These impulses as well can make fruitful fodder for more experimentation. At some point, it can be especially powerful to encourage the client to “become” the puppet—to move from speaking through his or her hand in the puppet to letting a particular voice speak through his or her whole body. This transition from the use of puppets to a more traditional empty-chair experiment can help a person more holistically integrate his or her awareness. And for those clients to whom puppets are very threatening, sometimes just the threat of puppets can help a person be more willing to engage with other expressive techniques, more palatable to his or her particular sensibilities.

EMOTION, EMOTION SHIELD Allison L. Smith and K. Hridaya Hall

Indications: Appropriate for a variety of presenting concerns, especially for individuals who

seem to have a weak sense of their own steadiness or grounding; also appropriate for those who are prone to assume emotions of others or react highly to others’ emotions Goals: To raise body awareness of emotions; to support awareness and centeredness when faced with emotions of others Modality: Dance and movement The Fit: This expressive arts activity is a perfect fit with Gestalt theory (Perls, 1969a) because the ultimate goal is to raise awareness of sensations, thoughts, and feelings as well as understand the connection between the mind and the body. This activity can be understood as a Gestalt experiment in which a counselor invites the client to participate. Populations: Adolescents/adults; Groups/individuals/couples Materials: Paper and pens Instructions: The activity is designed to take place within a 45- to 60-minute session, and may range between 20 and 45 minutes depending on whether it is being used with an individual or with a group. 1. Generate a list of four feeling words with the client including two more positive and two more challenging emotions (this may include feelings you have identified in sessions that are difficult for him or her to feel or to deal with others, etc.). 2. Write these four words on pieces of paper (one on each piece) and place one feeling word in each corner of the room (or otherwise, a defined space). 3. If working with a couple, the couple decides who goes first. If working with a group, invite the clients to pair up and let them decide who goes first. The first volunteer walks around the space until he or she reaches a corner that he or she wants to enter. After entering the corner, he or she should fully embody the feeling of that particular space (i.e., moving as if feeling it and assuming associated positions, postures, facial expressions, or breathing patterns). The partner remains outside the corner and stands witness to the emotions being displayed. 4. Encourage the client to visit the four corners of the room and to spend some time in the spaces between the corners. 5. Check with the client what he or she noticed about his or her body while experiencing different emotions. Process questions might include, Were you reluctant to visit some corners? What was different about the embodied experience in different corners? What did you do to transition out? What was the sensation in the in-between space? 6. Check with the client’s partner what he or she noticed within him or her while in proximity to the one embodying the emotion. Process questions might include, Were there certain emotions that were difficult for you to see in the other person? How do you react when others are emotional around you? What tools are available to support you holding your own ground when the environment around you is changing? Counseling student variation: class members or supervision group members are partnered, one serves as a witness who stands outside the space and witnesses the other embodying the 144

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emotion. Emotions that have been experienced with clients in recent sessions or with which supervisees have expressed hesitance are used to define the corners. The questions that can be used in addition to the aforementioned process are, How might your reaction to emotions impact your work with clients? What resources can we use to be with our clients in an emotionally charged space while remaining adequately shielded?

SHADOW PARTY Allison L. Smith and K. Hridaya Hall

Indications: The activity is designed for individuals to increase their self-awareness in relation

to their judgments of others. When a client, student, or supervisee reports not understanding why he or she reacted so strongly to another person or seems stuck in his or her perceptions and negative judgments of others, this activity may be helpful. It may also indicate whether an individual seems locked in one way of being or is responding (e.g., always emotionally collapsing when challenged). Goal: To have participants explore and integrate helpful elements of disowned parts of themselves and gain awareness related to their personal triggers Modality: Drama The Fit: Although the concept of the shadow is rooted in Jungian psychology, this shadow exercise fits well as a Gestalt intervention. One of the goals of Gestalt therapy is to support clients in becoming unstuck through increased awareness and in experimenting with new ways of being in their environment (Perls et al., 1951). Polster (1999) adds that clients are limited when they react stereotypically within their environments. The purpose of this expressive arts activity is to help individuals become more integrated through reclaiming judgments they may have of others and embracing disowned parts of themselves. Participants increase self-awareness as they embody what they reject in others and have the opportunity to shift from stereotyped patterns of responding through playful experimentation. Populations: Adolescents/adults; Groups Materials: Each client or student is responsible for his or her own costume. This may be as simple as a regular dress with an accessory, or more elaborate, depending on the person’s preference and the role that is being assumed (e.g., a person coming as highly judgmental or critical may wear a graduation gown and bring a gavel; a narcissist may choose to wear a crown). Instructions: The activity requires a minimum of two sessions. First, a 50-minute session will be used to introduce the concepts, invite reflection, and allow individuals to consider how they want to embody their shadows. The shadow party takes between 45 and 90 minutes to facilitate, depending on the size of the group. Between 10 and 15 minutes should be allowed for the initial phase of unstructured interactions, followed by 15 to 30 minutes of more formal introductions, and 15 to 20 minutes of debriefing. 1. Individuals are instructed to contemplate the following questions: What behaviors or traits in others do you find the most irritating? What would be the worst insult someone could say about you? What are some of the adjectives that you would use to describe your least favorite person? The concept of the shadow is then introduced. The shadow is described as representing parts of ourselves that are present but that we attempt to hide or disown, and that may be evident in what we find disdainful in others. The shadow sometimes emerges when an early reaction to another occurs and results in a disowning of all associated elements. For example, when witnessing a verbally aggressive adult, a child may subconsciously and broadly reject that way of being and disown not just the aggression, but also disown the potentially useful but associated elements such as power, strength, and assertiveness. Consequently, the person may be withdrawn, passive, and may harshly judge others who are assertive as “demanding.” 146

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2. Individuals are invited to reflect on the questions asked to assist them in identifying one of

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their shadow parts. Group members may seek support from the facilitator as they identify their shadow, but are asked to keep their shadow identity secret from other group members. Group members and facilitators dress up to embody their shadow parts and arrive at the next group acting as their shadow. (It helps to meet in a new location or somehow set up the classroom or group space as a party.) For 10 to 15 minutes, group members embody their shadows and interact with other members of the group as their shadows would. Members are invited to sit in a half circle still in their roles (e.g., narcissists may interrupt to bring attention back to themselves or a critic may periodically show disdain for the event). The facilitator invites each member individually to introduce himself or herself and asks the shadow a few questions: Do you have a name? Is there anything you would like us to know about you? What do you think of this party? Are there people here you like or dislike? Group members are then invited to guess what shadow the person is embodying and to get affirmation or clarification from the actor. This continues until all group members have been introduced. Members are invited to shake off their shadow role in whatever way they deem appropriate and to come together to debrief the experience. Processing questions may include, How was your experience being in this role? What feelings, thoughts, and ways of acting emerged? How was it to interact with others from this role? Did you see parts of yourself in others’ shadows? What are the positive aspects of this shadow? Are there elements of the shadow that could be drawn or adapted to serve you?

THE BOARDROOM Stephanie Helsel

Indications: This activity enables self-reflection and therefore can be used whenever it would

be helpful for clients to use a more playful or artistic format of exploration. It has been used with secondary school students, chemical dependence rehabilitation groups, and personal growth groups to help examine decision-making consequences and integrate previously unowned aspects of the self. In a group setting, members must have established trust and some knowledge of one another’s lives and struggles. Goal: To broaden and deepen clients’ understanding of the different aspects that make up the self, provide a foundation for conceptualizing and working with polarities and expand clients’ awareness of how they make decisions Modality: Psychodrama (group) or art (individual) The Fit: In Gestalt theory, the primary goal is to enable clients to gain awareness, that is, a sense of “what one is doing, planning, and feeling” (Harman, 1974, p. 180). This is essential, for without awareness, clients will not have an understanding of how they impede their own therapeutic goals of behavioral change. When a client has expressed a goal, such as wanting to be more assertive, yet finds himself or herself unable to do so, there is usually a part of the self that is not integrated into the whole of the person’s consciousness. Rather than work to do away with the passive part of the self, the Gestalt therapist works toward an expanded understanding of the self, where the opposites—or polarities—that exist within the client can be seen and expressed when appropriate. As integration is considered to be an ongoing process, finding ways to open up dialogues and communication between polar aspects of the self is an important focus of therapy. Populations: Adolescents/adults; Groups/individuals Materials: Drawing paper and an assortment of crayons, felt markers, paint, or colored pencils Instructions: 1. The session begins with a brief overview of the Gestalt concept of polarities and the usefulness of integrating opposite aspects of the self and, if possible, reviewing some examples that are based on past discussion or work. Opening remarks might include: One of the most useful things we can do is to gain awareness of what we are doing and how we do it. When do we sabotage ourselves? When do we interrupt ourselves? How do we make supportive decisions, manage conflict well, and how do we make life more difficult for ourselves? Most of the time, to answer these questions, we have to have an idea of all of the different aspects of ourselves that are operating. We all have many different aspects, and sometimes they are opposite of one another. These are called “polarities.” For example, people have a masculine and a feminine aspect, an aggressive and a passive aspect, and a courageous and a timid aspect. Different aspects emerge during different contexts. This exercise will help us examine the parts of yourself that you do not necessarily think about or like very much. I would like you to think about a situation in which you feel like you are never effective despite your best efforts, or where you notice yourself making impulsive or destructive decisions. We are going to deconstruct the process of deciding how and what you do so we can tell exactly who is calling the shots.

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2. Suggest engaging in an experiment that can help increase awareness about how uncon-

3. 4. 5.

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scious aspects of self can contribute to choices and behaviors that are counterproductive or otherwise unsatisfactory. Care must be taken to provide a full explanation of the proposed experiment with ample time for discussion. After the experiment has been described and full consent obtained, distribute the art materials or arrange for use of a whiteboard. Invite clients to draw a large rectangle representing a conference room table. This creates the “boardroom” environment. Ask them to consider all the different aspects of themselves that influence their behavior in a specific situation or context. They should decide who is at the head of the boardroom table, and arrange other characters, representing different aspects of self, in diminishing importance around the table. Each character is named (e.g., The Child, The Tyrant, My Father). Clients can illustrate the different characters with as much detail as they wish. Individual clients can take this home and work on it as homework if desired. When working on an individual level, the illustration can then be processed. The goal is to develop greater awareness of how behavior is influenced and which aspects of self are being given inappropriate control or are ignored. Encourage discussion that addresses how the client may make choices and future decisions. When working on a group level, a volunteer is obtained who wants to explore his or her boardroom with the group. The volunteer asks different group members to play the roles of their different aspects. At this time, it is important to make certain that all members are giving their full consent to participate and that they do understand that sometimes this experiment can result in experiencing very intense emotions. The volunteer engages the characters in a dialogue, expressing feelings as they emerge and responding to the spontaneous dialogue that develops. The counselor takes on the role of the director, helps the volunteer if he or she gets stuck, or prompts group members in their role-playing. The group leader must also manage the energy and timing of the experiment so that there is ample opportunity to process what is happening prior to the end of the group dialogue. Debriefing occurs on a group level, with the volunteer being the first one to talk about his or her experience. For the volunteer who led the enactment experiment, ask questions such as: What are you aware of now, having done this? What did you experience during the enactment? What did you learn? Which aspect of self felt the most powerful or weak? Which aspect of self would you like to be managing during decision making in this particular context? What changes do you need to make in order for that to happen? Would you like to receive feedback from others? If yes, help facilitate members to provide constructive feedback. For other group members, process questions may include the following: How was it like to watch (or participate in) this enactment? Which could you relate to? What was powerful for you? For observers, What feedback would you like to give the participants? How did this experiment make you think about your own unacknowledged aspects of self? From this point on, aspects of self can be referred to using the names developed during this exercise. It can provide a language the client can use when talking about his or her polarities and help the counselor conceptualize the client’s inner process.

UNPAID BILLS Stephanie Helsel

Indications: Group counseling settings that encourage the giving of mutual support in

members, as well as with groups whose members may be in need of reckoning with hurtful or manipulative past behavior. This should not be used as an icebreaker activity but instead, should be suggested once cohesion has been gained, personal material has been processed, and members have come to know of some of the relational issues, current stressors, and sources of shame or guilt with which others are struggling. Goals: To help clients take responsibility for the choices they have made in the past; to explore feelings of being stuck in negative behavior patterns or ways of relating to others Modality: Psychodrama The Fit: This activity provides group members with a nonthreatening way to think about their past actions, choices, and relationships. As a group activity, it relies on peer input and the observations and insights of group members to help expand understanding of the ways in which guilt, shame, and other destructive emotions and behaviors related to the past are being reexperienced in the present. This activity reflects the Gestalt assumption that unresolved feelings or issues, or “unfinished business,” can hamper the regular process of organismic self-regulation (Perls, 1969c). When people have resolved their past experiences, they are able to be flexible and react from a here-and-now orientation, unencumbered by dissatisfying or maladaptive behavior patterns that were created in response to stimuli they experienced in past contexts (Perls, 1973). As Gestalt is a noninterpretive orientation, the group leader must refrain from analyzing group members and instead encourage other members to share how they experience one another. This experiment includes the opportunity for enactment, which is considered to be a type of behavior that can lead to an expanded repertoire of possible ways of dealing with the environment. Populations: Adults; Groups Materials and Preparation: This experiment uses a “past due” invoice worksheet (see Figure 8.1). Instructions: 1. Present a brief overview of the Gestalt concept of unfinished business (see the script that follows) and review some examples. Suggest engaging in an experiment that can help members gain awareness of how they are reexperiencing their past problems in their present lives, and why this is a necessary step in resolving such issues. Be careful to provide a full explanation of the proposed experiment and allow time for group members to ask questions, review their personal histories, and otherwise process the suggested activity. Unfinished Business Script We are all asked to behave in certain ways to obtain the approval of our family members and become good members of society. We had to learn not to hit our siblings when we were angry, to be quiet and sit still in school, to respect our elders, to do our homework, and so forth. Sometimes, the expectations we have to live up to are not exactly healthy and result in our having to repress or suppress aspects of ourselves. For example, the natural exuberance of children is often experienced as inconvenient to adults or at odds with classroom behavioral standards. Sometimes 150

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Figure 8.1 Unpaid Bills Worksheet. Copyright Stephanie Helsel, 2009. Invoice Past Due Notice What is Due (Unfinished Business)

Amount Owed (Action to take)

Examples: A: Taking responsibility for mistreating mother during times of active addiction

Apologizing for stealing money from her; Asking for forgiveness

Possible action taken

Role playing with another group member, who plays the part of mother

B: Recognizing that divorce occurred as a result of both partners’ actions

Forgiving self for role in divorce

Possible action taken

Enacting a dialogue between blaming self and forgiving self Role-playing with another group member who plays the part of the spouse.

Plan for payment (What will you do to resolve this?) Plan for action (When will you do this? How willyou do this?) A: I will talk to my mother about my past behavior

Tomorrow night, I will go to her home and ask her to discuss these matters with me.

B: I will write in my journal about the ways I blame myself for my divorce

I will remind myself in writing that the divorce was not all my fault. I will also talk this over with a trusted friend.

Invoice Past Due Notice What is Due (Unfinished Business)

Amount Owed (Action to take)

A: Possible action taken B: Possible action taken Plan for payment (What will you do to resolve this?) Plan for action (When will you do this? How will you do this?) A: B:

we have conflicts with others that we have no way of resolving, because we are too young, they are older family members, there is no way to discuss such things in our families, and all kinds of reasons. These kinds of learned behaviors and unresolved conflicts can result in what is known as “unfinished business”—when we feel stuck, anxious, and unhappy with our lives, these are hints that there is some unresolved business for us to attend to that stems from our actions and relationships from the past. One of the useful things about groups is that we can help one another work out some of this unfinished business. We can help one another understand our behavior, why we relate to others the way we do, and how we can make changes. I ask all of you to consider engaging in an experiment together to help one another see how and where in our lives we are

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stuck and what we need to resolve in our past. If you all agree to do so, I will ask you to consider the person sitting on your right. Based on what the person has shared about self in the group, what you know about his or her life and history, and how you experience that person here in this group, consider what you believe may be pieces of his or her unfinished business. Sometimes it is helpful to see how others view us and gain insight based on what that tells us about ourselves. Using your special wisdom, you can record some ideas for the person sitting on your right, who can then review them. If there is anyone who wants to explore the ideas they receive in greater depth, I have some ideas on how we can do that. 2. After full consent is obtained from all members, distribute past due invoice worksheets and

3.

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invite members to write down at least one piece of unfinished business that they believe the group member to their right is carrying. This does not have to be accurate, but serves as a reflection of how the group members perceive one another based on prior group discussion and sharing of personal information. Ten to fifteen minutes is a sufficient time for members to reflect and choose one piece of business script. Group members pass their completed past due worksheets to the member on their right and are then asked to share what has been given to them and to reflect on its accuracy. Encourage members to discuss others’ perceptions of them, any unfinished business they may have in common, and how it manifests in their lives. A volunteer is invited to practice “paying the bill,” or enacting one of the activities listed on the worksheet. The goal is to help clients become more comfortable with the thought of actually engaging in the activity with the person involved, or as a means of taking responsibility for one’s difficulties and conflicts, and exploration of the feelings associated with these. For example, one enactment may involve apologizing to a family member for stealing money from them or mistreating them in some way. Ask the volunteer, with help from the group if necessary, to develop a way to “pay the bill.” Other group members are asked to help set the scene or play roles in the scene by rearranging furniture, assuming personas, and so forth. Ascertain group members’ full consent to participate and remind them that this experiment can result in experiencing intense emotions. The volunteer acts out the activity, as you take the role of the director. You may need to encourage other group members to prompt the volunteer when he or she is unsure or stuck, to help members assuming personas, to be as accurate as possible in their portrayal, and to manage the energy and timing of the experiment and allow for a timely closure and processing. As the experiment reaches an end, invite group members to discuss the thoughts, feelings, and experiences that emerged during the experiment. Suggested process questions for members who led the enactment include, What are you aware of now having done this? What did you experience during the enactment? What did you learn? What felt familiar or unfamiliar? Would you like to receive feedback from others? If yes, help facilitate members to provide constructive feedback. For the member who gave the “unpaid bill,” What prompted you to come up with the unfinished business? How do you see it affecting the group member? What did you experience while the group member participated in the enactment? What, if anything, can you relate to? For other members, How was it to watch this enactment? What could you relate to? What was powerful for you? What feedback would you like to give to the participants? How did this experiment make you think about your own unfinished business? Ask each member to fill out the bottom portion of his or her past due invoice worksheets and to brainstorm ideas for resolving the “unpaid bills” individually or with the group. If appropriate, ask the volunteer and other group members, time permitting, to share his or her plan of action for actually resolving the stuck behavioral patterns, past behavior, self-perceptions, or feelings that make up the unfinished business.

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REFERENCES Beisser, A. (2004). The paradoxical theory of change. International Gestalt Journal, 27(2), 103–107. Bernier, M. (2005). Puppetry in education and therapy: Unlocking doors to the mind and heart. Bloomington, IN: AuthorHouse. Bochner, S. (1965). Defining intolerance of ambiguity. Psychological Record, 15, 393–400. Cassell, S., & Paul, M. H. (1967). The role of puppet therapy on the emotional responses of children hospitalized for cardiac catheterization. Journal of Pediatrics, 71(2), 233–239. Chen, C. C., & Hooijberg, R. (2000). Ambiguity intolerance and support for valuing diversity interventions. Journal of Applied Social Psychology, 30, 2392–2408. Dermer, J. D. (1973). Cognitive characteristics and the perceived importance of information. The Accounting Review, 48(3), 511–519. Duncan, R. B. (1972). Characteristics of organizational environments and perceived environmental uncertainty. Administrative Science Quarterly, 17(3), 313–327. Ellison, J. A., Greenberg, L. S., Goldman, R. N., & Angus, L. (2009). Maintenance of gains following experiential therapies for depression. Journal of Consulting and Clinical Psychology, 77(1), 103–112. Furnham, A., & Ribchester, T. (1995). Tolerance of ambiguity: A review of the concept, its measurement and applications. Current Psychology, 14(3), 179–199. Goodman, P., & Stoehr, T. (1977). Nature heals: The psychological essays of Paul Goodman. New York, NY: Free Life Editions. Greenberg, L. S., Elliott, R., & Lietaer, G. (1994). Research on experiential psychotherapies. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 509–539). New York, NY: Wiley. Harman, R. (1974). Goals of Gestalt therapy. Professional Psychology, 5(2), 178–184. Ho, J. L., & Rodgers, W. (1993). A review of accounting research on cognitive characteristics. Journal of Accounting Literature, 12, 101–130. Kempler, W. (1973). Principles of Gestalt family therapy. Costa Mesa, CA: Kempler Institute. Kohler, W. (1992). Gestalt psychology: An introduction to new concepts in modern psychology. New York, NY: Liveright. Lennon, E. & Mistler, B. J. (2010). Breaking the binary: Providing effective counseling to transgender students in college and university settings. Journal of LGBT Issues in Counseling, 4(1), 228–240. Lennon, E., & Mistler, B. J. (2014). Cisgenderism. Transgender Studies Quarterly, 1(1), 63–64. Lobb, M. S., & Amendt-Lyon, N. (2003). Creative license: The art of Gestalt therapy. Vienna, Austria: Springer Verlag. McLain, D. L. (1993). The Mstat-I: A new measure of an individual’s tolerance for ambiguity. Educational and Psychological Measurement, 53(1), 183–189. Mistler, B. J. (2009a). Bisociation and second-order change: Relationships among tolerance for ambiguity, sense of humor, and humor styles (doctoral dissertation). Retrieved from FCLA Scientific Commons Database (UFE0024493). Mistler, B. J. (2009b). Gestalt therapy. In B. Erford (Ed.), American Counseling Association encyclopedia of counseling (pp. 211–212). Alexandria, VA: American Counseling Association. Mistler, B. J. (2011). Gestalt theory. In S. Degges-White & N. Davis (Eds.), Integrating the expressive arts into counseling practice (p. 137). New York: Springer Publishing. Mistler, B. J. (2015). Words I wish I wrote: An anthology of practical Gestalt theory. In B. J. Mistler & P. Brownell (Eds.), Global perspectives on research, theory, and practice: A decade of Gestalt! Newcastle upon Tyne, UK: Cambridge Scholars Publishing. Mistler, B. J., & Brownell, P. (Eds.). (2015). Global perspectives on research, theory, and practice: A decade of Gestalt! Newcastle upon Tyne, UK: Cambridge Scholars Publishing. Mistler, B. J., & Lennon, E. (2011). Effective interventions with LGBTQIQ populations. (Research Brief, Spring 2011). Washington, DC: National Association of Student Personnel Administrators Gay, Lesbian, Bisexual, Transgender Knowledge Community. Naranjo, C. (2000). Gestalt therapy: The attitude and practice of an atheoretical experientialism (2nd ed.). Williston, VT: Crown House. Perls, F. S. (1947). Ego, hunger and aggression. London, UK: Allen & Unwin. Perls, F. S. (1969a). Ego, hunger, and aggression: The beginning of Gestalt therapy. New York, NY: Random House. Perls, F. S. (1969b). Gestalt therapy verbatim. Lafayette, CA: Real People Press. Perls, F. S. (1969c). In and out of the garbage pail. Lafayette, CA: Real People Press. Perls, F. S. (1973). The Gestalt approach & eye witness to therapy. Ben Lomond, CA: Science and Behavior Books.

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Perls, F. S., Hefferline, R. F., & Goodman, P. (1951). Gestalt therapy: Excitement and growth in the human personality. New York, NY: Julian Press. Perls, F. S., Hefferline, R. F., & Goodman, P. (1994). Gestalt therapy: Excitement and growth in the human personality. Gouldsboro, ME: Gestalt Journal Press. Polster, M. (1999). Evolution and application. In E. Polster, M. Polster, & A. Roberts (Eds.), From the radical center: The heart of Gestalt therapy: Selected writings of Erving and Miriam Polster (pp. 96–115). Cambridge, MA: GIC Press. Sichera, A. (2003). Therapy as an aesthetic issue: Creativity, dreams, and art in Gestalt therapy. Creative License: The Art of Gestalt Therapy, 93, 93–99. Strümpfel, U. (2004). Research on Gestalt therapy. International Gestalt Journal, 27(1), 9–54. Strümpfel, U., & Goldman, R. (2002). Contacting Gestalt therapy. In D. J. Cain & J. Seeman (Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 189–219). Washington, DC: American Psychological Association. Van De Riet, V., Korb, M. P., & Gorrell, J. J. (1980). Gestalt therapy, an introduction. New York, NY: Pergamon Press. Yontef, G. M. (1993). Awareness, dialogue & process: Essays on Gestalt therapy. Highland, NY: Gestalt Journal Press. Yontef, G. M., & Jacobs, L. (2008). Gestalt therapy. In R. J. Corsini & D. Wedding (Eds.), Current psychotherapies (8th ed., pp. 328–367). Celmond, CA: Brooks/Cole-Thompson.

9 Person-Centered Therapy Melissa Luke

Although several hundred different theoretical approaches are said to be currently recognized within counseling and psychology, person-centered therapy continues to have a strong presence among the major theoretical systems (Wedding & Corsini, 2014). In fact, in 2007, the Psychotherapy Networker (Rogers, Minuchin, Satir, Bowen, & Gottman, 2007) named Carl Rogers, founder of person-centered therapy, as the most influential individual of the past 25 years. It has been speculated that the focus of person-centered therapy on the constructive, positive aspects of human nature have contributed to its longevity (Corey, 2013). Person-centered therapy postulates that people (a) are inherently trustworthy, (b) have a vast potential for self-understanding, and (c) have a self-directed capability to resolve their difficulties if they have a genuine, accepting, and empathic environment. Consequently, the tenets of person-centered therapy center on the clinician creating this environment, as opposed to engaging in diagnosis, giving advice, or persuasion. However, it should be noted that Rogers never believed person-centered therapy to be a static schema that was completely understood or articulated (Cain & Seeman, 2002). Rather, Rogers (1986a) saw person-centered therapy to be a dynamic theory and practice undergoing continual development based on research and practice. FOUNDATIONS OF PERSONCENTERED THERAPY Rogers’s work within person-centered therapy has been organized into four distinct phases (Bozarth, Zimring, & Tausch, 2002). Within the first phase, his work was focused on the clinician developing a warm, permissive, and nondirective therapeutic environment (Rogers, 1942). Rather than using techniques “on” the client, Rogers believed that it was the clinician’s responsibility to facilitate the client’s expression and self-awareness primarily through reflecting the client’s thoughts and feelings. Within the second phase of his work, Rogers increased his attention on the client’s phenomenological world (Rogers, 1957). He discussed the importance of the clinician’s exploration of the client’s subjective experience and internal reality through the use of accurate empathy. In the third phase of his career, Rogers (1961) focused on the therapeutic relationship, during which time he identified the necessary and sufficient therapeutic conditions for change. It was in this period that Rogers noted the clinician can facilitate the client’s actualizing tendency through remaining continually present with the client’s immediate experience, maintaining emotional and cognitive accessibility, and demonstrating unconditional positive regard (Rogers, 1966). 155

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The fourth phase of Rogers’s work was marked by his delineation of the core conditions for healing and development, extending these beyond counseling into educational and advocacy environments. Rogers believed that it was the clinician’s responsibility to do more than problem-solve with clients (Rogers, 1977), and instead he endorsed a process that returned the responsibility back to clients so that that they were better prepared to face and respond to future challenges (Sharf, 2005). Rogers (1986a) described this process as consisting of the clinician’s creative use of self as the instrument of change to ultimately expand the client’s cognitive, affective, and behavioral ways of being. APPLICATIONS AND RESEARCH FINDINGS According to Rogers, all individuals possess an actualizing tendency; “a directional process of striving toward realization, fulfillment, autonomy, self-determination, and perfection” (Corey, 2013, p. 169). Consequently, he believed that the core conditions of clinician congruence, unconditional positive regard, and accurate empathic understanding constitute an appropriate and beneficial approach with all clients, regardless of their symptomology or diagnosis. Nonetheless, Rogers advocated for the ongoing research that tested person-centered hypotheses for the purpose of better informing training as well as refining person-centered theory and practice. As a result, person-centered therapy has been widely investigated with individual clients, groups, and families presenting with a wide range of problems including mood disorders, personality disorders, substance abuse, adjustment, and interpersonal difficulties such as anxiety (Elliott, 2013; Nuding, 2013), depression (Kiosses & Karathanos, 2013; Rijn & Wild, 2013), psychosis (Traynor, Elliott, & Cooper, 2011), and schizophrenia (Stanghellini, Bolton, & Fulford, 2013). Although Rogers warned of the potential detriment that could result from rigid adherence to any one school of thought or method (Sharf, 2005), 70 years of research has supported the effectiveness of person-centered therapy (Quinn, 2013). In his review of this extant research, Watson (2002) concluded that not only is empathy the strongest predictor of client progress, but also that there has not been a single study that has correlated empathy with a negative outcome. More recently, mutuality was identified as a particularly salient aspect of the person-centered therapeutic process (Murphy, Cramer, & Joseph, 2012) and this and other tenets of person-centered therapy have been adopted by the medical community as well (Miles & Mezzich, 2011; Zinchenko, Pervichko, Mezzich, Krasnov, & Kulygina, 2013). MULTICULTURAL CONSIDERATIONS Although originally conceived as universally culturally applicable, person-centered theory has been criticized as not explicitly addressing how the counselor’s or the client’s cultural identity influences individuals’ experiences or the therapeutic process (Hett, 2013). That said, Cooper and McLeod (2011) have recently articulated how the pluralistic perspective that is inherent in person-centered theory permits specific benefits with historically marginalized populations. On a related note, Quinn (2013) reviewed the literature supporting the effectiveness of person-centered therapy with clients from diverse racial and ethnic groups, and noted that person-centered therapy effectively recognized the necessity for the person-centered therapist to “possess multicultural knowledge (cognitive empathy), awareness (affective empathy plus self-congruence), and skills (communication of unconditional positive regard)” (Quinn, 2013, p. 229). Supporting this, there is a growing body of literature that identifies applicability of person-centered theory to clients with diverse identities, including, but not limited to, clients across varied ages (Brouzos, Vassilopoulos, & Baourda, 2015; Sa’ad, Yusooff, Nen, & Subhi,

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2014), nationalities ( Jan Takens, 2013; Lago, 2011), affectual and gender identities (Lemoire & Chen, 2005), and types of disabilities (Carrick & McKenzie, 2011; Johnson, 2011). EXPRESSIVE ARTS PERSPECTIVE Natalie Rogers, daughter of Carl Rogers, is credited with having integrated person-centered therapy with the expressive arts. In 1984, after years of collaboration with her father, Rogers founded the Person-Centered Expressive Therapy Institute in Sonoma, California (www. nrogers.com). Although talk is the primary vehicle for communication in person-centered therapy, nonverbal modalities such as music, movement, drawing, painting, poetry, meditation, and imagery can all become potential vehicles for communication within the expressive arts (Malchiodi, 2005; Rogers, Tudor, Tudor, and Keemar, 2012). However, both approaches recognize the role of creative expression in the processes of self-awareness and understanding, as well as client healing and growth (deCarvalho, 1999; Rogers, 1993). In addition, numerous other consistencies have been identified across person-centered therapy and the expressive arts (Malchiodi, 2005; McNiff, 2004; Rogers, 1993; Rogers et al., 2012) including the following: ■ ■ ■ ■ ■ ■ ■

The importance of creating a safe, nurturing, and nonjudgmental environment The clinician’s responsibility to be an empathic, open, honest, congruent, and a deep listener, who conveys acceptance and understanding A trust in the client’s innate capacity to reach toward his or her full potential A belief that clients’ self-awareness, understanding, and insight can be achieved by delving deeper into one’s thoughts, emotions, and experiences Recognition that the process holds the transformative potential, not the product A creation of self-awareness facilitated through action that develops creative expressions to expand a client’s way of being Empathy providing clients an opportunity to empower themselves and discover their unique identity and potential

CONCLUSION In summary, person-centered therapy is broadly used with individual clients, groups, and families presenting with a wide range of problems including mood disorders, personality disorders, substance abuse, adjustment, and interpersonal difficulties. Person-centered therapy centers on the clinician creating a safe, nurturing environment where the client’s self-awareness facilitates action. Rogers (1986a) described this process as consisting of the clinician’s creative use of self as the instrument of change to ultimately expand the client’s cognitive, affective, and behavioral ways of being. Thus, the incorporation of the expressive arts provides a complementary nonverbal means by which to enact the theory.

Expressive Arts Interventions

CLIENT MIRROR Sheri Pickover

Indications: As part of play therapy with young children, this activity is an effective tool

to establish a quality relationship and is also effective as an intervention with children who demonstrate a lack of self-esteem, self-efficacy, or strong sense of ego development. This includes children who constantly seek adult approval or who make statements such as “I’m bad” or “I’m stupid.” Goal: To increase ego development and self-esteem Modality: Art The Fit: This activity seeks to validate the client’s self-worth and personal worldview. Theoretically, this intervention is derived from the Rogerian principles of unconditional positive regard and empathetic validation (Rogers, 1992). Populations: Children; Individuals Materials: Drawing or art-creating materials, such as markers, clay, play dough, crayons, paint, and several types of paper, canvas, and molding tools Instructions: 1. Using a nondirective approach; offer the client the opportunity to create art. If the client chooses an art project, begin by reflecting the client’s actions (i.e., You are choosing to work with clay). 2. Choose the same media and ask the client something like, I enjoy the activity you have chosen. May I copy you? If the client agrees, begin to copy the client’s art as closely as possible. Choose the same colors and shapes. Frequently ask the client if you are following him or her correctly. 3. If the client begins to ask for approval or for you to make decisions about the art, reiterate I am following your lead; what you are making is important; I want to engage in the same activity that you are. Ask the client for direction, if needed (i.e., What should I do next?).

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DOUBLESIDED MASKS TO IMPROVE CONGRUENCY Katherine Campbell and Bill Owenby

Indications: This intervention is useful for clients who feel stuck or confused between who they are and who they want to be. It allows clients to visually represent this incongruence in a tangible manner. Goal: To increase understanding and integration of the self within the client and decrease symptoms and issues associated with the incongruence Modality: Visual Art The Fit: Incongruence is the core of psychological maladjustment in which individuals estrange themselves from who they are in hopes of obtaining what others prefer. Within a client can be a house divided, and as a result, tension and inadequate function occur (Prochaska & Norcross, 2014, p. 117). By identifying the differences between who one is and how one thinks one should be, a person can identify this dissonance and begin working on reintegrating and developing a more authentic sense of self and condition of worth (Hill, 2013; Rogers, 1961). Population: Children, adolescents, and adults; Individuals and groups Materials: Blank masks purchased at craft stores, paper plates, or a similar material that would be sturdy enough to construct and hold the client’s creativity; coloring markers, colored pencils, crayons, magazines/pictures, glue, and string, in addition to other materials the counselor feels appropriate for assisting the client in creating the masks Instructions: 1. Briefly introduce the intervention to the clients in order to set the stage and provide some guidance for the clients to become more involved in the process. 2. Invite clients to reflect on their multiple “selves,” including how they prefer to be and/or how they actually are in their lives. This discussion generates the emotional content for the visual creation of the masks. Determine if it is appropriate to request one or both “selves” at this time, pending time constraints and client commitment. 3. Have all the materials and adequate work space available for client(s). 4. Invite clients to reflect on how they portray themselves now and how they want to be portrayed in the future by infusing these images into their masks (e.g., this can be done with individuals/groups who are more in the action/maintenance stage by having them reflect on how they portrayed themselves in the past and how they are portrayed now to further show their progress in treatment). 5. Allow adequate time for clients to reflect on these aspects and create their masks. Soothing music could be used in the background to increase concentration, as well as to facilitate bonding among group members if in a group setting. 6. Once clients have completed their masks, invite them to stand up and present their masks to the group (if in a group setting) or to you (if in an individual counseling session). Standing up allows clients to take ownership of their work and portray themselves more openly and outwardly to others, representative of their goals of doing so in their lives.

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7. Ask clients to explain each side of their masks beginning with what they consider the most

negative views of themselves. If in an individual setting, engage the client in a similar fashion. If in a group setting, include group members in providing supportive feedback. 8. This activity can be referenced throughout the course of counseling sessions and can be used as a foundation upon which to build over time.

DREAMCATCHER CREATION: A PROCESS OF BECOMING Hannah Bowers

Indications: When considered within the context of client-centered therapy, this art creation

activity can be effective working with clients facing mental health, behavioral, career, familial, cultural, substance abuse, and trauma-related issues, to name a few. Goal: Increased insight, expression of catharsis, self-empowerment Modality: Art The Fit: The dreamcatcher that was originally created through American Indian folklore is a small round frame with intricate webbing that is hung to protect sleeping children from nightmares (McCain, 1998). Creating a dreamcatcher within a therapeutic setting, which includes expression of empathy, unconditional positive regard, and congruence, promotes clients’ increased insight and self-empowerment, a crucial component of the process of becoming (Rogers, 1992). The circle in which the dreamcatcher is constructed is a representation of the clients’ holistic self. The intricate and complex created design on the inside mirrors the composition of who they think they are and a representation of their process of becoming. As clients engage in their dreamcatcher creation, they express control over their own life’s construction while reflecting on past incidents with renewed insight (Rogers, 1992). The process of becoming is complicated, filled with both victories and defeats. Interwoven within the inner circle, beads used within the dreamcatcher construction represent each of these momentous occasions. The clients are provided an opportunity to reflect, express emotion, and provide a new perspective in which to view life’s circumstances. Populations: Children, adolescents, adults; Groups, individuals, and families Materials and Preparation: Paper plate, colorful yarn, single-hole punch, scissors, beads, feathers, paint, and other decorative materials (glitter, stickers, gems, etc.). Trace a circle in the center of the plate, then cut the center circle so the plate creates a paper ring. Use hole punch to place 7 to 11 equally spaced points of contact. Prepare remaining materials for clients to decorate the ring. Instructions: 1. Start the session by introducing the dreamcatcher. Discuss with your client how the dreamcatcher represents the holistic self, the outer rim his or her own person and the intricate design on the inside a representation of his or her inner self. Begin processing the activity by presenting the paper ring to the client, and saying: “Tell me about who are you on the inside” (Robbins, 2001). Indicate client can begin decorating the plate ring with paints and other chosen décor. 2. Tell your client, “This yarn represents your journey; how long do you think it should be?” As the client measures and cuts the desired length of yarn, measure desired amount of yarn and tie off on one of the holes. 3. Introduce the concept of the beads to your client by saying, “Each bead represents victories or defeats you’ve encountered along your way.” Client begins to thread yarn through desired holes and, using beads, fills the inner circle with intricate patterns. 4. Check in with your client throughout the session. As clients choose a bead, inquire into what the bead represents and why that specific color or placement was chosen. Process 161

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the experiences shared by using expressions of empathy, unconditional positive regard, and congruence (Rogers, 1955). 5. Once yarn has 2 inches left, tie off through closest hole. 6. Cut three pieces of yarn and tie a feather to the end of each piece. Add beads to the yarn with feathers. Thread the three pieces of yarn through three holes next to each other at the bottom of the dreamcatcher. Tie off on the back. 7. Cut another piece of yard and create a loop at the top center hole to hang. Once the dreamcatcher is completed, process the client’s experience. Discuss the meaning of the space around the dreamcatcher as well as the intricate pattern within.

EMPOWERMENT OVER HURTFUL WORDS Beth McCabe

Indications: The client’s individually shared feelings and thoughts must be valued through

mutual respect of the counselor/therapist and other group members’ relationships. Trust must first be established by a safe, caring environment with a client or in a group setting for one to be willing to be open to the vulnerability of sharing. The universality provided by the sharing can increase individual support and further propagate healing. Goal: Self-exploration and self-discovery of feelings/emotions associated with hurtful words or actions from one’s past experiences; self-acceptance of the emotional trauma and internalization process resulting in poor self-esteem; personal empowerment over negative feelings and emotions through reframing Modality: Music and expressive writing The Fit: The purpose of this activity is to aid the clients in their resolution of the negative feelings associated with personally painful experiences. This is accomplished by using music analysis and interpretation in combination with journaling to allow them to safely tell their stories and receive personal validation. By listening to a given song, the lyric analysis aids in unlocking images of personally stored, painful memories, which in turn releases emotions in a safe, controlled, therapeutic setting allowing the individual the opportunity to heal through individual support of the counselor/therapist or support of individual group members. The clients empower themselves through the practice of self-talk by developing positive self-affirmations to reframe their painful experiences. In addition, positive self-talk lays a framework for healthy defensive coping mechanisms against future hurtful words or events and their negative impact on one’s psyche. Populations: Children/adolescents/adults; Groups/individuals Materials and Preparation: Christina Aguilera’s Stripped CD, CD player, individual copies of “Beautiful” song lyrics, copies of journaling worksheet, copies of a feelings identification sheet, copies of the self-affirmations sheet Instructions: 1. Begin the session by explaining that music can evoke personal emotions and experiences to surface. Inform the group members to listen silently to the lyrics of the song “Beautiful” recorded by Christina Aguilera as it plays for them. 2. Distribute the lyrics and the following lyric interpretation used for this activity: It was rumored that Christina Aguilera was emotionally traumatized in her youth and she used lyrics written and composed by Linda Perry (2002) as a tool to record a song to overcome her pain instead of defining who she is. The group is informed that writing about one’s feelings, thoughts, and experiences can be helpful. It can be a safe way of expressing oneself without the worry of hurting others’ feelings. Keeping one’s feelings in can make a person ill. This intervention can help clear one’s head and provide personal insights and a more positive perspective considering one’s situation. It can reveal and discern what is “my stuff ”—what I am responsible for, and what is “others’ stuff ”—what they are responsible for. Request that they listen to this piece of music or their chosen song and lyrics while journaling their thoughts and feelings regarding the given selection or their chosen one. 163

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3. Distribute a feelings/emotions handout. While the song is playing or the individuals are

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analyzing their own personal lyrics, ask the group members to individually reflect or think of a situation in the past where they felt hurt by someone’s words or actions. Distribute the journaling handout to each member. Ask them to reflect on the questions below and journal about their feelings and thoughts regarding their experience. Let them know that it is important for them to be honest and open in their sharing. Although it will be encouraged to share their responses during group discussion, their privacy will be respected if they are not ready. Additionally, the clients can indicate that it is something that they would rather share during individual counseling or have it privately read by the counselor/therapist. The feelings/emotions sheet can enable each individual to identify how he or she felt in response to his or her personal experience. Reflective questions may include, What hurtful words or actions from your past have blocked you from seeing or believing in good things or qualities about yourself? What hurtful words or actions from your past have prevented you from seeing your outward and/or inward beauty? How did this negative experience make you feel? What did these feelings do to your confidence? How did these feelings affect your behaviors or goals that you wanted to accomplish? How did you get past the pain? What types of behaviors or coping mechanisms did you employ as a mode of survival? Were these behaviors positive or negative? Are they still necessary? How can you learn from your reaction/choice and change it to make it more positive in the future if it ever happens again? How can you turn your “lemons into lemonade”? Each group member is given the opportunity to share what he or she journaled with other group members. Encourage group sharing by letting them know that it is freeing to tell others who are supportive and caring. Discuss other songs and music that have helped them get through tough times. Brainstorm as a group other strategies to overcome pain. Distribute the positive affirmation worksheet. Ask clients to devise their own statements of who they are. These are statements each individual group member will practice for the week to increase his or her positive thinking about self. Before dismissal of the group, each member shares his or her positive affirmation with the group, leaving on a positive note.

Journal Worksheet While the music is playing, think of a situation in the past in which hurtful words or actions have caused you undue pain and emotional trauma. Reflect on the following questions: ■

■ ■ ■ ■ ■ ■

What hurtful words or actions from your past have blocked you from seeing or believing in good things or qualities about yourself? What hurtful words or actions from your past have prevented you from seeing your outward and/or inward beauty? How did this negative experience make you feel? What did these feelings do to your confidence? How did these feelings affect your behaviors or goals that you wanted to accomplish? How did you get past the pain? What types of behaviors or coping mechanisms did you employ as a mode of survival? Were these behaviors positive or negative? Are they still necessary? How can you learn from your reaction/choice and change it to make it more positive in the future if it ever happens again? How can you turn your “lemons into lemonade”?

Positive Affirmations Directions: Review the samples of “I am” statements below (from the Livestrong.com website).

Think of your strengths, attributes, talents, and competencies. Create a message of self-talk

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that you will repeat to yourself until our next session. This will help keep you positive and make you feel better about yourself. Be ready to share your statement with the group. Samples ■ I am a good person . . . I am trusting. ■ I am creative . . . I am open. ■ I am caring . . . I am generous. ■ I am loving . . . I am courageous. ■ I am smart . . . I am forgiving. ■ I am beautiful . . . I am joyful. ■ I am competent . . . I am energetic. My Positive Self-Affirmation: I am ________________________ . . . I am ________________________

FAMILY OF ORIGIN BOUQUET Kristi Perryman, Paul Blisard, and Angela L. Anderson

Indications: This activity is appropriate for clients experiencing unresolved family issues. Goal: To become aware of and express unresolved family of origin issues Modality: Art/floratherapy The Fit: The purpose of this activity is to offer participants the opportunity to explore memories

and perceptions of their original family. This is an especially powerful activity and should be used only after a trusting therapeutic relationship has been established. According to Natalie Rogers’s (1999) person-centered expressive arts principles, “The expressive arts lead us into the unconscious and allow us to express previously unknown facets of ourselves, thus bringing to light new information and awareness” (pp. 130–131). Populations: Children (9 and older)/adolescents/adults; Groups/individuals Materials and Preparation: Large clay or plastic saucer (bottom portion of flower pot); fresh floral foam; moss; leather leaf; fresh flowers (may purchase prearranged bouquets and disassemble for this project); sticks or twigs; stones; hot glue and hot glue gun; scissors Prior to the beginning of the session, prepare the saucers by hot gluing floral foam to the saucer and cover the foam with moss (dampen moss to adhere). Instructions 1. Instruct participants to select flowers to represent each member of their family or people they consider to be their family, including themselves. 2. Instruct them to create a bouquet with the flowers/materials selected. 3. Ask members to share their creations and whom each plant symbolizes with the group or therapist, explaining why each flower was chosen for each family member. 4. Suggested topics for processing include, How do you feel when you look at your family of origin? Be aware of placement of plants (which family members are placed close or far away from each member (i.e., I notice you are by your mom and your brother is closer to your dad…). Facilitator should also be aware of other objects used in the bouquets and inquire as to their meaning such as stones or twigs.

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FEELING SCULPTURES MADE FROM GARBAGE Rachel Payne, Chloe Lancaster, Laura Heil, and Melina Pineda

Indications: This counseling session is appropriate for holistic exploration of feelings. Goal: To recognize feelings and to gain awareness of the many ways they are expressed Modality: Art The Fit: The purpose of this activity is to sharpen the clients’ ability to recognize, explore, and

honor their feelings. Used in a group, this activity aids in building group cohesion and trust, as it requires members to work cooperatively on an enjoyable and creative project. This activity lends itself to a person-centered approach, as it promotes contact and awareness with one’s subjective feelings and internal experience. According to Rogers, all clients have the capacity for self-actualization, which can be facilitated in an atmosphere that fosters trust, self-acceptance, understanding, and an exploration of one’s inner experiencing (Rogers, 1957, 1986b). Populations: Children/adolescents/adults; Groups/individuals Materials: Eclectic mix of garbage-type materials and art supplies—plastic bottles, scraps of material, egg boxes, tin foil, colored paper, tape, markers, pipe cleaners—and any other nondegradable garbage and art material Instructions: 1. Commence the session with a discussion of different types of feelings. Explore times in which clients may have ignored or reacted poorly to their own feelings and those of others (e.g., suppressed feelings, gotten angry, overreacted). During this discussion encourage clients to personify their feelings: What color, texture, sound, animal could describe/ represent this feeling? 2. After a brief discussion, ask clients to generate a list of feeling words. Guide clients to reflect on recent and significant events in their lives and ask them to come up with feeling words that adequately capture their inner experiencing. Encourage them to be creative in their choices of words and encourage them to avoid more simplistic feeling words such as “sad,” “mad,” “happy,” and “glad.” 3. As clients supply words, have one client record them on sticky notes. Once feelings have been recorded, each sticky note should be folded up so the word cannot be seen and placed in a container. 4. When clients have supplied several feeling words, let them know that they are going to play a game. First, split the group into smaller teams and ask one client from each team to pick a folded sticky note from the container. The individual client will share the feeling word selected with his or her own team members, but will keep their word a secret from the other teams. 5. Announce to the group that each team is going to work together to make a sculpture of the feeling word they chose. Emphasize to the groups the importance of not revealing their own group’s word to the others. Ask the clients to silently reflect on their feeling words from a multisensory perspective, including touch, texture, and shape. This reflective process will assist them as they create their team sculpture. 6. Give each group approximately 1 to 2 minutes (depending on time constraints) to select material from the garbage pile. If possible, have the material set up in another room so 167

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team members can discuss what material would best represent their feeling word. In an ideal setting, the groups create their sculptures in separate rooms so that the other teams do not hear clues that may reveal the identity of the other teams’ words. 7. Provide the teams with about 15 to 20 minutes to construct their feeling sculpture. Counselors should encourage the teams to work quickly and intuitively. Once you have supplied directions, step back, and allow the teams to engage in the creative process. Approximately 5 minutes before calling time, encourage the groups to start completing their sculptures and remind them of how much time they have left. 8. When the sculptures are complete, the whole group reconvenes to try to guess what the other teams’ sculptures represent. Prior to having clients guess, instruct the different teams to trade sculptures. Allow enough time for all the group members to examine all of the sculptures. 9. Let each team be asked six questions by members of the other groups to help them guess the feeling word symbolized by their sculpture. Encourage clients to consider how different elements of a sculpture can assist them in making an informed guess. Also remind them that the feeling words represented by the sculptures are limited to those words recorded earlier. If necessary, briefly review the words on the sticky notes. 10. Suggested discussion questions include, What key feature of the sculpture led you to believe that the feeling was__? (This is after client correctly guesses.) How did the shape, color, materials used help you determine the feeling? How did the sculpture’s use of comfortable versus uncomfortable features differ? Do the sculptures created here today resonate with your experiences of these feelings? If so, how? Do good and bad feelings really exist? Can anyone share how the garbage used in the sculptures represents how we sometimes treat our feelings?

FLORATHERAPY: A GARDEN OF DREAMS Kristi Perryman, Paul Blisard, and Angela L. Anderson

Indications: Floratherapy is very useful in working with grief issues related to illness, death,

and divorce. Sessions include introductory, working, and terminating activities. Uses also include goal setting, family exploration, and working on control and boundary issues. Goal: To assist clients in their efforts of self-growth and development in the face of loss Modality: Art/floratherapy The Fit: Floratherapy is a highly distinctive method of helping clients explore their inner worlds, which, by its very nature, focuses on client growth and development. Floratherapy involves the use of fresh plants and flowers in floral design activities. Using fresh flowers and plants as a medium to promote the therapeutic process, engagement in this process invites enhanced self-disclosure and expression. Flowers and plants have long been used for their therapeutic value here in the United States. In fact, the earliest documented cases of this method of healing were the work of Dr. Benjamin Rush, who was among those who signed the Declaration of Independence (American Horticultural Therapy Association, n.d.). Working with groups of psychiatric patients, he involved these individuals in the process of raising and tending plants as well as having his patients engage in walks through a garden as components of his therapy. The practice of floratherapy fits well within the person-centered construct as described by therapists such as Natalie Rogers (1993), Samuel Gladding (1998), and others. It is an expressive arts technique that is processed through person-centered techniques and therapeutic dialogue with the therapist. Populations: Children/adolescents/adults; Groups/individuals/clinical supervision Materials and Preparation: Live plants and flowers as well as vases, wreaths, flowerpots, and such things Instructions: This project symbolizes the future, both in terms of realizing unfulfilled goals and dreams as well as setting goals. It may be used as an introductory activity, allowing members to choose plants that represent their personal goals for the group. 1. Floral design process

Clients use live plants that are used to make a dish garden. The counselor instructs participants to select plants that they feel represent their goals and dreams. Some examples of areas of representation include career aspirations, relationships, spirituality, and passions. 2. Facilitator’s role 2.1 After designing their dish gardens, ask participants to share with the group their creations and what the overall garden and the individual plant choices symbolize for them. For example, in one group, a person chose a passion plant to represent his or her spiritual life. Another person explained that since the death of her husband she had not felt passionate about anything. She chose a passion plant to represent her unfulfilled desire to feel passion again. 2.2 Invite participants to describe their experiences and feelings about working with a living medium.

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2.3 Ask the clients to take home the garden of dreams as a way to encourage members to

continue working toward their goals and dreams. 2.4 Ask members to bring the dish gardens back at the last group meeting as a culminating

activity to discuss how they have nurtured their goals/dreams and to share how they have flourished.

LOVE YOUR SELFIE A SELFREFLECTION AND AFFIRMATION ACTIVITY Rachel A. Altvater

Indications: This activity is suggested for clients suffering from self-esteem difficulties including but not limited to depression, trauma, eating disorders, and other body image issues. Goal: To teach clients to utilize self-affirmations to strengthen self-worth and self-confidence. During the activity, counselors teach clients that recurrent messages strongly influence a person’s self-image and self-esteem. Therefore, it is important to increase the frequency of positive affirmations to facilitate psychological healing and growth. Modality: Visual Art The Fit: Carl Rogers, the father of person-centered psychotherapy, believed that clients’ presenting concerns emerged because their internal conditions of self-worth cause them to detach from their true selves (Cooper, O’Hara, Schmid, & Wyatt, 2007). The disconnect produces incongruence, anxiety, and possibly an impaired locus of control (Cooper et al., 2007). Individuals often suffer from low self-esteem due to the disconnect between self-image and ideal self. Individuals with compromised self-esteem frequently feel unworthy, unloved, and ashamed (Cooper et al., 2007). An activity designed to establish unconditional positive self-regard and general self-acceptance may help bridge the gap between self-image and ideal self. Population: Children, adolescents, and adults; Individual and groups Materials: Construction paper, markers, scissors, hot glue gun/hot glue sticks, glass jar (recommend to recycle washed glass food jars), square or round craft mirror, colored jumbo craft (popsicle) sticks, alphabet foam stickers, heart foam stickers, ribbon Instructions:

Part 1: 1. 2. 3. 4. 5.

Plug in the hot glue gun to allow enough time for the glue stick to heat. Have client choose preferred jumbo craft stick color, the letters I, M, and E out of the alphabet foam stickers, and at least one heart foam sticker. Once the glue gun is ready, ask the client to glue the selected ribbon around the outside of the mirror. Have the client bend the ribbon in half around the top and bottom of the mirror. This covers the potentially sharp edges of the mirror. Glue the jumbo craft stick to the back of the mirror so that it is positioned to allow approximately 2/3 of the craft stick to project from the bottom center of the mirror to serve as its handle. Instruct the client to arrange the alphabet and heart foam stickers on the handle to read, “I (heart) ME.” Optional: Invite the client to decorate the mirror with more heart stickers, being careful to leave enough open space on the mirror so that a person’s face is still visible in the mirror.

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Part 2: 1. Provide psychoeducational information to the client about the impact of recurrent messages

2. 3. 4. 5. 6. 7.

on one’s self-esteem (e.g., Inform client that primary caregivers or other adults who tell the client he or she is smart and will be successful teach the client to view his or herself positively. Whereas, primary caregivers or other adults who tell the client he or she is worthless and will not amount to anything teach the client to view his or herself negatively.) Explain that it is important to state consistent, recurring positive messages to oneself. This teaches us to cherish our positive qualities and accept who we are, as we are (unconditional positive regard). Provide the client with 10 slips of paper (or have the client cut construction paper into 10 equal pieces). Encourage the client to write a list of 10 positive self-affirmations on the construction paper strips with the markers; provide suggestions if the client gets stuck. Decorate the outside of the glass jar with a foam heart, alphabet stickers displaying positive message(s), and ribbon, if desired. Place the positive self-affirmations in the glass jar. Have the client pick three positive self-affirmations from the jar and read the messages aloud while looking in the mirror. Encourage the client to continue adding positive self-affirmations to the jar and choosing three to read aloud each day.

MAGIC WANDS Jill Packman and Ireon LeBeauf Dupree

Indications: This activity can be used with a host of presenting problems because of its

goal-setting nature. However, it is important to remember that while goal setting occurs, the process of making the wands is equally as important. Goal: Impetus to change: to give someone the “power” to make a miracle happen Modality: Art The Fit: The purpose of this activity is to provide a leaping point for change. Through this activity, children are able to express how they would like to be different and how these changes might occur. This activity can be utilized in a group, family, or individual session. This activity provides insight into how a situation might be different by allowing the clients to fantasize about their “magic” situation. The activity facilitates the client in setting concrete goals and helps the client become aware of those goals and desires. However, in being consistent with a humanistic perspective, the outcome is not the goal. Rather this activity should focus on the process of goal awareness. Humanistic philosophy states that clients should be provided with an accepting, empathic environment to develop a sense of personal choice through person-to-person contact (Task Force for the Development of Guidelines for the Provisions of Humanistic Psychosocial Services, 1997). The rationale for using this activity includes the idea that conventional talk therapy is not appropriate for children. They do not have the cognitive development to express themselves verbally. Instead, play is the child’s language (Landreth, 1991). Populations: Children (9 and older)/adolescents/adults; Groups/individuals/families Materials and Preparation: Wooden dowels cut to approximately 18 ins. in length, construction paper, glue, glitter, pipe cleaners, markers, paint, scissors, feathers, gems, tissue paper, pom-poms, ribbon, and crayons (any available art supplies will work) Instructions: 1. Open with a discussion about superheroes and about what magic powers different heroes possess. The powers can be discussed in terms of what we wish we could do or what different people do with their powers. If necessary at this point, you can have the clients develop a list of superpowers and how they could be used. 2. Ask the clients to imagine they have a superpower. What power would they possess? What would the world look like if they had this power? 3. Present the clients with the wooden dowels and art supplies. Invite them to create a token that represents their magic power; they do not have to use the dowels. 4. Lead into a discussion addressing each client’s rationale for choosing a specific power and how it would make things different, how he or she would use the object to make things different, and how he or she can use that power in everyday life. 5. Possible questions to facilitate exploration include, How did you choose your power? What do you like about having your power? How would things be different if you had this power? If you could do anything with your power, what would you do? What steps can you begin to take today that could make this come true? How can you help others achieve their power or wish?

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PERSONALITY ZOO Jill Packman and Ireon LeBeauf Dupree

Indications: This activity can be used to introduce young group members to each other’s

unique personality characteristics in the group setting. Additionally, this activity allows group members to consider how their behaviors affect a group dynamic. The activity can be revisited periodically during groups to discuss why certain people believe, act, or feel in a certain manner. Also, this activity provides a safe place for children to interact while learning conflict resolution. Goal: Learning about others: similarities and differences Modality: Art The Fit: Mental health is a critical component of children’s learning and general health. Fostering social and emotional health in children as part of healthy child development must, therefore, be a national priority (U.S. Public Health Service, 2001, p. 5). Play therapy and activity therapy are interventions that are sensitive to the developmental needs of children and preadolescents. Humanistic principles are used throughout this activity. Populations: Children/adolescents/adults; Groups/families Materials: Paper bags, markers, crayons, arts and crafts supplies Instructions: 1. Begin with a discussion about differences and similarities. Each characteristic should be valued and discussed for its advantages. Shift the discussion to focus on how differences and similarities do not occur just in people, but in animals, too. Invite a discussion of the similarities and differences in the animal world. 2. Instruct each group member to imagine the animal that most closely matches his or her personality. An exploration of how that animal reacts in certain situations, how it looks, feels, and takes care of itself follows. 3. Invite group members to create this animal out of a paper bag and other art supplies. 4. Ask group members to introduce themselves and the animal persona to the group. 5. Open a discussion about how the different animals/group members might handle different situations and how they might interact with one another. Possible questions to facilitate discussion include, How did you pick your animal? What about your animal is like you? What isn’t like you? How does your animal react to different situations? (fear, anger, happiness, excitement, etc.?) How does your animal protect itself? If you could change something about your animal, what would it be? Who in this group will your animal get along with? Who will it have challenges with? How will you face and work out those challenges? Who in the group is your animal most like? Different from?

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POSTCARD POETRY SLAM Melissa Luke

Indications: Appropriate for use across clinical presentations and problems, it effectively

assists clients in voicing aspects of individual experience about which they are conflicted and unresolved, such as experiences of loss, struggles with addictive behavior, and familial or other relational concerns. Because clients readily engage in this intervention and frequently disclose aspects of their experience that they have not otherwise shared with the clinician or group, it is recommended that the intervention be introduced only after the group is at the working stage and therapeutic boundaries and group norms have been established. Goal: To facilitate client engagement with understanding and expression of his or her own experience Modality: Imagery, music, poetry The Fit: Consistent with what person-centered expressive arts therapist Natalie Rogers (1993) described as the “creative connection,” this intervention combines a number of expressive art modalities. Extending the permissive and accepting therapeutic stance advocated by Carl Rogers (1942) in person-centered therapy, clients are invited to participate in the intervention as an experiential experiment and are free to choose whether to participate and/or to simply observe (Malchiodi, 2005). In addition, the clinician refrains from evaluating what, if anything, is produced by clients within the intervention and, instead, encourages clients to be present with and voice their own subjective experiences of the process (Rogers, 1957). Populations: Adolescents; Groups/individuals Materials: Three primary types of materials are required for this activity: postcards, music selections, and writing supplies. First, a wide variety of postcards are required for this intervention and these should offer an array of images that can stimulate and/or be associated with a range of affective and cognitive responses, both positive and negative. A collection will include, but not be limited to, the following: (a) black and white as well as color photographic images of people, places, and things; (b) copies of paintings, drawings, sculpture, and lithographs representing realist, impressionist, cubist, modern, abstract, and surreal styles; (c) reproductions of iconic signage, labels, trademarks, and graffiti; (d) abstract and not easily identifiable images; and (e) multiple different pictorial examples of animals, architecture, vehicles, musical instruments, and food. Musical selections should represent varying musical forms, styles and use of instruments, as well as include examples from different cultures and periods. These may be preselected by the clinician or chosen in session by group members. Necessary writing materials include various types of pens, colored and graphite pencils, gel and felt-tipped markers, lined paper of assorted sizes, colored construction and tissue paper, and when possible, computers. Instructions: 1. Invite group members to participate in an experiential experiment. Explain the title, objectives, and processes of the intervention, which can include showing a video clip of a prior poetry slam. 2. Remind group members that they are free to decide whether and how they will participate, elect not to participate, and/or observe. Attend to and voice what is happening in the moment with individuals, subgroups, and the group as a whole. 175

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3. Encourage group members to take some time to view the available images. This may be

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done by circulating the postcards from one group member to another if seated in a circle, distributing a handful to each group member and allowing them to exchange as they wish, or by placing the postcards on a table or the floor and encouraging group members to make the rounds to see them all. During this portion of the intervention, attend to the experience of the group members, reflecting, and clarifying their process. Group members will likely be sharing some of their reactions and associations with the images, as well as with the intervention process. Next, ask group members to select a number of postcard images. Communicate that each group member may make his or her selections on whatever criteria he or she would like (i.e., attraction, repulsion, associations, randomly). Following this, facilitate a discussion about the postcards selected. Each group member is given the opportunity to share as well as to react to what others offer. Encourage group members to attend to affective, cognitive, sensory, spiritual, behavioral, physiological, or experiential aspects of their experience. Model a number of ways that the visual images of the postcards can be extended into verbal forms of poetic communication. Be intentional in demonstrating a range of different examples, many of which might be viewed as incomplete or incongruous. For example, extending a postcard image of a Salvador Dali painting, you might offer “Slippery, sliding, sludgy time,” whereas in response to a postcard image of James Dean, you might offer “His chin reminds me of father, strong and sturdy; his eyes like uncle’s, luring and lewd. I can smell the crisp scent of lingering cologne.” In addition, the following could be demonstrated as an example that translated a black and white postcard image of an art deco building into a verbal metaphor, “Glistening in the open air, standing tall and alone as if she were dressed for the prom, awaiting her ride.” Ask group members to experiment with different ways that they can extend the visual images on the postcards, although they are given space and material to work individually. During this time, encourage the creative process of each group member, reiterate unconditional acceptance and regard, and provide empathic reflective and observational statements as you move about the room. You may elect to play music during this process, but it is not necessary to do so. Carefully observe the group members during this process, and judge how much time is sufficient before inviting group members to sequence their verbal extensions of the various postcard images into creating a poetic “whole.” Group members can be given the choice about how to proceed with this portion of the intervention, whether within this session or in the next. As a third option, group members may choose to work on this outside of session, bringing the whole back to the next group meeting. Refocus clients on the process, as at this point they are apt to focus more on the product. Once the group members have completed their poetic whole, make a request for any group members who are interested to share their work, much like a poetry slam. As part of helping group members process their experiences and reactions to the intervention, you can ask clients to respond to direct questions, such as, Where in your body did you feel this poem? What did you discover about yourself? Which image struck you in each group member’s poem and how? What title might you give to your reaction to the process? When might you have been holding back and how do you know? How might your experience “move” or “dance”? Which sound could give voice to the collective group dynamic? What did you notice about your thoughts as you created? performed? listened? observed? To close this intervention, encourage group members to make a music selection (from the tapes, CDs, audio files, or iTunes) in response to each group member’s poem. Encourage clients to make the selection as if they were gathering a “gift” to be presented to each group member.

THERAPY TIMELINE Seydem Yesilada

Indications: This activity is useful in assessing client progress in therapy. Goal: To increase group cohesiveness and facilitate exploration of group experiences Modality: Art The Fit: This activity is consistent with a person-centered approach, as it helps clients ex-

press their feelings through art (Rogers, 1993). This activity focuses on the process of visual expression to conceptualize clients’ experiences in therapy. The intent is to help clients share their emotions and experiences through individual or group therapy. This activity prompts clients to draw a therapy timeline to explore positive treatment goals for their personal growth (Rogers). It also incorporates a non-directive approach, with unconditional positive regard and empathetic listening, which are inherent in the person-centered approach as well. This activity is appropriate to use after trust is established between group members as well as between the client and the therapist in individual therapy. Populations: Children/adolescents/adults; Group/individuals Materials: Paper, markers, crayons, and paint Instructions: 1. Clients are provided with a single sheet of paper as the counselor discusses the title of the activity, Therapy Timeline, and its purpose. The counselor invites clients to participate in the activity, reminding them that participation is voluntary and they are free to choose whether or not to engage in the activity. Clients are asked to draw a timeline that represents their shared time in the group setting spanning the time between their first to last therapy sessions. Have clients mark this line with three points; one for the beginning, one for the middle, and one for the end. Instruct clients to draw themselves in each of these three phases of group therapy as a way to demonstrate their feelings and thoughts at those certain times. 2. Some examples for instruction to be given to clients: Draw a group member who has supported or challenged you. Draw about your experiences with a group member, or the group therapy as a whole. Draw about your goals. Draw your feelings or thoughts that were difficult to articulate in the beginning. Draw what the barriers were that prevented you from sharing your feelings. For the initial sessions, the counselor may want to provide examples for some of the uncomfortable emotions, such as anxiety or shame. For later sessions, if clients began feeling a sense of support, acceptance, and emotional safety, examples about these positive feelings should be provided. 3. With the restatement of the core conditions of the person-centered approach, including empathy, unconditional positive regard, and congruence (Rogers, 1986b), the counselor should encourage the clients to express these concepts in their drawings. During this time, the counselor should provide empathetic understanding to each client by using here-and-now statements. Discussion focuses on the time period within group sessions. This part of the group activity promotes expression of thoughts, emotions, and expectations for the group. 4. The counselor can process this activity by inviting clients to share their timelines and respond to processing questions, such as, I notice you represented yourself with dark colors and can you talk about the color and the shape? What feelings did you have for the initial sessions and for 177

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now? Was there a time when you felt supported or ignored? Have there been other times that you felt supported or ignored? Group cohesion is enhanced as clients discuss their shared time in therapy and how it feels to receive support from other members. 5. Once the timeline drawings are complete, the counselor facilitates a discussion of the drawings of individual clients. The first question to ask the clients about their experience with this activity is: Could you tell us what you felt while doing this activity? The discussion should then move on to examining aspects of the figures. Are the figures getting bigger or smaller towards the end of the therapy timeline? Are there new figures joining the old figure? Is the figure changing in three time points? In order to encourage discussion among the clients, the counselor uses empathic language and statements. The activity can further be explored by reflecting on the client’s self-growth, as well as the growth of the group as a whole. It’s also here that members can discuss the similarities and differences between their timelines. The counselor should then ask the clients if this activity increased cohesiveness within their group. 6. For the endpoint in the timeline, clients are asked to represent how they envision themselves in the future by applying the skills learned in the group therapy sessions. Future work may ask for the clients to set new goals in light of their past experiences. This can be done at each point interval on the timeline, the beginning, the middle, or the end. The counselor may encourage, After having seen your first drawing and the progress you’ve made since, set yourself new targets that you believe to be realistically achievable until the next time point. 7. At the end of the session, clients can be invited to bring in their completed work at the termination session and explore whether or not the drawing relates to their experiences and initial expectations for the group.

USING METAPHOR IN FACILITATING SELFAWARENESS Corie Schoeneberg, Nancy Forth, and Atsuko Seto

Indications: Counselors should consider if the client will be able to effectively articulate the

metaphor and create one’s own interpretation before using this intervention. Multicultural and diversity issues should also be considered. Some clients may be uncomfortable with the subjectivity of the activity and the abstract thinking that is required. Goal: Enhanced self-awareness, new insights into personal experience, and goal setting Modality: Art The Fit: The purpose of this activity is for the client to discover a new or different way of thinking about or conceptualizing a personal experience in order to further facilitate the therapeutic process of healing. This activity prompts the client to create a metaphor between his or her personal experience and a picture, explore meanings of the metaphor in relation to his or her life (Hutchinson, 2007), as well as assisting in increasing personal growth and development (Freud, 1965; Jung, 1961). According to Hanna (2007), a metaphor is “a word or phrase that represents another condition by analogy” (p. 223). Using metaphors as a therapeutic intervention provides a reframe for the client’s reality (Alvarado & Cavazos, 2008; Hanna, 2007) and offers the client a visual image that captures his or her “inner experience” (Chen & Giblin, 2002). Metaphors also provide the client with a new perspective to his or her problem or circumstance while facilitating powerful insights and therapeutic processing. Additionally, the client’s focus on a metaphor creates a psychological distance from the direct emotions and cognitions surrounding a particular experience, thus providing safety for the client in a way that discreetly yet powerfully lowers defenses and self-protecting barriers of affective processing. Populations: Adolescents/adults; Groups/individuals Materials and Preparation: Before the session, the counselor should collect and cut out a variety of pictures and images from magazines, the Internet, newspapers, and so forth. They may include both animate and inanimate objects, such as people engaged in activity, animals, scenes found in nature, simple objects, or words. Place the pictures in a container, like a hat or a bowl, from which the client will randomly select a picture. You may also invite the client to take the picture with him or her at the end of the session to encourage continued self-reflection between sessions. Instructions: 1. Ask the client to reach into the container of pictures and without looking, randomly select an image. 2. Once the client has selected a picture, ask the client to create a metaphor between his or her personal experience (or presenting concern) and the image. For example, the counselor may ask, How does this image describe (or speak to) what you are going through right now and how you are thinking and feeling about it? Allow the client time to reflect and process this question before answering. 3. As the client begins to verbalize the metaphor, reflect the client’s feelings about these connections with the metaphor. For example, the client selects a picture of a dog burying a bone. The client may create a metaphor between the burying of the bone and keeping the secret of past abuse experiences. You may reflect the client’s feelings of vulnerability and 179

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exposure regarding his or her “buried” secret as well as the emotions surrounding the urgency to self-preserve, protect, and hide. When the client seems to be finishing the reflection, you may disclose any other connections you observe between the client and the picture. 4. As the client finishes processing the metaphor, the following questions may be asked to close the activity: What was it like for you to do this activity? What are you going to take with you (or what meaning do you take) from this activity? What do you plan to do with this picture? 5. Future work may include goal setting resulting from the client’s exploration of the metaphor. For example, in the metaphor between the buried bone and the client’s undisclosed abuse, the counselor may facilitate goal setting by extending the metaphor by asking such questions as, What needs to happen for the dog to feel safe enough to unearth the bone? What are the pros and cons of having the bone buried? What would the dog hope to do with the bone?

WALL OF IMAGES Tina R. Paone

Indications: The presenting issues that would be appropriate for use with this intervention may be self-esteem, self-image, or body image. Other areas of concern related to self are also appropriate and this activity can be altered to address these topics. Goal: To recognize and counter self-defeating thoughts through more positive self-perceptions Modality: Art and movement The Fit: This activity encompasses a predominantly client-centered approach, but also includes shades of a cognitive behavioral/rational emotive behavior therapy (REBT) approach. Initially, as the activity is described, there is a directive approach taken with the group members that would be considered more cognitive behavioral in nature rather than client centered. During the actual activity, while group members are creating their own collage, the facilitator will reflect back what is seen through the creation process. By doing so, the facilitator will create a safe and comforting environment while establishing rapport with the participants (Rogers, 1957). This rapport building will continue as the facilitator begins to process through the first several questions following the activity, allowing group members to respond at their own pace all the while continuing to build rapport with the facilitator as well as with other members. Once the process stage increases in intensity through the questions being asked and the answers given by the group members, the goal of the facilitator is to move into a cognitive behavioral/REBT approach. As group members process the remaining questions, they tend to become more goal oriented through their responses. Through the help of the facilitator, they also become more aware of the self-defeating thoughts and behaviors that they hold concerning self-image. Through the process, they develop a new way to approach images, thoughts, and current behaviors around their own self-image (Ellis, 2001). Populations: Older children/adolescents/adults; Groups/individuals Materials: Variety of magazines, large pieces of construction paper, glue, and scissors Instructions: 1. Opening: Ask group members to imagine how the ideals of beauty in America affect the way that they deal with individuals whose appearances do or do not reflect the image that the media promotes. Also ask group members to examine how they view themselves based on the ideals generated and presented by the media. Discuss with group members both the idea of how beauty in America is perceived and how they perceive themselves in relation to it. Group members will cocreate a visual understanding of this concept by creating a collage that, in effect, becomes the wall of images. 2. Instructions: Ask group members to flip through the various magazines and create their own personal collages of ads or photos they perceive as reflecting the American ideal of beauty. Ask them to present their collages to the group and explain why they chose specific ads or photos. After each group member has presented his or her image, tape each individual collage on the wall to create a “wall of images.” 3. Ask the clients to move around the room as they view and react to the wall of images. Discuss their physical and emotional responses to this wall with the group. 4. Processing questions: These can include, but are not limited to, What were your reactions to this activity? What was it like to view the media expression? What reactions do you have regarding your examination of what the media portrays as beauty? How did it feel to create 181

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and share your own collage? How did it feel to see your collage become a part of the whole? Where have you received these ideas about beauty? How can you take that critical eye and that unconscious experience with you to better help you understand aspects of true beauty? How can you apply what you have learned in this group to your life? 5. Cautions. This activity can touch on sensitive issues for members, potentially evoking strong positive and negative emotions. All groups and their group energy are different; therefore, it is important to maintain flexibility during processing to allow group members to touch on issues they feel are important.

WRITING YOUR OWN SEQUEL Kathryn Kozak

Indications: This intervention is suitable for a variety of presenting concerns. The future-oriented

nature of the activity makes it particularly applicable when working with clients at a transition point in their life cycle, or clients who seek change (e.g., relational, vocational, etc.). It is most effective if used once the presenting concern has been thoroughly explored in counseling, so that the client may have greater self-awareness of incongruences. Goal: Increased self-awareness, goalsetting, empowerment to make change Modality: Art The Fit: The activity allows clients to assume the expert role by imagining themselves as the authors of their own life stories. Clients explore discrepancies between their current realities and the ideals represented in their sequel, thus increasing awareness of areas of congruence and incongruence. Clients are able to capitalize on their self-actualizing tendencies (Rogers, 1961) by recognizing the barriers between their real and ideal selves through their art. By completing this activity in an environment in which the counselor demonstrates unconditional positive regard, congruence, and empathy, clients’ conditions of worth surrounding the futures they envision for themselves are diminished (Rogers, 1961). This facilitates movement toward the ideals portrayed in their sequels. Populations: Adolescents/adults; Individuals/groups Materials: Unlined white paper; drawing instruments, such as markers, crayons, colored pencils, or pens Instructions: 1. Invite clients to imagine that their life stories have been written into a book. Each book’s time span encompasses the client’s life from its beginning until the present moment. Ask clients to now imagine that they are beginning to write a sequel. Clients are then prompted to use the materials provided to design the book cover for their life sequel, an autobiography. Clients may choose how far into the future the next installment of their life’s story will reach. For example, some clients may choose a general time frame, such as the next 10 years, while some may choose a specific anticipated event, such as completing college, as their endpoint. 2. As the client creates the autobiography’s cover, the counselor may make content-focused comments. Do not offer interpretations regarding the meaning or significance of the client’s work. For example, the counselor may make process observations such as, “The title of your autobiography is colored red” or “The sun is shining over the house,” and so on. The observations should draw client attention toward specific elements of his or her art for increased reflection, whether that reflection occurs internally or is shared aloud. 3. The counselor may also make process comments as the client works. Again, interpretations should not be provided by the counselor. Examples of process comments might include, I noticed you hesitated before choosing the green marker or You decided to fold your paper in half, and so on. 4. When the client determines that the autobiography cover is complete, process the activity. Possible processing questions include, What was it like for you to do this activity? How do you feel when you look at your completed book cover? What unexpected plot twists does this book contain? Who in your life might read this book and be especially surprised by those plot 183

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twists? Who are the main characters in this book? Have the main characters remained the same from the first book to the second, or have they changed? What might the table of contents for this book include? What part of this book will make readers feel the most ____ (insert any feeling word: excited, sad, etc.)? 5. As clients discuss their autobiographies, encourage them to reflect on goals and plans they identify for the future. Particular attention may be drawn to exploring the impetus for those goals, available resources, and any aspects of their lives at present which have either facilitated or inhibited their plans. REFERENCES Alvarado, V. I., & Cavazos, L. J. (2008). Allegories and symbols in counseling. Journal of Creativity in Mental Health, 2(3), 51–59. American Horticultural Therapy Association. (n.d.). The history and practice of horticultural therapy. Retrieved from http://www.ahta.org/what-is-horticultural-therapy Bozarth, J. D., Zimring, F. M., & Tausch, R. (2002). Client-centered therapy: The evolution of a revolution. In D. J. Cain & J. Seeman (Eds.), Humanistic psychotherapies: Handbook of research and practice (pp. 147–188). Washington, DC: American Psychological Association. Brouzos, A., Vassilopoulos, S. P., & Baourda, V. C. (2015). Members’ perceptions of person-centered facilitative conditions and their role in outcome in a psychoeducational group for childhood social anxiety. Person-Centered & Experiential Psychotherapies, 14(1), 32–46. Cain, D. J., & Seeman, J. (Eds.). (2002). Humanistic psychotherapies: Handbook of research and practice. Washington, DC: American Psychological Association. Carrick, L., & McKenzie, S. (2011). A heuristic examination of the application of pre-therapy skills and the person-centered approach in the field of autism. Person-Centered & Experiential Psychotherapies, 10(2), 73–88. Chen, M., & Giblin, N. J. (2002). Individual counseling: Skills and techniques. Denver, CO: Love Publishing. Cooper, M., & McLeod, J. (2011). Person-centered therapy: A pluralistic perspective. Person-Centered & Experiential Psychotherapies, 10(3), 210–223. Cooper, M., O’Hara, M., Schmid, P. F., & Wyatt, G. (Eds.). (2007). The handbook of person-centered psychotherapy and counselling. New York, NY: Palgrave McMillian. Corey, G. (2013). Theory and practice of counseling and psychotherapy (9th ed.). Belmont, CA: Brooks/Cole. DeCarvalho, R. J. (1999). Otto Rank, the Rankian circle in Philadelphia, and the origins of Carl Rogers’s person-centered psychotherapy. History of Psychology, 2(2), 132–148. Elliott, R. (2013). Person-centered/experiential psychotherapy for anxiety difficulties: Theory, research and practice. Person-Centered & Experiential Psychotherapies, 12(1), 16–32. Ellis, A. (2001). Overcoming destructive beliefs, feelings, and behaviors: New directions for rational emotive behavior therapy. Amherst, NY: Prometheus Books. Freud, S. (1965). The interpretation of dreams. New York, NY: Avon Books. Gladding, S. T. (1998). Counseling as an art: The creative arts in counseling (2nd ed.). Alexandria, VA: American Counseling Association. Hanna, S. M. (2007). The practice of family therapy: Key elements across models (4th ed.). Belmont, CA: Thomson Brooks/Cole. Hett, J. (2013). Person-centered skills training in a Syrian context: Pitfalls and possibilities. Person-Centered & Experiential Psychotherapies, 12(1), 79–93. Hill, C. E. (2013). Helping skills: Facilitating exploration, insight, and action (3rd ed.). Washington, DC: American Psychological Association. Hutchinson, D. (2007). The essential counselor: Process, skills, and techniques. Boston, MA: Houghton Mifflin Company. Jan Takens, R. (2013). Special section on person-centered and experiential psychotherapy in the Netherlands. Person-Centered & Experiential Psychotherapies, 12(2), 98–99. Johnson, C. (2011). Disabling barriers in the person-centered counseling relationship. Person-Centered & Experiential Psychotherapies, 10(4), 260–273. Jung, C. G. (1961). Memories, dreams, reflections. New York, NY: Vintage Books. Kiosses, V., & Karathanos, V. (2013). Depression in patients with CKD: A person centered approach. Journal of Psychology & Psychotherapy, 3(Suppl). doi:10.4172/2161-0487.S3-002 Lago, C. (2011). Diversity, oppression, and society: Implications for person-centered therapists. Person-Centered & Experiential Psychotherapies, 10(4), 235–247.

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Landreth, G. (1991). Play therapy: The art of the relationship. Muncie, IN: Accelerated Development Press. Lemoire, S., & Chen, C. (2005, March). Applying person-centered counseling to sexual minority adolescents. Journal of Counseling & Development, 83(2), 146–154. Malchiodi, C. A. (2005). Expressive therapies. New York, NY: Guilford Press. McNiff, S. (2004). Art heals: How creativity cures the soul. Boston, MA: Shambhala. McCain, B. R (1998). Grandmother’s dreamcatcher. Morton Grove, IL: A. Whitman. Miles, A., & Mezzich, J. (2011). The care of the patient and the soul of the clinic: Person-centered medicine as an emergent model of modern clinical practice. International Journal of Person Centered Medicine, 1(2), 207–222. Murphy, D., Cramer, D., & Joseph, S. (2012). Mutuality in person-centered therapy: A new agenda for research and practice. Person-Centered & Experiential Psychotherapies, 11(2), 109–123. Nuding, D. (2013). Anxiety in childhood–person-centered perspectives. Person-Centered & Experiential Psychotherapies, 12(1), 33–45. Perry, L. (2002). Beautiful [Recorded by Christina Aguilera]. On Stripped [CD]. New York, NY: RCA Records. Prochaska, J. O., & Norcross, J. C. (2014). Systems of psychotherapy: A transtheoretical analysis (p. 117). Pacific Grove, CA: Brooks/Cole. Quinn, A. (2013). A person-centered approach to multicultural counseling competence. Journal of Humanistic Psychology, 53(2), 202–251. Rijn, B. V., & Wild, C. (2013). Humanistic and integrative therapies for anxiety and depression: Practice-based evaluation of transactional analysis, gestalt, and integrative psychotherapies and person-centered counseling. Transactional Analysis Journal, 43(2), 150–163. doi:10.1177/0362153713499545 Rogers, C. R. (1942). Counseling and psychotherapy: Newer concepts in practice. Boston, MA: Houghton Mifflin. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95–103. Rogers, C. R. (1961). On becoming a person: A therapist’s view of psychotherapy. Boston, MA: Houghton Mifflin. Rogers, C. R. (1966). Client-centered therapy. In S. Arieti (Ed.), American handbook of psychiatry (Vol. 3, pp. 183–200). New York, NY: Basic Books. Rogers, C. R. (1977). Carl Rogers on personal power. New York, NY: Delacorte Press. Rogers, C. R. (1986a). Carl Rogers on the development of the person-centered approach. Person-Centered Review, 1(3), 257–259. Rogers, C. R. (1986b). Client-centered therapy. In I. L. Kutash & A. Wolf (Eds.), Psychotherapist’s casebook (pp. 197–208). San Francisco, CA: Jossey-Bass. Rogers, C. R. (1992). The processes of therapy. 1940. Journal of Consulting and Clinical Psychology, 60(2), 163–164. Rogers, C. R., Minuchin, S., Satir, V., Bowen, M., & Gottman, J. (2007). The top 10: The most influential therapists of the past quarter-century. Psychotherapy Networker, 31(2), 24–68. Rogers, N. (1993). The creative connection: Expressive arts as healing. Palo Alto, CA: Science and Behavior Books. Rogers, N. (1999). The creative connection: A holistic expressive arts process. In S. Levine & E. Levine (Eds.) Foundations of expressive arts therapies. London, UK: Jessica Kingsley. Rogers, N., Tudor, K., Tudor, L. E., & Keemar, K. (2012). Person-centered expressive arts therapy: A theoretical encounter. Person-Centered & Experiential Psychotherapies, 11(1), 31–47. Sa’ad, F. M., Yusooff, F., Nen, S., & Subhi, N. (2014). The effectiveness of person-centered therapy and cognitive psychology ad-din group counseling on self-concept, depression and resilience of pregnant out-of-wedlock teenagers. Procedia-Social and Behavioral Sciences, 114, 927–932. Sharf, R. S. (2005). Theories of psychotherapy and counseling: Concepts and cases (3rd ed.). Pacific Grove, CA: Brooks/Cole. Stanghellini, G., Bolton, D., & Fulford, W. K. (2013). Person-centered psychopathology of schizophrenia: Building on Karl Jaspers’ understanding of patient’s attitude toward his illness. Schizophrenia Bulletin, 39(2), 287–294. Task Force for the Development of Guidelines for the Provision of Humanistic Psychosocial Services. (1997). Guidelines for the provision of humanistic psychosocial services. The Humanistic Psychologist, 24, 64–107. Traynor, W., Elliott, R., & Cooper, M. (2011). Helpful factors and outcomes in person-centered therapy with clients who experience psychotic processes: Therapists’ perspectives. Person-Centered & Experiential Psychotherapies, 10(2), 89–104. U.S. Department of Health and Human Services. (2000). Mental health: Culture, race, and ethnicity—A supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Public Health Service. Watson, J. C. (2002). Re-visioning empathy. In D. J. Cain (Ed.), Humanistic psychotherapies: Handbook of research and practice (pp. 445–471). Washington, DC: American Psychological Association. Wedding, D., & Corsini, R. J. (2014). Current psychotherapies (10th ed.). New York, NY: Wiley. Zinchenko, Y. P., Pervichko, E. I., Mezzich, J. E., Krasnov, V. N., & Kulygina, M. A. (2013). Person-centered approaches in medicine: Clinical tasks, psychological paradigms, and postnonclassic perspective. Psychology in Russia, 6, 95–109. doi:10.11621/pir.2013.0109

10 Narrative Approaches Shawn Patrick

This chapter presents a brief discussion about the origins of narrative therapy and its progression to current practice. This discussion highlights the creative aspects of the approach as conceived by Michael White and David Epston. Early work by White with children and families demonstrated how narrative principles were able to help families gain a sense of agency over once-perceived “impossible” problems. This early work led to the development of the “story metaphor” and the ability to help families enter into these stories and create new meanings, outcomes, and actions. CORE CONCEPTS OF NARRATIVE THERAPY Narrative practitioners maintain that individuals derive meaning through telling and reenacting stories (Combs & Freedman, 2004). In the retelling of story, a person aligns himself or herself within the context of the dominant story. It is in the metaphor of storytelling that people can become “stuck” in the dominant story (White & Epston, 1990). The script or narrative positions them to relate to themselves and others in a narrow and fixed fashion. It becomes a thin story of how one is to live. Identifying oneself to this thin narrative creates a limitation for different possibilities or outcomes. A client may say, “I am depressed” or “I am a sexual abuse survivor.” It is in these claims of how a person aligns to the problem that his or her story is revealed. He or she experiences the problem or problem-saturated story as oppressive and often concludes that it is “oneself ” that is the problem. Externalization is the process by which the problem is redefined in a manner that takes the problem outside of the person (White & Epston, 1990). Using the example earlier, a person who presents the problem by stating, “I’m depressed,” demonstrates how the problem has become the center of identity. Through externalization (i.e., “Depression has entered my life”), the problem is rewritten in a way that allows the person to create an identity that can allow for new ways of experiencing or even eradicating the problem. Naming the problem outside of the person is only the first step in this process, however (White & Epston, 1990). Once the problem has been named, then the person can examine the influence of the problem on his or her life, as well as his or her influence on the problem. Referred to as deconstruction, this new discussion of the externalized problem allows clients to take a stand in relation to this problem. For example, a person may decide to ask depression to leave or may conclude that instead of depression making all of the decisions, the person will decide over which areas depression can have control. 187

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Developing these stances is a collaborative process that also emphasizes the client’s ability to make decisions about his or her approach to life. Because problem-saturated stories often rob individuals of this sense and undermine their efforts at changing the problem, externalization and deconstruction allow clients to regain their sense of agency as these richer and more developed stories provide for previously unrecognized alternatives. These alternatives, or unique outcomes, demonstrate to the person instances where the problem does not dominate the circumstance, and the person has been able to somehow overcome the effects of the problem. It is important to note that positive events and strengths can be externalized just like problems or perceived weaknesses. The exploration of the person’s influence on the development of these positives can become an empowering discussion that highlights the types of resources and abilities the person does possess. Moreover, being able to describe the stance one has developed or one wants to continue to develop with these positive areas can strengthen commitment to a course of action or reinforce an existing plan. These areas of success, sometimes referred to as “the project” or “preferred story,” can also be contrasted with the externalized problem (White, 2007). In other words, clients can examine what sorts of actions or ideas contribute to continuing the problem versus those actions that contribute to the preferred story. Narrative approaches, even when being used to interview just one person, also emphasize the systemic nature of relationships and experiences. Thus, narrative approaches also invite commentary on social and cultural influences on the person as well as connect people to larger communities. In some ways, this contextual emphasis provides one of narrative therapy’s best strengths in that it seeks to remove people from the isolating tendency of problem-saturated stories. Documenting practices and the development of communities of concern are two broad techniques that attempt to connect people with others who have experienced similar problems. Documentation includes writing letters, creating certificates, or generating other statements that clients can use to identify the ways in which they have resisted the problem. In some instances, clients might share these documents with others to demonstrate their successes or offer support. The sharing of these documents could lead to creating a community of concern of others who have experienced something similar and those who are interested in the success of the person now seeking help. These communities could include people meeting for support, communicating through writing, or could be simply metaphorical. For example, a client could be asked to think of those people who would be supportive of his or her success; these people might not be alive anymore but would still constitute a community from which the individual can draw strength. CONCERNS ADDRESSED BY THEORY Using these ideas, narrative approaches have been applied to various situations and concerns experienced by families and individuals. Some of the earliest work describing these approaches involved using externalization to address encopresis (White, 1984). Once thought to be a condition brought on by inadequate parenting, White’s (1984) redefinition of the problem as an outside figure (i.e., “Sneaky Poo”) that attempted to defeat the family allowed parents and children to identify the ways in which they could resist the problem’s efforts and “win the battle.” These approaches demonstrated great success in an area once thought to have poor success rates (Silver, Williams, Worthington, & Phillips, 1998). Narrative approaches have since been shown to work well with areas such as eating disorders, experiences of trauma and hardship, and relational conflict. Research into the effectiveness of narrative approaches is a young but slowly growing area (Brimhall, Gardner, & Henline, 2003). St. James-O’Connor, Meakes, Pickering, and Schuman (1997) found support for the appeal of narrative methods to families. Because the style of a narrative interview involves examination of ways in which people have influenced the problem or previously resisted the negative effects of problems, these approaches also tend to

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emphasize strength and self-creation. Individuals are able to identify the ways in which they actively work to create new or different ways of knowing, being, or behaving, thus emphasizing personal agency. Families who experienced this approach reported appreciating being viewed as “the expert” on their own problems and noted the strength-based approach as one of the most helpful aspects of therapy (St. James-O’Connor et al.). Narrative approaches can also be used in nontraditional counseling settings. Because narrative approaches include practices of therapeutic letter writing and documenting, sessions can be spaced out over different time frames. As such, narrative-based practices can suit clients who may not have the ability to meet weekly or who might live in isolated communities. MULTICULTURAL CONSIDERATIONS Postmodern approaches and narrative therapy specifically are well-suited to address a wide variety of cultural contexts (Semmler & Williams, 2000). Rather than defined as a static trait, culture is an expression of a fluid, moving interaction of multiple influences including but not limited to family, history, shared tradition, religious practice, sociopolitical climate, and power hierarchies (Monk, Winslade, & Sinclair, 2008). Influenced by Foucault, narrative approaches recognize the role of power on the shaping of one’s identity, relationships, beliefs, and expectations. Specific to the counseling relationship, narrative approaches also take into consideration the potential for the counselor’s power to influence interactions between client and counselor. Thus narrative interviews attend to these power differentials and place counselors in a “decentered yet influential” position in relation to clients (White, 2011). Clients are known as the experts on their own experiences, thus narrative practitioners focus on creating a conversation that assists, rather than determines, generation of meaning and preferred story. Often social discourses can cloud, distort, or hinder clients’ abilities to live in growth-enhancing ways. For example, social norms connected to gender can dictate decisions such as what to wear, what to say, and even what job to take. Yet if these prescribed expectations conflict with how we come to know ourselves, discourses often communicate that it is the individual, not society, who must conform or else be labeled as deviant. Thus, these discourses become “overprivileged” in determining clients’ lives. Narrative processes aimed at deconstructing discourse assist clients in identifying and reauthoring insider or “local” knowledge. In turn, problematic discourses are “put in their place” as clients construct new or preferred identities (Monk, Winslade, & Sinclair, 2008). Narrative approaches have been successfully applied in a variety of contexts toward a multitude of situations. Because narrative methods can pair well with expressive modes of communication, counselors do not have to rely on formal, spoken language in the coconstruction of client stories. In fact, counselors ideally utilize the language and communication mode most natural to the client. Narrative practices have been used worldwide, can be adapted across age groups, and have addressed experiences as complex as coming-out, grief and loss, trauma, asylum-seeking, conflict mediation, and bullying (Caldwell, 2005; Lee, 2013; Saltzsburg, 2007; Shalif, 2005; Winslade & Monk, 2007). These practices also demonstrate how the performance of one’s preferred identity and story becomes a way for clients to reclaim power and act upon social discourses. NARRATIVE APPROACHES AND THE EXPRESSIVE ARTS Expressive arts in therapy attempts to use active methods such as art, music, drama, movement, or storytelling to aid people in creating meaning around the events in their lives (Allen & Kreb, 2007). Individuals engaging in such methods allow their stories to unfold through these

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media, and the process allows for a reinterpretation and expansion of the story that can be personally transformative. Moreover, expressive arts includes the eventual “performance” of the creation, whether it be through sharing the painting, demonstrating the dance, or storytelling. This performance also carries the individual from isolation to connection with the audience. Narrative therapeutic approaches match exceptionally well with expressive arts. Narrative approaches are based on the premise that individuals lead storied lives and, as such, are in a constant and active process of creating these stories (White, 2007). The creation of communities of concern or outsider witness groups mirrors the expressive arts’ emphasis on community building (Denborough, 2008; White, 2000). The sharing of documents or therapeutic letters becomes an expression of the new preferred stories over the problem-saturated story and the audience becomes witness to this change. Narrative approaches are not limited to verbal or written form, however; in more recent years clinicians have paired narrative interviewing practices with music, photography, drama, and even scrapbooking (Beckenbach & Patrick, 2015; Douge, 2010; Heath & Arroyo, 2016). Expressive arts also contends that the telling of the story is an affirming process that expresses personal identity, value, and tradition (Allen & Kreb, 2007). For example, in the “statement of us” activity described later in this chapter, couples are asked to write a statement that reflects their identity as a couple. This statement is intended to become the groundwork for what is most central to the couples’ needs for stability and growth. By putting this in the form of a document, each couple has the opportunity to share this statement publicly, an act that asserts their new position on who they commit to be as opposed to living dominated by the problem (Beckenbach, Patrick, Sells, & Terrazas, 2014). Thus, this process parallels the goal of expressive arts in giving couples an active method generating meaning around their status of couplehood. CONCLUSION In conclusion, narrative therapy helps people identify values and provides self-knowledge to confront issues with clarity through identification of their personal experiences. While many identify narrative therapy with writing, new narrative approaches may be paired with music, photography, drama, and more. Through all narrative approaches, finding meaning through externalization of story lines and lived experience enables the change process. Recognizing the role empowerment of the client through the process of deconstructing discourse sets the stage for powerful expressive art techniques.

Expressive Arts Interventions

CHEROKEE GOURD PAINTING AS TAUGHT BY MOMFEATHER ERICKSON FROM MARION, KENTUCKY Nan J. Giblin

Indications: This technique can be used with almost any group and with individuals in

counseling. It is a nonthreatening way of telling the major events of their lives. Goal: Visual expression and sharing of life stories; listening and respecting the life stories of others (if in a group setting) Modality: Art The Fit: Narrative therapy (White, 2007) stresses the importance of telling one’s story. Through storytelling, people are able to give meaning to their lives while putting their life experiences into a larger context of universal life themes. The theory behind narrative therapy is consistent with the practice of Cherokee gourd painting, which is a visual way to represent and preserve one’s life story. In a group setting, life stories may be shared. Group members show respect for the experiences and history of participants. This technique began with the Cherokee people hundreds of years ago. According to Momfeather Erickson (personal communication, February 22, 2009), a Cherokee elder and teacher of the traditional ways, when a child was born, the mother would begin drawing on a gourd as a gift for that child. First, the mother would draw a symbol of centering and balance on the bottom of the gourd. Then, each major event in the life of the child was artistically recorded by the mother. When the child grew to about 18 years of age and was ready to leave home, the mother would give him or her the gourd as a farewell gift. These pictorial gourd diaries aided the young adults in remembering and telling the stories of their lives. The gourd is used because it was readily available to the Cherokee. As a natural substance, it was familiar to the people and conveyed a sense of home for the young adults to carry with them throughout their lives. Natural dyes were used. Populations: Children/adolescents/adults; Groups/individuals Materials: Clean large gourds (one per client); markers of different colors (Sharpie markers are closest to the Native colors) Instructions: 1. Place the gourds on a table and let each client choose one. 2. Introduce the history of the Cherokee gourd painting and add any stories or additional information you would like about the Cherokee people. It is important for the participants to understand that this is a traditional way of art-making that calls for respect for the process and for the stories of other group members. 3. Ask clients to draw something on the bottom of the gourd to provide a “center.” The Cherokee people believe in the importance of being personally centered as exemplified by the medicine wheel. It is traditional to provide a symbolic representation of being centered before the other symbols are placed on the gourd. 191

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4. Ask clients to draw representations and/or symbols to represent the major events in their

lives. 5. When the gourds are completed, each person tells his or her life story as represented on the

gourd. Participants may tell as little or as much as they would like. Maintaining a feeling of safety in the group is important. No judgments are to be made about the drawings on the gourds. Listening and respect for others are the key. 6. The group members discuss what it was like to do this activity. Processing questions may include, How did you choose your gourd? How did you center the gourd? Did you plan? Did you plan what you are going to draw on the whole gourd or did you just do it without a lot of planning? When you look at your gourd, does it say what you want it to say? Do you like how it turned out? What do the colors that you chose symbolize for you? Is there space left on your gourd? What will you do with that space? What would you title your gourd? Possible Variations: Substitute other materials for gourd such as pieces of wood, tree bark, or other natural materials. Make the finished gourd into a birdhouse by cutting a small circular hole in the lower part of the gourd, adding a coat of shellac so it can be placed outside, and glue on a small piece of doweling for the birds to land on before going into the house. Paint gourd first with a base coat before adding your story. You may read more about Momfeather Erickson and the Living Village project at www. manataka.org/page1562.html or purchase gourds online at www.amishgourds.com.

COCONSTRUCTED STORIES Katrina Cook and Varunee Faii Sangganjanavanich

Indications: Most presenting concerns that can be addressed in group counseling can use this

intervention. A sample of possible presenting concerns includes low self-esteem, depression, major life transitions, problem solving, stress, and the development of social skills. This activity can also be used to facilitate the development of group cohesion. Goal: To facilitate social dialogue and a collective environment for clients to reevaluate and reauthor their own life stories Modality: Writing The Fit: Narrative therapy focuses on the stories that individuals create about their lives. Often, individuals creating stories notice only the events that support the storyline and ignore an opportunity to examine other options or alternatives. This activity allows clients to coconstruct each other’s stories while becoming aware of other possibilities for their own stories (Monk, 1997). Populations: Older children/adolescents/adults; Groups Materials and Preparation: The only materials needed for this intervention are pens and several sheets of paper for each group member. Pens are preferable to pencils because they create less friction when writing, enabling the writer to write more quickly. A flat writing surface such as a table or lapboards would also be needed. Instructions: 1. Ask each group member to identify a problem with which he or she has struggled during the previous week. However, do not begin a discussion about the problems at this time. 2. Instead, ask clients to tell a story describing this problem and their reactions to it in writing. Inform them that they will be sharing what they write with the rest of the group to prevent unintended disclosures. 3. After 6 minutes of writing, ask each client to pass his or her paper to the person on the right. Some clients may protest that they have not yet finished their story. Reassure them that the story does not have to be completed. As each group member receives his or her neighbor’s paper, instruct him or her to read what the previous person has written, and then to continue the story from his or her point of view. After 6 minutes of writing, ask the group members to pass the paper they now have to the person on their right and continue writing on that paper. This will continue until each paper has been returned to the original writer. As this proceeds and the papers become longer, you will need to increase the amount of time that passes before passing the paper to the person on the right. However, you still want to have them pass papers before they are completely finished writing about the one they are on, so the story has not been completed before the next person gets it. 4. Once the original writers get their own stories back, ask them to read what the others have written, and then to complete the story they started. At this step, allow enough time for each person to finish his or her story. 5. Then ask each original writer to read out loud the coconstructed story and examine the different viewpoints and reactions that emerged from the other group members.

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6. Facilitate a discussion about the alternative viewpoints that occur in each story and what

surprised them the most about how their stories changed once in other people’s hands. The discussion might focus on how different people view the same problem from a unique perspective, how a problem that seems insurmountable to one person may appear easy to another, and the viability of the alternative stories. Often, clients will include humorous elements in their alternative stories. How does having a sense of humor about a problem change a person’s perception of that problem?

“EXTERNALIZING THE PROBLEM” SCULPTURE AND PROCESSING Madeline Clark

Indications: This activity is appropriate for persons with a presenting concern they can label such as anxiety, depression, anger, impulse control, grief/loss, trauma, and so on Goal: To assist the client in creating an external representation of his or her presenting concern. Following the sculpting of the concern/problem, counselor and client will work together to name the problem, externalize the problem, and begin to re-story the problem. Modality: Art, sculpture The Fit: This approach allows clients to externalize their problem and name their problem, congruent with narrative approaches (White, 2007). The externalization and re-naming allows for clients to begin re-storying their experience (Brown & Augusta-Scott, 2007; Madigan, 2011; White, 2007). Additionally, counselor and clients can work together to re-story and describe sparkling outcomes (Madigan, 2011; Meier, 2012; White, 2007). Population: Children, adolescents, adults; Individuals Materials: Clay, play-doh, model magic, or any sculpting medium Instructions: 1. Provide the sculpture medium to your client(s) and ask them to create an image/sculpture of their presenting problem. Give the clients a few minutes to create their sculpture; it can be helpful to offer process commentary and immediacy to what the clients are creating. It is important to note that some clients may be hesitant to engage in this activity at first, worried that their creation may not be good or artistic. That response can be processed with the clients and insight offered into clients’ lived experiences. It is important to reassure the clients that the outcome is not as important as the process of creating the sculpture and the discussion to follow. 2. After the clients are finished with their sculpture, give them some time to name it. Throughout the rest of the session, refer to the sculpture of the presenting concern by its given name. 3. Process with each client how it felt to make his or her sculpture; allow the client to tell the story of the sculpture’s creation and naming, and why it was meaningful to him or her. It is appropriate to use reflections of feeling, empathy, and probes in this exploratory storying step. 4. Ask the client to describe how it feels now that his or her presenting concern has a name and how he or she might exist now knowing that the problem exists outside of self. Continue to call the sculpture by its given name to encourage separation from the problem. 5. Encourage clients to conceptualize what their lives might be like without the presenting problem as a part of them. Have there been times in the past when they felt that they were not burdened with the problem? What did that feel like? How can you work together to ensure the problem stays separate? 6. As the session concludes, ask clients what they would like to do with their sculpture. Some clients may wish to keep the sculpture as a symbol of their presenting concerns, others may

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wish to return it to its packaging. It is appropriate to ask the client if you can continue to use the name he or she has given the problem throughout your work together, or if the client would prefer to leave that name in the present session. Conclude the session asking the clients for their own reflection of the processing, if they would have done anything differently, and how they will use the experience going forward in their lives.

FRACTIONS OF COLORS Ileana Lane

Indications: Appropriate for clients dealing with sadness caused by an event (mixed emotions), anger toward another person, stress, depression, mixed emotions about an incident, peer mediation, feelings of resentment Goal: To help clarify and give weight to what issues the client may be focusing on when experiencing conflicting or distressing emotions Modality: Art The Fit: This activity allows clients to tell their story of the presenting issues they may be facing between a peer, family member, event, or other situation. This strategy helps clients put their concerns into perspective by “quantifying” the presenting issues. Clients may sometimes feel there are several conflicts they may be facing; following through this activity will help clients understand, interpret, and give volume to the problems they are experiencing. This activity is congruent with the ideas of David Epston and Michael White in having the counselor collaborate with the client in the process of creating a richer story about what the problem’s place is in the client’s life by naming and by deconstructing the issues of the presenting problem. Populations: Children (age 6 and older)/adolescents; Groups/individuals Materials: Markers, crayons, paint, or inkpads, and so forth; paper plate, printer paper, white construction paper, or posterboard, and so forth; writing paper; pencil or pen Instructions: 1. Invite client to write a list of different things that may be issues between client and event or person (e.g., peer mediation or level of stress). 2. Ask client to assign colors to each issue using markers, crayons, paint, inkpad, or whatever source of colors chosen, creating a color legend for the issues. 3. Using the chosen paper, ask the client to go down a list of issues and give him or her a color fraction using colors on the legend. 4. Once all issues have been given a color fraction, use the art piece to visualize what the bigger issues may be between the client and the event or person. This will help clarify and/or summarize other issues on which the client may be focusing instead of the main problem. 5. An extension to this activity would be to have the client cut the fractions to compare them physically instead of visually. Processing questions may include, If you could throw all your problems on this paper, what would that look like? Self-disclosure may be helpful when you provide examples of a time when you felt that way and perhaps found that there were more reasons for your feelings than the obvious. Allowing the client to be alone for a few minutes to write down the list of issues can be helpful in allowing the client to be in his or her thoughts and reflect on the issues.

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MULTILEVEL TIMELINE Sheri Pickover

Indications: Clients who are addressing chronic depressive and negative narrative themes in their

lives. This activity is designed to occur over several sessions throughout the course of therapy. Goal: To increase self-awareness and personal strengths Modality: Art The Fit: The purpose of this activity is to increase a client’s sense of self-efficacy and self-worth by encouraging the client to “re-story” a personal history. Theoretically, this intervention uses a solution-focused treatment model by assisting the client to find exceptions, strengths, and personal goals. Populations: Adolescents/adults; Groups/individuals Materials: Butcher-block paper and several kinds of drawing media, including pencils, crayons, pens, and markers Instructions: 1. Begin by cutting a large piece of butcher-block paper and dividing the paper by either folding the paper in half or drawing a line midpoint through the paper. 2. Ask the client to create a timeline on the bottom half of the paper. Encourage the client to highlight any significant points he or she chooses, beginning with birth. The client is free to document the event using art, words, or both. Assist the client if the client initially appears resistant and/or struggles with writing. During this part of the intervention, the counselor should provide reflective feedback as the client creates the timeline of his or her own story. 3. Once the client completes the timeline, the counselor determines how to use the top half of the timeline based on the client’s narrative. The following is the list of several ways to “layer” the timeline. 3.1. Option No. 1: Provide an emotional representation of the narrative. You can use this option for clients who benefit from a visual representation of the narrative to demonstrate both positive and negative changes in mood. a. Ask the client to draw the emotions associated with each point on the timeline on the top half of the paper. If the client struggles to spontaneously draw the emotion, suggest possible emotion metaphors such as faces or weather. b. Once the client has completed the upper portion (which may take several sessions), use the client’s emotional metaphor to demonstrate the ebb and flow of life. This process often allows the client to visualize change and cope with current stressors because the client now has a visual representation of his or her coping. 3.2. Option No. 2: Use specific exception finding to re-story the narrative. You can use this option for clients who identify only negative aspects of their lives in the original story. The goal is to help the client identify successful relationships or pieces of relationships to alter the chronic negative perspective.

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a. Unfold the paper and ask the client to identify specific positive aspects of his or

her life. Here are some examples: Who taught you to tie your shoes? Who taught you to ride a bike? Do you remember when you had a birthday cake? Do you remember who taught you to throw a ball? b. Once the client has identified positive relationships or events, ask the client to identify the emotions associated with all the events on the time line as in Option No. 1. 3.3. Option No. 3: Once the client completes both levels of the timeline, flip the paper over and divide this side in half. a. Ask the client to create a timeline on the bottom part of the paper for the next 5 years. If the client needs assistance, use guided imagery with the client to help him or her visualize the future such as, What kind of car will you drive? What kind of work will you be doing? What will your marriage look like? b. On the top half of the paper, ask the client to identify emotions associated with his or her dreams, hopes, and plans. c. Use both sides of the timeline for ongoing discussions about coping and use the client’s metaphors in his or her narrative to continue increasing self-efficacy.

MY METAPHOR Allison L. Smith and K. Hridaya Hall

Indications: Appropriate presenting concerns include, but are not limited to, self-esteem,

stress, anxiety, or depression. Goal: To provide a means for clients to externalize their presenting concerns to facilitate client change Modality: Visual art and metaphor The Fit: According to narrative therapy (White & Epston, 1990), reality is subjective and individually constructed. Meaning is derived through the structuring of experience into stories and the retelling and reliving of these stories are central to client change (Legowski & Brownlee, 2001; White & Epston, 1990). The purpose of this expressive activity is to use the narrative intervention externalization so that clients can explain, reframe, and solve their own presenting concerns within the counseling context. Through use of metaphor, clients will not only explain presenting concerns but also construct these concerns. Using art materials to create a metaphor for the presenting concern, clients gain meaning, reframe, and solve their own struggles. Actually creating the metaphor makes it more tangible and central to client change. Populations: Adolescents/adults; Groups/individuals Materials: Paper; drawing materials such as pastels, colored pencils, and crayons; clay or Play-Doh; collage materials such as magazines, scissors, glue, and any other art materials that client and counselor deem necessary to create the metaphor Instructions: 1. Introduce the client to the topic of structuring our experiences into stories so that we retell and relive them. 2. Encourage client to use a metaphor to describe the presenting concern that motivated him or her to come into counseling. Give an example of a metaphor, if needed. For example, if the client is ready to get a fresh start after a recent divorce, an appropriate metaphor might be, I am a snake—ready to shed my old skin. 3. Create the metaphor using art materials. For example, the client uses clay to create a snake shedding its skin. 4. Use metaphor throughout the counseling relationship so that clients can explain, reframe, and solve presenting concerns. For example, the counselor might keep the snake in her or his office and refer to it, and modify it when needed.

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NARRATIVE SANDTRAY WITH CLIENTS Adele Logan O’Keefe and Kathleen Levingston

Indications: Appropriate for clients who would benefit from engaging in the process of growth

and healing through play and enactments of their experiences, particularly if talk therapy proves challenging or becomes stagnant. Goal: Exploration and expression of feelings and thoughts through a tactile recreation of each client’s personal narrative Modality: Sandtray The Fit: The purpose of sandtray therapy is to provide a useful, tangible tool to facilitate emotional and psychological healing and growth in clients. Sandtray therapy is highly applicable for a wide range of clients experiencing trauma, grief, loss, sexual or emotional abuse, anger, depression, or anxiety as a way to externalize their experiences and process them in a safe, contained interaction with objects that can represent or symbolize the details of these experiences. In addition, this technique is helpful for clients who tend to depend heavily on thought patterns because the items or figurines this modality uses can bring new thoughts, memories, or personal experiences into mind that bring a fresh perspective. Professionals who use this technique in an interpretive way should be properly trained and should have completed their own trays before using this technique with clients. Populations: Children/adolescents/adults; Couples/families/individuals Materials: Purified sand to fill one-third of a 30 × 20 × 3 plastic or wood tray (the tray should be painted blue on the bottom and sides to represent either the water or the sky); figurines including people representing a wide variation of roles for both genders, animals, vegetation, buildings, landscape, vehicles, barricades, natural pebbles, sticks, stones; and figurines that represent socially symbolic meaning, such as medical, religious, educational, or life event–oriented objects that can represent stages and experiences throughout the life span. Instructions: 1. Prepare the space by ensuring the tray is at eye level and empty of any objects. Arrange the miniatures by grouping similar items into categories and spreading the figurines out in a neat and appealing presentation that allows the client to clearly see and access the miniatures. 2. Introduce the client to the tray and the figurines. Allow the client to spend some time exploring all of the materials. 3. Introduce the client to the process. Tell the client something such as: This tray can represent your world. As you look around, find some items that speak to you and build a scene with these items in the sand. You can pick as many or as few as you need. If working with a client who is dealing a particular loss or traumatic experience, you may give a directive: Divide the tray in two. In one half, create a scene before the event and in the other half, a scene that shows your world after the event. For example, one half could be a scene of life before deployment to war and the other half, a scene of life after deployment. While the client creates the tray, the professional quietly observes and holds the space. Gently remind clients of the time they have left to complete their trays (5 or 10 minutes). 4. Once the client completes the experience, explore the sandtray with the client. This portion of the activity depends on the sandtray therapist’s philosophy about processing the sandtray. 201

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It is important to note that the power of the sandtray lies in the client’s engagement in the sandtray, so if the client is not willing or able to share his or her thoughts and feelings, this is acceptable and appropriate. However, if the clinician chooses to process the sandtray, the following are suggested reflections, prompts, and questions that can facilitate further psychological or cathartic movement: What is the title of your tray? Tell me what is happening in the sandtray. Tell me about the characters in the sandtray. If you could change the story for the (main character or current expression of the experience), how would you change it? 5. At the conclusion of the sandtray session, leave the sandtray and figurines in place. If the client asks if he or she needs to clean the sandtray or place objects back on the shelves, let the client know that this is not necessary and that you will take care of it. The client’s process can become disrupted or upsetting if he or she sees his or her creation destroyed! Take a photograph or draw a picture of the sandtray and write notes about the process that took place for the client. For more detailed and expanded instructions, we recommend: ■ ■ ■

Boik, B. L., & Goodwin, E. A. (2000). Sandtray therapy: A step-by-step manual for psychotherapists of diverse orientations. New York, NY: W. W. Norton & Co. Homeyer, L. E., & Sweeney, D. S. (1998). Sandtray: A practical manual. Canyon Lake, TX: Lindan Press. Turner, B. (2005). The handbook of sandplay therapy. Cloverdale, CA: Temenos Press.

THE STATEMENT OF US John Beckenbach

Indications: Useful for couples in relationships where conflict can influence the quality of the relationship and also useful in relationship enhancement experiences Goal: To assist couples in securing relational commitment and enhance relational quality through the process of documentation Modality: Expressive writing The Fit: Sells, Beckenbach, and Patrick (2009) developed the couples conflict reconciliation model, which included integration of narrative concepts. This included ideas of externalization, documentation/lettering, and reauthoring (White & Epston, 1990). The statement of us is a practice that is particularly rooted in these concepts. Aided by the principles and practices of externalization, the statement of us promotes reauthoring a relational story. This reauthoring becomes embodied through the documenting/lettering. Populations: Adults; Couples Materials: Paper and writing instruments; large, poster-type paper, word-processing software/ printer, and so forth, are appropriate; a photo frame or other means of displaying the document may also be used in this process. Instructions: 1. Instruct the couple to jointly create the statement of us. Examples of questions that help in the development of the statement of us are provided to the couple. These may include the following: Think about couples that you have observed who had a great “us.” What did each couple do to build the structure of their relationship? What images of “us” do you carry from your grandparents and your parents to your relational partnership? How do you see these influencing your current relational partnership? What are the aspects of your spouse’s relational partnership or marital tradition that you have seen reflected in your current relationship? What sacrifices will you have to make in order for the “me” to become an “us”? How will this be difficult for you? How will “us” be different from the current status of “you and me”? What will be the real-life attitude and perspective changes necessary for this to be successful? What do you think couples who create a successful relational partnerships/marriage do to make it work? Reflecting on the questions answered before and other sources of insight you may have had, create a relational partnership/ marriage purpose statement that reflects your priorities, values, and hopes for the relationship. These questions can assist in the production of this written statement but are not intended to be a recipe or exhaustive. Questions can be modified, added, or deleted given the context in which they are to be used. 2. Encourage the couple to reflect on any number of ideas as they generate the statement of us. The couple can approach the document in or out of session. 3. Upon completion, the couples share the document with the counselor, group, or other format in which it is being used. 4. Encourage the couples to reflect on how they would like to present the document or memorialize the statement of us. This might include framing the statement and displaying it in a prominent location in their homes and/or a public reading with family and friends.

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This process serves an important function in the narrative tradition to promote and firmly establish a new story to “us.” By documenting the reauthoring, a new story can be embodied in the relationship with renewed commitment. Here is an example of the statement of us: We will commit to seeking God’s Kingdom first in all that we are and do. Our home will be a place where family, friends, and guests find joy, comfort, peace, and happiness. We will exercise wisdom in what we choose to eat, read, and do in our home. We will learn to love another as we develop our own talents. We will exercise initiative in accomplishing our life’s goals. We will act on situations as opportunities, rather than to be acted upon. We will always try to keep ourselves free from addictive and destructive habits. We will develop habits that free us from old labels and limits and expand our capabilities and choices. Our money will be our servant, not our master. Our wants will be subject to our needs and means. We will honor God and choose to obey him every day of our lives. Signed, David and Sabrina

YAKIMA TIME BALL ADAPTED FROM A TRADITIONAL NATIVE AMERICAN PRACTICE Nan J. Giblin

Indications: This technique would be very useful for a beginning group where people were getting to know each other. It could also be used later in a group setting because as the trust level of the group increases, the depth of the stories deepens. The counselor needs to understand that in the storytelling, there is no objective truth. With the same time ball, a woman might tell her story several different ways. The point is that each woman owns her own story and can modify it as she wishes. Goal: Visually portray one’s personal narrative; enhance listening and self-disclosure skills; increase the participants’ cultural sensitivity Modality: Art The Fit: Native American people have historically recognized the importance of telling one’s story. Likewise, construction of a personal narrative is the basis of narrative therapy (Monk, Winslade, Crocket, & Epson, 1997; White, 2007). In the Yakima Native American tradition, the time ball is an artistic expression of the events of a woman’s life. Additionally, it provides a means of remembering and telling a personal story. In the old days and perhaps even today, a Yakima woman began her time ball when she married. A bead that represented the marriage was attached to a long piece of hemp or other natural fiber. Other beads were added for important events such as the birth of a child or the death of a loved one. The beads woven through the hemp became a visual personal narrative. The Yakima women would use their time balls to share their stories with the other women in the tribe. Often during the long winter evenings, women telling their stories through beads and hemp would sit around a fire. These time balls were so important that when a woman died, her time ball would be buried with her. A representation of a Yakima time ball can be found in the new Native American Museum of the Smithsonian in Washington, DC. The value of this technique can be explained through the use of narrative therapy, which stresses the importance of being able to tell one’s life story. The importance of community is also implicit in the act of storytelling. Populations: Adults (especially midlife and older); Groups/individuals Materials: Natural string, jute or flax; beads of different shapes, sizes, and colors; pamphlet by Yakima Indians Instructions: 1. The group leader tells the story and the meaning behind the traditional practice of making a Yakima time ball. 2. Group members discuss the importance of telling their own stories. 3. Group members choose string (approximately 6–10 ft. per person) and beads for their time balls. Note: Groups may choose to make their own beads from papier-mâché or another commercially available product. 4. Group members tie the beads onto their strings. Each bead represents an event or emotion in their lives. 5. The string holding the beads is rolled into a ball. 205

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6. Group members take turns unrolling their time balls and sharing the events represented

by each bead on their string. 7. Members may choose not to share information about certain beads. 8. The meaning of different beads may change for each person. 9. Group members discuss how it was for them to do the activity. 10. Processing should focus on the interpretations of the client, not the counselor. Questions

may include the following: How did you choose your beads and string? How did you begin your time ball? What events do the different beads symbolize? Which bead is your favorite? What does your favorite bead represent? What do the colors that you chose symbolize for you? If you had done this beginning as a child, how would it be different from the way you did it today? What emotions did this activity bring out for you? 11. Activity may be varied by making a time ball as someone you love would do it or making beads of your own for the original time ball. Journaling about the experience would also be helpful. REFERENCES Allen, R., & Kreb, N. (2007). Dramatic psychological storytelling: Using the expressive arts and psychotheatrics. New York, NY: Palgrave MacMillan. Beckenbach, J., & Patrick, S. (2015, May). Project I am. Paper presented at IAMFC Northampton Summer Institute, Northampton, UK. Beckenbach, J., Patrick, S., Sells, J., & Terrazas, L. (2014). The statement of us: A narrative-based practice for enhancing couples’ preferred identity. Journal of Systemic Therapies, 33(2), 50–61. Brimhall, A. S., Gardner, B. C., & Henline, B. H. (2003). Enhancing narrative couple therapy process with an enactment scaffolding. Contemporary Family Therapy: An International Journal, 25(4), 391–414. Brown, C., & Augusta-Scott, T. (Eds.). (2007). Narrative therapy: Making meaning, making lives. Thousand Oaks, CA: SAGE. Caldwell, R. (2005). At the confluence of memory and meaning—Life review with older adults and families: Using narrative therapy and the expressive arts to re-member and re-author stories of resilience. The Family Journal, 13(2), 172–175. Combs, G., & Freedman, J. (2004). A poststructuralist approach to narrative work. In L. E. Angus & J. McLeod (Eds.), The handbook of narrative and psychotherapy: Practice, theory, and research (pp. 137–155). Thousand Oaks, CA: SAGE. Denborough, D. (2008). Collective narrative practice. Adelaide, South Australia: Dulwich Centre Publications. Douge, J. (2010). Scrapbooking: An application of narrative therapy. Procedia Social and Behavioral Sciences, 5(2010), 684–687. Heath, T., & Arroyo, P. (2016). Spitting truth from my soul: A case story of rapping, probation, and the narrative practices (part II). Journal of Systemic Therapies, 34(4), 80–93. Lee, P. (2013). Making now precious: Working with survivors of torture and asylum seekers. International Journal of Narrative Therapy and Community Work, 1, 1–10. Retrieved from http://nzap.org.nz/wp-content/uploads/2016/08/making-now-precious-by-Poh-Lin-Lee.pdf Legowski, T., & Brownlee, K. (2001). Working with metaphor in narrative therapy. Journal of Family Psychotherapy, 12(1), 19–28. Madigan, S. (2011). Narrative therapy. Washington, DC: American Psychological Association. Meier, S. T. (2012). Language and narratives in counseling and psychotherapy. New York, NY: Springer Publishing. Monk, G. (1997). How narrative therapy works. In G. Monk, J. Winslade, K. Crocket, & D. Epston (Eds.), Narrative therapy in practice: The archaeology of hope (pp. 3–31). San Francisco, CA: Jossey-Bass. Monk, G., Winslade, J., Crocket, K., & Epson, D. (Eds.). (1997). Narrative therapy in practice: The archaeology of hope. San Francisco, CA: Jossey-Bass. Monk, G., Winslade, J. & Sinclair, S. (2008). New horizons in multicultural counseling. Thousand Oaks, CA: SAGE. Saltzsburg, S. (2007). Narrative therapy pathways for reauthoring with parents of adolescents coming-out as lesbian, gay, and bisexual. Contemporary Family Therapy, 29, 57–69. Sells, J., Beckenbach, J., & Patrick, S. (2009). Pain and defense vs. grace and justice: A model of relational conflict and restoration. The Family Journal, 17(3), 203–212.

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Semmler, P., & Williams, C. (2000). Narrative therapy: A storied context for multicultural counseling. Journal of Multicultural Counseling and Development, 28(1), 51–60. Shalif, Y. (2005). Creating care-full listening and conversations between members of conflicting groups in Israel: Narrative means to transformative listening. Journal of Systemic Therapies, 24(1), 35–52. Silver, E., Williams, A., Worthington, F., & Phillips, N. (1998). Family therapy and soiling: An audit of externalizing and other approaches. Journal of Family Therapy, 20, 413–422. St. James-O’Connor, T., Meakes, E., Pickering, M., & Schuman, M. (1997). On the right track: Client experience of narrative therapy. Contemporary Family Therapy: An International Journal, 19, 479–495. White, M. (1984). Pseudo-encopresis: From avalanche to victory, from vicious to virtuous cycles. Family Systems Medicine, 2(2), 150–160. White, M. (2000). Reflections on narrative practice: Essays and interviews. Adelaide, South Australia: Dulwich Centre Publications. White, M. (2007). Maps of narrative practice. New York, NY: W. W. Norton. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York, NY: W. W. Norton. White, M. (2011). Narrative practice: continuing the conversations. New York, NY: W. W. Norton. Winslade, J., & Monk, G. (2007). Narrative counseling in schools: Powerful & brief (2nd ed.). Thousand Oaks, CA: Corwin Press.

11 Trauma-Informed Counseling and the Expressive Arts Charles E. Myers

OVERVIEW OF TRAUMA AS A CONCERN FOR COUNSELORS In 2010, a powerful magnitude-7 earthquake shattered Port-au-Prince, Haiti. The aftermath of the earthquake resulted in over 316,000 deaths and left 2 million people homeless. Traumatic events like the Haiti earthquake occur every day and affect millions of people across the globe each year. These events might be a singular event such as a car accident, earthquake, terrorist attack, or tornado, or a series of events over time as in child abuse or domestic violence. The impact of traumatic events can be devastating, altering lives and often leaving survivors emotionally and psychologically wounded. Untreated trauma can have pervasive and profound lifelong negative effects on the survivors, especially if the trauma occurs in childhood. Counselors need to utilize caring and responsive, effective approaches to helping these vulnerable populations, such as expressive art therapies. Trauma Trauma is an emotional response to a deeply distressing or disturbing experience that overwhelms an individual’s normal coping mechanisms and results in feelings of helplessness, vulnerability, and the loss of safety and control (Briere & Scott, 2006; Herman, 1992; James, 1989; van der Kolk & Fisler, 1995). Survivors experience these events both intimately and forcefully (Everstine & Everstine, 1993) and often with resulting feelings of danger, anxiety, and instinctual arousal (Eth & Pynoos, 1985). Untreated trauma may become rigidly fixed, leaving survivors to relive the trauma repeatedly (van der Kolk, McFarlane, & van der Hart, 1996). Neurology provides an increased understanding of the effects of trauma on the brain and memory. The human brain is composed of four main areas, the brain stem, diencephalon, limbic system, and neocortex, which helps to regulate our bodily processes, information receiving and processing, and memory storing and retrieval (Ziegler, 2002). The brain stem contains state memory, which regulates our body’s basic functioning required for survival, such as blood pressure, breathing, and heart rate. The diencephalon stores movement memory, which oversees motor functioning such as appetite, arousal, movement, and sleep. The limbic system contains emotional and verbal memory, which regulates functions such as attachment, motivation, and reproduction. The neocortex hosts cognitive memory, which regulates executive functioning such 209

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as personality, goals, decision making, and problem-solving behaviors. Trauma is preoperational and impacts people on a sensory level (Sweeney, 1999), bypassing the formal operations of the neocortex, and is stored primarily in the physical and emotional areas of the brain. Our bodies have memories that exist separate from the cognitive memory of the neocortex. Preverbal children who experience a physical trauma will instinctually react to stimuli when they perceive a threat to the traumatized body area, even though they have no cognitive memory of the event. An adult dancer who had experienced abuse as a child reported that certain dance movements would trigger memories stored in her body and bring them to awareness, thus allowing her to process the abuse in counseling. Emotional memory, located in the limbic system, is a complex amalgamation of perceptions, experiences, memory, and body chemistry and is very vulnerable to traumatic stress (Ziegler, 2002). The limbic system controls autonomic responses, overseeing bodily functions and somatic reactions. Trauma affects these implicit memories. Memories consist of implicit memory, instinctual and survival-oriented (e.g., fight, flight, or freeze) responses, and explicit memory, which is conscious and fact oriented (figures, places, people; the where, when, and why) (Ziegler, 2002). Traumatic memories are a form of implicit memory that provides mental representations of the trauma made up of images, emotions, and state memory. These memories reside in the limbic system and brain stem and are unavailable to cognitive processing. Activated traumatic memories result in a trauma state of hyperarousal, resulting in all attention and survival focus and interfering with growth. Trauma states result in adaptation, imprinting, sensitization, and overreaction/deprivation (Perry, Pollard, Blakely, Baker, & Vigilante, 1995). Adaptation prepares the brain for survival by shutting down all functions not related to perceptual awareness and physiological response to perceived threats. Imprinting creates a template, based on the trauma experience, through which the brain processes all new information. Sensitization is a full arousal response to a perceived trauma-related stimulus, even if it is only a minor stress. Overactivation occurs when the sensory information of adaptation, imprinting, and sensitization overwhelms the brain, resulting in a state of hyperarousal and survival mode. Overactivation can cause deprivation by overfocusing the brain on survival, making it unavailable for critical period neurological development (Perry et al., 1995, pp. 45–46). Trauma can have devastating effects on survivors, affecting their sense of safety and growth. The brain stores trauma, both physical and emotional, in the limbic system and brain stem, respectively, leaving them unavailable to cognitive processing and difficult to access in talk therapy. Survivors experience trauma on the emotional and physical levels, requiring approaches that directly tap into those elements. Expressive art therapies provide a natural and responsive approach to helping survivors of trauma. EXPRESSIVE ART THERAPIES AND TRAUMA Survivors of trauma need interventions that connect and draw from the state and emotional memory in order to help them to tell their stories, to process their emotions and memories, and to release their self-healing abilities. The goals of trauma treatment are many. Counselors need first to form a therapeutic relationship that allows them to enter the reality of the survivor’s emotions and experience while maintaining a clinical perspective (Everstine & Everstine, 1993). That relationship allows clients to revisit painful experiences, overcome intrusive memories, make meaning, and regain hope (Malchiodi, 2015c). Trauma treatment goals focus on regaining trust and safety through deconditioning anxiety, fear, and other sensitized emotions; finding reasoning; stabilizing stress reactions, processing traumatic experiences, and reengaging life (Turner, McFarlane, & van der Kolk, 1996; Ziegler, 2002). These treatment goals naturally dovetail with expressive art therapies. Trauma treatment is inherently expressive (Ziegler, 2002).

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Expressive art interventions engage clients on the sensory level, promote self-empowerment (Malchiodi, 2015c), and their concrete expression allows survivors of trauma to let go of the unspeakable aspects of a trauma and move forward (Dass-Brailsford, 2007). Expressive art therapies are an experiential and expressive approach to counseling, encompassing a wide range of modalities, including art, dance/movement, drama, music, play, sandtray, and multiple other expressive approaches. Indigenous healers across the world have used dancing, drumming, music, and other expressive arts for healing and self-expression. Many modern mental health professionals continue the use of expressive art therapies in their own work with clients. Art therapy has helped with children with refugee backgrounds and survivors of mass terrorism (Drubant & Edwards, 2015; Loumeau-May, Seibel-Nicol, Hamilton, & Malchiodi, 2015). Dance and movement therapy has healed survivors of sexual abuse and trauma (Gray, 2015; Valentine, 2007). Drama and psychodrama have relieved survivors of torture and trauma (Haen, 2015; Hudgins, 2015). Music helped survivors of sexual abuse and children and adolescents with grief (Gonsalves, 2007; Hillard, 2015). Play has healed child survivors of natural disasters (Baggerly, 2005; Myers, 2010). Sandtray has relieved children of trauma and war refugees and survivors (Duffy, 2015; Hunter, 1998). Expressive art therapies have been used for many other presenting concerns and in many other settings. Expressive art therapies engage the body and senses, tapping into state and emotional memory, and opening up doors closed to the typical cognitive processing of traditional talk therapy. Trauma is elemental and sensory in nature, requiring sensory-based treatment (Sweeney, 1999). The use of expressive art therapies provides therapeutic distancing by transferring emotion-laden material to the medium, creating a safe space in which to process and express the unspeakable. Expressive art therapies provide trauma survivors a means to explore and express traumatic experiences that they are unable to express verbally (Malchiodi, 2015b). Expressive art therapies promote creativity, imagination, and self-expression (Malchiodi, 1999). Malchiodi identified five unique characteristics in the use of expressive art therapies in the treatment of trauma with children that are applicable to all survivors. Expressive art therapies facilitate externalization, sensory processing, right-hemisphere dominance, arousal reduction and affect regulation, and relational aspects. Expressive approaches promote externalization of negative emotions, thoughts, and experiences. They facilitate the processing of those emotions, thoughts, and experiences through use of auditory, kinesthetic, and visual means. Expressive art interventions engage right-brain dominance that plays a crucial role in nonverbal expression and attachment. Expressive art therapies provide a soothing environment that promotes arousal reduction and affect regulation. Finally, expressive art therapies are inherently inter-relational through sharing of one’s experiences with another person and intra-relational in that movement-based interventions promote reintegration of the body. CONSIDERATIONS OF EXPRESSIVE ART TRAUMA WORK Expressive art therapies provide counselors with effective tools in helping survivors of trauma. With these tools come responsibilities. Counselors have a number of considerations in using expressive art trauma work such as ethics and self-care. Expressive Art Trauma Work Ethics Expressive art therapy ethics include training, experience, client preparation, and supervision. First, counselors using expressive art therapies need to be familiar with the modality they are using through training. Pursuing training in a modality prepares a counselor with knowledge of the modality and the skills necessary to facilitate that expressive art. Many expressive art

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therapy organizations have codes of ethics and standards of training such as the American Art Therapy Association (arttherapy.org), American Dance Therapy Associations (adta.org), American Music Association (www.musictherapy.org), Association of Play Therapy (www. a4pt.org), and North American Drama Therapy Association (www.nadta.org). Second, ethical counselors should experience an expressive art modality before inviting a client to participate. Only through experience may counselors gain an understanding of what it is like to be a client and to use a particular modality. This awareness provides counselors with greater empathy and sensitivity to what that modality may bring up for a client. Third, expressive art therapies bypass spoken language and the mind’s normal regulation of material and may result in unexpected disclosure of emotional and raw material. Expressive art counselors need to prepare clients by informing them of the possible exposure of subconscious meaning or else clients may feel betrayed or tricked. Finally, counselors using expressive art therapies need to train under supervision. As in any counseling approach, counselors practice expressive arts under supervision. Supervision provides counselors a support in developing knowledge and skills in conceptualizing clients, implementing treatment, and ensuring quality of treatment. Expressive Art Trauma Work Self-Care Trauma work in counseling is an emotionally tolling service. Witnessing children’s sexual abuse stories through play, hearing teens’ music that “is personal” while they contemplate suicide, watching women dancing fears and pain after domestic violence, sitting with a mother as her baby dies in her arms, all of these situations leave a heavy weight upon a counselor’s heart. These examples can lead to vicarious trauma or posttraumatic growth. Trauma work requires counselors to debrief the material that they absorb. Counselors can debrief through seeking consultation with a colleague or supervisor, seeking their own counseling, or engaging in their own expressive art. The danger in not debriefing is that it may lead to vicarious trauma, the cumulative effect of exposure to the pain of other people (Best Start Resource Centre, 2012). Vicarious trauma may result in physiological symptomology (e.g., fatigue, headaches, and hypertension), psychological difficulties (e.g., depression, anxiety, feelings of helplessness, and reduced self-esteem and sense of purpose), and behavioral problems (e.g., impaired job performance, insomnia, and impaired relationships) (Fogg, 2007). On the other side, the use of self-care in trauma work may lead to counselor posttraumatic growth, vicarious resilience, and compassion satisfaction (Myers, 2016). Vicarious posttraumatic growth occurs when counselors experience a parallel growth following vicarious exposure to the trauma of a client (Brockhouse, Msetfi, Cohen, & Joseph, 2011), increasing compassion, empathy, and resiliency. CONCLUSION Expressive art therapies are a powerful and sensitive approach to working with survivors of trauma with a long history of effectiveness. The use of expressive art mediums allows survivors to express their experience in a manner that is comfortable and meaningful to them. Counselors using expressive arts therapies need both training and supervision in working with both survivors of trauma and the use of expressive art therapies. The effective use of expressive art therapies gives voice to the unspoken in trauma work.

Expressive Arts Interventions

ACTING OUT THE TRAUMA Coresair Mack

Indications: The activity can be applied to a wide variety of traumatic events including natural disasters, shootings, abuse of any type, and more. The model allows clients to distance themselves from the traumatic event, gain different points of view, and develop more rational thought processes about the traumatic event. Goal: To help clients accept and move past their traumatic experience Modality: Drama Therapy The Fit: According to the North American Drama Therapy Association (NADTA), “Drama therapy is the intentional use of drama and/or theater processes to achieve therapeutic goals” (Heuristic, 2016). Drama therapy helps prevent flashbacks, dissociated thoughts, avoidance, phobic reactions, emotional numbing, hypervigilance, hyperarousal, and other things in that nature (Landy, 2010). According to the NADTA, the benefits of utilizing drama therapy are reducing feelings of isolation, developing new coping skills and patterns, broadening the range of expression of feelings, improvement of self-esteem and self-worth, increasing sense of play and spontaneity, and developing relationships (Heuristic, 2016). Drama therapy is utilized mainly in counseling children adolescents, but can be applied to adults and the elderly if needed. This model also gives counselors a chance to interact and participate with clients as well as give feedback and process as needed. Populations: Children and adolescents for ages 5 to 18 years; Individuals and groups Materials and Preparations: Minimum materials needed are paper of any size or color, coloring utensils, scissors or some type of cutting utensil, tape or glue, and toys. Other materials that can be included are props, puppets, stage setting, and anything the counselor can think of to bring out clients’ creativity. Activity Instructions 1. Begin by inviting the client to brainstorm and select a scene that would be beneficial and therapeutic to act out. Ask the client to describe the setting, the characters, and any props the client may want to use or make for the scene. 2. Before beginning the action, process the scene with the client to generate insight for the reasons that this particular scene and any other aspects of the scene were chosen. This assists the counselor in making connections to the presenting issue that enhance the potential benefit of the activity. 3. Invite the client to select or create any props that may be needed. This will also allow the counselor more time to process the experience with the client. 4. Empower the client to be the director and the actor in the scene. Encourage the client to make any changes or revisions in the scene necessary as the client acts out the scene. If the

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client would like, the counselor may be assigned a role or counselors can take part in being a character or assisting with props, if the client is comfortable with the idea. 5. After the scene is finished, reflect and process with the client the acting out of the scene and any changes that were interjected into the action. Encourage the client to reflect on feelings, thoughts, and physical sensations associated with the acting out of the scene. 6. Invite the client to reenact the scene with any new changes from the client or suggestions from the counselor. 7. Keep the story moving by allowing the client to invent a new scene to add onto the story or allow the client to create a new scene with different settings and characters. Alterations There will be clients who may not like acting out scenes that they create. Here are a few alterations that may help with this barrier. Storytelling. Storytelling can serve the same purpose as acting, but may be more inviting to individuals who are not comfortable enough to “act out” a scene. This technique relies more on verbal than on physical communication. Storytelling offers clients the opportunity to verbally articulate the story that is selected and this can provide the emotional distance from the trauma necessary to narrate the story. Counselors are provided the opportunity to listen to the clients’ stories, make observations, and dive deeper with clients into the stories they are telling. Scene writing. Screen writing is similar to the acting out of a scene, but offers clients the option of writing down their scenes. If clients are uncomfortable acting or speaking about the issue, they can write out their scenes and characters. Clients may write simple narratives of events or choose to add greater description and creative license in the scene. When clients share their narratives with their counselors, they open themselves up to hearing alternate perspective and connections that may provoke insight for the client. Toy animation. When acting or storytelling may be too much for a child, toy animation makes telling or reenacting the story easier. “Toy animation provides the safety of distance and anonymity for the child and is an empowering technique that facilitates the expressions of emotions, sharing of traumatic experiences and the forming of safe therapeutic relationships” (Schwartzenberg, 2008, p. 7). Children give toys life through the attribution of humanlike characteristics, allowing for the child to tell the story through playing with the toys. This also offers counselors the opportunity to play and interact with children by acting out scenes with children (Schwartzenberg, 2008).

EMOTIONS WITH EMOJI Jasmine Young

Indications: This activity can be applied to survivors of a variety of traumatic experiences.

The rise of emoticons provides a great way to incorporate modern-day aspects into counseling. Goal: To help clients establish ways to express emotions Expressive Art Modality: Visual Art The Fit: The purpose of this activity is to assist clients who have experienced various forms of environmental trauma and are having difficulty expressing emotions. This activity makes use of the current trend of using emoticons to express emotional responses. “Natural disasters cause people to experience severe negative emotions, such as anxiety, depression, and fear” (Yanhui, Ruifang, Yiqi, & Lei, 2016, p. 500). Through the use of emoticons, clients can express the emotional responses that they may otherwise have difficulty accessing. This activity reduces the pressure to express emotions verbally, while letting clients identify what emotions they are currently feeling in session while taking into consideration personality types, coping skills, and immediate emotional responses. Populations: Couples and individuals starting at the age of 5. Materials and Preparation: Emotion Pillows. These plush emoticons can be found at various locations and come in various sizes. Because of their recent popularity, they are easily located in stores or online and can be purchased in sets through numerous retailers. Activity Instructions: 1. Begin by explaining to the client the purpose of the pillows. Normalize the difficulty of expressing and verbalizing emotions. Explain that these will be tools that can be incorporated in the session when feeling words become difficult to use. 2. Though these emoticon pillows have what people would consider evident emotions, it is important to let clients explain what each pillow means to them. 3. Invite the client to ascribe emotions to each of the pillows to be used in the session. Ask the client, “What is your interpretation of this emoticon?” Let the client establish the emotion and continue until all have a dedicated emotion related to each pillow. 4. While the client establishes various emotions for each pillow, allow the client to interact with the pillows and feel the texture and weight. 5. Continue with the session prompting the client to use the emoticon pillows when they become distressed or uncomfortable using the emotion words. 6. Encourage the client to draw or otherwise create “personal emoticons” to communicate personal and complex feelings that may be associated with the trauma. 7. After the client has grown comfortable expressing emotions through the emoticon language, invite the client to begin to use other ways of describing feelings. Brainstorm with the client ways to cope with upsetting emotions.

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SENSORY MEMORY BOOK Erin Wold

Indications: Grief and loss, separation, interpersonal trauma, relationship review, discover

meaning, establishing mindfulness Goal: To help clients recall and reestablish positive memories that are otherwise difficult to recall during stressful and overwhelming moments by utilizing the connection between their senses and their memories; to review memories of a loved one and to explore client memories and relationships to discover themes, meaning, and identity of the relationship; to have something tangible and comforting in times of uncertainty during a change in relationship. By connecting the mind and body through thoughts, memories, and the senses, the client can become more mindful of the present and reveal implicit memories through creative exploration. Modality: Multimedia art; collage, drawing, writing, music, guided imagery The Fit: Through non-verbal expressive activities, clients are able to access and work through memories that are embedded in sensation and emotions (Malchiodi, 2008). Narrative therapy provides the opportunity to explore memories, implicit and explicit, and emotions one degree removed from direct reflection. This distance invites the client experiencing interpersonal trauma to open the pathway toward exploring difficult thoughts and feelings. Maintaining a “here and now” presence by using mindful sensory stimulation to elicit repressed memories also creates therapeutic distance. Populations: Children, adolescents, and adults; Individually or in group with clients in a relationship. Use caution with clients who have experienced complex trauma or abuse. Settings: Schools, clinics, shelters, private practice Materials: A blank scrapbook or photo album. A variety of fabrics and textiles, cotton batting or filler, fabric glue, tape, scissors, and ruler. Pencils, colored pencils, acrylic paint, brushes, pens, markers. Copies of personal photographs (if available), pictures from magazines, or the Internet. Compact disc and player or other means of playing music. Quart of gallon-sized plastic storage bags, stapler. Candles with a variety of scents. Samples of food and/or drinks specific to client’s memories. Instructions: Since this is a multiple session intervention, allow six to eight sessions to prepare, complete, and process the sensory book. A shortened version of the sensory memory book can be done by reducing the art mediums and simplifying the sensory exploration. Introduce the Activity The activity should be discussed prior to the session in which the intervention will begin. Describe the activity to the clients and encourage clients to bring materials that they would like to include in their memory books to the following session. Provide tailored materials, if appropriate. Bear in mind that recalling memories can be difficult for those who have experienced trauma. In the working sessions, it may be helpful to use guided imagery with the clients to reveal memories or simply invite clients to describe favorite places, pictures, items, activities, and so forth to begin the process. Relate favorite things to possible positive memories your clients may have. During each of the sensory sessions, invite the clients to write down the memories. They can also draw pictures, attach images related to the memory, or bring in items that symbolize the memory. Reassure the clients that examples are only common examples. The clients may 216

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have special, uncommon meanings for different things. Allow room for the clients to add details or items in the future. Having actual replications for the five senses may not be possible, for example, snow falling. Within each of the sessions, use mindfulness to incorporate all of the senses, not just the one specified. 1. Sensory Session 1—Sight a. Explore memories through things that you see. b. These could include photos (if available), found pictures, or memories of seeing specific

images, such as recalling a smile, the snow falling, or the fire glowing in the fireplace. 2. Sensory Session 2—Sound a. Explore memories through things that you hear. b. These could be music, but they could also include, for example, the sounds of water, or

rustling leaves, or a clock ticking, kettle whistling, laughter, silence. 3. Sensory Session 3—Scents a. Explore memories through things that you smell. b. For example, the scent of perfume or cologne, something cooking, flowers, new shoes, sand. c. Include samples of scents to attach to the memory book. Scented candle shavings or

scented oils may be substituted. 4. Session 4—Feel a. Explore memories through things that you touch. b. For example, a special blanket or toy, a sweater, warm water, anything pleasing or significant. c. Have the client choose fabric/material to use for a cover. 5. Session 5—Taste a. Explore memories through things that you eat or drink. b. Food is often associated with people and special occasions. Smells are also related. c. Have client taste the chosen food or drink. 6. Session 6—Relationship a. Review the memories and reflect on the characteristics of the relationship. b. Are there common themes? How will the future change the relationship?

Reflection and Closing Allow time for the client to make any additions and to complete the memory book. Review the book with the client, discussing the process, the senses, and the memories. REFERENCES Baggerly, J. (2005). Tsunami relief work in Sri Lanka: USF professor provides play therapy techniques. The Playful Healer, 12(1), 6–7. Best Start Resource Centre. (2012). When compassion hurts: Burnout, vicarious trauma and secondary trauma in prenatal and early childhood service providers. Toronto, ON, Canada: Author. Retrieved from http:// www.beststart.org/resources/howto/pdf/Compassion_14MY01_Final.pdf Briere, J., & Scott, C. (2006). Principles of trauma therapy: A guide to symptoms, evaluation and treatment. Thousand Oaks, CA: SAGE. Brockhouse, R., Msetfi, R. M., Cohen, K., & Joseph, S. (2011). Vicarious exposure to trauma and growth in therapists: The moderating effects of sense of coherence, organizational support, and empathy. Journal of Traumatic Stress, 24(6), 735–742. doi:10.1002/jts.20704 Dass-Brailsford, P. (2007). A practical approach to trauma: Empowering interventions. Thousand Oaks, CA: SAGE. Drubant, S., & Edwards, C. (2015). Building bridges: Art therapy with refugee children in Australia. In S. L. Brooke & C. E. Myers (Eds.), Therapists creating a cultural tapestry: Using the creative therapies across cultures (pp. 74–92). Springfield, IL: C. C. Thomas.

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Duffy, S. C. (2015). Therapeutic stories and play in the sandtray for traumatized children: The moving stories method. In C. A. Malchiodi (Ed.), Creative interventions with traumatized children (2nd ed., pp. 150–168). New York, NY: Guilford Press. Eth, S., & Pynoos, R. S. (1985). Interaction of trauma and grief in childhood. In S. Eth & R. S. Pynoos (Eds.), Posttraumatic stress disorder in children (pp. 171–183). Washington, DC: American Psychiatric Publishing. Everstine, D. S., & Everstine, L. (1993). The trauma response: Treatment for emotional injury. New York, NY: W. W. Norton. Fogg, D. (2007). Vicarious traumatization, secondary traumatic stress, and burnout among child welfare workers (Master’s thesis). Retrieved from http://commons.pacificu.edu/spp/158 Gonsalves, M. C. (2007). Music therapy and sexual violence: Restoring connection and finding personal capacities for healing. In S. L. Brooke (Ed.), The use of creative therapies with sexual abuse survivors (pp. 218–234). Springfield, IL: C. C. Thomas. Gray, A. E. (2015). The broken body: Somatic perspectives on surviving torture. In S. L. Brooke & C. E. Myers (Eds.), Therapists creating a cultural tapestry: Using the creative therapies across cultures (pp. 170–190). Springfield, IL: C. C. Thomas. Haen, C. (2015). Vanquishing monsters: Group drama therapy for treating trauma. In C. A. Malchiodi (Ed.), Creative interventions with traumatized children (2nd ed., pp. 235–257). New York, NY: Guilford Press. Herman, J. L. (1992). Trauma and recovery: The aftermath of violence: From domestic abuse to political terror. New York, NY: Basic Books. Hillard, R. E. (2015). Music and grief work with children and adolescents. In C. A. Malchiodi (Ed.), Creative interventions with traumatized children (2nd ed., pp. 75–93). New York, NY: Guilford Press. Hudgins, K. (2015). Spiral healing: A thread of energy and connection across cultures. In S. L. Brooke & C. E. Myers (Eds.), Therapists creating a cultural tapestry: Using the creative therapies across cultures (pp. 260–281). Springfield, IL: C. C. Thomas. Hunter, L. B. (1998). Images of resiliency: Troubled children create healing stories in the language of sandplay. Palm Beach, FL: Behavioral Communications Institute. James, B. (1989). Treating traumatized children: New insights and creative interventions. New York, NY: Free Press. Landy, R. (2010). Drama as a means of preventing post-traumatic stress following trauma within a community. Journal of Applied Arts and Health, 1(1), 7–18. doi:10.1386/jaah.1.1.7/1 Loumeau-May, L. V., Seibel-Nicol, E., Hamilton, M. P., & Malchiodi, C. A. (2015). Art therapy as an intervention for mass terrorism and violence. In C. A. Malchiodi (Ed.), Creative interventions with traumatized children (2nd ed., pp. 94–125). New York, NY: Guilford Press. Malchiodi, C. A. (Ed.). (1999). Medical art therapy with children. London, UK: Kingsley. Malchiodi, C. A. (Ed.). (2008). Creative interventions with traumatized children. London, UK: Jessica Kingsley. Malchiodi, C. A. (2015b). Neurobiology, creative interventions, and childhood trauma. In C. A. Malchiodi (Ed.), Creative interventions with traumatized children (2nd ed. pp. 3–23). New York, NY: Guilford Press. Malchiodi, C. A. (2015c). Preface. In C. A. Malchiodi (Ed.), Creative interventions with traumatized children (2nd ed., pp. xiii–xviii). New York, NY: Guilford Press. Meyers, C. E. (2010). Play therapy with survivors of interpersonal trauma: Overcoming abuse and crime. In K. J. O’Connor, C. Schaefer, & L. Braverman (Eds.), Handbook of play therapy (2nd Ed., pp. 417–436). Hoboken, NJ: Wiley. North American Drama Therapy Association. (2016). Drama therapy with children and adolescents. Retrieved from http://www.nadta.org/assets/documents/children-adolescent-fact-sheet.pdf Perry, B. D., Pollard, R., Blakely, T., Baker, W., & Vigilante, D. (1995). Childhood trauma, the neurobiology of adaptation and ‘use-dependent’ development of the brain: How “states” become “traits.” Infant Mental Health Journal, 16(4), 271–291. doi:10.1002/1097-0355(199524)16:4 271::AID-IMHJ2280160404 3.0.CO;2-B Schwartzenberg, K. (2008). Drama play techniques in play therapy. Play Therapy Seminars. Retrieved from http://www.playtherapyseminars.com/Articles/Details/10007 Sweeney, D. S. (1999). Forward. In L. J. Carey (Ed.), Sandplay therapy with children and families (pp. ix–xxvi). Northvale, NJ: Aronson. Turner, S. W., McFarlane, A. C., & van der Kolk, B. A. (1996). The therapeutic environment and new explorations in the treatment of posttraumatic stress disorder. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on the mind, body, and society (pp. 537–558). New York, NY: Guilford Press. Valentine, G. E. (2007). Dance/movement therapy with women survivors of sexual abuse. In S. L. Brooke (Ed.), The use of creative therapies with sexual abuse survivors (pp. 181–195). Springfield, IL: C. C. Thomas. van der Kolk, B. A., & Fisler, R. (1995). Dissociation and the fragmentary nature of traumatic memories: Overview and exploratory study. Journal of Trauma Stress, 8(4), 505–525. doi:10.1002/jts.2490080402

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van der Kolk, B. A., McFarlane, A. C., & van der Hart, O. (1996). A general approach to treatment of posttraumatic stress disorder. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on the mind, body, and society (pp. 417–440). New York, NY: Guilford Press. Yanhui, X., Ruifang, W., Yiqi, J., & Lei, M. (2016). Relationships among personality, coping style, and negative emotional response in earthquake survivors. Social Behavior & Personality: An International Journal, 44(3), 499–508. doi:10.2224/sbp.2016.44.3.499 Ziegler, D. (2002). Traumatic experience and the brain: A handbook for understanding and treating those traumatized as children. Phoenix, AZ: Acadia.

12 Family Counseling and the Expressive Arts Edward F. Hudspeth, Krystal Burks, and Keith Bowden

In any group of living organisms, a pattern of information exchange will inevitably develop. Language is, of course, one of the most effective means of this exchange that our particular species has developed. One experiences a thought that is then shared through language. Language is simply a device to move data from one point to another: an exchangeable code that can represent vastly complex concepts and imagery. The accuracy of this exchange depends on several factors, but it most immediately depends upon the ability of the one expressing the thought to do so accurately, as well as the capacity of the individual receiving the thought to perceive the description through sensory input; one must be able to understand, consider, and visualize that thought in his or her own mind. Forms of communication have been endlessly modified to adapt to sensory absences, such as deafness, blindness, or the absence of speech. These principles can easily be applied to understanding the efficacy of information exchange or communication in family counseling. Through expressive arts, in family counseling we can further the process of understanding by giving unidimensional words and mental visualizations life through art, music, movement, and other forms of expression. Regardless of the source, family counseling is often described as a form of counseling that seeks to reduce distress and dysfunction of individuals by improving the interactions between members of a family system or social unit. Traditionally, family counseling involved multiple family members and focused on relationships and interactions, both simple and complex, within a family. Contemporary family counseling extends the concept of family to include all the individuals who play important roles in an individual’s life. Thus, from this perspective, a family may be defined as a system of individuals with significant interrelationships. As might be expected, the goals of family counseling may include improving interactions, increasing understanding of others, and developing functional problem-solving skills within the family system. Family counseling differs from individual counseling in that within family counseling, the problems of an individual member are conceptualized in relation to the various systems and situations he or she engages. Family and individual counseling are similar in that there are multiple models and theories from which to view family clients.

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FOUNDATIONS OF FAMILY COUNSELING It is likely that as counselors we have taken a class or participated in a workshop about family counseling. If quizzed, we would probably recognize names such as Satir, Bowen, or Minuchin. Although it is beyond the scope of this chapter to give a complete history of family counseling, readers should be aware that family counseling has a long history with many key figures. We might remember that historically, as with individual counseling, family counseling’s roots originate from early psychology theory (e.g., Freud, Adler, et al.), experiments in social psychology, and the guidance movement of the early 20th century. However, unless an individual has a thorough background in family counseling, he or she would not recognize many of the early figures who played a part in what became family counseling. In the late 1930s, Nathan Ackerman wrote what is credited as the first article about unity within the family (see Ackerman, 1938). This was followed in 1945, by Bertalanffy’s publication of Zu Einer Allgemeinen Systemlehre, which when translated is A General System Theory. It was much later, in the 1960s, when Bertalanffy’s original work was translated from German to English, that American readers could read how he originally conceptualized systems theory. By the late 1940s, Gregory Bateson’s work with schizophrenics helped extend systems theory to the behavioral science field (see Ruesch & Bateson, 1951). In the mid-1940s, when Ackerman, Bertalanffy, and Bateson were in the midst of well-established careers, Murray Bowen was beginning his work at the Menninger Clinic, Carl Whitaker was beginning at Emory University, and James Framo and Virginia Satir were high school students. By the time the early works of Bowen, Whitaker, Framo, and Satir were published, Ackerman, Bertalanffy, and Bateson had published many articles and books (see Bowen, 1967; Framo, 1968; Satir, 1964; Whitaker, 1976). Salvador Minuchin, a student of Ackerman’s, began to conceptualize his family theory in the early 1960s. Jay Haley became the founding editor of the journal Family Process (see Haley, 1963; Minuchin, 1974). In the late 1970s, Murry Bowen was the founder and first president of the American Family Therapy Association and Virginia Satir was an advisor involved in the creation of the International Family Therapy Association. SELECTED MODELS OF FAMILY COUNSELING From seeing the dates in the preceding paragraphs and reading the following, it will be evident that many of the key figures, in family counseling, converge and much was accomplished during the 1960s and 1970s. In the following sections, selected key figures and their theories and models of family counseling are briefly described. For a more detailed and comprehensive coverage of family counseling, see Nichols (2012) and Goldenberg and Goldenberg (2012). Bowenian Theory The Bowen Center for the Study of the Family (n.d.) described Murray Bowen as a psychoanalytically trained psychiatrist who was one of the first to develop and present a comprehensive model of family counseling. It was during his work with schizophrenics, at the Menninger, that he began to involve family members in the treatment of clinic patients. This continued when he moved to the National Institute of Mental Health and then when he established his research institute at Georgetown University. Over time, he focused on nonpsychotic clients and by 1966 his theory was developed and presented. Considering his psychoanalytic training, it should not be a shock that Bowen’s theory centers on anxiety and the ways in which families attempt to reduce or diminish this anxiety. Bowen also believed that family problems and behaviors

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were passed from generation to generation through what he called the “intergenerational family process.” Jones-Smith (2016) notes that the two primary goals of Bowenian theory are (a) to promote familial understanding of their emotional system and its functioning and (b) to facilitate differentiation among family members so that individuals within the system make personal changes rather than changes for the family. According to Brown (1999), central to Bowenian theory are eight concepts: (a) Emotional Fusion and Differentiation of Self, (b) Triangles, (c) Nuclear Family Emotional System (which encompasses Couple Conflict, Symptoms in a Spouse, and Symptoms in a Child), (d) Family Projection Process, (e) Emotional Cutoff, (f ) Multigenerational Transmission Process, (g) Sibling Positions, and (h) Emotional Processes in Society. For more specifics, see Kerr (2003). Minuchin and Structural Family Theory When detailing the history of structural family therapy, Nichols and Schwartz (2003) stated that Salvador Minuchin was trained as a child psychiatrist. His focus on families began when he was working with displaced children in Israel. Additional study in interpersonal psychiatry and work with troubled boys furthered his interest in work with families. Later in his career, Minuchin collaborated with fellow practitioners, such as Jay Haley, to formalize structural family therapy. Nichols and Schwartz (2003) described structural family therapy as the map for understanding familial interactions. The three primary components of structural family theory are structure, subsystems, and boundaries. They noted that within structural family therapy, family structure is described as organized patterns of interactions. As these patterns are repeated, they become habit and members of a family fall back on these patterns rather than seek new ways of interacting. Generations, gender, and/or commonalities create family subsystems. Structural family therapy refers to boundaries as the barriers to contact. These barriers provide rules and regulate interactions with others. In this sense, boundaries that are too strict limit contact with subsystems outside the family (viz., disengagement) and boundaries that are lax result in dependence (viz., enmeshment). Structural family theory is appealing to practitioners because it is practical, easy to operationalize in the therapeutic setting, focuses on the present rather than the past, and views families as having the ability to find solutions for their problems. Haley and Strategic Family Theory Jay Haley was unlike many of the early family counseling theorists in that he was not formally trained as a therapist, but had a degree in communications (Mental Research Institute [MRI], n.d.b). He began to formulate his family counseling theory in the early 1950s while working with the Palo Alto Group studying schizophrenics. It was as part of this group, at the Mental Research Institute, that Haley was influenced by Bateson and Satir. According to Nichols and Schwartz (2009), Haley and wife Cloe Madanes developed strategic therapy. Their method was practical and it emphasized the role that client environment, specifically the family, played in creating and supporting dysfunction. Thus, from his perspective, the family could be a source of developing functional behavior. Strategic therapy is a form of brief family therapy that takes a problem-solving approach. As such, a focus of strategic therapy is change and measureable outcomes rather than insight and awareness. After Haley’s death, the Mental Research Institute (MRI, n.d.a.), when describing his approach, wrote: This approach posits that individuals and their problems are to be seen not as pathology within the individual but as a response to interactions occurring in the present. The interactional perspective further asserts that behavior makes sense within the context in which it occurs, that the family is the system most amenable to effecting change for the symptom bearer, and that relieving symptoms is the most sensible and humane approach to helping people solve their problems.

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Satir and Experiential Family Theory The Virginia Satir Global Network (satirglobal.org) thoroughly described Satir’s education, career path, and legacy. Virginia Satir was trained as a social worker and began working with families in the early 1950s. Like Haley, Satir worked as part of the Palo Alto Group at the Mental Research Institute. Satir’s experiential family therapy is unique in that she was influenced by the likes of Rogers, Perls, Bateson, and humanistic psychology. Therefore, depending on the text, some list Satir’s approach as a communications approach (i.e., it originates from the work of Bateson), while others consider her approach as solely experiential. From this dichotomous view originate the many names of Satir’s approach: The Satir Model, The Satir Growth Model, Human Validation/Satir Model, Experiential Family Therapy, and Transformational Systemic Theory. It would be difficult to find any literature that does not describe Satir as warm and personable. As noted in Satir, Banmen, Gerber, and Gomori (1991), the assumptions of Satir’s model included (a) meaning comes from within, (b) growth occurs when present-focused, (c) self-esteem and self-awareness are vital, (d) congruence and authenticity must be communicated, and (e) family systems can adapt to change, but, when strained, fall back on old behaviors. THE USE OF EXPRESSIVE ARTS IN FAMILY COUNSELING In family sessions, it is often difficult to engage all family members at one time. A counselor may be able to speak with parents or older children, but fail to find a way to effectively involve younger children. Through the use of expressive arts, therapists can engage a wide range of ages at the same time. By having the entire family participate, there is a higher likelihood for success in treatment. Expressive arts activities and techniques have additional qualities that are not found in traditional talk therapy. These techniques include self-expression, active participation, imagination, and mind–body connections (Lowenstein & Sprunk, 2010). Family expressive therapy assists in connecting the intellectual, cerebral, abstract world of adults to the imaginative, spontaneous, metaphoric, and creative world of children (Lowenstein & Sprunk, 2010). Expressive arts in family counseling can assist in enhanced communication, understanding, and emotional relatedness of family members. There are many modalities for self-expression in creative and expressive therapies which include, but are not limited to, the following: painting, writing, drawing, sculpting, singing, dancing, playing instruments, design, games, puzzles, sandtray, puppets, and toys. It seems as though the possibility for expressive art interventions is endless. Utilizing new and exciting interventions will increase participation and interest of clients in family sessions. While each individual task and assignment is not necessarily scrutinized or picked apart for meaning, the task gives the clients a way to express themselves that may have been difficult with the use of words and can still be used as a tool for assessment. Expressive therapies have been utilized in the assessment of abilities, preferences, and interests; assessment of life experiences and capacities; and assessment of psychological, psychosocial, and/or cognitive aspects (Malchiodi, 2005). These activities and assessments may be used in combination with other forms of evaluation and counseling techniques. While expressive arts are suitable in many contexts, including individually with children or adults, in groups of children or adults, and in couples, there are aspects of creative therapies that are unique in the family counseling setting. Using expressive arts places all family members on even ground in the therapeutic setting, allowing each generation to have a voice in the process (Riley & Malchiodi, 2003). Expressive family counseling also enhances communication among family members and uncovers family patterns of interactions and behaviors (Riley & Malchiodi, 2003). This will be useful in assessing the family’s dynamics and formulating goals

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and treatment plans based on dysfunctions within the family’s interactions. Expressive therapies give families a new way to solve problems, opening themselves to a broader perspective to support changes in behavior (Riley & Malchiodi, 2003). Families are most often comfortable with their routine and the way they do things, even if their way of doing things is maladaptive and dysfunction. Giving families new outlets to express themselves as individuals in a way that connects them to their family unit will increase their likelihood of learning new skills and overcoming family issues. MULTICULTURAL CONSIDERATIONS Each family has its own dynamics. Each family sets its own range of behaviours. No two families are alike. Yet in studying them there may be unity manifest in diversity; there may be similarities among all the differences; there may be principles that unite. (Davis, 1976, p. 3)

Rather than attempt to engage in a discourse addressing how culturally sensitive each family counseling theory is, it would be more beneficial to convey how the shared principles of family counseling theories measure up in the face of cultural sensitivity, followed by some of the shortcomings of family counseling theories and general recommendations. As described previously, systems theories (viz., family counseling) take a holistic view of the family, rather than focusing on one member, highlighting the interrelatedness of family members as parts of a larger system. With this in mind, one could say family counseling is collectivist instead of individualistic. Systems theories are also dynamic; conceptualizing families as in flux (i.e., changing but not necessarily growing). From this perspective, treatment would involve conceptualizing each family’s patterns of interacting and rules as unique. As such, the tenets of family counseling are rooted in a place of familial, cultural sensitivity. Regardless of the family counseling theory, during theoretical development, only traditional families (viz., nuclear families [father, mother, and children] and/or families with man–woman coupling) were considered and studied. Also, some family counseling theories operate from a place of traditional gender roles (viz., the man is the head of the house). Finally, of the family counseling theories covered in this chapter, only Satir’s model operates from an egalitarian stance, wherein the counselor uses his or her personality and is sensitive, empathetic, and models acceptance. Within family work, general, cultural sensitivity recommendations might involve the counselor (a) exploring personal awareness of his or her own culture, values, and biases and how these influence his or her work with traditional and nontraditional families; (b) gathering information, from families, about their culture, values, and biases; (c) showing respect for family traditions, yet challenging them when they lead to dysfunctional patterns of relating; and (d) engaging in collaborative goal setting with families. CONCLUSION Utilizing expressive arts in family counseling is a valuable process. It is similar to the teenager who does not like talking about his day, for whatever reason, and might be more comfortable letting his dad listen to music to which the teenager relates. At times, family members do not share interests, and this can divide them. Something that each of them can understand, though, is feeling. There are many forms of poetry that might be utilized as a considered approach to expressing those feelings. There is no guarantee that using expressive arts will bridge all significant divides or disagreements, but it does allow us to access modes of communication attainable by our brains that are not always available through the logical character organization of language.

Expressive Arts Interventions

BUILT TO LAST Edward F. Hudspeth

Indications: This activity is appropriate for use with families that have lost sight of their abil-

ities and strengths. It is utilized to identify individual as well as family abilities and strengths. Primary Goal: To bring about awareness of each family member’s strengths and how these strengths are family assets. It may also offer a visual demonstration of how a family unit will change or become unstable, if there is no recognition and utilization of abilities and strengths. Modality: Game-Based Play The Fit: Often within families too much attention is given to problems and little is given to strengths. When strengths are not acknowledged as family assets, problem resolution is difficult to conceptualize. Through this intervention, family members learn to embrace, acknowledge, and make an effort to address the strengths and difficulties equally. In the activity, each family member is equal, in that each has an equal number of blocks that represent an equal amount of impact on the family system. Populations: Families, groups Materials and Preparation: A Tumbling Tower Game (alternative to Jenga) available in a min-size at dollar stores or in standard size at discount stores; permeant markers; sheets of copy paper; quart size zip-top bags. Prior to the first family session, based on the number of members involved in the session, divide the wooden blocks of the Tumbling Tower Game into equal portions for each family member. Place each portion in a quart size zip-top bag. Based on the number of blocks each family member will receive, place an equal number of numbered lines on a sheet of copy paper for each family member. Instructions: 1. At the end of the initial family session, introduce this intervention. Describe the intervention as a demonstration of recognizing, utilizing, and balancing the strengths of each member and the family. 2. Give each family member a bag of blocks and a sheet of copy paper. 3. Instruct them to choose a permanent marker and each to write his or her name on the sheet of paper. 4. Describe the blocks as: Building blocks of their family. Pose the question, “What strengths do you add to your family?” Ask family members to write their individual strengths on one of the elongated sides of the blocks. Then, pose the question, “What strengths do you have as a family?” Ask them to write the family strengths on the opposite, elongated side of the block. Once done, ask them to color code their blocks by choosing a permanent marker and placing a colored line on the two remaining elongated sides. 5. Ask them to transcribe their individual strengths and family strengths to the sheet of paper as well as mark their sheet with their chosen color. Ask the family members to place their blocks back in their bag and leave them with you. Also, ask them to leave their key with you. 226

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6. Prior to the next family session, the counselor, utilizing the instructions of the game, builds a

tower composed the blocks. Mix all of the family members’ blocks together prior to building the tower. When constructing the tower, make sure only color-coded sides or the unaltered ends of the block are showing. 7. With the family present, remind them of the intervention and present the tower. Follow the game instructions. The basic instructions challenge players to strategically remove blocks without making the tower collapse. 8. As family members remove a block, ask them to read it aloud. Ask the owner to identify him or herself, and ask the family, “How would it affect the family if this strength (individual or family) was ignored or unrecognized?” Continue to play the game until the tower collapses. You may now also process the strengths that were represented in the tower at the time of its collapse.

MY NEEDS, YOUR NEEDS, OUR NEEDS Edward F. Hudspeth

Indications: This activity is appropriate for use with families who fail to or will not listen to each other. Primary Goal: To improve communication about one’s needs and listening skills Modality: Narrative, Visual Arts The Fit: Over time, some families develop patterns of communication that stem from not listening to each other. The tone may be condescending and judgmental. The less family members listen and respond appropriately, the more detached they become from the original issue. In these situations, they need a reminder that each member has his or her needs and that his or her actions are an attempt to get these needs met in each family situation/issue. Populations: Families, groups Materials and Preparation: Version 1: Sheets of transparency film and wet-erase markers. Version 2: Transparency film, wet-erase markers, a cardboard box, tape, a light source. (For best success, the light source should use an incandescent bulb.) For version 2, see the instructions, for making a simple projector, demonstrated on YouTube. plus.google.com/hangouts/_/calendar/ZnJhbmNodWRzcGV0aEBnbWFpbC5jb20 .ucton8vt7apqok8rpslo511tqc?authuser=0 For written instructions, see the information on Cleverly Inspired cleverlyinspired.com/2013/03/diy-overhead-projector-how-to-paint-an-image-on-the-wall/ Draw two large circles on the transparency film. Imagine that each circle is divided into four equal quadrants. Centered atop one quadrant write NEEDS. Atop the opposite quadrant write WANTS. For the two remaining quadrants, write MISSING atop one and TOO MUCH for the final quadrant (see Figure 12.1). This process can also be accomplished utilizing a word-processing program to create a template that can be printed directly on the transparency film. Have at least one circle for each family member.

Figure 12.1 Individual needs and wants. 228

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Instructions: 1. Start by telling the family members that they will be doing an exercise that helps to identify

2. 3. 4.

5.

6.

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each individual’s needs and wants as well as the things that each perceives as having no power (missing) or too much power in the family. Ask each member to write his or her response in the appropriate quadrant of the circle. Ask members to do this individually, and at this point, refrain from discussing their responses. Ask them to place their name at the center of the circle. Take up the circles. Process the responses. 4.1 Begin by stating that, As a person, we are surrounded by our own needs, wants, the things we see as missing, and the things we see as having too much power. This is our personal circle. Because we are involved in relationships, others’ circles overlap ours. When we have similar circles, the overlap is unnoticed, but when the circles differ, the overlap puts stress on our circle. When our circle is stressed, we often respond with anxiety, anger, and fail to listen or take the time to understand others’ circles. Take the circles that the family members completed and begin to overlap them. 5.1 Pose the questions: When these are overlapped, can you still see everything in your circle? Have things become blurred? Can you care for yourself when your needs and wants are fuzzy? Can you care for the others in your relationships when everything is jumbled together? 5.2 Pose the questions: What can you change to care for yourself? What can you do, as a family, to care for your family? If there are similar needs, wants, and so forth, overlap them. 6.1 Pose the questions: When our similarities overlap, are things clearer? Is it easier to get along with others? Do we know how to communicate better or listen more, when we are doing so from a place of similarity? Finally, overlap the circles to a point that there is a shared, empty space in the middle. 7.1 Pose the questions: What happens if we ask to understand others’ circles? What happens if we allow all of our circles to overlap for something shared, like our family? (see Figure 12.2).

Family

Figure 12.2 Family overlap.

SEMISTRUCTURED STRENGTHS SORTER Lucy C. Parker

The creation and success of this intervention is dedicated to my father, Louis Parker, who is a foundation in my own family . . . Indications: This intervention is designed to encourage client families to take a broader perspective on how they view each other and themselves. Goal: Strength-based techniques allow the clinician to explore various issues that might arise in the various familial relationships, along with allowing the counselor and each family member to get to know one another at a deeper level. The activity below uses the strengthbased, narrative technique of strength creation. This family theory technique ultimately further helps the counselor to more fully engage the family to reconsider one another in active dialogue and to begin with strengths. Furthermore, instead of societal marginalization or preconceived value impositions on a family to be “normal,” strength-based techniques, such as this family strengths sorter, allow for family members to be authors in their own life story(ies). Modality: Expressive writing, visual art The Fit: Narrative therapy was developed by Michael White and David Epston (1992). This therapy assumes that the counselor’s role includes being a facilitator and investigator. Techniques and theory information about narrative therapy include separating a family and its members from their problems in a process called “externalization,” allowing the family to assume their narrator roles in their own life story, naming feelings associated with life events, and their own creation of reframing their past family story and/or ending to their current familial circumstances (White, 1995). This therapy allows family members and individual clients to rely on their own skills to deal with and decrease problems in their lives. According to Simon (2003), narrative therapy is identified by five main dimensions constructing worldview. These dimensions include: (a) being both an individualist and/or family-based theory practitioner, (b) exhibiting a view of freedom from (i.e., an eudaimonistic philosophical stance), (c) seeing people as vessels that are primarily “good” and not defined by their mistakes, (d) viewing individuals as intellectualist and eager to use the facilitation provided in counseling, and (e) seeing families as clients who are always becoming as they continue to create and recreate their new life narratives. Through the ability to create and recreate their own life experiences, families form their own story and identity. It is through this strength-based and holistic lens that clients and their lives are evaluated and facilitated by the facilitator. Just as the description that follows will summarize, narrative therapy integrates many metaphors and creative ways for families to recognize, externalize, and deal with their pain and/or problems. Populations: Families, groups Materials and Preparation: Copies of Form A (see Figure 12.3); black or blue pens or pencils; red pens or fine tip markers. Print out a copy of Form A for each family member.

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FORM A:

Author/ Name: Family Strengths Template: What hurts? Author: What internal pain do you currently have in your life? Members: What internal strengths does this person have to help this person with his or her pain? Author: What internal pain do you currently have in your life? Members: What internal strengths does this person have to help this person with his or her pain?

Figure 12.3 Family strengths template.

Instructions:

This intervention is delivered in five phases: 1. Pre-Construction Phase. Begin by handing the template (Form A) to each family member involved in the current session. 2. Reflection Phase. Ask family members to use their black or blue writing instrument to write areas of internal or external pain on their administered self-template (Form A). Family

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members may write or draw symbols to represent their pain. Give approximately (i.e., at least) 10 minutes for this process. 3. Distribution Phase. Have each member pass his or her template to the member on the right. With each passing, have each family member write or draw, using the red pen/marker, unique strengths that each member has shown in front of them, to survive some of the pain they have written/drawn about on their templates. Please note, this activity is based off of postmodern and strength-based interventions and should be left fluid; however, one requirement is to have each member be required to write at least one strength for each other member in the session. Give approximately (i.e., at least) 15 minutes for this process. This processing may take longer with a larger family. 4. Co-Construction Phase. Once all members have written at least one strength on each other’s template, have one member at a time read his or her prescribed strengths aloud. Also, after reading, ask each member the following reflection questions: 4.1 How does it feel to read these strengths? 4.2 How else have your family members helped you see your strengths or have supported you during your times in pain? 4.3 Which specific family members have helped you the most? 4.4 Which of the strengths written for you (i.e., on your template) do you see in other family members? (Give approximately 20 minutes for this processing.) 5. Future Family Construction Phase. At the end of the session or in a separate following session, have each family member combine all of the written strengths for each member on a white board and/or poster board so that they may collectively view all of the cumulative strengths that they offer as a cohesive family unit. This can reinforce instillation of hope for each member and the family, as a whole (Yalom, 2002). During this time, as the family facilitator, reinforce the written strengths and reflect that these are tools already existent as the family works through painful events, as members may individually, and as the family will holistically. (This cumulative intervention takes about 50–60 minutes. However, this intervention may also be incorporated into two sequential sessions, if preferred.) Potential Supplementation. Other possible additions to this semi-structured strength sorter include incorporating a family-made body sculpture, drawing, narrative of “their future family,” or genogram which incorporates the strengths mentioned in their cumulative templates. Please note, the Form A template is the template to be used for each family member to identify his or her pain and others for their strengths.

THE SAME BUT DIFFERENT Edward F. Hudspeth

Indications: This activity is appropriate for use with families experiencing change. The change

has disrupted the family’s routine and/or changed the roles of the members of the family system. Examples would include, but are not limited to, divorce, death, loss of a job, or relocation. Goal: To bring about awareness of how change has affected each family member, impacted the family unit, and to allow families to experience verbally and visually how change has affected him or her, each other, and the family unit. The secondary goal is to demonstrate and bring about awareness that regardless of the change, the individuals remain a family and can find solutions to ease the transition. Modality: Art The Fit: Change is not easy and even a good change, within a family, affects the functioning of the family. When individuals have relied on circumstances being consistent, a change in these circumstances causes inconsistencies. Inconsistencies may lead to worrying, anxiety, and even grief. The purpose of this activity is to provide family members with the opportunity to express, in a visual modality, how a change has affected each family member and the family as a whole. Thus, this activity creates a sense of universality. Populations: Families, groups Materials and Preparation: Two paper doll–shaped cutouts for each member of the family; crayons, marker, or colored pencils for decorating the cutouts; clear tape Instructions: 1. Tell the family members that one of the paper dolls represents him or her prior to the change and the other represents him or her after the change. 2. Prompt them to think about how they felt before the change and encourage them to let this guide them when designing/decorating the cutout. 3. After each individual has finished the first cutout, ask him or her to give it to you prior to beginning the second cutout. 4. Repeat the process for the cutout that represents him or her after the change. 5. While the family members are working on the second paper doll cut-outs, the counselor should gather all of the completed initial cut-outs and tape them together at their hands as if they were all holding hands in a circle. The finished product should resemble a cylinder. Make sure the decorated side of the cutout is facing outward. 6. Repeat the process once the second cutouts are complete. 7. Process the cutouts. 7.1 Ask the family members to describe what they wanted to represent with cutout one. 7.2 Repeat the process for the circle of second cutouts. 8. Now, display the circles of cutouts side-by-side. 9. Process the two circles. 9.1 Ask what each notices about the cutouts. What is consistent from before to after and what is different from before to after? 9.2 Ask about the colors chosen and specific details of the image. 9.3 Allow family members to discuss what they did not realize or what each has in common. 9.4 Allow responses to lead to goal setting. 233

TOGETHER IN THIS WORLD Edward F. Hudspeth

Indications: This activity is appropriate for use with blended families that are having difficulty

transitioning to life as a new family unit. Primary Goal: To bring about awareness of each family member’s likes, dislikes, strengths, and shortcomings. From awareness of others can come insight into how individual members have similarities and how this can be a place of learning, growth, and compromise. Modality: Art The Fit: There are times when divorce and then remarriage occur within a short time span with little effort being made to introduce family members from both sides of the union. These transitions can lead to defensiveness, jealousy, and anger. Often, all that is needed is for family members to have the opportunity to become acquainted with each other and be willing to listen. The support and safety of the counseling session can be the buffer and ease tension. Populations: Families, groups Materials and Preparation: A cardboard or papier-mâché sphere (can be purchased at most crafts stores); papier-mâché paste or decoupage glue (there are many recipes for this on the Internet); various colors of construction paper cut into 1- to 2-in. squares; permanent markers; Styrofoam bowls, disposable gloves, copy paper. Instructions: 1. Introduce the activity as a way to become acquainted with new family members. 2. Ask family members to pick four squares each of four colors of construction paper. Next, ask them to label one color likes, one dislikes, one strengths, and the final, shortcomings. On the copy paper ask them to create a key of their labels and colors. State, “For now, don’t let your family members see what you are writing.” Finally, since they have four squares of each color, ask them to write four likes, four dislikes, four strengths, and four shortcomings (include only one on each square of construction paper). 3. Once the squares have their items listed on them, ask the individuals to transcribe the information from the squares to the appropriate place on the key. 4. Give each a Styrofoam bowl and pour in it some glue/paste. 5. Present a family member with the sphere and ask him or her to glue/paste a like anywhere on the sphere that he or she would like. Repeat this process for each family member. Then, repeat this process for dislikes, strengths, and shortcomings. 6. Retrieve the sphere for drying and instruct the family members: Take your key home and think about the things that you wrote. Think about where you placed each square. What was beside/near where you placed each square? You can write, on your key, notes about what you remember and/or thought about as you were placing your squares, and maybe, what was beside/near each square. Remind them to not talk about the activity at home. 7. During the family’s next session, process the activity. To guide the discussion, return to the questions that were posed at the close of the previous session. 8. Discuss similarities and differences among family members. Discuss the placement of squares and what was beside/near each square. 234

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9. Wrap the session up by asking the family members if they feel as though they know about

each member. Also, in the case of differences or when they do not understand, ask if they are willing to learn from each other and/or will they ask each other to explain? This last process can be conceptualized as contracting with the family to be willing to engage each other. REFERENCES Ackerman, N. W. (1938). The unity of the family. Archives of Pediatrics, 55, 51–62. Bowen, M. (1967). Toward the differentiation of self in one’s own family. In J. L. Framo (Ed.), Family interactions: A dialogue between family researchers and family therapists (pp. 111–173). New York, NY: Springer-Verlag. Brown, J. (1999). Bowen family systems theory and practice: Illustration and critique. Australian and New Zealand Journal of Family Therapy, 20(2), 94–103. Davis, A. K. (1976). Systems analysis of family interactions and a demonstration of its applications (Master’s thesis, Simon Fraser University, Burnaby, Canada), Retrieved from http://summit.sfu.ca/system/files/ iritems1/6125/b15923320.pdf Framo, J. L. (1968). My families, my family. Voices: The Art and Science of Psychotherapy, 4, 18–27. Goldenberg, H., & Goldenberg, I. (2012). Family therapy: An overview (8th ed.). Pacific Grove, CA: Brooks/Cole. Haley, J. (1963). Strategies of psychotherapy. New York, NY: Grune & Stratton. Jones-Smith, E. (2016). Theories of counseling and psychotherapy (2nd ed.). Thousand Oaks, CA: SAGE. Kerr, M. E. (2003). One family’s story: A primer on Bowen Theory. Washington, DC: Bowen Center for the Study of the Family. Lowenstein, L., & Sprunk, T. P. (2010). Creative family therapy techniques: Play and art-based activities to assess and treat families. Retrieved from http://www.lianalowenstein.com/articleFamilyTherapy.pdf Malchiodi, C. A. (2005). Expressive therapies: History, theory, and practice. In C. A. Malchiodi (Ed.), Expressive therapies. New York, NY: Guilford Press. Mental Research Institute. (n.d.a). In tribute: Jay Haley (1923–2007). Retrieved from http://www.mri.org/ pdfs/jay_haley_tribute.pdf Mental Research Institute. (n.d.b). Jay Haley’s biography. Retrieved from http://mri.org/jayhaley Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Nichols, M. P. (2012). Family therapy: Concepts and methods (10th ed.). Hoboken, NJ: Pearson. Nichols, M. P., & Schwartz, R. C. (2003). Family therapy: Concepts and methods (6th ed.). Boston, MA: Allyn & Bacon. Nichols, M. P., & Schwartz, R. C. (2009). Family therapy: Concepts and methods (8th ed.). Hoboken, NJ: Pearson. Riley, S., & Malchiodi, C. A. (2003). Family art therapy. Handbook of art therapy. New York, NY: Guilford Press. Ruesch, J., & Bateson, G. (1951). Communication: The social matrix of psychiatry. New York, NY: W. W. Norton. Satir, V. (1964). Conjoint family therapy. Palo Alto, CA: Science and Behavior Books. Satir, V., Banmen, J., Gerber, J., & Gomori, M. (1991). Satir model: Family therapy and beyond. Palo Alto, CA: Science and Behavior Books. Simon, G. M. (2003). Beyond technique in family therapy. Boston, MA: Pearson. The Bowen Center for the Study of the Family. (n.d.). About Murray Bowen. Retrieved from http://www .thebowencenter.org/theory/about-murray-bowen The Virginia Satir Global Network. (n.d.). Who Virginia was and why she mattered. Retrieved from https:// satirglobal.org/about-virginia-satir von Bertalanffy, L. (1945). Zu einer allgemeinen Systemlehre (An outline of general system theory). Blatter fur Deutsche Philosophie (Vol. 18). Extract in Biologia Generalis (Vol. 19, pp. 114–129). (Reprinted in General system theory: Foundations, development, applications, 1968, New York, NY: George Braziller). Whitaker, C. A. (1976). The hindrance of theory in clinical work. In P. J. Guerin (Ed.), Family therapy: Theory and practice (pp. 154–164). New York, NY: Gardner Press. White, M. (1995). Re-authoring lives: Interviews and essays. Adelaide, Australia: Dulwich Centre Publications. White, M., & Epston, D. (1992). Experience, contradiction, narrative, and imagination: Selected papers of David Epston & Michael White, 1989–1991. Adelaide, Australia: Dulwich Centre Publications.. Yalom, I.D. (2002). The gift of therapy. New York: HarperCollins.

13 Integrative Theory in the Expressive Arts Sally S. Atkins, Keith M. Davis, and Lauren E. Atkins

Integrative approaches to counseling and psychotherapy involve careful, thoughtful, and systematic selection of ideas and methods from a variety of theoretical systems. This process involves analyzing and synthesizing concepts from different theoretical orientations in order to form a counseling approach that fits the philosophy and skills of the counselor as well as the differing needs of individual clients. As the field of counseling has matured, the tendency to cross ideological barriers in order to enhance effectiveness and to find the most appropriate ways of working with diverse populations has increased. The movement toward both theoretical and practical integration has developed rapidly within the field of counseling since the 1980s (Brooks-Harris, 2008). Current major texts in counseling and psychotherapy typically include a chapter on integrative theory. The trend toward integration is based on the realization that no single theory is adequate to explain the complexities of human experience or to address the diverse problems of humans within differing personal, familial, and cultural contexts (Corey, 2012). Although arts-based approaches to therapy developed initially around expertise within a particular modality such as music, drama, or dance, a major trend in using the arts within the context of counseling is to use two or more of the arts together (Gladding, 2011). Interdisciplinary or intermodal expressive arts therapy is the practice of arts integration, using any or all of the arts together in a therapeutic context to facilitate positive change. The complex practice of interweaving arts modalities, carefully transitioning from one form to another, is grounded in the fundamental sensory interrelatedness of all of the arts. The art-making process is viewed both as a mode of personal inquiry and as a vehicle for therapeutic change. The practice of integrative expressive arts draws concepts not only from counseling and psychological theory, but also from the artistic disciplines themselves and in some cases from philosophical and anthropological theory as well (Knill, Levine, & Levine, 2005). Thus, the practice of expressive arts in counseling and therapy is well suited to an integrative theoretical perspective. FOUNDATIONS OF INTEGRATIVE EXPRESSIVE ARTS The integrative use of the arts is ancient. Indigenous cultures all over the world still use the arts together in the service of life and healing. In Western practices of counseling and psychotherapy, however, integrative use of expressive arts is a relatively recent phenomenon. In 1981, 237

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Shaun McNiff published the groundbreaking work, The Arts in Psychotherapy, articulating the intentional use of an interdisciplinary approach to the arts as therapy. This approach had been developing during the 1970s among a community of artist/scholars at Lesley University, including McNiff, Paolo Knill, Norma Canner, Elizabeth McKim, and others at Lesley’s Institute for the Arts and Human Development. This interdisciplinary approach emphasized the intermodal nature of the arts, acknowledging that working in any art form necessarily involves other forms and that purposeful integration of more than one artistic form can offer a wide array of therapeutic possibilities. Working therapeutically with the arts is receiving increasing attention and interest among all of the helping professions. Within the counseling profession, Sam Gladding’s The Creative Arts in Counseling (2011) has been significant in bringing awareness of the arts-based therapies and of the power of the arts to heal to the attention of counselors. Another significant step in bringing the arts to counseling has been the recent creation of the Association for Creativity in Counseling as a Division of the American Counseling Association and the creation of its journal, the Journal of Creativity in Mental Health. CORE CONCEPTS OF INTEGRATIVE THEORY Using the expressive arts in an integrative way in counseling and therapy is still in its early stages as an emerging approach, and at this time, no single theoretical framework exists. Of the multiple pathways toward achieving an integrative approach, the path of technical eclecticism is most commonly used, with counselors choosing techniques from different approaches without necessarily subscribing to their underlying theoretical positions. Within mainstream mental health literature, expressive therapies are often defined by commonalities of practice, such as the use of arts media and nonverbal methods, the emphasis on creative expression, and an action orientation (Weiner, 1999; Weiner & Oxford, 2003). While the use of expressive arts in counseling is frequently methodology based, the rationale for the effectiveness of arts-based work is consistent with differing theoretical approaches. For example, Jungian concepts of cross-cultural archetypes, myths, and symbols in the collective unconscious, which can be accessed through creativity and imagination, are important aspects of most expressive arts work. From the humanistic and existential psychotherapies, the concept of an innate, creative, positive striving capacity within each individual is very consistent with arts-based work. Fundamental to expressive arts work is the idea that every person possesses creative capacity which can be activated and nurtured to enhance healing and well-being. In the future, more in-depth theoretical integration, aimed at producing a consistent theoretical framework beyond a mere blending of techniques, will likely characterize integrative practice in this field. ISSUES ADRESSED BY THEORY Therapeutic use of the expressive arts is finding its way into a wide array of arenas. Literature in mental health, education, nursing, and related fields reveals that the expressive arts are effective in working with both groups and individuals of all ages and with a variety of psychological and medical issues. While the expressive arts do not rely solely on nonverbal communication, their capacity to access sensory-based experience and to utilize imagery offers unique therapeutic possibilities. Work in the arts can offer opportunities for self-expression of clients for whom verbal language is limited. The capacity of the expressive arts to bypass the psychological defenses of the conscious mind makes them a potent method for revealing and addressing a variety of problems. However,

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because of their potency, these methods should be used with care and with sensitivity to the developmental stage, the personality organization, and the interpersonal dynamics of the individual client. Expressive arts therapists must be especially careful to establish a climate of safety and to move into and out of art experiences appropriately.

INTEGRATIVE THEORY AND THE EXPRESSIVE ARTS Incorporating the power of the arts into the counseling process offers rich possibilities for therapeutic work. Using intermodal or interdisciplinary expressive arts is necessarily integrative from a practical and a technical perspective. Further attention to theoretical aspects of integration will insure that intermodal work in the arts can become more than a toolbox of eclectic practice without theoretical grounding. The following statements represent our own synthesis of ideas from the emerging literature and interweaving of concepts that we consider to be fundamental to the practice of using expressive arts in counseling. 1. Creativity is a basic human activity (Levine, 1992; May, 1975). 2. All human beings are creative and are imbedded in a creative universe (Atkins & Williams,

2007; Eberhart & Atkins, 2014). 3. Expressive arts in counseling centers upon the primary use of creative process as a vehicle

of change (Atkins & Williams, 2007; Eberhart & Atkins, 2014; Rogers, 1993). 4. Creativity in the arts offers humans the possibility to give form to and to reflect upon

experience and emotion (Knill et al., 2005; McNiff, 1992). 5. The arts are inherently interrelated by virtue of their common base in sensory experience.

(Knill, 1994). 6. Using the arts together in an interdisciplinary way can enhance the possibility of therapeutic

7.

8. 9.

10.

11.

change, especially when experiences are designed with attention to the respective qualities and challenges of different art forms (Atkins & Williams, 2007; Eberhart & Atkins, 2014; Knill et al., 2005; McNiff, 1992). In expressive arts therapy the concept of beauty has not to do with a formal aesthetic but with the authenticity and integrity of the artistic process and product (Eberhart & Atkins, 2014.) Imagination can be a potent resource for healing and growth (Atkins & Williams, 2007; Eberhart & Atkins, 2014; Knill, 1994; McNiff, 1992). The arts can be used in a variety of ways in counseling to access internal and external resources, to express emotion, to make choices, to explore questions and possibilities, to build relationships, to enrich and deepen meaning, to distance from and reflect upon problems, and to contact and embrace different parts of the self (Atkins & Williams, 2007; Eberhart & Atkins, 2014). The interpersonal relationship between therapist and client is the ground of therapeutic work, including arts-based therapeutic work (Atkins & Williams, 2007; Eberhart & Atkins, 2014; Rogers, 1993). In order to cultivate the capacity for therapeutic presence in holding the space for art making, the expressive arts therapist must develop a “daily practice” of centering and grounding the self (Atkins & Williams, 2007; Eberhart & Atkins, 2014).

The making of an integrative theory is an ongoing and emergent process. It requires careful reflection on the nature of human existence, what causes problems in living, and how change happens. For using the expressive arts in counseling, integrative theory making requires additional reflection upon the power of the arts and the role of the arts in human experience.

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CONCLUSION Integrative theory is the integration of elements from a variety of psychotherapy approaches and theories and is supported by the understanding that any single approach may inhibit the process. Thus, the advantage is the flexibility it allows in the treatment plan. The approach requires thoughtful incorporation of tailoring what works for the client. Using intermodal or interdisciplinary expressive arts is an integrative strategy that complements the eclectic practice.

Expressive Arts Interventions

ANIMAL MEDICINE/STRENGTH SHIELDS Keith M. Davis

Indications: This activity has been used with children and adolescents facing challenges

with anger management, bullying, grief/loss, eating disorders, self-esteem, domestic violence, and physical/sexual abuse. It has also been used with counseling students as part of a class in ecotherapy, emphasizing the healing connections and relations between humans, animals, and the natural environment. Goal: To provide a safe way for students/clients to express the meaning of life experiences and circumstances when words fail; it is particularly useful with young children who often do not have the vocabulary or cognitive development to verbally express themselves fully. Modality: Intermodal expressive arts The Fit: This intervention is an example that integrates intermodal expressive arts with elements of ecotherapy (Davis & Atkins, 2004, 2009) and both humanistic and existential theories within the context of individual and/or group counseling. For intermodal expressive arts, animal medicine and/or strength shields combine visual art making, writing, and storytelling. Should you choose to integrate aspects of ecotherapy, materials for the making of the shield can be gathered from the natural environmental elements (e.g., tree branches, bark, sticks, plants, stones, and rocks), emphasizing connections and relations between humans, animals, and the natural environment. Because the purpose of the shield making is to emphasize aspects of one’s own healing and strengths as metaphorically represented through our connections with certain animals, the activity fits well within humanistic and existential theories. Specifically, humanistic theory emphasizes the strength and healing of genuine relationship. If one’s pet becomes the focus of the shield making, then elements of unconditional positive regard can be incorporated, as pets generally love without judgment. The shield making helps facilitate one’s own attempt to make meaning from life experience and circumstance. Thus, the very act of this activity is existential in nature. Populations: Children/adolescents/adults; Groups/individuals Materials: Construction paper, crayons, markers; old magazines, particularly ones with wildlife, and other collage materials such as feathers, leather strips, colored tissue paper, ribbons, and yarn; scissors, hole punch, glue, string, and stapler; and, should an ecotherapy approach be used, then students/clients can gather natural elements from the environment (e.g., tree branches, bark, sticks, plants, stones, rocks). Instructions: 1. Materials can be arranged around a table and/or workspace. 2. To help build rapport and empathy with the group, you may also choose to create an animal medicine/strength shield. This is particularly helpful working with children and adolescents who may need a “template” for the activity.

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3. Using construction paper, each participant decides on the basic shape and size of the shield

(e.g., circle, square, rectangle) and cuts with scissors to suit. 4. Cut pictures of animals and/or wildlife from magazines. 5. Glue, staple, or tie pictures to the shield. 6. Hole punching can be used as a way to tie string, yarn, feathers, or animal pictures onto

the shield. 7. Natural elements (e.g., tree branches, bark, sticks, plants, stones, rocks) can also be used. 8. The activity can be done either in silence or with soft music playing. You can act as an “art

coach,” helping with materials and offering assistance. 9. Allow 45 minutes for the completion of the activity and, if time allows, the processing of

the activity by having the individual and/or group share either verbally or a small written paragraph, sentence, or words to convey the process and product of the animal medicine/ strength shield. (Note: In a school setting, it may be necessary to have a follow-up meeting or series of meetings for processing the activity.) 10. Process can include how the animal medicine/strength shield represents one’s own strengths (i.e., What aspects does one see in oneself that are represented within the animals chosen for the shield?). Variations: This activity may vary depending on the developmental level of the individual and/or group. For younger children, clear instructions and some modeling (without imposing values) may be necessary. If the shield is to be made using natural elements from the environment, then additional time should be allowed for the gathering of these elements in an outdoor environment. The activity can be used either individually or in a group setting. Additionally, if using this activity with children and/or adolescents in a public school setting, it is best to refer to it simply as an animal strength shield as opposed to using the term medicine, which may not take into account issues of religious preference. As always, when working with children and adolescents individually or in groups, it is often best to gain parental permission or support.

BOX OF THE SELF Sally S. Atkins

Indications: This activity can build cohesion and foster meaningful personal sharing within a

group. It has been used with persons with anxiety and depression, with adolescents with anger management issues, with incarcerated adolescents and adults, with cancer patients, with clients with developmental disabilities, with victims of domestic violence, and with graduate students in training and supervision. It is particularly appropriate for persons with identity and self-image issues and/or relationship problems. It is useful in any situation in which it would be valuable for clients to claim and value different aspects of the self and to share themselves with others. Goal: A more complete acceptance and claiming of one’s many inner facets Modality: Intermodal expressive arts The Fit: This intervention is an example of intermodal expressive arts, using different artistic modalities of movement, visual art making, and writing in conjunction with personal sharing in a small group setting. Simple collage construction is an example of using low-skill, highsensitivity art making. The task is simple enough not to frustrate the clients, yet sensitive enough to reflect sophisticated and complicated personal themes. It is an example of using artistic expression to access, embrace, and share different parts of the self. Populations: Children/adolescents/adults; Groups/individuals Materials: Containers of various sizes and shapes, such as shoe boxes, hat boxes, gift boxes, cigar boxes, and oatmeal boxes; small paper bags can also be used as containers if boxes are not available; old magazines and other collage materials such as tissue paper, feathers, felt scraps, ribbons and yarn; scissors and glue Instructions: 1. Arrange materials on tables around the workspace. 2. Counselor and client(s) take a few moments to breathe, stretch, center, and ground themselves in the body. 3. Have a verbal check in. In a group, this could be a go-around with brief introductions and expectations for the experience. 4. Introduce the materials and experience to clients: This exercise is designed to help us to think about and to express in artistic form how we think and feel about ourselves. 5. Instructions: You have about 45 minutes to create a “box of yourself.” Take some time to explore the materials. See what colors, shapes, and images attract you. Think about images that reflect who you are on the outside and decorate your container with those. Think also about your inner self. Choose images that reflect your inner self for the inside of the container. Let your work be an interplay of intention and surprise. Pay particular attention to surprises, to what happens that you did not plan. Be open to contradictions. 6. The art activity can be done in silence or with soft music playing. You will become a kind of “art coach,” helping with the materials and assisting clients when needed. 7. About 10 minutes before the allotted time is up, remind clients about the time. At the conclusion of the art experience, assist clients with cleaning up the space and materials. 8. Invite clients to return to the circle with their boxes of self. Ask them to write about the art experience, reflecting on new learning and awareness about themselves that may have 243

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emerged from the process of the experience as well as from the product created. Also ask them to reflect on what resources, both internal and external, were used to accomplish the task of creating the box. 9. Give each person the opportunity to show his or her box and to tell something from the experience with the group. Remind the group to refrain from judgment of others or themselves. 10. At a final go-around, ask each group member to share with the group one thing he or she will take with him or her from the experience. Variations: If the group is an ongoing group, members can be asked to prepare an artwork of their choice (e.g., song, movement, visual art, poem) as a response to witness the sharing of the boxes of self in the circle. This experience can also be adapted for use with individual clients. Making the box can be done in a single 1.5-hour session or assigned as a homework activity.

MUSICINSPIRED POETIC SHARING Keith M. Davis

Indications: This activity can be used to develop trust, empathy, cohesion, and facilitate

meaningful personal sharing within a group setting. It has been used in groups of adolescents facing various developmental and personal challenges; marital and relationship counseling where trust and empathy have been challenged; counselor training and supervision programs as a demonstration for building trust, empathy, and cohesion; and various adult counseling groups. Goal: To facilitate the development of trust, empathy, and rapport Modality: Intermodal expressive arts The Fit: This intervention is an example that integrates intermodal expressive arts with elements of humanistic and existential theories within the context of group counseling and/or group counseling supervision. For intermodal expressive arts, music, poetry writing, and visual art making are combined in conjunction with sharing in a small group setting. This activity also fits well within humanistic and existential theories. Trust and empathy form two important cornerstones in humanistic approaches to counseling. As an intervention, this activity relies on group members to trust and empathize with one another through the shared creation of poetic writing with words derived from instrumental musical composition clips. As group members create their poetic writing from the music, they become involved in an existential process of meaning making. Populations: Adolescents/adults; Groups/couples Materials: CD player; various CDs that contain instrumental music (i.e., music without words); construction paper; crayons, colored pencils, and/or markers Instructions: 1. Arrange materials on a table or workspace. 2. Give each group member a sheet of paper and something with which to write. 3. Play an approximately 1-minute clip or sample of some instrumental music piece from selected CDs (i.e., it is best to have an assortment of eclectic music that can elicit a range of feelings/thoughts). 4. Ask each group member (or couple if used in marital or relationship counseling) to jot down a series of one-word feelings or thoughts elicited by each musical piece. At the end of all musical pieces, each member should have a list of feeling or thought words. 5. Ask each group member to exchange his or her own list of words with another group member (i.e., this is where trust is emphasized as many members may have emotional attachments to his or her own list). 6. Once each group member has the list of another group member, issue the directive that each group member, using the list of words of another group member, is to create a poem using as many words on the list as possible. Additional words not on the list may be included (e.g., conjunctions, nouns, pronouns) for the poetic composition. 7. Group members can use the construction paper and colored pencils and/or markers to create, in essence, a “Hallmark” card of sorts.

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8. Once each group member has completed the poem and “card” using the list of words from

another group member, instruct them to give the card with poem back to the originator of the list of words. 9. Each group member then takes a turn reading aloud to other group members the poem created by the other group member from his or her list of words (i.e., this is the first time the poem is read aloud within the group). 10. After all poems have been read, process the experience with the group. 11. Allow approximately 90 minutes for this activity. Variations: It is recommended that instrumental musical pieces are used for this activity because music with lyrics may unduly influence the word choices of participants. However, if working with adolescents, lyrical music may be used and adolescents may be encouraged to bring in their own musical selections. This activity has been successfully used with groups experiencing challenges in rapport building, trust, empathy, and cohesion. Members are often emotionally connected to their own word list, and the giving of the list to another for poetic creation has proved helpful in overcoming such group challenges.

NAMING AND CLAIMING THE BODY Lauren E. Atkins

Indications: This activity helps to support dialogue regarding body image issues and

self-awareness. Body awareness and movement experiences can be helpful as an intervention and as a wellness tool. Goal: To promote positive self-esteem and to build group cohesion and community Modality: Intermodal expressive arts The Fit: This intervention is an example of intermodal transfer, using the artistic modalities of movement/dance and visual art making in conjunction with personal reflection and community sharing. Populations: Female children/adolescents; Groups/individuals Materials: Music player (either recorded music on iPod or CD or live music is appropriate); any musical accompaniment that can provide a steady beat and/or atmospheric quality is helpful to setting a tone for the experience; markers and/or crayons; large and small paper Caution: The movement/dance modality can feel particularly scary and vulnerable to clients, so the counselor must take care to establish a sense of safety. Instructions: 1. Beginning. Make a circle with the group surrounding a large piece of paper. This is a time to become acquainted with each other. Going around the circle, each person has a turn to say his or her name and something he or she loves in his or her life (e.g., color, pet, family). 2. Asking the question. How does your body feel right now in this moment? The clients respond by writing on the paper in the middle of the circle creating a collective nonverbal sharing of present body experience. 3. Taking turns around the circle again. Each person is asked to share a movement that would feel good in his or her body, possibly a response to the written information. As each client shares movement, all the participants learn the movement. The group can repeat the movement around the circle again, flowing from one movement to the next to create a sustained movement experience. This pattern can be repeated again with music added (if music is not already playing as background ambiance) for added rhythmic stimulus. 4. Asking the question again. How does your body feel, now in this moment? These responses are shared verbally and written on the communal paper. The paper then holds the individual body experience within a collective context, with a subtle suggestion of possibility of change through movement. 5. Clients then separate to find personal space in the room. Direct the clients to find a comfortable position, close their eyes, and focus on their breathing. Then guide the clients through a personal movement experience with the following questions (Clients are encouraged to keep their eyes closed during this process): How might your body move/respond if you are waking up in the morning? How do you move when you feel happy/content? How do you move when you feel angry? How do you move when you feel sad? How do you move when you are excited? Let your body continue to move according to how it feels today, now in the present moment. (Soft atmospheric music can support the process by providing a soothing auditory environment.) 247

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6. Ask each client to take a smaller individual piece of paper and crayons or markers to respond

visually to his or her experience. He or she can use words or images as needed to create a visual manifestation of the experience. 7. Invite clients to come together in a final circle and show their images and add new phrases or words to describe their present experience verbally and on the communal large paper. This last group gathering will close the circle and is a time to find completion with the process. Commentary: This activity provides a structure to support investigation of different types of personal issues, struggles, and triumphs. Adjust and change questions as needed for the working population. The questions listed previously are meant as general concepts to address within a movement experience. In-depth body awareness is a valuable asset for forming healthy body image and sense of self. This is particularly important for young women as they navigate the complex cultural images, expectations, and myths of women in society. This activity can create a safe space to begin dialogue regarding these types of issues for young women. REFERENCES Atkins, S., & Williams, L. D. (2007). Sourcebook in expressive arts therapy. Boone, NC: Parkway. Brooks-Harris, J. E. (2008). Integrated multitheoretical psychotherapy. Boston, MA: Houghton Mifflin. Corey, G. (2012). The art of integrative counseling (3rd ed.). Belmont, CA: Brooks/Cole. Davis, K. M., & Atkins, S. S. (2004). Teaching a course in ecotherapy: We went to the woods. Journal of Humanistic Counseling, Education and Development, 43, 211–218. Davis, K. M., & Atkins, S. S. (2009). Ecotherapy: Tribalism in the mountains and forest. Journal of Creativity in Mental Health, 4(3), 272–282. Eberhart, H., & Atkins, S. (2014). Presence and process in expressive arts work: At the edge of wonder. London, UK: Kingsley. Gladding, S. (2011). The creative arts in counseling (4th ed.). Alexandria, VA: American Counseling Association. Knill, P. J. (1994). Multiplicity as a tradition: Theories for interdisciplinary arts therapies: An overview. Arts in Psychotherapy, 21(5), 319–328. Knill, P. J., Levine, E. G., & Levine, S. K. (2005). Principles and practice of expressive arts therapy: Toward a therapeutic aesthetics. London, UK: Kingsley. Levine, S. K. (1992). Poiesis: The language of psychology and the speech of the soul. London, UK: Kingsley. McNiff, S. (1981). The arts and psychotherapy. Springfield, IL: Thomas. McNiff, S. (1992). Art as medicine: Creating therapy of the imagination. Boston, MA: Shambhala. Rogers, N. (1993). The creative connection: Expressive arts as healing. Palo Alto, CA: Science and Behavior Books. Weiner, D. (ed.). (1999). Beyond talk therapy: Using movement and expressive techniques in clinical practice. Washington, DC: American Psychological Association. Weiner, D., & Oxford, L. (Eds.). (2003). Action therapy with families and groups: Using creative arts in improvisation in clinical practice. Washington, DC: American Psychological Association.

II Emerging and Special Issues in Expressive Arts and Counseling

14 Neuroscientific Applications for Expressive Therapies Jim M. Nelson and Patrick L. R. McMillion

The neuroscience of expressive therapy and counseling is an exciting but complex subject. This chapter is intended as a very brief general introduction for people with less background in neuroscience. For technical details, readers should consult articles referenced in the bibliography. Internet resources such as the Digital Anatomist Atlas (www9.biostr.washington.edu/da.html) provide an additional reference for those unfamiliar with the human brain and nervous system. FOUNDATIONS OF NEUROSCIENTIFIC PERSPECTIVE IN COUNSELING It is increasingly necessary for therapists and counselors to have some understanding of the applications of neuroscience as they relate to therapy and counseling. Understanding and observing brain activity in relation to human behavior has been called the “last frontier of the biological sciences” (Kandel & Hudspeth, 2013, p. 5). Others have described the integration of counseling and neuroscience as “the cutting edge of the next decade” (Ivey, Ivey, Zalaquett,  & Quirk, 2009, p. 1) for the mental health field. Although the emergence of the neuroscientific study of expressive therapies is quite recent, related research has been carried on since the mid-19th century when psychologists became increasingly interested in the physiological bases of sensation and perception. Studies of individuals with neurological damage, such as those by Alexander Luria with traumatic brain injury (TBI) patients during World War II, provided new ideas about brain organization and function at the same time that cognitive psychologists were studying these issues in normal humans. The mid- to late-20th century also saw technological advances that allowed scientists to better study the living brain, such as structural and functional imaging techniques. Although our understanding of the brain is still quite incomplete, neuroscientists have been eager to apply our current knowledge to the study of things like aesthetic perception and creativity (Chatterjee, 2011; Zeki, 1999). While we certainly know much about brain–behavior relationships, there are also reasons to be modest about our current state of knowledge. The research methods employed by scientists—such as shutting a person in a noisy neuroimaging machine—seem to make it impossible to study many aspects of aesthetic production (Schott, 2015). Even when research produces interesting findings, some writers (e.g., Ansdell, 1995) argue that expressive therapies derive no practical benefit from any type of psychological or counseling theory. However, given the strong connections between mind and brain in humans, 251

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processes like artistic creativity should have interesting links to brain function that are important to understand and may be helpful for therapists and counselors utilizing expressive arts (Malchiodi, 2012; Thaut, 2002). The use of research to better understand and appreciate creative processes rather than explain them mechanistically is not only more realistic given the current (and likely future) state of our knowledge about the brain (cf. Frixione, 2011), it also better matches the experience of people as they are spectators or creators of artistic work. THEORY AND COMPONENTS Many neuroscientists operate from an evolutionary paradigm and explain the development of creativity from the point of view of adaptive function (e.g., Zaidel, 2015) such that creativity may allow for increased options for communication, for expression, for pattern recognition, and for overall problem solving, thus increasing the likelihood of one’s survival. Chatterjee and Vartanian (2014) suggested that experiencing or expressing art engages the following neural processes: ■ ■ ■

Sensorimotor perceptual processes, including visual and auditory processes as well as centers involved in perception of body sensation, taste, and smell Meaning or knowledge processes, involving interpretation of an image within a context; familiarity from previous experiences may affect this process Emotion and valuation processes, related to the generation of aesthetic pleasure or displeasure in response to beauty or unattractiveness

Some aspects of creative experience appear to involve general brain processes, while others engage systems that are unique to specific types of art (Boccia et al., 2016). The neuroscience of expressive therapies is built upon an understanding of how the brain works in supporting mental functions like perception and creativity. Contemporary theory and research emphasize that the brain is composed of many small structures linked together in complex systems that talk to each other and cooperate to regulate behavior. Much of this activity involves the cortex or the outer, folded part of the brain, including the frontal, parietal, temporal, and occipital lobes. Modern research suggests that a host of structures and systems in the lower or subcortical parts of the brain are also intensively involved. Neurons: Information is passed throughout the brain through electrochemical processes between cells called “neurons.” Neurons connect to create neural pathways and systems that together define how we perceive, experience, and interact with the world. 2. Anterior–posterior systems: A basic organizational principle of the brain is that functional systems in the posterior or back of the brain are devoted to basic sensory processing, while the anterior or front regions are more involved in behavior planning and motor activity. 3. Right–left systems: Differences between the “right brain” and “left brain” have been a feature of popular speculation for many years, even though the similarities between the two sides of the brain are greater than the differences. Anatomic differences between the right and left sides of the brain do exist, however, particularly in the temporal lobes and areas related to language. Along with some small differences in shape and cellular composition, some individual structures that have both right (R) and left (L) side versions are different. This difference appears to relate to the lateralization or location of word formation to the L side of the brain but control of tonality to the R side. When lateralization occurs, it generally represents differences in efficiency or preference for certain aspects of complex abilities. For instance, both sides of the brain are involved in hearing all types of sounds, but rhythm discrimination and the processing of nonlanguage sounds like melody seem 1.

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to be preferentially done in the right hemisphere. These patterns appear to be affected by handedness and gender, as well as substantial individual differences; therefore, it is difficult to make broad statements about “right brain” or “left brain” functions. 4. Dorsal–ventral systems: A lower or ventral “what” system runs from the occipital to the frontal lobe through the temporal lobe; it is sensitive to form and color and carries out the process of object recognition, partly through a process of comparison with previous experiences and learned categories (Clarke & Tyler, 2015). The perception of some types of visible objects, like faces, appears to involve unique areas and pathways within this system. In addition, an upper or dorsal “where” system runs from the occipital to the frontal lobe through the parietal lobe and is focused on spatial aspects of vision like location and motion. Activity runs in both directions with sensory information moving from back to front and control signals moving from the frontal lobe to the sensory areas.

APPLICATIONS OF NEUROSCIENTIFIC PERSPECTIVE Core Principles A neuroscientific view of expressive therapy and counseling looks at the relationship between directed artistic activity, either passive-receptive or active, and brain functions or processes. The neuroscientific properties of various expressive therapies such as art and music have been researched separately and no doubt have unique features, although in theory they may share some common processes, since artistic perception and activity largely use brain systems that are employed in many different situations for multiple purposes. The following will describe the application of neuroscience principles to expressive therapies and counseling in general, as well as to the popular expressive therapies of art and music. General Applications A simplified view of the brain can divide it into three parts of functioning (MacLean, 1990). These are (a) basic survival, (b) emotional decision making, and (c) higher order cognition (language, problem solving, creativity, etc.). We function best when all three components are working together and working equally. If one aspect of functioning is working more or less than the others, then we tend to be dysregulated and experience struggles or pathology. Creative and expressive methods can uniquely engage all three areas of functioning and bring about better harmony of functioning as a whole. Clinicians should assess what areas of functioning are overactive or underactive and respond appropriately. If an area is overactive, then your creative intervention should target the other areas of functioning. If an area is underactive, then your creative intervention should target that area. Every creative intervention or process should then end with equal engagement of all areas. ■

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Overactive Basic Survival Functions: Provide a creative intervention that first validates the experience that is causing the overactive survival behaviors and responses. Then introduce creative factors that allow for emotional processing and decision making. Then introduce creative problem solving or meaning-making factors. It is important to go in that order with overactive basic survival functions because the brain is designed for survival functions to trump all other functions, followed by emotions, then higher order cognition. Underactive Basic Survival Functions: Engage the client in “primitive” creative interventions that involve larger kinesthetic movement and reflect the basic needs of life.

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Overactive Emotional Decision-Making Functions: Start by providing an intervention that assists clients with validating their emotions and then introduce creative problem solving or meaning-making factors. Underactive Emotional Decision-Making Functions: This may be the condition to which clinicians most commonly connect the use of creative and expressive interventions. Provide clients with creative opportunities to express their emotions. Overactive Higher Order Cognition: This is likely a result of trying to avoid discomfort related to an experience impacting basic survival functions or to avoid addressing emotional aspects of experiences. Start by providing a creative intervention to help you assess which area is being denied and underactive, then provide clients with the appropriate intervention from the preceding. Underactive Higher Order Cognition: First assess whether there are overactive basic survival functions or overactive emotional decision-making functions. Address those first if necessary, then introduce creative problem solving or meaning-making factors.

EXPRESSIVE ARTS AND ART THERAPY The neuroscience of art therapy begins with an understanding of how the brain perceives art. Production of art involves motor and planning structures in the frontal lobe, while the perception of art involves visual systems within the brain and subcortical structures related to emotion (Vartanian & Skov, 2014). One contribution of the study of the neuroscience of art therapy has been an understanding of how neurological disease or dysfunction can affect the process of art perception and production (Zaidel, 2016, pp. 77–124). Subgroups of individuals with certain conditions like neurodevelopmental disorders and autism spectrum disorder (ASD), sometimes have enhanced artistic expressiveness and productivity (Chatterjee, 2014), but many have important impairments in their ability to appreciate or produce art. Production problems have been studied through the work of artists suffering from brain damage. For instance, artist William deKooning developed Alzheimer’s disease and, as the condition progressed, his productivity declined and paintings became more abstract and simpler in the use of form and color (Chatterjee, 2004; van Buren, Bromberger, Potts, Miller, & Chatterjee, 2013). It is sometimes possible to draw connections between art therapy interventions, cognitive improvements, and changes in brain structure or function. For instance, Park and colleagues (2015) found that an arts education program for children resulted in improved executive functioning abilities. Art therapy can be used with individuals suffering from a variety of neurological problems (Weston & Liebmann, 2015). Here we provide information about using art therapy with individuals suffering from TBI, an injury to the brain due to a physical outside force. It is a common problem, generating approximately 2 million emergency room visits annually in the United States. The effects of TBI manifest as a wide variety of problems including cognitive effects, psychological effects, and physical problems. Specific cognitive effects typically include memory and concentration problems, a loss of mental efficiency and automation of tasks so that activities require greater time and effort, and problems with executive functioning and social communication (e.g., social awareness). Psychological effects may include impulsiveness and personality changes, mood changes like depression and irritability, and the development of psychiatric problems like posttraumatic stress disorder (PTSD). Interestingly, there is a very low correlation between severity or type of injury and effects or outcomes. Individuals with TBI have altered abilities, and thus struggle with forming and accepting a new and realistic sense of self. This problem is compounded by the fact that individuals with TBI often have difficulty with accurate self-perception due to executive functioning problems.

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One way to address this problem is by using a selfbox technique. In the first part of the procedure, the individuals are given a box with a lid and a variety of collaging materials. They are instructed to decorate the outside of the box as they think they appear to other people, and the inside of the box according to who they “truly” are. During the second part, they are given a second box and materials and asked to decorate it according to their ideal external and internal self. Conversations with the therapist about the work are conducted after the completion of each box. The selfbox technique has many advantages: it provides assessment of the clients’ self-perception and helps them express their vision for the future. The task is interesting and easy to do, thus increasing engagement and attention. Music and Music Therapy Altenmuller and Schlaug (2015, p. 237) note that music “involves listening, watching, feeling, moving and coordinating, remembering, and expecting musical elements,” as well as experiencing emotions, so that many brain regions and systems are affected by music and music therapy. Music produces its effects through a complex interaction of changes in consciousness, external awareness, and emotion. Interesting theories of how this interaction might work have been proposed (e.g., Dimitriadis & Smeijsters, 2011), although these theories are speculative and do not necessarily provide benefits in the development of clinical techniques. Some music therapies appear to have their effect by increasing activation in certain areas of the brain, thereby producing desirable (or undesirable) effects. For instance, listening to preferred or familiar music tends to increase activation in neural circuits that help regulate emotion (Koelsch, 2010; Moore, 2013). Other brain processes that appear to be modulated by music include attention, memory, and some aspects of language and social cognition (Koelsch, 2009). These therapies may also alter activation balance between different areas of the brain. For instance, successful melodic intonation therapy increases activation in L hemisphere language structures while decreasing activity in corresponding areas of the R hemisphere (Breier, Randle, Maher, & Papanicolaou, 2010). Active music therapies are associated with higher levels of activation in the middle parts of the frontal lobe in addition to temporal auditory areas, in keeping with the active aspect of the therapy (Raglio et al., 2016). These changes may help a person build more successful mood regulation abilities; however, this will depend in part on how the therapist and client use music. Use as part of an avoidance strategy for coping may actually weaken the person’s ability to deal with difficult situations (Carlson et al., 2015). Some alterations produced by music therapy are temporary but others are more permanent, altering the structure and/or function of the brain through processes of brain plasticity. These permanent effects are greater with more repetition, so that professional musicians show greater changes than occasional users or producers. The emotion-producing effect of music also seems to be important for producing plastic changes (Altenmuller & Schlaug, 2015). Music therapy may also be useful in a variety of situations, including treatment of longterm neurologically based conditions. Here we give an example where it can be used in the treatment of dementia or major neurocognitive disorder (MND), a condition marked by significant decline in a number of cognitive abilities, such as memory, which leads to difficulties in independent living. MND can be caused by a variety of neurological problems, including general degenerative diseases of the brain (e.g., Alzheimer’s disease) and vascular problems, such as strokes, that affect specific areas. For instance, a large stroke may affect only the left side of the brain, causing problems with language (aphasia). In that situation, procedures like melodic intonation therapy can stimulate right-sided brain structures, causing them to pick up language functions no longer able to be produced on the left side. Using music therapy activities that also require motor activity can improve recovery of motor functions after a stroke (e.g., Rojo et al., 2011). Music may also be used for assessment; Pfeiffer and Sabe (2015) developed Screening of Music and Cognition assessment procedures that utilize musical tasks to assess

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important aspects of cognition like attention, memory, and executive functions. Music therapy also has the advantage of being pleasurable for most participants and enhancing motivation and compliance with a rehabilitation program (Altenmuller & Schlaug, 2015). In nursing home settings, it can be helpful to use a memory gradient singing technique to enhance memory and improve mood. In MND, individuals frequently lose access to recent memory, but retain remote memories. In the first stage of the therapy, counselors play examples of popular music from each decade until they determine the most recent music familiar to the client. This establishes a memory loss gradient. Counselors invite clients to sing (if possible) or listen to favorite songs from that period. The process of singing has multiple effects: it accesses and strengthens memory recall, provides a pleasurable experience by successfully accessing familiar songs, and provides opportunities for socialization with the therapist or with others in a group setting. CONCLUSION Neuroscientists have not yet successfully penetrated important aspects of the creative process, but the study of neuroscience has allowed us to reflect in various ways on these processes. When working with the many individuals with neurological problems who could benefit from expressive therapy or counseling, a basic understanding of neuroscience is essential to understanding the client and making appropriate therapy or counseling choices. REFERENCES Altenmuller, E., & Schlaug, G. (2015). Apollo’s gift: New aspects of neurologic music therapy. Progress in Brain Research, 217, 237–252. Ansdell, G. (1995). Music for life. London, UK: Jessica Kingsley. Boccia, M., Barbetti, S., Piccardi, L., Guariglia, C., Ferlazzo, F., Giannini, A. M., & Zaidel, D. W. (2016). Where does brain neural activation in aesthetic responses to visual art occur? Meta-analytic evidence from neuroimaging studies. Neuroscience and Biobehavioral Reviews, 60, 65–71. Breier, J., Randle, S., Maher, L., & Papanicolaou, A. (2010). Changes in maps of language activity activation following melodic intonation therapy using magnetoencephalography: Two case studies. Journal of Clinical and Experimental Neuropsychology, 32, 309–314. Carlson, E., Saarikallio, S., Tolviainin, P., Bogert, B., Kliuchko, M., & Brattico, E. (2015). Maladaptive and adaptive emotion regulation through music: A behavioral and neuroimaging study of males and females. Frontiers in Human Neuroscience, 9, 466. Chatterjee, A. (2004). The neuropsychology of visual artistic production. Neuropsychologia, 42, 1568–1583. Chatterjee, A. (2011). Neuroaesthetics: A coming of age story. Journal of Cognitive Neuroscience, 23, 53–62. Chatterjee, A. (2014). The aesthetic brain. Oxford, UK: Oxford University Press. Chatterjee, A., & Vartanian, O. (2014). Neuroaesthetics. Trends in Cognitive Science, 18, 370–375. Clarke, A., & Tyler, L. (2015). Understanding what we see: How we derive meaning from vision. Trends in Cognitive Sciences, 19, 677–687. Dimitriadis, T., & Smeijsters, H. (2011). Autistic spectrum disorder and music therapy: Theory underpinning practice. Nordic Journal of Music Therapy, 20, 108–122. Frixione, M. (2011). Art, the brain, and family resemblances: Some considerations on neuroaesthetics. Philosophical Psychology, 24, 699–715. Ivey, A. E., Ivey, M. B., Zalaquett, C., & Quirk, K. (2009). Counseling and neuroscience: The cutting edge of the coming decade. Counseling Today, 52, 44–55. Kandel, E. R., & Hudspeth, A. J. (2013). The brain and behavior. In E. R. Kandel, J. H. Schwartz, T. M. Jessell, S. A. Siegelbaum, & A. J. Hudspeth (Eds.), Principles of neural science (5th ed., pp. 5–20). New York, NY: McGraw-Hill. Koelsch, S. (2009). A neuroscientific perspective on music therapy. New York Academy of Sciences, 1169, 374–384. Koelsch, S. (2010). Towards a neural basis of music-evoked emotions. Trends in Cognitive Science, 14, 131–137.

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MacLean, P. D. (1990). The triune brain in evolution: Role of paleocerebral functions. New York, NY: Plenum Press. Malchiodi, C. (2012). Art therapy and the brain. In C. Malchiodi (Ed.), Handbook of art therapy (2nd ed., pp. 17–26). New York, NY: Guilford Press. Moore, K. S. (2013). A systematic review on the neural effects of music on emotion regulation: Implication for music therapy practice. Journal of Music Therapy, 50, 198–242. Park, S., Lee, J.-M., Baik, Y., Kim, K., Yun, H. J., Kwon, H., … Kim, B. N. (2015). A preliminary study of the effects of an arts education program on executive function, behavior, and brain structure in a sample of nonclinical school-aged children. Journal of Child Neurology, 30, 1757–1766. Pfeiffer, C., & Sabe, L. (2015). Music therapy and cognitive rehabilitation: Screening of music cognition in adult patients with right hemisphere stroke. Psychomusicology: Music, Mind, and Brain, 25, 392–403. Raglio, A., Galandra, C., Sibilla, L., Esposito, F., Gaeta, F., Di Salle, F., … Imbriani, M. (2016). Effects of active music therapy on the normal brain: fMRI-based evidence. Brain Imaging and Behavior, 10, 182–186. Rojo, N., Amengual, J., Juncadella, M., Rubio, F., Camara, E., Marco-Pallares, J., … Rodriguez-Fornells, A. (2011). Music-supported therapy induces plasticity in the sensorimotor cortex in chronic stroke: A single-case study using multimodal imaging (fMRI-TMS). Brain Injury, 25, 787–793. Schott, G. (2015). Neuroaesthetics: Exploring beauty and the brain. Brain, 138, 2451–2454. Thaut, M. (2002). Toward a cognition-affect model in neuropsychiatric music therapy. In R. Unkefer & M. Thaut (Eds.), Music therapy in the treatment of adults with mental disorders: Theoretical bases and clinical interventions (pp. 86–103). Gilsum, NH: Barcelona Publishers. van Buren, B., Bromberger, B., Potts, D., Miller, B., & Chatterjee, A. (2013). Changes in painting styles of two artists with Alzheimer’s disease. Psychology of Aesthetics, Creativity, and the Arts, 7, 89–94. Vartanian, O., & Skov, M. (2014). Neural correlates of viewing paintings: Evidence from a quantitative meta-analysis of functional magnetic resonance imaging data. Brain and Cognition, 87, 52–56. Weston, S., & Liebmann, M. (2015). Art therapy with neurological conditions. London, UK: Jessica Kingsley. Zaidel, D. (2015). Neuroaesthetics is not just about art. Frontiers in Human Neuroscience, 9, 1–2. Zaidel, D. (2016). Neuropsychology of art (2nd ed.). London, UK: Routledge. Zeki, S. (1999). Art and the brain. Journal of Consciousness Studies, 6, 76–96.

15 Clinical Supervision Montserrat Casado-Kehoe and Kathy Ybañez-Llorente

Bernard and Goodyear (2014) describe supervision as comprised of two words, super and vision, and yet most of traditional supervision does not always show this vision. In many cases, it is more of a continuation of talk therapy, a cognitive focus, describing with words rather than seeing the case. The integration of expressive arts and creativity in supervision provides an opportunity to experience and see visuals during supervision and enhance the “vision.” The idea is that the use of symbols or pictures can assist in projecting one’s perception of inner and outer reality (Lahad, 2000), providing insight in supervision. Supervision is a safe place where the counselor can explore new behaviors to become a more competent and effective counselor. Whereas traditional supervision focuses on case conceptualization, the use of expressive arts interventions may add a different focus, facilitating supervisees’ exploration of self and how that affects the case or provides a different perspective about the case. The use of expressive arts interventions can facilitate communication and enhance this development of therapeutic competence that the supervisee needs to feel and experience. OVERVIEW This chapter describes the integration of a Gestalt and experiential learning approach in supervision. Gestalt theory is a phenomenological experiential approach developed by Fritz and Laura Perls in the early 1950s (Corey, 2009; Neukrug, 2007). In play therapy, Violet Oaklander (1988, 2007) successfully integrated a Gestalt approach with the use of play working with children, adolescents, and families. For a more complete discussion of Gestalt theory, please see Chapter 8. Hoyt and Goulding (1989) extend the integration of a Gestalt psychotherapy theory to supervision. Gestalt therapy postulates that people have the ability to change as they become more aware of self by allowing themselves to perceive, feel, and act rather than continue to interpret the past (Yontef, 1993). Operating in the “here and now,” the individual works through unfinished business, bringing it to awareness. At different points in life, an individual may become “stuck” and start to express neurotic behaviors that, once confronted, bring awareness to the client (Neukrug, 2007). It is only in the present, experiencing the now, that the individual can have experiences that help him or her let go of what is blocked and move toward growth. The goal is to become more fully aware and alive, feeling free from the past. Focusing in the moment, the process, a dialogic relationship exists in which the therapist and client allow themselves to experience, ultimately engaging in dialogue about those experiences. Although communicating what is being experienced, the goal is for the client to become aware of what he or she is doing, 259

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how he or she is doing it, and how he or she can change, gaining value of self (Corey, 2009; Yontef, 1993). In therapy, there is a strong emphasis on gaining personal responsibility. The therapist emphasizes feelings to help the individual become aware of projections and takes responsibility for all of his or her parts. Various techniques can be used, such as awareness exercises, use of “I” statements, empty chair, role-playing dreams, and playing the projection, among others (Neukrug). Like person-centered therapy, Gestalt proposes that individuals have the power to change if they develop awareness of self. It is a positivist theory that believes in the potential of the human being and the innate ability toward health and growth (Ruiz, 2009). Unlike psychoanalysis, Gestalt does not seek to interpret but to allow individuals to experience all parts of the self and to establish a relationship that is caring, accepting, and nonjudgmental. One experiences self in comparison with other, and how one experiences other is related to how one experiences self (Yontef, 1993). In therapy, the individual learns how to establish contact with self and others, feeling more alive. Freud emphasized the past in therapy, whereas Fritz Perls paid attention to the present, how the person feels in the here and now about his or her unfinished business (Neukrug, 2007). Thus, the Gestalt approach helps the individual focus on the present because the past is gone and the future has not come. It is in the present that the individual experiences and develops awareness and insight of this experience. CORE PRINCIPLES An important component of Gestalt therapy is the relationship, an I–Thou experience. Without a relationship, nothing happens therapeutically (Oaklander, 2007). The therapist engages in a mutual relationship with the client spontaneously and genuinely. In this relationship, the therapist models for the client’s awareness of self and the courage to be authentic and able to express one’s feelings. It is through contact that the client is experiencing the moment and organizing processes (Kaplan, Kaplan, & Serok, 1985). Contact involves having the ability to be fully present while engaging the senses, body, emotions, and intellect. Resistance is part of the therapeutic process and part of self-protection. As the therapeutic relationship deepens, the resistance will lower. To help the client experience, the focus is on senses and the body. As one engages the senses and becomes aware of one’s body feelings and sensations, one starts to define the self and makes contact with the world (Oaklander, 1988). The role of the therapist is also to strengthen the self of the client, helping him or her make choices, experience mastery, own projections, set boundaries and limits, experience power and control, and be able to express aggressive energy (Oaklander, 2007). It is in this process of experiencing and learning that the client learns to trust the self. GESTALT APPROACH TO SUPERVISION The purposes of clinical supervision are varied: (a) to help the supervisee understand the case, contentwise and processwise; (b) to help the supervisee gain awareness of how he or she impacts the case; (c) to gain an understanding of the dynamics between therapist and client; (d) to assess the interventions used; (e) to develop a deeper understanding of theory; and (f ) to empower and challenge the supervisee. Given the multipurpose nature of supervision, some of the areas the supervisor may choose to address in supervision are the following: (a) personality functioning of the client; (b) personality functioning of the supervisee; (c) supervisee–client relationship; (d) supervisee–supervisor relationship; (e) development of theory; (f ) issues related to change; (g) diagnosis and treatment plan; and (h) ethical, professional, and administrative issues (Resnick & Estrup, 2000).

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A Gestalt therapy and supervision model focuses on holism, phenomenology, and a strong dialogic supervisory relationship. Thus, the emphasis is on an I–Thou relationship where the supervisee experiences in the here and now an awareness of self and how he or she impacts the case. In the here and now, the supervisee is seen and feels connected to the supervisor in dialogue. This relationship is one that is characterized by presence, genuineness, open communication, and inclusion (Pack, 2009). Although insight and awareness are part of the supervisory experience, what makes it unique and therapeutic is the dialogic relationship where both supervisee and supervisor honor one another (Resnick & Estrup, 2000). Guided by standards of care, the supervisor ensures safe practice and monitors that the needs of the client are being met (Pack, 2009). Thus, the quality of the relationship is paramount to help the supervisee grow clinically and personally. In this dialogic relationship, the role of the supervisor is to be supportive, accepting, emphatic, relational, and challenging (Corey, 2009). In supervision, the contact boundary between supervisee and client is examined, as well as the contact boundary between supervisee and supervisor. In exploring these dynamics, the supervisee gains awareness and becomes more creative (Pack, 2009). At times in supervision, the supervisor may also focus on assessing the supervisee’s diagnoses, the treatment plan, and psychoeducation about specific issues. However, perhaps the most important elements are to help the supervisee define the use of self in therapy and teach a process orientation that facilitates clinical and personal growth (Harman & Tarleton, 1983). In supervision, a Gestalt approach emphasizes experiential processes that support confluent or contactual functioning (Kaplan et al., 1985). Thus, Gestalt supervision is a process-oriented model that encourages the supervisee to experiment and try new interventions as a way to be flexible with clients. In this process, the supervisor helps the supervisee look at boundary disturbances such as the use of projections, retroflections, and confluence that may be blocking the case (Harman & Tarleton, 1983). The use of expressive interventions such as role-plays (role-playing the client) or objects (to represent supervisee and client) can assist in providing insight and a different perspective about the case, enhancing awareness in the here and now. Additional benefits are that the use of expressive art interventions can enhance the learning experience, provide self-awareness and clarity to the supervisee’s use of theory, and facilitate the use of clinical skills (Bratton, Ceballos, & Sheely, 2008). In the context of supervision, the ultimate goal is to help the supervisee experience, organize, and express how he or she feels about self, the client, and the relationship in the present moment, while helping him or her develop inner guidance and gain clinical competence. Expressive Arts Perspective Expressive arts interventions can facilitate the understanding of the case and the professional development of the counselor. Experiential activities with a right brain focus provide an opportunity to express the self and experience various emotions. They provide safety and structure as well as decrease the anxiety that supervisees sometimes feel when looking at their own clinical work. The supervisor can choose to focus the supervision on client-centered issues, therapist-centered issues, or process-centered issues (Lahad, 2000). Literature abounds regarding the effectiveness of expressive arts work with clients in the counseling process (Gladding, 2005; Malchiodi, 2003). One would expect the same to be true in the area of supervision, yet the scant literature that exists demonstrating or exploring its use is relegated to clinical observations, case examples, and application (Malchiodi, 2005). What has contributed to this deficit? Could it be supervisors’ hesitancy to include expressive arts in their work with supervisees? To shed light on what has prevented the infusion of expressive arts in supervision, Lahad (2000) asks these questions: “Why are

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we so perplexed in the face of imagination? Why are we so defensive and apologetic in supervision when we share our non-logical thinking, circular perception, images, smells, inner pictures, metaphors, and lateral thinking?” (pp. 12–13). In supervision, supervisors are found to respond in the way they were supervised, including the ongoing lack of creativity in expression. Lahad (2000) suggests that the use of the right hemisphere of the brain, particularly involving imagination, can easily be married in supervision with the more often employed left hemisphere processes of thought and logic. Given the parallel processes that exist in the work of a supervisor and supervisee when compared to the work of counselors and clients, the suggestion has been made by many authors to use expressive arts in clinical supervision, aiding in supervisees’ self-awareness, because they are known to benefit clients’ self-awareness in therapy (Gladding, 2005; Lahad, 2000; Oaklander, 2007). Oster and Crone (2004) note that “the act of creating drawings provides an expanded and insightful view of the self and serves as a tangible focus for discussion, interpretation, evaluation, change, and review of progress in therapy” (p. 2). These same processes are of benefit to supervisees within a supervisory relationship. Bratton et al. (2008) assert, “the use of expressive arts with supervisees can enhance the supervisory experience by fostering self-awareness, enhancing client conceptualization, encouraging exploration and clarity of supervisees’ theoretical framework, and facilitating development” (pp. 211–212) of clinical skills. Expressive arts has several specific characteristics that are not often found in strictly verbal therapy/supervision approaches: self-expression, active participation, imagination, and mind–body connection (Malchiodi, 2005). Lahad (2000) notes that it is the engagement of the right hemisphere of the brain in accessing emotions, thoughts, creativity, and experiences that can facilitate a supervisee’s self-expression or self-awareness, critical to personal growth and professional development. Active engagement in “creative and playful supervision can help supervisees acquire their own therapeutic identity, develop their own internal supervisor, achieve a sense of personal autonomy, and become empowered as therapists” (Stewart & Echterling, 2008, p. 283). The use of imagination in clinical situations can allow for alternate understandings of client process and progress, freeing the counselor to try more creative approaches in his or her clinical work with clients. Malchiodi (2005) points out that the mind–body connection is supported by the creative process of making art be related to health and wellness, as evidenced by the classification of art therapy as a mind–body intervention by the National Institutes of Health. Art is understood to elicit a relaxation response or mood-altering effect that alleviates stress, helpful for supervisees working to increase their proficiency in providing counseling services to clients while under supervision. A supervisor can choose to focus clinical supervision on client-centered issues, therapist-centered issues, or process-centered issues (Lahad, 2000). Depending on the need present in the supervision session, expressive arts interventions can facilitate understanding of the client’s case presented for supervision, the ongoing personal growth and professional development of a counselor or supervisee, or the supervisory relationship. Oftentimes, when a supervisee reports feeling “stuck” in his or her work with a client, the inability to look at the presenting issue from another angle contributes to the impasse. Expressive arts interventions “provide different ways of looking at things, strengthen the supervisee’s feeling of resourcefulness; and through these they find a new sense of control” (Lahad, 2000, p. 15). Experiential activities, having a right brain focus, provide an opportunity for supervisees to express the self and experience various emotions involved in their work with clients. They provide safety and structure as well as decrease the anxiety that supervisees sometimes feel when looking at their own clinical work. The benefit of using alternate methods of expression that do not rely on “either verbal language or narrative discourse” (Estrella, 2005, p. 187) is the

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ease that supervisees report they feel in expression of thoughts, emotions, or problems involved in counseling. Malchiodi (1998) asserts the nature of expressive art activities is such that they “can generate self-esteem, encourage risk taking and experimentation, teach new skills, and enrich one’s life . . . . Making something with one’s own hands and realizing that one can make something unique is a powerful experience with undeniable therapeutic benefits” (p. 14). These powerful experiences are beneficial to the professional development of a supervisee learning to work with new and complex client problems. The relationship between the counselor and supervisor is one that should involve, from the beginning, a discussion of responsibilities, expectations, and expressive arts interventions to be used in supervision. This will help to begin the process of forming a working relationship that is “an authentic encounter, a dialogue, a creative process that is experiential rather than interpretive. Both the therapist and the supervisor participate in a mutual exploration and learning process” (Resnick & Estrup, 2000, p. 130). A supervision relationship that is collaborative, rather than purely hierarchical in nature, can work to foster successful resolution of supervision relationship problems. Fall and Sutton (2004) call attention to a supervisor modeling the process of recognizing the conflict, giving name to it, and processing it in such a way that both individuals feel free to express feelings, thoughts, and phenomenological experiences that demonstrate the Gestalt approach to supervision that is “responsible, honest, direct, and authentic” (Malchiodi, 2003, p. 63). Limitations of Expressive Arts Interventions As with any approach, there are limitations to consider in the use of expressive arts in supervision. Malchiodi (2003) devotes sections in her text demonstrating how expressive arts has been beneficial to clinical and nonclinical client populations consisting of adults, children, adolescents, families, couples, and groups. Malchiodi (2005) asserts supervisees must be mindful that expressive arts approaches may not be suitable for all clients in these populations. Clients who believe they will be unable to produce something creative, who are hesitant to share about themselves, or who are expecting to be in a less active participant role, may not be suitable candidates for this work. Although supervisees are not expected to be resistant to participation in the process of supervision, those supervisees who have had previous artistic training may have difficulty with activities where the focus is on the process, rather than the artistic product, as is regularly the case in the following interventions. Similarly, supervisees who have not received additional training in expressive arts modalities are cautioned against using expressive interventions experienced in supervision without fully understanding the appropriate use and processing with clients. Expressive Arts Interventions in Supervision Supervisors can easily find detailed descriptions of expressive arts activities, but their use in supervision relies heavily not only on the presentation or direction of a particular activity but also on the supervisor’s processing of that activity with the supervisee. Deaver and Shiflett (2011) stress the utility of expressive arts by outlining a variety of art-based supervision techniques and approaches used to conceptualize cases, increase supervisee self-awareness, explore the supervisory relationship, and facilitate counselor stress reduction. Bratton et al. (2008) suggest guidelines to be used in processing expressive arts activities in supervision, varying according to the level of control held by the supervisee over what is shared about the activity: Level 1: Supervisor encourages supervisees to describe/share their creations: “Tell me about your (scene or drawing or creature).” Level 2: Supervisor tentatively shares his or her observation of the process/creation: “I noticed that Pegasus and the fairy seem very connected . . . and they both have wings and seem kind of sad.”

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Level 3: Supervisor invites supervisees to enter into the metaphor they have created: “Pretend that you are the fairy (client) and tell Pegasus (supervisee) what you need.” Level 4: Supervisor encourages supervisee to personalize the metaphor: “As you think about how you described Pegasus, does anything fit with how you see yourself?” (p. 217). Assessing the developmental skill level and readiness of the supervisee along with the strength of the supervisory relationship will allow a supervisor to ascertain which level of processing is warranted with each expressive arts activity used. Given the wide-ranging nature of interventions that encompass expressive therapies, this chapter focuses on four specific expressive arts interventions that can be used when supervising from a Gestalt perspective: the use of drawings, the use of clay, experiential role-plays, and the use of objects. Each intervention can be adapted from an individual supervision focus to that of a group supervision focus. Use of Drawings Drawings allow supervisees to facilitate communication and offer a visual to express what is sometimes difficult to verbalize. For instance, artwork may provide a picture of what may help them manage anxiety, direction, and goals in their work with clients, or how the clients may begin to find solutions. Malchiodi (2005) refers to the experience of the use of art as healing and a way to bring self-understanding and behavioral changes. At times, the supervisor may use drawings to represent what he or she hears the supervisee saying during supervision (Fall & Sutton, 2004). This helps illuminate the message shared in supervision and speeds the process of coming to a resolution or the next step in handling a client issue. Lahad (2000) presents a color, shape, and line activity whereby the supervisee is asked to represent relationships in a client’s life through the drawing of shapes and lines using color. The processing of this exercise included the supervisee filling in a “color chart” where he or she gave descriptions of each person’s selected color according to the ideas indicated in the chart: “first association, tempo, weight, animal, season, clothing, and scenery” (p. 27), along with exploration of how each color affected his or her work with the client and the client’s family. Haber (1996) also reminds us that the use of art changes the medium in supervision and provides different perspectives. Gladding (2005) offers two examples of the use of drawings: helping a client to alter his or her perception of a problem from being insurmountable to manageable, and helping a supervisee assess his or her own mental health by identifying strengths as well as defeating statements and behaviors. Lahad (2000) also describes the use of drawings when problem solving with a supervisee. The supervisee is asked to draw three pictures: one of the client’s current problems, one with the problems solved, and ultimately one picture of what happens before the resolution. Oster and Crone (2004) discuss the benefit of drawings as “excellent tools for interpretation and for enhancing the therapeutic framework. They are permanent records of progress or deterioration and cannot easily be denied” (p. 182). Fall and Sutton (2004) describe the use of artwork in accomplishing important functions of a supervisor, from assessing the supervisee formatively, serving in a supportive capacity, to an administrative capacity. Supervisees were asked to draw a picture indicating where they saw themselves in relation to becoming professional counselors. The bridge of life (Casado-Kehoe, 2006) activity presented at the end of this chapter sheds light on the processing of this type of professional growth and development activity. Other directives include asking the supervisee to draw his or her best and worst supervision experiences and to draw “helping hands” that demonstrate who has helped him or her get to his or her current position, as well as who he or she has helped along the way (Stewart & Echterling, 2008). Use of Clay Clay serves as another material often used in expressive arts interventions. Gladding (2005) noted the infrequent use of clay because of its manipulation difficulty and messiness. Over

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the years, new versions of claylike materials have been developed, as seen in Bratton et al. (2008) who describe the ease of use of Play-Doh and Model Magic in a similar fashion as clay. Manipulation of this artistic medium allows for creative expression by the supervisee, through sensory experiences and a cathartic release of feelings. If the supervisee is anxious, the use of clay can reduce anxiety and help bring insight. Supervisees feel empowered because the final product, using clay, is entirely in their hands; that is, they are in complete control of the clay (Gladding, 2005). In supervision, clay may be used to create symbols that facilitate the development process and help the supervisee to use his or her senses in symbolic expression of his or her thoughts, emotions, expectations, and needs. In their supervision of play therapists in training, Bratton et al. (2008) describe an activity where supervisees participating in group supervision use clay to create a creature or animal that represents them. Once completed, the supervisor processes with each supervisee by asking: “What is your animal/creature good at? What is hard for your creature to do? What kinds of things does your creature like to do? What does it wish it could do? What does it wish it did not have to do? What does your creature need? What keeps your creature from getting what it needs?” (Bratton et al., 2008, p. 219). Follow-up discussions of needs in supervision are facilitated through the answers given by each supervisee. The possibilities of directions given by supervisors in the use of clay are limitless. Additional examples of use of sculpting are creating a sculpture that represents the supervisee as a counselor, creating a sculpture of a part of the supervisee that is anxious about clients, creating the wall that is felt between the supervisee and his or her client, and asking the supervisee to create the family with which he or she is working to explore family dynamics (Malchiodi, 2005). Role-play The use of role-plays allows for opportunities to test out new behaviors and to explore hidden aspects of the supervisee as well as the client. Gladding (2005) points out that the use of drama helps focus on communication and the roles individuals may play in life. While acting, the supervisee gains awareness of what may be going on with the case as well as how he or she comes across and impacts the client. At the same time, when using dramatic techniques, the counselor may be more aware of a range of feelings he or she is experiencing in and out of the counseling session. Harman and Tarleton (1983) discuss boundary disturbances in counseling relationships and how supervisees may find themselves to be ineffective in counseling when they are too similar to their clients, or when they are having feelings, usually negative, that the supervisees are not verbally expressing. Role-playing in this situation, using Perls’s empty chair technique, helps bring these situations and emotions to light, facilitating an honest exploration of what is occurring in counseling, and where to go next on the part of the supervisee. Melnick and Fall (2008) remind us of Perls’s focus on Gestalt techniques, particularly creative experiments, where the supervisee is asked to try something in that moment of supervision, for the purpose of increasing awareness. Group supervision allows for more than just the supervisor’s reaction to a counselor’s role-play, so “if the group is bored when a therapist . . . role-plays his patient, it is almost certain that the therapist himself (perhaps unconsciously) is bored with the patient” (Mintz, 1983, p. 20). Furthermore, asking the supervisee to become and role-play the patient allows for a more-in-depth presentation and understanding of the client, reveals what the counselor really feels toward the client, highlights the client’s feelings, and the therapist may become “aware that the patient has touched an area of insecurity or pain which the therapist has not completely resolved” (Mintz, p. 23). As a follow-up, Mintz allows the opportunity to test out new behaviors that may be seen as solutions to the impasse, and reports that clients typically respond favorably to counselors experiencing this type of role-play. Variations on the role-play technique can also include asking the counselor to role-play the client talking with a friend about therapy and its progress, and role-playing the client’s feelings not being expressed in counseling (Mintz, 1983). Stewart and Echterling (2008) highlight

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the playful nature of role-play in supervision with the activity called “tag team role-playing.” Building on the therapeutic nature and strength of relationships found in groups, supervisees are called on to help each other by jumping in or “tagging out” when a supervisee needs help in the role-play. Supervisees are encouraged to role-play not only positive outcomes in counseling but also situations they fear the most, creating an opportunity to practice responses before the situation occurs in session. Use of Objects Objects or miniatures can easily be used in the supervision process, serving as an alternative method of conceptualizing cases, discussing counselor development, or planning for treatment interventions with clients. Small objects, including buttons, rocks, marbles, buckles, shells, beads, character miniatures representing various ethnicities and cultures, animals, coins, or any other small object that is readily available can be used for this approach. Stewart and Echterling (2008) propose the use of objects in supervision to discuss valued qualities in the supervisory relationship. Supervisees are directed to select an object or symbol that represents this quality and speak to the object’s representative qualities. Lahad (2000) also proposes using objects to conceptualize cases by including various family members who form part of the client’s life represented as objects to help understand the relationships and family dynamics. The objects can serve as metaphorical symbols that may also contain deeper meaning about the client and family. The supervisor may also ask the supervisee to place or select an object representing self to discuss clients’ perception of the therapist. Haber (1996) also concludes that these metaphorical objects may serve as a way to represent the different parts of the counselor–client relationship. Furthermore, Lahad refers to the use of small objects and their positioning to represent a story, also called a “spectogram.” The use of small objects in the spectrogram signifies various individuals, relationships, group structures, or perspectives in a given situation. The person working with the objects is asked to move the objects around in such a way that a picture can also be gained from the placement and movement of the objects, yielding awareness and new perspectives about the case. Supervisees can also be asked to take the perspective of another in this scenario, moving objects according to how that person may view the given situation. MULTICULTURAL CONSIDERATIONS In supervision, like in counseling and counselor education, we recognize the need to address multicultural issues and how those may affect the supervisor–supervisee relationship. Each supervisee experience is different, despite the sameness we may all share. Eagle, Haynes, and Long (2007) highlight the importance of addressing multicultural differences in supervision as counselors working in community clinics work progressively more with culturally different clients. As supervisors, we recognize that idea and embrace the multiple perspectives that supervisees may bring as they work with clients of diverse backgrounds. Borders and Brown (2005) stress undetected biases and assumptions can influence supervisory behavior and “it is the supervisor’s responsibility to introduce multicultural issues early in the supervision relationship, to check in about them often, and invite the supervisee to discuss them at any time, regarding both the counseling relationship, and the supervision relationship” (p. 70). Failing to attend to multicultural issues in supervision greatly reduces the possibility of supervisees continuing to expand their own awareness. As a result of a critical incident in supervision, “(supervisees) experienced a change in personal awareness and gained understanding, attention, or insight on how culture affected them or the counseling and supervision processes” (Borders & Brown, 2005, p. 74). Consider the impact of an opposite experience: “internalization of self-doubt and

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incompetence when they (supervisees) perceived supervisors not open to discourse about race . . . believed they were doing something wrong” ( Jernigan, Green, Helms, Perez-Gualdron, & Henze, 2010, p. 69). Supervisors may even use specific techniques that tap into the richness of the supervisee’s culture. For instance, as they use the bridge of life activity, the supervisor may ask questions such as, “Tell me about your world. What are the values that guide your ways of being in this world? How does your culture inform your decisions?” One cannot forget the impact of cultural differences between the supervisor and the supervisee (Fong, 1994). With that in mind, the supervisor facilitates multicultural conversations and creates a safe container where differences can be respected and valued. By culture, we mean ethnic background, race, gender, sexual orientation, disability, social status, among others. Early on in the supervisory relationship, we address these cultural factors as well as negotiate the power differential that supervision brings. Creative techniques can be used to facilitate this discussion and enhance bonding. As supervisors, we are open to looking within and exploring how our own culture impacts every supervisory encounter we have with others. We are mindful of how expressive arts activities can facilitate a deeper understanding of culture and seek consultation and supervision as needed. CONCLUSION Supervision of counseling students is an essential part of training for their future professional role. A supervisor may focus on a variety of supervision issues including client-centered issues, therapist-centered issues, or process-centered issues. Through discussions with the supervisee, the supervisor assists in discussion, interpretation, evaluation, and change. The relationship of supervisor and supervisee can be greatly enhanced by the expressive arts interventions that provide optional insight and solutions for issues.

Expressive Arts Interventions

A PICTURE AND A THOUSAND WORDS: COUNSELING THEORY STUDENT MANDALA COLLAGE Angela L. Anderson and Kristi Perryman

Indications: This semester-long activity is designed to help counseling students develop a thorough understanding of the theories presented throughout the course. Goal: To engage students in the concepts of various theoretical orientations of counseling and to allow students to provide a visual representation of their own developing personal theory Modality: Art The Fit: One of the major challenges in teaching counseling theories is to help students relate to the material in a personal and applied way. Students must be taught to be more than “consumers” of facts about the therapeutic processes and to engage them in an active process of critique, dialogue, exploration, self-awareness, and finally, development of their own delivery system of counseling. Current literature stresses the evolution of therapy to a more integrated approach in an increasingly pluralistic world (Downing, 2004; Lampropoulos, 2000; Wilber, 2000). Parrot’s (1993) assertion that students should be taught “skill in theorizing” would support the use of critical thinking and expressive skills in developing a student’s integrative approach. The authors are interested in presenting information in an experiential way and giving students an opportunity to explore meanings through visual and artistic processes. As Robbins (1994) describes, “[T]he image pulls together many levels of the psyche and can make a more accurate and complex statement of cognition than any verbal interpretation” (p. 41). Populations: Counselors-in-training; Groups/individuals Materials: Poster board or heavyweight drawing paper (18 × 24 in.); a variety of magazines; markers, crayons, oil pastel crayons. For each group mandala or theory, draw a large circle on the paper and hang on the wall for each student to contribute his or her image. Instructions: 1. After completing relevant readings for each theory, ask students to identify and bring to class a small image (a magazine cutout, clip-art, photo, etc.) that represents the theory or a significant aspect of the theory from their perspective as well as a reflective journal entry that addresses the resonance or personal experiences they have with the theory or its concepts as well as describing the ways in which their image relates to the theory. 2. During class, ask each student to explain his or her image choice and its connection to the theory while attaching the image to a large poster board mandala, creating a “group” image. 3. In a group discussion of the mandala, explore concepts that were represented by multiple images or students, note concepts that were omitted from the mandala, and explore any new connections/understanding students experience through the activity. You may want to reiterate specific aspects of the theory and to make use of teachable moments to clarify the material covered prior to the class meeting. As each new theory is covered, a new mandala will be created using this process. 268

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4. At the end of the semester, ask students to retrieve their own individual contributions from

each week’s mandala and to create a “personal theory” mandala. Let students know that they may use all, part, or none of their images from the semester. Ask students to create a final response paper that describes their image and its relation to their personal theory.

BRIDGE OF LIFE Montserrat Casado-Kehoe and Kathy Ybañez-Llorente

Indications: This activity is appropriate for supervision sessions in which you want to explore

how supervisees feel about their professional life accomplishments and goals and what helps them in that process. Goals: To enhance self-awareness, identify accomplishments and coping mechanisms, explore feelings, and build self-esteem Modality: Art The Fit: This activity can be used individually, in dyads, or in a group setting in supervision. This activity is inspired by another activity, “bridge drawing,” which focuses on allowing the client to see where he or she is on the bridge and in which direction he or she is moving (Hayes, 2006). However, the bridge of life (Casado-Kehoe, 2006) focuses on looking at the bridge as a metaphor for where the supervisee is in life, looking at what he or she has accomplished up to this point (past and present), and what lies ahead that he or she is planning to achieve (future goals). At the same time, the drawing also identifies the pillars of resources that the supervisee has used to help him or her get where he or she is in life. Individually, the activity can be used to help the supervisee gain awareness of what he or she has accomplished, a moment to pause and reflect on self, and build self-esteem. In dyads or in group, the activity can also be used at the beginning of the supervisory process to enhance group awareness and cohesion, assist in creating goals, and help develop self-confidence. However, it can also be used at the end of supervision to celebrate accomplishments, focus on strengths, and foster self-esteem. Artwork serves as a form of nonverbal communication of feelings, thoughts, and worldviews (Malchiodi, 2005). Drawings can allow supervisees to create a visual picture to encourage processing of feelings and enhance personal awareness. The use of art, specifically the drawing, becomes a vehicle of communication that focuses on the here and now. Gestalt therapy emphasizes the relevance of the I–Thou relationship, one that promotes dialogue in the here and now as a way to create growth of awareness (Pack, 2009). Ideally, the supervisor wants to create this kind of relationship in supervision, so supervisees can learn, grow, and flourish. The use of creative interventions such as the bridge of life facilitates that kind of dialoguing that is genuine, caring, and accepting between the supervisor and the supervisee(s). In Gestalt therapy and supervision, the use of processing helps one develop awareness, and gain an understanding of self and others (Harman & Tarleton, 1983). Processing is a big part of what the supervisor does after the creation of the drawing as a way to promote growth and self-understanding. Populations: Clinical supervisees; Groups/individuals/dyads/triads Materials: White or colored paper, colored pencils, crayons and markers, or paints. You may also use relaxation music to promote a relaxation response and encourage focusing on the activity.

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Instructions: 1. Invite the supervisee to draw a bridge. This is his or her bridge of life (professional).

Ask the supervisee to place herself somewhere on the bridge to represent where she sees herself now. Ask her to reflect in the drawing what is behind her, particularly the things she has accomplished professionally. Also, ask her to pay attention to what lies ahead of in terms of professional or personal goals she has. Ask him or her to pay attention to what gives support, what gives life, what has helped her get here. Allow plenty of time for the supervisee to draw the bridge of life, and while drawing, you can have music playing in the background. 2. Ask the supervisee to title his or her bridge of life drawing (e.g., “Guided by light”). 3. After the supervisee has finished drawing, process the drawing with questions such as Can you tell me about your drawing? Where are you on this bridge of life? What is behind you? What have you accomplished? What is ahead of you professionally? What goals do you have? What emotions come up when you look at the drawing? How do you feel about yourself? How does your body respond? What sensations do you have? Any awareness? Any words of wisdom the drawing is giving you? 4. Note the dynamics that are present in the process. As your supervisee shares the meaning of the drawing, reflect back on what has been shared and emphasize strengths and accomplishments to foster self-esteem in the supervisee. Figures 15.1 and 15.2 show examples of the bridge of life.

Figure 15.1 Bridge of life example No. 1.

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Figure 15.2 Bridge of life example No. 2.

COLLAGE CASE CONCEPTUALIZATION Mardie Howe Rossi and Karen L. Mackie

Indications: Appropriate for clinical supervisors who wish to facilitate the development of case conceptualization skills Goal: To develop new perspectives on client issues and clarify the steps and interventions needed to facilitate change Modality: Art The Fit: The use of the expressive arts is multicultural, holistic, and nonlinear, and shows promise as a supervision method (Lahad, 2000; Lett, 1995; Levine & Levine, 1998; Neswald-McCalip, Sather, Strati, & Dineen, 2003). Diversity is increasing among students, clients, and faculty, which requires creative supervision and counseling practices to meet their needs (Henderson & Gladding, 1998; Kim & Lyons, 2003). There is an increased need for experiential methods, including expressive arts, in counseling supervision (Bratton et al., 2008; Grant, 2006). Expressive arts therapy facilitates the development of self/other awareness, new perspectives, and healing and growth (Atkins & Williams, 2007; Knill, Levine, & Levine, 2005). These goals are congruent with the goals of counseling supervision. Populations: Clinical supervisees; Groups/individuals Materials: Various magazines that include ethnic and racial diversity, various age groups, and subject matter; assorted collage materials such as feathers, colored paper, markers, paints, stickers, ribbon, buttons, printed materials, photographs, and quotes; scissors, glue sticks, and large paper or poster board (12 × 18 in.) Instructions: 1. Invite supervisee to select a client case on which he or she would like to focus for this session. 2. Instruct the supervisee to fold the large paper into thirds. 3. On the first section, have the supervisee write the word “Problem.” 4. Ask the supervisees to create a collage about the client and his or her issues. Suggest

that they use words and pictures to create a picture of the client’s thoughts, feelings, and behaviors; the cultural context of the client or his or her issues; his or her history; and relationships. Instruct supervisees to focus on what the client has told them and what they have perceived, intuited, or come to understand. 5. When they are finished with the first section, have them move to the third section, and write “Solution” at the top of the page. Instruct them to make a collage that depicts the problem solved from the client’s perspective, as well as their own. 6. When the third section is finished, ask the supervisees to write “Goals and Interventions” on the top of the paper. Ask them to imagine what interventions would be needed for the client to move from the first collage “Problem” to the third collage “Solution.” Ask them to include client behaviors, thoughts, feelings, and counseling interventions. 7. When all the sections are finished, process the activity by asking each student the following questions: What was it like for you to participate in this exercise? Did you find this activity helpful? In what ways? Did you learn anything new about your client, and/or working with your client? What can you take from the exercise that will help you in working with your client? What did you learn about yourself? Would this exercise be helpful for your client to do? These questions can also be answered through a reflective paper or journal-writing activity after the supervision session. 273

CREATING A FOUND POEM Christine McNichols

Indications: Supervisors may wish to use this technique if supervisees are experiencing a lack

of clear counselor identity, a lack of empathy for a client’s situation, or frustrations concerning the counseling relationship. Supervisors may also use this intervention to encourage reflection, promote personal well-being, or help reauthor negative supervisee narratives. Goal: To foster supervisee growth and insight Modality: Writing The Fit: Counselors-in-training create narratives that describe and explain who they are as counselors and how they view their clients. This process usually occurs through interaction and dialogue between the supervisor and the supervisee. Editing and helping to reauthor these narratives are the major goals of narrative supervision (Carlson & Erickson, 2001). Having a supervisee create a found poem helps the supervisee reflect on who he or she is as a counselor as well as how he or she views, thinks, and feels about his or her work with clients. This reflective process may help supervisees gain different perspectives, change negative views or opinions, and gain new meaning or insight. Populations: Clinical supervisees; Groups/individuals/dyads/triads Materials: Pens, paper, and highlighters Instructions: 1. Distribute materials to supervisees and write a prompt on the board dealing with what you would like the supervisees to focus on such as When I think about my client and his or her situation I feel . . . Or As a counselor I am . . . Or During the counseling session I feel . . . when . . . 2. Give supervisees 10 to 15 minutes to journal using the prompt. Encourage them to write openly about what they are experiencing. 3. When they are at a stopping point, ask the supervisees to put down their pens and pick up a highlighter. 4. Ask supervisees to highlight words or phrases in their journal entries that they feel have special meaning or stand out to them. 5. Once the supervisees have completed this task, they are asked to take the highlighted words from their journals and turn them into a poem. Not all the words must be used. It may be helpful for some to first create a separate list of the words or phrases they would like to use and then arrange them into a poem. 6. Supervisees are then asked to volunteer to share their poems by reading them aloud to the group. 7. Debrief and process the experience of writing and sharing the poems and explore any insights that may have been gained. Discussion questions may include: What was the experience of writing a poem like for you? Did anything surprise you about what you wrote in your journal or poem? If so, what is it? What insight did you gain about yourself or your client from completing this exercise? How will this insight change the way you view yourself as a counselor or how you work with this client?

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FINDING MY VOICE Allison L. Smith and K. Hridaya Hall

Indications: The activity is designed for counselor-trainees or supervisees who are expe-

riencing anxiety related to working with clients or apparently hindered or immobilized in implementing new supervision feedback or skills. It also can be beneficial for trainees of supervisees who desire a shift from a contemplative to a more active stage of change (e.g., a supervisee who expresses verbally that he or she desires to use more confrontation skills but has struggled to take action). Goal: To gain confidence in working with a challenging client or presenting concern Modality: Drama The Fit: The purpose of this expressive arts intervention is to support counseling trainees in reducing anxiety related to their work with clients and increasing their flexibility in trying on new ways of being with clients. The activity does so by highlighting through enactment the contradictory voices that may be keeping the person stuck or paralyzed. It is an application of Hal and Siddra Stone’s (1989) seminal work, “voice dialogue,” with counseling trainees. ■ ■

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The activity fits with Gestalt theory because it invites creative adjustment to one’s environment rather than acting from stereotyped patterns (Polster, 1999). Also, the activity fits with Gestalt theory because here-and-now enactment and experimentation with the counselor are used to facilitate greater integration and wholeness (Polster & Polster, 1973; Yontef, 1993). Finally, the activity fits with Gestalt theory because it serves to support individuals in shifting from a perception of being stuck to greater awareness, contact, and experimentation (Perls, Hefferline, & Goodman, 1951).

Populations: Clinical supervisees; Groups/individuals Materials: Seating that is flexible for rearranging during the activity Instructions: 1. When it is evident that an issue is present that could be explored using a dialogue, the

supervisor will explore the issue with the supervisee. Possible facilitation questions might include the following: It seems like we keep coming back to your desire to be more direct with clients but it is not happening; what do you think is getting in the way? It seems like you’re feeling really paralyzed or stuck in your work with this person. You seem pulled, on the one hand, you’re generating several possibilities for your work with this client, but on the other hand, you’re already convinced they are doomed to fail. What are some of the things that you’re saying to yourself related to your work with this person? 2. Invite the supervisee to participate in an experiment to explore the hesitance/stuckness. 3. Begin with the supervisee in a central chair that represents the face he or she normally shows to the world (in Stone’s work this is referred to as the “aware ego state”). 4. From here, have the supervisee identify a dominant voice that seems to be operating in his or her clinical work (perhaps a perfectionist, a judge, a scared child, a critic).

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5. Ask the supervisee to shift his or her chair to a slightly different location, close his or her

eyes, and internally align, embody, or act himself or herself as if he or she is that voice and only that voice. 6. When he or she is fully in role, invite him or her to open his or her eyes and begin to interview this voice. You will ask questions and offer reflections and summaries of what you are hearing. Potential questions you may ask include the following: Can you tell me about your name and role in [supervisee’s name]’s life? (Refer to the . . . separate entity.) What are your concerns about [supervisee]’s life? Are there things that [supervisee] does that irritate or frighten you? How do you operate, or let him or her know what you want? What do you think about his or her counseling? How do you influence his or her counseling approach, way of being in class/group/supervision? Is there something you’d like him or her to hear from you? Is there another player/voice that you are aware of that [supervisee] listens to sometimes that you really don’t like? 1. Summarize what you have heard from this voice and what this voice will want and need

before thanking this voice and inviting the supervisee to move the chair back to the central location and assume his or her normal way of being. Summarize to the supervisee what you heard the voice is saying. 2. Invite the supervisee to imagine what the opposite voice might be. When the supervisee is ready, invite him or her to move the chair to a new location, close his or her eyes, and get in touch with that voice. When the supervisee feels he or she has embodied that voice, invite him or her to open his or her eyes and speak only from that voice’s perspective. 3. Repeat Steps 6 and 7 with this voice, being sure to attend to how this voice is impacting his or her work with clients. 4. Invite the supervisee to move back to his or her original location now to sit opposite from where the two voices had sat, perhaps next to you. Ask the supervisee to try to hold the two opposite energies experienced and summarize what the voices said. Possible facilitation questions include: What are you aware of as you sit here? How was it for you to hear those differing perspectives? Does one or the other tend to take over the reins more often? How do you feel about that? What does any of this have to do with your work here with me in supervision, or with your clients? How do you see yourself moving forward in your work with clients given what you know now?

USING SANDTRAY IN SUPERVISION Kristi Perryman and Angela L. Anderson

Breathing in the Sea Air—Introduction: The supervision process for counselors can feel stressful and full of anxiety, more like merging into rush hour traffic than a tranquil walk on the beach. The use of a sandtray process (sandplay) in supervision can help focus the process and promote growth for both supervisors and supervisees. The techniques offered in this chapter help structure the supervision session so that both participants are invited to engage in a playful yet meaningful process as they metaphorically “breathe in” the sea air on their journey down the beach of counselor development. Taking Your Shoes Off—Rationale: Contemporary sandplay techniques were developed as a counseling modality based initially on the work of Margaret Lowenfeld (1979), who developed the “world technique” in the 1920s in London. Lowenfeld became aware that children often were not able to verbalize their feelings and she instead wanted the children to show her rather than tell her about their inner experiences. Lowenfeld credited the children with the development of her world technique as a model, as she focused on the value of play. Much of our current understanding has evolved from the efforts of Dora Kalff (1980/2003), a Swiss Jungian analyst who is credited with coining the term “sandplay.” Kalff and others have noted that adults also responded well to the symbolic representation of sandplay, finding that “the same developmental processes occurred as in children, indicating that sandplay operated on a quite primitive level of the unconscious” (Weinrib, 1983, p. 8). Both Lowenfeld and Kalff were interested in giving symbolic and creative expression to internal and external meanings. Kalff, in particular, noted that potential in sandplay, prompting various applications and modalities that have developed based on the foundation of this work (Armstrong, 2008; Carey, 1999; Oaklander, 1988; Turner, 2005). Counselor Development and Supervision: Counselor-trainee supervision may focus on didactic teaching, technical skills, self-awareness of the trainee, increased understanding of the client, and/or process of the supervisory and counseling relationships. Arguably, all of these are important elements of supervision (Bernard & Goodyear, 2014; Campbell, 2000; Falender & Shafranske, 2004). According to Keller (2008), “counselor development is an evolving process of self-exploration, awareness of personal issues and biases that can affect the counseling relationship, and enhancement of counseling skills” (p. 14). Developmental models (Stoltenberg, McNeill, & Crethar, 1994) presume that the process of becoming a counselor is essentially a process that will result in the continued development of the counselor with experience, as the supervisee expands his or her knowledge and skills through both clinical experience and supervision. Counselor-trainees’ needs in supervision change as the trainee grows in knowledge, skills, and awareness. In Bernard’s (1997) discrimination model, the components of supervision include process and intervention skills (therapeutic responses), conceptualization skills (knowledge), and personalization skills (awareness and personal development). Bernard proposes that supervisors assume different roles throughout the supervisory relationship. Thompson (2004) also discusses the complexity of counselor development. Namely, counselors-in-training transition between different stages of competency and confidence prior to achieving counselor readiness. In Stage 1 (dependency), the counselor-in-training is highly motivated yet lacks basic counseling 277

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skills. In this stage, counselors-in-training are preoccupied with learning skills necessary to become a competent counselor. In Stage II (trial and turbulence), the counselor-in-training experiences anxiety about shifting his or her view of the counseling profession from a cognitive framework to an experiential process. To lessen the anxiety, he or she will often rely heavily on the expertise of his or her counseling supervisors. Th e counselor-in-training will become involved in many interpersonal and intrapersonal experiences, and toward the end of the stage, he or she will begin taking on counselor roles. In Stage III (growth), the counselor-in-training has a deep knowledge of counseling skills and theory and strives to further enhance counselor efficacy. All of these areas are accessed in sandplay process, depending on the developmental level of the counselor-trainee. Some have quipped that there are likely as many models of supervision as there are supervisors (Campbell, 2000; Falender & Shafranske, 2004). It is our presumption that supervisors have appropriate training in supervision models and adhere to a consistent approach to which these techniques can be applied. In this chapter, we presume that the counselor-trainee is a developing and self-actualizing being, and that counselor-trainee awareness is a key component to unlocking the facilitation of the counseling process. We presume that as trainees progress, there will be a transition in complexity from a more didactic, skill-based focus to a deeper knowledge of application of counseling skills and use of the self (counselor) in the therapeutic endeavor. Sandplay has been recommended as an effective modality for supervision in a limited number of studies (Markos, Coker, & Jones, 2006/2007; Markos & Hyatt, 1999), although the professional counseling literature is sparse in its description of the use of expressive techniques in supervision, specifically sandplay. In this chapter, we highlight the importance of the value of modeling, parallel process, and increasing awareness by engaging in experiential learning. Focusing on process in supervision will raise the personal awareness of the supervisor and the counselor leading to more healthy interactions, which will ultimately benefit the most important person in the triadic system—the client (McBride, 1998). At the level of training when supervisees are applying their acquired academic knowledge to the actual process of counseling clients, supervision strategies shift accordingly to optimize growth. Because the expressive and creative arts are nonthreatening, they offer a natural transition to the deepening of the supervision process. “[S]tudents would excel in practicum experiences if they were given the opportunity for expressive freedom within a safe environment” (Markos et al., 2006/2007, p. 6). On a cautionary note, however, expressive techniques are also extremely powerful in a way that is not immediately understood. This process often taps into the unconscious, allowing those feelings under the surface to emerge in a concrete way. Once exposed, the supervisor can gently midwife the process of growth. In a chapter entitled, “Midwives of Consciousness: Supervising Sandplay and Expressive Art Therapists,” Morena (2008) writes, “Professional mentoring or supervision is the way therapists learn to apply academic knowledge to concrete situations. It is a complicated process that involves establishing a supportive relationship, sharing information, and modeling effective interventions and communication” (p. 191). Another benefit of using sandplay as a supervision modality is in introducing counselor-trainees to sandplay as a strategy for their own counseling work. When using expressive arts, it is particularly important that students experience the projective process prior to using it with a client. Through their own experience in the sandtray, counselor-trainees gain awareness of their own projections and introjects, correct those perceptions, and learn to sense a deeper potential of the therapeutic relationship. Because this occurs within an environment of unconditional positive regard with the supervisor, trainees sense the applicability to their own client work, underscoring the parallel process.

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Footprints in the Sand: Using Sandtray in Supervision

General Guidelines: 1. Supervisors should be aware of the developmental level of the trainee and modify these

instructions accordingly. 2. Start with a clean tray with smoothed sand. Figures should be neatly arranged by theme

and accessible to the supervisee. 3. Supervisors must remember to ask permission prior to touching the tray or any objects in it. 4. Remember that the power of sandplay, like other expressive techniques, lies in its ongoing

process. It taps into vital themes and growth edges in the supervisee’s process, some of which will not be readily apparent. Supervisors should be mindful of creating a holding environment for this process to begin and to encourage the counselor-trainee to continue the exploration beyond the supervision session through journaling, and so forth. 5. Supervisees should not be present when the sandtray is disassembled. Clean-up is not their job! Introductory Phase (Person-Centered): 1. Choice points for supervisor: 1.1 Specific client session 1.2 Identified supervision issue or growth edge of counselor-trainee 1.3 Recurrent themes or blocks with specific client(s) 1.4 Unrecognized counter-transference 1.5 Anxiety or resistance 2. Begin with relaxation or centering exercise. 3. Invite counselor-trainee to choose items that represent all aspects of the client situation, therapeutic impasse, theme or personal growth edge (supervisor may prompt further as processing time continues). Facilitator’s language and response should be neutral and invite the trainee to take control. Avoid using descriptions such as “what you like.” 4. If counselor-trainee asks for guidance, respond with a neutral nondirective answer that places focus back to him or her. 5. When supervisee is placing items in the sandtray, remain silent and attentive, allowing him or her to work in his or her free and protected space. The supervisor notices the order, placement, movement, and both his or her own and the supervisee’s emotional responses to the process. 6. When tray is complete, supervisor may begin processing. Working Phase (Combined Person-Centered and Gestalt): 1. The supervisor’s role is to maintain a safe working environment and resist the urge to interpret, label, or guide. Allow a person-centered emergence. 2. First, ask how the counselor-trainee feels as he or she views his or her tray. 3. At a pause, or when the trainee makes contact with the supervisor, ask if the tray is how he or she wants it. 4. Reflect his or her descriptions, statements, emotions, and feelings. 5. Ask him or her to tell a story about what is happening in the sand, and how he or she feels. 5.1 Ask if he or she is in the story, and invite him or her to add something to represent himself or herself if not. 5.2 If the supervisee is talking about someone or something else that is not there (the supervisor, etc.), ask him or her to add a figure to represent this thing or person and add it to the sand. 5.3 Invite him or her to “be” each figure as he or she plays out the story. It is important to remember that this step should include all objects (animate and inanimate alike; i.e., What are the stairs saying?). With resistance to speaking for objects, be gently persistent, But if they could speak, what would they say?

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6. Gently explore incongruent statements. 7. Additional process questions to be used when the supervisor senses trust and appropriate

timing: Is anything familiar about these feelings . . . statements for you? How do you feel when you look at it now? With permission, turn the tray to different angles, asking the supervisee to signal you when some new awareness emerges, or to see the “point of view” of a figure across the sandtray, What does it look like from here? Culminating Phase (Person-Centered): 1. Counselor-trainees are likely to signal some discomfort with the placement of objects in the sand as they describe relationships and become aware of their own counter-transference. Supervisors should prompt the supervisees to make needed changes to make the story “look the way it needs to look.” This is often a very powerful moment, and the counselor-trainee may sigh deeply or may engage deeply with the objects, almost as if the supervisor is not present. Change and fluidity are important, and help the supervisee to realize a sense of control. Remember to use person-centered skills to continue holding the free and protected space and to reflect the process without interfering. 1.1 Allow the supervisee to again describe the new story from a first-person perspective. 1.2 It is important to encourage “ownership” of the story and its changes, by following his or her pace and being attentive. 1.3 Again, turn the tray if it seems appropriate. 2. In powerful supervision sessions, the supervisor may be represented in the story, sometimes being left out of the sandtray. This represents an opportunity to address the gestalt of the supervisory relationship as it relates to both the client work and the counselor-trainee’s development in the here and now, modeling parallel process and the importance of all aspects of the triadic relationship. 3. Ask how he or she feels about the sandtray now. 4. Photograph the tray, asking the supervisee from which angle it is most meaningful. 5. Encourage the supervisee to allow this process to continue working and recommend journaling or other avenues to continue processing either individually or in future supervision sessions. 6. Remember to allow the counselor-trainee to leave the room before disassembling the tray. Counselor-trainees may reach a plateau while they process their new perceptions or awareness. Although there may be an immediate and profound impact in the next client session, it may subside for a few weeks as they continue to integrate. Supervisors should be aware of this developmentally appropriate process, and, in response, may alternate modalities of supervision to accommodate the supervisee’s learning. Ethics: Being Mindful of Marine Life and Avoiding Jellyfish: Supervisors should abide by their professional guidelines for practice (ACA Code of Ethics for counseling and ACE Code of Ethics for counselor supervision). The International Society for Sandplay Therapy (ISST) publishes its own guidelines for therapy, resulting in therapists being guided by up to three codes of ethics: state regulations, professional codes of ethics, and Sandplay Therapists of America guidelines (Hegeman, 2008). We highlight some specific ethical considerations for using sandplay and other expressive techniques in supervision. Training: As always, supervisors and counselors should avoid using techniques for which they are not adequately trained. Although training in the use of sandplay is available at various professional conferences and in some commercial offerings, according to Hegeman (2008), there were only 100 certified U.S. clinicians in the 2006 ISST. Supervisors should obtain adequate training and seek consultation when needed. In addition, effective sandplay supervisors should have a high tolerance for ambiguity, a deep trust in the self-actualizing capacity of their trainees, and strong clinical and supervisory skills and training.

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Consideration of “Self in the Sand”: The sandtray, as with other expressive modalities, represents an extension of the participant’s self, and should be regarded with the same respect and care as the supervisee himself or herself. It is not always apparent to the supervisor how identified the counselor-trainee is with his or her objects in sandplay, so a cautionary reminder is suggested for the supervisor not to touch or engage without asking. Displaying Images: Photographs and descriptions of sandplay should be protected just as therapy case notes. Avoid the temptation to display images of sandplay supervision or to use without permission. Boundaries/Dual Relationship Considerations: Boundaries are easily blurred when working with supervisees on the edges of their own personal development. Often the same awareness that blocks the supervisee is an issue that would be better served if the supervisee were to seek personal counseling. Supervisors should monitor this potential for an exploitative dual relationship and not attempt to provide personal counseling. “This caution is particularly important when the objective is increased self-awareness” (Newsome, Henderson, & Veach, 2005, p. 154). Resistance: Counselor-trainees experience resistance in supervision for various reasons: fear of being judged, internalized expectations, intimidation, fear of failure, and discomfort with trusting themselves and their own innate process, among other reasons. Although sandplay is an excellent modality for addressing resistance because it is nonthreatening and projective (it is easier to talk about things in the sand than inner process of the self ), supervisors should also keep in mind the importance of using the resistance trainees may express by choosing the timing of sandplay until trust is developed. Expediting the Self-Awareness Process: Expressive techniques expedite the process of self-awareness and, as such, are likely to blur the edges between supervisory process related to the client and personal process of the counselor-trainee. This potential is heightened when using projective and expressive techniques (Perryman, Blisard, & Cantrell, 2009). Supervisors should be aware of their own boundaries and limitations of the supervisory process. Diverse Populations: Several considerations are relevant to diverse populations, from selection of objects included in sandplay to cultural implications for individual supervisees. Supervisors should be mindful of the figures selected so that they are representative of a wide range of cultural themes, including race/ethnicity, age, religion, disabilities, sexual orientation, and gender. Supervisors may be aware of limited and often stereotypical figurines available (i.e., culturally inappropriate dress in Native American figurines). We advise having various representations of multicultural figures. Sandplay themes may be interpreted differently based on cultural meanings and these should be clarified with the supervisee. Placement of shelving should be accessible to those in wheelchairs or with other physical limitations. Contraindications: Not all students will be well suited for sandplay as a supervision modality. For some, this may be an issue of timing—supervisors should remember that the development of trust is crucial before embarking on sandplay. Trainees who are at a very early level of their own counselor identity development or those whose maturity is insufficient may not be able to engage deeply enough for a meaningful sandplay experience. In addition, students whose sensory capacities are fragile might find the process overwhelming. In such cases, limiting the number of figures or even modalities available is a recommended strategy. These trainees may be better served through other supervision strategies. Some counselor-trainees may be very resistant to the process with their resistance often rooted in deep inadequacy or fear of loss of control of the process (Boik & Goodwin, 2000). For some, this is a repeat of the role of child in their growing-up world and it triggers responses of fear. If these trainees are able to develop trust with the supervisor and embark on a sandtray, this can result in a certain healing or cathartic process.

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Purposeful Supervision: Supervisors should have the activity prepared and allow plenty of

time for the activity and process. Because sandplay can be very personally engaging and can tap deeply into the supervisee’s process, adequate time should be allowed for the counselor-trainee to emerge from the work and be able to process sufficiently before rejoining their daily activities. Making Footprints in the Sand—Conclusion: Supervisors of counselor-trainees have an opportunity to not only impact the life and development of the future counselor they supervise but also, by extension, all of the clients they will someday serve. This ripple effect should inspire supervisors to be creative and to explore ways to deepen the growth process of both themselves and their supervisees. This chapter outlined a model for structuring supervision so that both participants emerge with increased self-awareness and more openness to the process. As we continue our journey down the beach of counselor development, we note that the sets of footprints in the sand are often indistinguishable—the client’s, the counselor-trainee’s, and those of the supervisor’s. Because we are all experiencing the waves of humanness together, the growth of any one of us impacts us all, and the whole is indeed greater than the sum of its parts. REFERENCES Armstrong, S. (2008). Sandtray therapy: A humanistic approach. Dallas, TX: Ludic Press. Atkins, S. S., & Williams, L. D. (Eds.). (2007). Sourcebook in expressive arts therapy. Boone, NC: Parkway. Bernard, J. M. (1997). The discrimination model. In C. E. Watkins (Ed.), Handbook of psychotherapy supervision (pp. 310–327). New York, NY: Wiley. Bernard, J. M., & Goodyear, R. K. (2014). Fundamentals of clinical supervision (5th ed.). Upper Saddle River, NJ: Merrill/Pearson. Boik, B. L., & Goodwin, E. A. (2000). Sandplay therapy. New York, NY: W. W. Norton. Borders, L. D., & Brown, L. L. (2005). The new handbook of counseling supervision. Mahwah, NJ: Lahaska/ Lawrence Erlbaum. Bratton, S., Ceballos, P., & Sheely, A. (2008). Expressive arts in a humanistic approach to play therapy supervision. In A. A. Drewes & J. A. Mullen (Eds.), Supervision can be playful: Techniques for child and play therapist supervisors (pp. 211–232). Lanham, MD: Aronson. Campbell, J. M. (2000). Becoming an effective supervisor: Workbook for counselors and psychotherapists. New York, NY: Taylor & Francis. Carey, L. (1999). Sandplay therapy with children and families. Northvale, NJ: Jason Aronson. Carlson, T. D., & Erickson, M. J. (2001). Honoring and privileging personal experience and knowledge: Ideas for a narrative approach to the training and supervision of new therapists. Contemporary Family Therapy: An International Journal, 23(2), 199–220. Casado-Kehoe, M. (2006). [Supervision drawings: Bridge of life]. Unpublished raw data. Corey, G. (2009). Theory and practice of counseling and psychotherapy (8th ed.). Belmont, CA: Thomson Brooks/Cole. Deaver, S. P., & Shiflett, C. (2011). Art-based supervision techniques. The Clinical Supervisor, 30, 257–276. doi:10.1080/07325223.2011.619456 Downing, J. N. (2004). Psychotherapy practice in a pluralistic world: Philosophical and moral dilemmas. Journal of Psychotherapy Integration, 14(2), 123–148. Eagle, G. T., Haynes, H., & Long, C. (2007). Eyes wide open: Facilitating student therapists’ experiences with the unfamiliar. European Journal of Psychotherapy and Counseling, 9, 133–146. doi:10.1080/13642530701363270 Estrella, K. (2005). Expressive therapy: An integrated arts approach. In C. A. Malchiodi (Ed.), Expressive therapies (pp. 183–209). New York, NY: Guilford Press. Falender, C. A., & Shafranske, E. P. (2004). Clinical supervision: A competency-based approach. Washington, DC: American Psychological Association. Fall, M., & Sutton, J. M. (2004). Clinical supervision: A handbook for practitioners. Boston, MA: Pearson. Fong, M. L. (1994). Multicultural issues in supervision. Greensboro, NC: ERIC Digest. Gladding, S. T. (2005). Counseling as an art: The creative arts in counseling (3rd ed.). Alexandria, VA: American Counseling Association. Grant, J. (2006). Training counselors to work with complex clients: Enhancing emotional responsiveness through experiential methods. Counselor Education and Supervision, 45, 218–230.

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Haber, R. (1996). Dimensions of psychotherapy supervision: Maps and means. New York, NY: W. W. Norton. Harman, R. L., & Tarleton, K. B. (1983). Gestalt therapy supervision. The Gestalt Journal, 6(1), 29–37. Hayes, P. (2006, April 28). Art therapy and anxiety: Healing through imagery. Seminar provided by the Cross Country Education Seminars, Orlando, FL. Hegeman, G. (2008). Ethical dilemmas in sandplay supervision. In H. S. Friedman & R. R. Mitchell (Eds.), Supervision of sandplay therapy (pp. 67–72). New York, NY: Routledge. Henderson, D. A., & Gladding, S. T. (1998). The creative arts in counseling: A multicultural perspective. The Arts in Psychotherapy, 25, 183–187. Hoyt, M. F., & Goulding, R. L. (1989). Resolution of a transference-countertransference impasse using gestalt techniques in supervision. Transactional Analysis Journal, 19, 201–211. Jernigan, M. M., Green, C. E., Helms, J. E., Perez-Gualdron, L., & Henze, K. (2010). An examination of people of color supervision dyads: Racial identity matters as much as race. Training and Education in Professional Psychology, 4(1), 62–73. doi:10.1037/a0018110 Kalff, D. (1980/2003). Sandplay: A psychotherapeutic approach to the psyche. Cloverdale, CA: Temenos Press. Kaplan, M. L., Kaplan, N. R., & Serok, S. (1985). Gestalt therapy’s theory of experiential organization and mutual support processes in psychotherapy and supervision. Psychotherapy, 22(4), 687–695. Keller, E. (2008). The effects of an expressive arts group on female counselors-in-training: A qualitative study (Unpublished master’s thesis). Missouri State University, Springfield, MO. Kim, B., & Lyons, H. (2003). Experiential activities and multicultural counseling competence training. Journal of Counseling and Development, 81, 400–408. Knill, P. J., Levine, E. G., & Levine, S. K. (2005). Principles and practice of expressive arts therapy: Toward a therapeutic aesthetics. London, UK: Jessica Kingsley. Lahad, M. (2000). Creative supervision: The use of expressive arts methods in supervision and self-supervision. London, UK: Jessica Kingsley. Lampropoulos, G. K. (2000). Evolving psychotherapy integration: Eclectic selection and prescriptive applications of common factors in therapy. Psychotherapy, 37, 285–297. Lett, W. (1995). Experiential supervision through simultaneous drawing and talking. The Arts in Psychotherapy, 22(4), 315–328. Levine, S. K., & Levine, E. G., (1998). Foundations of expressive arts therapy: Theoretical and clinical perspectives. Philadelphia, PA: Jessica Kingsley. Lowenfeld, M. (1979). The world technique. London, UK: George Allen & Unwin. Malchiodi, C. A. (1998). The art therapy sourcebook. New York, NY: McGraw-Hill/Contemporary Books. Malchiodi, C. A. (Ed.). (2003). Handbook of art therapy. New York, NY: Guilford Press. Malchiodi, C. A. (Ed.). (2005). Expressive therapies. New York, NY: Guilford Press. Markos, P., & Hyatt, C. (1999, Summer). Play or supervision? Using sandtray with beginning practicum students. Guidance & Counseling, 14(4), 3–6. Markos, P. A., Coker, J. K., & Jones, W. P. (2006/2007). Play in supervision: Exploring the sandtray with beginning practicum students. Journal of Creativity in Mental Health, 2(3), 3–15. McBride, M. (1998, Summer). The use of process in supervision: A gestalt approach. Guidance & Counseling, 13(4), 41–50. Melnick, J., & Fall, M. (2008). A gestalt approach to group supervision. Counselor Education & Supervision, 48, 48–60. Mintz, E. (1983). Gestalt approaches to supervision. Gestalt Journal, 6(1), 17–27. Morena, G. D. (2008). Midwives of consciousness: Supervising sandplay and expressive art therapists. In H. S. Friedman & R. R. Mitchell (Eds.), Supervision of sandplay therapy (p. 191–197). New York, NY: Routledge. Neswald-McCalip, R., Sather, J., Strati, J. V., & Dineen, J. (2003). Exploring the process of creative supervision: Initial findings regarding the regenerative model. Journal of Humanistic Counseling, Education, and Development, 42(2), 223–237. Neukrug, E. (2007). The world of the counselor: An introduction to the counseling profession (3rd ed.). Belmont, CA: Thomson Brooks/Cole. Newsome, D. W., Henderson, D. A., & Veach, L. J. (2005). Using expressive arts in group supervision to enhance awareness and foster cohesion. Journal of Humanistic Counseling, Education & Development, 44(2), 145–157. Oaklander, V. (1988). Windows to our children: A gestalt therapy approach to children and adolescents. Highland, NY: Gestalt Journal Press. Oaklander, V. (2007). Hidden treasure: A map to the child’s inner self. London, UK: Karnac. Oster, G. D., & Crone, P. G. (2004). Using drawings in assessment and therapy: A guide for mental health professionals. New York, NY: Brunner-Routledge. Pack, M. J. (2009). Supervision as a liminal space: Towards a dialogic relationship. Gestalt Journal of Australia and New Zealand, 5(2), 60–78.

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Parrott, W. G. (1993, August). Teaching skill in theorizing. Paper presented at the annual meeting of the American Psychological Association, Toronto, Ontario, Canada (ERIC Document Reproduction Service No. ED 371 280). Perls, F. S., Hefferline, R. F., & Goodman, P. (1951). Gestalt therapy: Excitement and growth in the human personality. New York, NY: Julian. Perryman, K. L., Blisard, P. D., & Cantrell, N. (2009). Floratherapy handbook (2nd ed.). Unpublished manuscript. Polster, E., & Polster, M. (1973). Gestalt therapy integrated: Contours of theory and practice. New York, NY: Brunner-Mazel. Polster, M. (1999). Gestalt therapy: Evolution and application. In E. Polster, M. Polster, & A. Roberts (Eds.), From the radical center: The heart of gestalt therapy: Selected writings of Erving and Miriam Polster (pp. 96–115). Cambridge, MA: GIC Press. Resnick, R. F., & Estrup, L. (2000). Supervision: A collaborative endeavor. Gestalt Review, 4(2), 121–137. Robbins, A. (1994). A multi-modal approach to creative art therapy. London, UK: Jessica Kingsley. Ruiz, C. (2009). Distintos enfoques en terapia de juego: Psicoanálisis, gestalt, estratégico y arenero [Different approaches to play therapy: Psychoanalysis, gestalt, strategic therapy, and use of sandtray]. Unpublished manuscript. Stewart, A. L., & Echterling, L. G. (2008). Playful supervision: Sharing exemplary exercises in the supervision of play therapists. In A. A. Drewes & J. A. Mullen (Eds.), Supervision can be playful: Techniques for child and play therapist supervisors (pp. 281–307). Lanham, MD: Aronson. Stoltenberg, C. D., McNeill, B. W., & Crethar, H. C. (1994). Changes in supervision as counselors and therapists gain experience: A review. Professional Psychology: Research & Practice, 23, 633–648. Stone, H., & Stone, S. (1989). Embracing our selves: The voice dialogue manual. San Rafael, CA: New World Library. Thompson, J. M. (2004). A readiness hierarchy theory of counselor-in-training. Journal of Instructional Psychology, 31(2), 135–142. Turner, B. A. (2005). The handbook of sandplay therapy. Cloverdale, CA: Temenos Press. Weinrib, E. L. (1983). Images of the self. Boston, MA: Sigo Press. Wilber, K. (2000). Integral psychology: Consciousness, spirit, psychology, therapy. Boston, MA: Shambhala Publishers. Yontef, G. M. (1993). Awareness, dialogue & process: Essays on gestalt therapy. Highland, NY: Gestalt Journal Press.

III Additional Clinical Uses of the Expressive Arts

16 Adventure Therapy Mark Gillen

FOUNDATIONS OF ADVENTURE THERAPY Adventure therapy, or therapy in an outdoor setting, has many origins. Williams (2000) described the first evidence of adventure therapy after the 1906 San Francisco earthquake. After buildings at the Agnew Asylum were destroyed, Williams described how patients were forced to live in tents, set up on the asylum grounds, and assisted in the reconstruction of the city. The staff was surprised to find that many of the patients showed immediate and remarkable changes in their behavior. There has been a long history of providing therapy using camping and other outdoor experiences to maladjusted children. Specialized camps, like the University of Michigan Fresh Air Camp, offered controlled experiences, creative learning opportunities, real living situations, and excitement without the client reverting to antisocial behavior (Morse, 1947). Such camps also provided therapists an opportunity to observe clients for a continuous period. However, most researchers agree that adventure therapy evolved from the Outward Bound tradition (Russell, 2001). Outward Bound, a term used to designate the leaving of a safe harbor for a journey into the unknown, originated with Kurt Hahn, an educator, to promote inner qualities of survival. Hahn sought to accomplish this by enhancing emotional and physical ability to deal with stressful events (Pommier, 1994). In the 1960s and 1970s, Outward Bound gained reputation as an alternative treatment to incarceration for delinquent adolescents. Early researchers of adventure therapy posited that change occurred because of Hahn’s orientation toward character development (Russell, 2001). Defining Adventure Therapy The definition of adventure therapy has continued to evolve through the years. Many definitions developed from the idea that adventure therapy was the use of traditional therapy techniques in a wilderness setting with therapeutic intent (Russell, 2000). Davis-Berman and Berman (1993) supported this definition when they described adventure therapy as planned and systematic use of traditional therapy in an outdoor setting. Pommier (1994) stated that adventure therapy combined experiential learning with therapy. The author stated that adventure therapy occurred when clients were integrated into unique environments as participants, where the activities were real and the information gained was 287

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present- and future-oriented. Pommier stated that adventure therapy was an intervention that presented clients with activities that challenged dysfunctional behaviors and rewarded change. Adventure therapy has also been defined as an active approach that included behavioral change, adventure activities, and unique outdoor settings as the therapeutic milieu (Gillis & Simpson, 1991). Alvarez and Stauffer (2001) agreed that adventure therapy was any intentional use of adventure tools to guide change toward therapeutic goals. Itin (2001) added another layer to the definition of adventure therapy stating that adventure-based practice included change directed at the meta-process level, as well as concrete behaviors, cognitions, and feelings. Itin contended that therapy began only when counselors focused on the unconscious and relevant historical issues. Components of Adventure Therapy Beyond the definition lie the attributes or components of adventure therapy, which include effective processing with clients, immediate and direct consequences for behavior, and behavioral reinforcement that occurs in a unique learning environment (Pommier, 1994). Adventure therapy usually incorporates phases through which clients make progress and during which accomplishment of tasks related to future goals is made possible (Russell, 2001). Kiewa (1994) stated that in effective adventure therapy, clients must first do something and then reflect on it. Kiewa believed that client tasks must have meaningful reality, the consequences must be clear, trust must be included as a component of growth, the client must have choices, and there must be an environment where success is possible. Pommier (1994) synthesized the components of adventure therapy into experiences where clients (a) confronted fear; (b) experienced trust; (c) received immediate, concrete feedback; and (d) experienced consequences. Activities that required the engagement of clients were seen as essential change elements of adventure therapy. What were oftentimes perceived as high-risk activities by the client were actually contrived situations where the perception was greater than the actual risk (Mitten, 1994). Mitten contended that the use of high-risk activity, such as rock climbing, may have enhanced one’s self-esteem; however, it may also have led to negative outcomes if the emotional stress caused by the activity led the client to make poor judgments. Likewise, activities with higher perceived risk increased the dependency of clients on leaders as opposed to supporting self-efficacy (Mitten, 1994). Alvarez and Stauffer (2001) declared that activities should be based on an assessment by the therapist and that these adventure therapy activities create corrective life experiences. Alvarez and Stauffer stated that a counselor must assess the strengths and limitations of the client and plan activities that could be learned and transferred into other parts of the client’s life. An important step in this process was the framing of treatment goals (Marx, 1988). Marx stated that treatment-goal planning or behavioral contracting assisted the client and the counselor to clearly communicate their expectations, as well as develop behavioral tasks. Activities and consequences may be core elements of adventure therapy; however, their effectiveness was suspected without an empathic connection to staff (Russell, 2001). Counselors in the outdoors have practical skills that clients required, including knowledge about how to stay warm, to cook, to backpack, to canoe, or to stay safe when crossing a river. These skills and the interactions between clients and staff allow for the formation of a powerful therapeutic alliance (Williams, 2000). Each adventure therapy program differed in the way that adventure therapy is used. For example, Outward Bound used the natural environment to support individual learning. The components that they used were physical activity, intentional use of stress, group work,

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and the strengthening of cause and effect relationships through the acquisition of new skills (Doud, 1977). The Outward Bound model placed the client in a unique physical and social environment in which he or she was expected to examine problems, solve problems, and repeat learned behaviors (Kiewa, 1994). Characteristics of this approach included group processing, incremental challenges with high perceived stress, and therapeutic techniques used in a wilderness environment (Russell, 2001). Another commonly imitated adventure therapy program has been known as “adventure-based counseling.” This holistic counseling milieu included behavioral, affective, and cognitive experiences. It is characterized when clients participate in activities that encourage physical and emotional trust building. This behavior leads to goal setting, challenging situations, and continuous feedback to the participants regarding their behavior (McNamara, 2001; Schoel, Prouty, & Radcliffe, 1988). Theory and Practice Gillis and Simpson (1991) described successful adventure therapy programs as those that focused on a target group; aimed to promote long-term change; provided an opportunity for the learning of new coping skills; strengthened interactions with home, school, and community; and collected rigorous analytical data. Combs (2001) established that changes in client behavior occurred, but research has been confounded by variables influencing empirical evidence. For example, adventure therapy often takes place as a part of a larger therapeutic environment, such as long-term residential facility or day treatment program where the efficacy of an adventure therapy program can be difficult to establish. There are also concerns about the analytical rigor of adventure therapy programs. Mitten (1994) stated that there were no set standards for processing in adventure therapy: no body of research that identified how changes were made, for whom the changes could be predicted, or the duration of the changes. Parker (1992) agreed that the empirical support for adventure therapy was hindered by poor controls, inadequate sample sizes, insufficient follow-up, short treatment, and a lack of theoretical models. Researchers of adventure therapy may also have contributed to the lack of analytical rigor. Investigators may have become so invested in the process of adventure therapy that they assumed outcomes related to treatment effects (Parker, 1992). Levitt (1994) supported this contention and stated that those who love the environment and argued for its benefits might hope that there is something inherently unique that caused favorable effects. Researchers may also have focused on outcome variables to the detriment of the theory behind changes within adventure therapy (McNamara, 2001). Another early concern is the lack of research on the ways in which adventure therapy actually promoted change in the behavior of adolescents (Russell, 2000), the most commonly studied adventure therapy population (McNamara, 2001). Adventure therapy seemed to work with clients who had experienced trauma (Mitten, 1994), exhibited conduct-problem behaviors (Pommier, 1994), or suffered from lack of trust, interpersonal problem-solving deficiencies, depression and anxiety (Williams, 2000). However, more research is needed to define the underlying basis for change within this population when treated in the outdoors. Researchers agree that physically demanding and stressful situations seem to support growth and interpersonal effectiveness, trust enhancement, and an internal locus of control (Doud, 1977; Mitten, 1994; Parker, 1992; Russell, 2000). Regardless of the type of adventure therapy adopted by a counselor, it should include a theoretical basis with clear assumptions and outcomes (Russell, 2001). Theory is intended to inform practice. Without a working theory as a guide, important decisions are made with less skill and less effect (Schoel, Prouty, & Radcliffe, 1988).

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CONCLUSION To summarize, adventure therapy occurs primarily in outdoor settings. The emphasis is on experiencing challenging activities that promote behavioral change. Additionally, the activities are accompanied by feedback regarding the immediate and direct consequences of behavior in a unique learning environment. The therapy incorporates steps and phases through which each client progresses allowing for processing and reflection at each marker. REFERENCES Alvarez, A. G., & Stauffer, G. A. (2001). Musings on adventure therapy. The Journal of Experiential Education, 24(2), 85–91. Combs, S. E. (2001). The evaluation of adventure-based counseling with risk youth (Doctoral dissertation, Boston College, 2001). Dissertation Abstracts International, 62, 1569. Davis-Berman, J. L., & Berman, D. S. (1993). Wilderness therapy: Foundations, theory, & research. Dubuque, IA: Kendall Hunt. Doud, R. S. (1977). The effects on self of a twenty-three day experiential wilderness program for adults: Implications for counseling (Doctoral dissertation, Western Michigan University, 1977). Dissertation Abstracts International, 38, 6531. Gillis, H. L., & Simpson, C. (1991). Project choices: Adventure-based residential drug treatment for court-referred youth. Journal of Addictions and Offender Counseling, 12(1), 12–27. Itin, C. (2001). Adventure therapy: Critical questions. The Journal of Experiential Education, 24(2), 80–84. Kiewa, J. (1994). Self-control: The key to adventure? Towards a model of the adventure experience. Women & Therapy, 15(3–4), 29–41. Levitt, L. (1994). What is the therapeutic value of camping for emotionally disturbed girls? Women & Therapy, 15, 129–137. Marx, J. D. (1988). An outdoor adventure counseling program for adolescents. Social Work, 33(6), 517–520. McNamara, D. N. (2001). Adventure-based programming: Analysis of therapeutic benefits with children of abuse and neglect (Doctoral dissertation, University of South Carolina, 2001). Dissertation Abstracts International, 53, 4964–4965. Mitten, D. (1994). Ethical considerations in adventure therapy: A feminist critique. Women & Therapy, 15(3–4), 55–84. Morse, W. C. (1947). Some problems of therapeutic camping. The Nervous Child, 6(2), 211–224. Parker, M. W. (1992). Impact of adventure intervention on traditional counseling interventions (Doctoral dissertation, The University of Oklahoma, 1992). Dissertation Abstracts International, 53, 4964–4965. Pommier, J. H. (1994). Experiential adventure therapy plus family training: Outward Bound School’s efficacy with status offenders (Doctoral dissertation, Texas A&M University, 1994). Dissertation Abstracts International, 55, 3311. Russell, K. C. (2000). Exploring how the wilderness therapy process relates to outcomes. The Journal of Experiential Education, 23(3), 170–176. Russell, K. C. (2001). What is wilderness therapy? The Journal of Experiential Education, 24, 70–80. Schoel, J., Prouty, D., & Radcliffe, P. (1988). Islands of healing: A guide to adventure-based counseling. Hamilton, MA: Project Adventure. Williams, B. (2000). The treatment of adolescent populations: An institutional vs. a wilderness setting. Journal of Child & Adolescent Group Therapy, 10, 47–56.

17 Animal-Assisted Therapy Cynthia K. Chandler

OVERVIEW OF ANIMALASSISTED THERAPY Animal-assisted therapy (AAT) is a complex modality that requires appropriate knowledge and skill to practice effectively. The incorporation of a qualified therapy animal into a counseling session significantly increases the number and type of psychodynamics available with which to work, that is, the aggregate of motivational forces, both conscious and unconscious, that determine human behavior and attitudes. In AAT, a counselor not only attends to the psychodynamics involving the counselor and client, but also values and attends to the psychodynamics involving the therapy animal and client, as well as those involving the therapy animal and counselor. With increased psychodynamics come increased therapeutic opportunities. In AAT, a therapy animal is valued as a social being with whom the client desires to relate. The human therapist is the primary therapeutic agent for change, and the therapy animal serves as a secondary therapeutic agent for change. FOUNDATIONS OF HUMANANIMAL RELATIONAL THEORY To aid in the understanding, practice, supervision and research of AAT, I developed the Human–Animal Relational Theory (HART). In HART, AAT is conceptualized as the facilitation of human–animal interaction for the purpose of providing opportunity for therapeutic human–animal relational moments to occur between a therapy animal and counseling participants, including both the client and the counselor. From the moment the therapy animal is brought in the proximity of the client and counselor, the animal is relating to the client and to the counselor in some way. Over the course of the therapy session, many opportunities for relational moments will occur: (a) between client and therapy animal, while the counselor is observing; (b) between counselor and therapy animal, while the client is observing; and (c) between client and counselor, while the therapy animal is observing (Chandler, 2012). Any of these interactions may happen consecutively or concurrently. With multiple relational dynamics present in a session, a counselor has many therapeutic opportunities with which to recognize and process conscious and unconscious motivational forces of a client. There is much relational activity occurring during an animal-assisted counseling session. Even some of the simplest relational moments can have a big impact. For example, being greeted by a therapy dog might contribute to a warmer therapeutic atmosphere, or a client petting a therapy dog 291

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might soothe a client’s anxiety enabling the client to be more present, genuine, and less defended in a session and form a stronger therapeutic alliance with a counselor. Some human–animal relational moments may even facilitate recognition by a client and counselor of client issues that were previously not consciously realized. For instance, a therapy animal suddenly changing its position or proximity to a client may signal the animal has perceived a shift in the internal experience of a client, such as, an increase in emotional distress of the client or some other type of emotional shift. This perception might have been accomplished by the animal through its detection of visual (see), auditory (hear), tactile (touch), olfactory (smell), or gustatory (taste) cues; or perhaps via some sensory pathway of animals of which we are not currently aware. When a counselor values human–animal relational moments that occur during an AAT session and recognizes these moments may potentially reveal something important to the client, and explores with the client through counseling process what these moments may reveal, significant and often potentially greater gains can be made for clients who participate in AAT as compared to counseling without a therapy animal present. In AAT, human–animal interaction occurs offering opportunity for multiple human–animal relational moments; some of these will have a greater impact or have the potential for greater impact than others. In HART, a significant human–animal relational moment (SHARM) is referred to as a SHARM. Once a counselor and/or a client recognizes that a SHARM has occurred, it can be acknowledged and processed for therapeutic impact. It is not just that the SHARM occurred that is important, but also the effectiveness to which it is processed. Processing may occur when the moment is considered privately by a client who is processing the experienced or observed event internally, considered privately by a counselor who is processing the experienced or observed event internally, and/or considered by a counselor and client together who are processing the experienced or observed event externally. Processing of a SHARM is referred to as “human–animal relational process,” or HARP; internal processing is referred to as I-HARP, while external processing is referred to as E-HARP. It is the combination of a recognized SHARM and activated HARP together that determine the depth and type of therapeutic impact of a significant relational moment involving a therapy animal. This is represented in the formula with the following qualitative values: SHARM + HARP = HARTI (human–animal relational therapeutic impact). Insights derived from HARP affect the potential therapeutic impact, or the HARTI. I chose the term “relational” as a descriptor in HART because I believe it best represents the social dynamic that occurs in therapeutic human–animal interaction. SHARMs represent impactful events between a person and animal, an animal with which that person feels a connection or desires to feel a connection. Feelings of connection and desires for connection can result in either nurturing or challenging moments of interaction. Someone who wants a dog to bring a ball back after the person throws the ball may feel rejected if the dog takes the ball to someone else. Someone grooming a horse that refuses to lift its hoof for cleaning may feel frustrated by the horse’s lack of cooperation. Someone who has a cat snuggling in the lap may feel comforted. Both nurturing and challenging relational moments can assist conscious and unconscious motivational forces of the client, originating from past or present experiences, to be presented in the here and now, thus providing opportunity for counselor and/or client to process these constructively. Each of the examples just described reflects actual cases. When an adolescent client felt rejection because my dog Rusty did not bring the ball back to him, this provided opportunity to process his feelings in the moment with me, as therapist, and gain insight into these same feelings that were present in relationship with family members. The adolescent who felt frustrated by the horse’s lack of cooperation immediately recognized the situation was similar to the one she presents to her mother and declared, “Now I know what I put my mother through!” From her internal processing of this experience with the horse, the adolescent gained significant new insight and became motivated to change her problematic behavior at home; within one week she and her mother both reported the adolescent

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was extremely more cooperative and pleasant. The adolescent who felt comforted by my cat, Snowflake, in her lap processed with me, as therapist, that this was the most relaxed she had been in a long time. She then elaborated on her anxiety which provided opportunity for her to gain important insight. Human–animal interaction can produce more impact and be more therapeutic if a social connection or even a desire for social connection with the animal is present. And it is important the therapeutic environment allows for social relatedness to occur between client and therapy animal. The animal, however, should not be considered just as an object for interaction, as this limits the potential benefit that may be gained. A counselor must appreciate the animal as a social being and social stimulus, honoring the contributions the animal may make to the psychodynamics of counseling. A counselor facilitates human–animal relational moments by bringing a therapy animal into a session. Spontaneous relational moments occur (e.g., dog walking up to client) as well as those that may be more directed by the counselor (e.g., game of fetch between client and dog). A counselor may guide or direct the client or therapy animal in interactions to achieve certain goals, while at the same time keeping in mind the need to allow the client and animal to interact naturally. While the counselor is facilitator of AAT, the modality works best if counselors honor, value, and respect the natural state of the animal and work within those parameters. Counselors, however, should set limits on animal and human behaviors for preservation of safety and welfare of therapy animals and humans engaged in the therapy. The state, attitude, needs, desires, ability or disability of humans and animals must be taken into consideration during AAT. It is important to remember the fewer inhibitions placed on an animal’s natural social-relational behavior during therapy, within safe and comfortable limits for humans and animals, the freer the animals and humans are to relate to one another naturally, and thus greater relational opportunity can be presented for possible therapeutic gain. Human-directed activities are effective in AAT, but be mindful of how directed activities may either facilitate or interfere with relational opportunity between client and therapy animal. Just having a therapy animal present in a room or space without being directed can result in spontaneous interactions initiated either by the animal or the client. With adequate processing, these moments can be quite therapeutic for a client. Facilitating engagement between a therapy animal and a client can be accomplished with or without utilizing additional objects such as treats, toys, or agility challenges. Treats, toys, or agility obstacles, and so forth, can be used to gain the animal’s attention and direct the animal’s interaction. These objects are very helpful when a counselor wishes to have the client engage in command giving or play behavior with a therapy animal as part of the therapy session. When these objects are brought into the therapy session, however, they will direct the animal’s focus, attention, and behavior and, to some extent, predetermine the amount and type of the animal’s social engagement. What may be lost in directed activities, since the animal is otherwise occupied, is the degree to which the animal may sense, reflect, or attend to the internal state of the client or the internal state of the counselor. It is likely that a therapy animal may discern more information about personal dynamics of human participants when the animal’s attention or behavior is less directed by a counselor. Also, the more a counselor directs a client’s engagement with a therapy animal, the fewer the opportunities available for client-initiated interactions that may reflect a meaningful conscious or unconscious motivational force of the client. In some cases, a counselor may err through underutilizing or overutilizing human–animal interaction. In overutilizing, the counselor overdirects human–animal interaction in a manner that does not allow for a significant relational dynamic to occur between the therapy animal and the client. In underutilizing, the counselor fails to recognize when a significant relational dynamic is actually occurring or has occurred and the counselor misses an opportunity to point out and process that relational moment with a client. Both overutilization and underutilization are two sides of the same coin; both overutilization and underutilization can limit therapeutic opportunities in human–animal interactions. They are both symptoms of a

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counselor undervaluing the potential contribution of the therapy animal as a relational being capable of significantly contributing to the therapeutic dynamic. When a therapy animal is present in a session, it attends to the social dynamics of all beings present, including other animals and all humans. During a therapy session, the animal is not only discerning the client’s emotions and behaviors but also those of the counselor. If a counselor is frustrated with a client, the therapy animal may sense this and signal the counselor’s frustration with a client in some manner, such as attending to the counselor in a nurturing way or trying to break the tension up by redirecting attention, perhaps by bringing a toy to the counselor. A counselor must be aware of when a therapy animal is signaling something about the counselor as well as the client. COMMON SIGNIFICANT HUMANANIMAL RELATIONAL MOMENTS I have described how integration of human–animal interaction into counseling provides additional opportunities for therapeutic impact from SHARMs that may occur. It is important to recognize and process these SHARMs to enhance therapeutic value. In my work as a counselor and supervisor, I began to identify SHARMs that can tend to occur in counseling sessions and have identified them as: Greeting, Acknowledgment, Speculation, Interpretation, Comfort, Assurance, and Checking In. While the SHARMs described are quite common in occurrence, the behavior of the animal that signals a particular SHARM can vary across animals. While some animal behaviors are common within a species, it is important to remember that even within a single species, animals may have different personalities and behavioral tendencies. For instance, a particular behavior by one dog may mean something different when enacted by a different dog in a different context. It is important to become familiar with the commonly accepted meaning of animal behaviors as well to understand those behaviors that are more unique to the animal with which you are working. It is not always necessary to accurately comprehend what an animal may be communicating because therapeutic benefit may occur when clients project their own meaning onto the animal’s behavior. Following are descriptions of potential SHARMS that are commonly presented in AAT. Greeting With a Greeting SHARM, a counselor facilitates a greeting between client and therapy animal each time the client comes to a session where the animal is present. The counselor comments on the animal’s body language in response to the greeting and the possible meaning or value of this body language. This aids in conveying acceptance and warmth to a client. Acknowledgment With an Acknowledgment SHARM, a counselor or client acknowledges that the animal is communicating something of value that needs to be attended to about a person present in a session or about the animal itself. For example, an animal may demonstrate a stress signal or an alerting signal. This is one of the most valuable assets of a therapy animal, to signal when it detects an intense emotional experience of a client, even if it is not apparent from the client’s outward appearance. This is most likely due to the animal’s ability to smell the client’s emotional experience. Since human therapists lack the ability to detect emotions masked by a client’s outward appearance, the presence of a therapy animal may provide insights into issues that can be addressed in the moment that would otherwise go unnoticed. Common stress signals (sometimes called “calming signals”) or alerting signals in dogs include lip licking, eye

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blinking, looking away, yawning, quick and vigorous shake of the body, moving toward or away from the source of distress, quick bark, and so forth. Other species have some stress and alerting signals similar to dogs and also some that are different from dogs. The information being communicated by a therapy animal is highly valuable; when this communication is acknowledged and explored by counselor and client, it may significantly benefit the client. An animal’s contribution should be acknowledged to the animal also, by petting and thanking the animal, thereby reinforcing its tendency to serve this positive role. An untrained therapist working with a therapy animal might find the animal’s stress signaling and alert signaling behavior annoying or distracting and might either ignore or correct the animal. This error not only devalues the animal’s contribution but also discourages the animal from providing these important signals in the future. Speculation With a Speculation SHARM, a counselor may wonder aloud what the animal is thinking or feeling in an effort to make a point that may provide insight or awareness to the client. The counselor may also invite the client to speculate about this to provide a medium through which the client may project the client’s internal experience. In this instance, the speculation does not have to be accurate to be of value. Interpretation With an Interpretation SHARM, a counselor offers an interpretation of the animal’s behavior or asks a client to interpret an animal’s behavior to imply what the animal is experiencing or communicating. In this instance, counselors are seeking an accurate interpretation of what the animal is likely communicating. Comfort With a Comfort SHARM, a counselor reflects on the animal’s spontaneous engagement in providing comforting physical touch to the client such as snuggling, lying in the lap, or trying to lick the face or hands. With this SHARM, the animal’s perception of a client’s need for comforting is shared. Alternately, it may also reflect the animal’s desire to be comforted by a client with whom the animal feels safe. Assurance With the Assurance SHARM, a client experiences assurance or self-assurance because of how the animal behaves around the client or from a client observing some behavior of the animal. Issues of worth and safety are often involved in this SHARM. For instance, a therapy animal that chooses to engage with a client can contribute to a client’s feelings of worth. An adolescent who is exhibiting avoiding behaviors may choose to engage or participate in therapy when accompanied by a therapy animal. Checking In With the Checking In SHARM, a counselor points out the animal is checking in to make sure the client is okay or the counselor is okay. Alternately, the counselor or client can check in with the animal to see if the animal is okay in order to model care or facilitate sharing. An animal’s checking in behavior is demonstrated by its movement toward a client and sniffing

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or licking the client’s face or hand. Licking often provides additional olfactory information for some animals if that species has an additional olfactory pathway in the mouth (like dogs and cats). Thus, licking can increase the animal’s ability to discern emotion through smell. Horses increase their sense of smell by curling their upper lip to capture and hold odor molecules in the upper regions of their long nasal cavity; this is termed the “flehmen response.” This flehmen response by a horse may signal that a horse is checking in and gathering information about a client’s emotional state. My intention in labeling and describing various commonly presented SHARMs in counseling sessions is not meant to suggest these are all the SHARMs that may take place in AAT. Recognizing the occurrence of a SHARM, the related HARP, and the resulting HARTI is useful for more efficacious practice of AAT, and also valuable for teaching, supervision, and research of AAT. NEUROBIOLOGY OF SIGNIFICANT HUMANANIMAL RELATIONAL MOMENTS Current scientific understanding of social engagement by mammals provides support for ways in which human–animal interaction can contribute to the manifestation of SHARMs. Within a few minutes of the initiation of positive social interaction with a therapy animal, human hormones associated with the social response system and the experience of well-being rise: dopamine, endorphins, and oxytocin (Odendaal, 2000; Odendaal & Meintjes, 2003). Simply put, dopamine stimulates pleasure centers in the brain, endorphins lift mood, and oxytocin stimulates social connection. The effects of oxytocin are enhanced when positive touch occurs during social interaction which causes skin sensors in the one being touched to stimulate release of large amounts of oxytocin in the brain, which has multiple positive effects, including calming, uplifting mood, and social bonding; this works in a similar way for both humans and other mammalian animals (Handlin et al., 2011; Uvnäs-Moberg, 2010; Uvnäs-Moberg, Arn, & Magnusson, 2005). Animals can experience contact with humans as nurturing in much the same way as humans can experience contact with animals as nurturing. This mechanism underlies an animal’s desire to seek and provide affection that is so beneficial to a client. The stress response systems of humans and animals who are mammals are also similar. When humans and animals perceive there is a reason to be distressed, stress-related hormones such as aldosterone, cortisol, and adrenaline are released into the body that result in fight, flight, or freeze responses (Panksepp, 1998, 2005). These responses will be maintained until the human or animal no longer experiences the need to be distressed. Thus, animals can experience distress from negative social interaction in much the same way as humans, and when the animal’s behavior reflects this in response to a client, the event can promote self-insight for a client when effectively processed. While many different species of domesticated mammals participate in AAT, the most common therapy animals are dogs and horses. This is not only because of their ability to be trained, it is also because these two species are biologically designed to be a part of a social system; horses are biologically engineered to be herd animals and dogs are biologically engineered to be pack animals. Each of these species has shown a willingness, through a history of domestication, to accept humans as members of their herd or pack family. Properly socialized, horses and dogs desire to interact with humans, to give and receive nurturance, and to show concern in the presence of emotional distress. In fact, dogs especially tend to move toward a person in emotional distress to check on them and nurture them. While acknowledging the value of horses and dogs as participants in AAT, I do not discourage the incorporation of other species that can also be valuable in providing SHARMs. Horses and dogs, however, may offer a greater number of relational opportunities in therapy because social interaction is such an integral part of their makeup. Other species utilized in AAT include cats, rabbits,

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pot-bellied pigs, hamsters, gerbils, rats, birds, llamas, alpacas, and so forth. All animals should pass a standardized evaluation for temperament and aptitude before serving as a therapy animal. It is clear that scientific understanding of psychophysiological effects of human–animal interaction is consistent with the constructs of HART. HART focuses on the neurobiological activity and resulting behavior of human and animal participants in a counseling session. For instance, a SHARM between a client and a therapy animal occurs because an animal enacts purposeful behavior in relation to a client, or vice versa. This behavior is initiated from and guided by an animal’s and a client’s biologically based social response system and/or stress response systems. The occurrence of a SHARM in AAT provides opportunity for a counselor and client to explore and discern, through counseling process (HARP), possible meaning for the client of the human–animal interaction for possible therapeutic gain (HARTI). CONCLUSION HART was developed as a means for assisting counselors to better understand and utilize the contribution a therapy animal makes to the social-relational dynamics of a counseling session. When a therapy animal detects, through one of its sensory pathways, a significant emotional experience of a human client, the animal immediately responds with a genuine reaction reflective of what the animal is perceiving and conceptualizing. The animal’s reaction is manifest: through its innate social response system, by moving toward comfort; through its innate stress response system, by moving away from discomfort; and through an interaction of the two innate systems, by seeking and/or providing comfort in an attempt to alleviate discomfort in itself and/ or another being. The immediacy of authentic, uncensored behavioral responses by animals to perceived external and internal emotional experiences of a client provides a client and counselor with valuable information that may reveal something therapeutically important to the client. The more adept a counselor is at recognizing and attending to the social cues of a therapy animal, the greater benefit can be had from incorporating a therapy animal into a counseling session. HART is not meant to substitute for a counselor’s primary counseling guiding theory. On the contrary, since HART specifically addresses the human–animal interaction components of AAT, it can be implemented in a counseling session along with any existing primary counseling guiding theory. REFERENCES Chandler, C. K. (2012). Animal assisted therapy in counseling (2nd ed.). New York, NY: Routledge. Handlin, L., Hydbring-Sandberg, E., Nilsson, A., Ejdebäck, M., Jansson, A., & Uvnäs-Moberg, K. (2011). Short-term interaction between dogs and their owners: Effects on oxytocin, cortisol, insulin, and heart rate: An exploratory study. Anthrozoös, 24(3), 301–315. Odendaal, J. S. J. (2000). Animal-assisted therapy: Magic or medicine? Journal of Psychosomatic Research, 49(4), 275–280. Odendaal, J. S. J., & Meintjes, R. A. (2003). Neurophysiological correlates of affiliative behavior between humans and dogs. The Veterinary Journal, 165, 296–301. doi:10.1016/S1090-0233(02)00237-X Panksepp, J. (1998). Affective neuroscience: The foundations of human and animal emotions. New York, NY: Oxford University Press. Panksepp, J. (2005). Affective consciousness: Core emotional feelings in animals and humans. Consciousness and Cognition, 14, 30–80. doi:10.1016/j.concog.2004.10.004 Uvnäs-Moberg, K. (2010, July). Coordinating role of oxytocin. Paper presented at the Twelfth International Conference of the International Association of Human-Animal Interaction Organizations (IAHAIO), Stockholm, Sweden. Uvnäs-Moberg, K., Arn, I., & Magnusson, D. (2005). The psychobiology of emotion: The role of the oxytocinergic system. International Journal of Behavioral Medicine, 12(2), 59–65.

18 Child-Centered Play Therapy Charles E. Myers

OVERVIEW OF CHILDCENTERED PLAY THERAPY Child-centered play therapy (CCPT) is the developmentally responsive application of person-centered theory (Rogers, 1957/1992) in helping children and is “an encompassing philosophy for living one’s life in relationships with children” (Landreth, 2012, p. 53). This core philosophy builds upon the fundamental belief that all people, including children, have an innate capacity for growth and healing with an inherent inner wisdom to enact and to direct this process (Landreth, 2012; VanFleet, Sywulak, & Sniscak, 2010). Children exhibit this innate capacity for growth and healing through their play (Erikson, 1963). Although children possess these innate abilities, life experiences may significantly interrupt their natural capacity for healing (Perry, Pollard, Blakely, Baker, & Vigilante, 1995) and may require help to reignite this capacity. Children are naturally relational and seek out supportive relationships with significant others who are important to them. Child-centered play therapists recognize the importance of these two principles and strive to develop a safe and nurturing environment based on a genuinely accepting, caring, and trusting relationship. CCPT evolved from the work of Virginia Axline (1947) who developed nondirective (humanistic) play therapy based on the person-centered tenets espoused by her mentor, Carl Rogers (1957/1992). She based her approach on the belief that the natural healing process of children is central to individuation of self and the development of basic self-esteem. Axline (1969) recognized that the play of children holds meaning and that children need to feel understood and accepted. She emphasized the importance of recognizing the feelings and experiences children express through their play and reflecting that understanding back to them. The works of Guerney (1983) and Landreth (2012) contributed to the further development of today’s CCPT. FOUNDATIONS OF CHILDCENTERED PLAY THERAPY The importance of play and relationships in the lives of children provides the basis for CCPT. Play is the central activity of childhood (Landreth, 2012). Children use play to explore, organize, and understand themselves, their relationships with other people, and the world around them. Child-centered play therapists recognize play as being the most natural mode of communication

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of children (Landreth, 2012; VanFleet et al., 2010). Children naturally express their inner experiences and beliefs through play and activity. Ginott (1982) asserted toys are the words of children, and play is the symbolic language in which children communicate. The right and importance of play for children has been widely acknowledged by many, including the United Nations (United Nations General Assembly, 1990) and the American Association of Pediatrics (Ginsburg, American Academy of Pediatrics Committee on Communications, & American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health, 2007; Milteer, Ginsburg, Council on Communication and Media, & Committee on Psychosocial Aspects of Child and Family Health, 2012). Rousseau (1762/1979) recognized play as being important in the healthy development of children in the 1700s. Researchers have shown that the quality of play has a direct effect on the cognitive, affective, and social development of children (d’Heurle, 1979; Ginsberg et al., 2007) and is the most developmentally appropriate learning strategy in working with children (Bredekamp, 1987; Erikson, 1963; Montessori, 1964; Piaget, 1962). At the heart of CCPT is the belief that healing occurs in the context of a caring, therapeutic relationship between the child and the play therapist. Rogers (1957/1992) outlined Six Necessary and Sufficient Conditions for Change. These conditions occur when two persons, a child and a play therapist, meet in a therapeutic relationship (condition 1). The child experiences a state of incongruence (condition 2). The play therapist demonstrates genuineness within the relationship (condition 3), experiences unconditional positive regard for the child (condition 4), and possesses empathic understanding of the child’s internal perceptions and communicates this experience to the child (condition 5). The child perceives the play therapist as being real, warm, and accepting (condition 6). Developed upon Rogers’s (1957) six conditions, CCPT encapsulates a philosophy of attitudes and behaviors in living one’s life in relationship with children (Landreth, 2012). Child-centered play therapists hold a deep and abiding belief in the ability of children to self-direct their play in constructive ways that are both healing and meaningful to them (Landreth & Sweeney, 1997). The play therapist’s goal is to relate to children in ways that will release their inner directional, constructive, forward-moving, creative, and self-healing power.

CORE CONCEPTS OF CHILDCENTERED PLAY THERAPY Child-centered play therapists endeavor to develop a relationship facilitative of a child’s inner emotional growth and self-perception. Landreth (2012) highlighted the importance of a child’s self-perception, “how a child feels about herself is what makes a significant difference in behavior” (p. 54). Based on Rogers’s (1951) client-centered therapeutic constructs, CCPT therapists recognize the importance of the child’s self-perception and that this perception is the child’s reality. CCPT personality structure builds upon three central constructs: (a) the person, (b) the phenomenal field, and (c) the self (Landreth, 2012). Person Children are much more than physical bodies, defined by their behavior. The person of a child encompasses all aspects of the child: feelings, thoughts, behaviors, and physical being. Children view their lives and the world around them through a perceptual lens they have developed from their phenomenal field, or total experience. Based on their perceptions, children react to the world around them as a complete, interacting system reaching for self-actualization. Children strive for growth and autonomy. Through this process, children attempt to satisfy their perceived needs in the best manner they know (Landreth, 2012). CCPT therapists recognize

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and honor a child’s total self and actively work to develop a safe and nurturing environment to facilitate a child’s innate drive for self-actualization. Phenomenal Field A child’s phenomenal field consists of everything a child experiences, consciously and subconsciously, externally and internally. A child’s reality is based on perceptions of self, others, and the world in which one lives. Whether or not these perceptions are accurate, they are the child’s reality. Child-centered play therapists recognize the importance of understanding the world of children as seen through “their eyes” and accepting their perceptions as their reality (Landreth, 2012). Self As children interact with significant others in their lives (e.g., mother, father, teachers) and their own phenomenal field, they begin to differentiate some experiences as their own, developing a sense of self. Children start to realize they experience some things differently than others do. Through this awareness, children develop a need for positive regard and acceptance. Children begin to perceive themselves as being judged by others and fear the loss of their positive regard. These perceptions may lead children to believe that in order for others to love and to find them worthy, they have to behave, believe, or feel a certain way, even if it is not congruent with their self-image. When children strive for these “conditions of worth” (Fall, Holden, & Marquis, 2004), or conditional positive regard, they experience incongruence between their true self and the self they believe they need to be in order to be accepted. This incongruence creates psychological stress and pain. CCPT therapists recognize the need of children for positive regard and the importance of congruence and strive to provide unconditional positive regard for the children they serve. HEALING RELATIONSHIP Rogers (1957/1992) contended significant change occurs only within a relationship and that the relationship is the catalyst for therapeutic change. Child-centered play therapists create accepting, nurturing environments, facilitating change and healing, which allow children to grow. Experiencing the core conditions of an accepting relationship frees children’s self-expression and ability to grow. New experiences formed through the therapeutic relationship help children to increase their levels of self-understanding and self-acceptance. Children (Axline, 1969) are able to explore who they are within the therapeutic relationship and to express themselves through their play, increasing their self-knowledge and utilizing their capacities in ways that are more effective. Child-centered play therapists strive to provide a nonthreatening, empowering environment that promotes positive relationship between child and therapist and a child’s development of a self-enhancing structure (Ray, 2011). Child-centered play therapists must approach, understand, and treat children from a developmental perspective (Landreth, 2012). CCPT is a developmentally responsive therapeutic approach to meeting the needs of children (Axline, 1969; Guerney, 1983; Landreth, 2012; Vanfleet et al., 2010), providing children opportunities for growth, mastery, and healing (Bratton, Ray, & Landreth, 2008). The play-based approach of CCPT is rooted in Piaget’s (1962) theory of cognitive development. Children differ from adults in how they understand, process, and communicate information. Adult therapy is heavily dependent on Piaget’s formal operational stage, being abstract and sophisticated, whereas the communication of children is concrete and simple

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(Sweeney, 1997). Children use symbolism through their play and activity to express their internal frames of reference about themselves, about others, and about the world around them. Play and verbal language are contrasting forms of communication. When a therapist insists children communicate their experiences, feelings, and thoughts cognitively and verbally, they are essentially asking children to translate their symbolic experiences into the therapist’s preferred medium of communication. This translation of communication form is similar to asking adult clients with only rudimentary knowledge of Spanish to share their deep feelings, inner thoughts, and intimate experiences solely in Spanish (Myers, 2008). Child-centered play therapists understand the importance and purpose of play in the lives of children. Children naturally communicate through play, which provides them a concrete means to express their inner world. Play is essential to the healthy development of children, being effective and facilitative in their growth and healing. CCPT is a developmentally responsive approach to the intellectual, emotional, and social development of children (Landreth & Sweeney, 1997). ISSUES AND CONCERNS APPROPRIATE FOR CHILDCENTERED PLAY THERAPY Play therapy has seven-decade, research-based, established history as an effective approach to treating a wide range of presenting concerns of children. Bratton, Ray, Rhine, and Jones’s (2005) meta-analysis of 93 controlled outcome studies (1953–2000) supported the effectiveness of play therapy with a large mean effect size of .80, showing play therapy to have a large treatment effect in addressing the concerns of children. Bratton et al. found an even larger mean effect size (.93) for the 73 studies utilizing humanistic/nondirective approaches, such as CCPT. Furthermore, Lin and Bratton’s (2015) meta-analysis of 52 controlled CCPT outcome studies from 1995 to 2010 found a moderate effect size (.47). Their findings support the overall effectiveness of CCPT. Play therapy is an effective, developmentally responsive approach to working with children, addressing presenting concerns in the affective, behavioral, educational, physical, and social realms (Bratton et al., 2005). CCPT is helpful in treating children presenting with emotional concerns such as trauma and loss, abuse and neglect, domestic violence, and low self-esteem and behavioral concerns like attention deficit/hyperactivity disorder, autism, anger, conduct disorder, and oppositional-defiant disorder. CCPT has positive outcomes in education, increasing reading skills and cognitive dimensions. CCPT has been useful in meeting the unique needs of children with physical and medical concerns like sensory integration and terminal illness and has been demonstrated to help children struggling with social concerns like familial and peer relations and adjustment to life changes like divorce and global concerns like war and natural disasters. The Association for Play Therapy’s (www.a4pt.org/?page=MiningReport) website offers a continuingly increasing library of “mining reports,” brief papers on current research on a number of play-therapy issues. CHILDCENTERED PLAY THERAPY WITH DIVERSE POPULATIONS The accepting and empathic nature of CCPT provides child therapists a culturally sensitive approach in helping a diverse population of children. In fact, some researchers (Cochran, 1996; Garza & Bratton, 2005; Post & Tillman, 2015) recommended CCPT as the most appropriate treatment approach in working with culturally diverse children. Child-centered play therapists strive to create a safe and inviting space, in which children can explore themselves and their experiences, and to understand children’s phenomenological experience without judgment

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(Hinds, 2006; Landreth, 2012; Post & Tillman, 2015). These ways of being with children demonstrate cultural sensitivity that promotes a therapeutic relationship built on respect and trust that allows children to be themselves and to feel understood and accepted. In addition to the relationship, child-centered play therapists attend to the physical environment of the playroom. Child-centered playrooms are inclusive of diverse populations, containing a breadth of cultural considerations and materials. Playrooms need to contain neutral and culturally specific toys, including dolls of different facial features and skin color, diversity of play food (e.g., Mexican, Japanese), and a variety of religious and cultural symbols. Lin and Bratton (2015), as part of the meta-analysis, explored the multicultural effectiveness of CCPT. They found statistical significance (p = .009) when comparing the mean effect size (.76) for studies with non-White populations to the mean effect size (.33) studies with White populations. These results support the cultural effectiveness and sensitivity of CCPT in working with children from diverse cultures. CONCLUSION In summary, CCPT therapists trust in the inner direction of children for self-actualization and place the focus of treatment on the child rather than on the problem (Landreth, 2012). Child-centered play therapists strive to provide a supportive and understanding relationship, removing emotional blocks, and freeing children’s inner direction for growth and utilize the natural mode of communication, exploration, and discovery of children to help them grow and heal. Through play, children open a window to their inner world, their reality. Child-centered play therapists are able to see and understand how children view themselves and what is important to them. They recognize the value of play and the importance of a caring relationship in treating children. True change occurs when we honor childhood and the child. REFERENCES Association for Play Therapy. (n.d.). Mining reports. Retrieved from http://www.a4pt.org/ps.index.cfm?ID51996 Axline, V. M. (1947). Nondirective therapy for poor readers. Journal of Consulting Psychology, 11(2), 61–69. Axline, V. M. (1969). Play therapy. New York, NY: Ballantine Books. Bratton, S. C., Ray, D., & Landreth, G. (2008). Play therapy. In M. Hersen & A. M. Gross (Eds.), Handbook of clinical psychology: Vol. 2. Children and adolescents (pp. 577–625). New York, NY: Wiley. Bratton, S. C., Ray, D. C., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children: A meta-analytic review of treatment outcomes. Professional Psychology: Research and Practice, 36(4), 367–390. Bredekamp, S. (Ed.). (1987). Developmentally appropriate practice in early childhood programs serving children from birth through age 8. Washington, DC: National Association for the Education of Young Children. Cochran, J. L. (1996). Using play and art therapy to help culturally diverse students overcome barriers to school success. The School Counselor, 43(4), 287–298. d’Heurle, A. (1979). Play and the development of the person. Elementary School Journal, 79(4), 224–234. Erikson, E. H. (1963). Childhood and society (2nd ed.). New York, NY: W. W. Norton. Fall, K. A., Holden, J. M., & Marquis, A. (2004). Theoretical models of counseling and psychotherapy. New York, NY: Brunner-Routledge. Garza, Y., & Bratton, S. (2005). School-based child-centered play therapy with Hispanic children: Outcomes and cultural consideration. International Journal of Play Therapy, 14(1), 51–79. doi:10.1037/h0088896 Ginott, H. G. (1982). Group play therapy with children. In G. L. Landreth (Ed.), Play therapy: Dynamics of the process of counseling with children (pp. 327–341). Springfield, IL: Charles C. Thomas. Ginsburg, K. R., American Academy of Pediatrics Committee on Communications, & American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health. (2007). The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Pediatrics, 119(1), 182–191. Guerney, L. F. (1983). Client-centered (nondirective) play therapy. In C. E. Schaefer & K. J. O’Connor (Eds.), Handbook of play therapy (pp. 21–64). New York, NY: Wiley.

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Hinds, S. (2006). Play therapy in the African American “village.” In E. Gil & A. A. Drewes (Eds.), Cultural issues in play therapy (pp. 115–147). New York, NY: Guilford Press. Landreth, G. L. (2012). Play therapy: The art of the relationship (2nd ed.). New York, NY: Brunner-Routledge. Landreth, G. L., & Sweeney, D. S. (1997). Child-centered play therapy. In K. J. O’Connor & L. M. Braverman (Eds.), Play therapy theory and practice: A comparative presentation (pp. 17–45). New York, NY: Wiley. Lin, Y.-W., & Bratton, S. C. (2015). A meta-analytic review of child-centered play therapy approaches. Journal of Counseling & Development, 93(1), 45–58. doi:10.1002/j.1556-6676.2015.00180.x Milteer, R. M., Ginsburg, K. R., Council on Communications and Media, & Committee on Psychosocial Aspects of Child and Mental Health. (2011). The importance of play in promoting healthy child development and maintaining strong parent-child bond: Focus on children in poverty. Pediatrics, 129(1), e204–e213. doi:10.1542/peds.2011-2953 Montessori, M. (1964). The Montessori method. New York, NY: Schocken Books. Myers, C. E. (2008). Development of the trauma play scale: Comparison of children manifesting a history of interpersonal trauma with a normative sample (Unpublished dissertation). University of North Texas–Denton, TX. Perry, B. D., Pollard, R., Blakely, T., Baker, W., & Vigilante, D. (1995). Childhood trauma, the neurobiology of adaptation and ‘use-dependent’ development of the brain: How “states” become “traits.” Infant Mental Health Journal, 16(4), 271–291. doi:10.1002/1097-0355(199524)16:43.0.CO;2-B. Piaget, J. (1952). The origins of intelligence in children (2nd ed., M. Cook, Trans.). New York, NY: International Universities Press. (Original work published 1936) Post, P., & Tillman, K. S. (2015). Cultural issues in play therapy. In D. A. Crenshaw & A. L. Stewart (Eds.), Play therapy: A comprehensive guide to theory and practice (pp. 496–510). New York, NY: Guilford Press. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–103. Rogers, C. R. (1992). The necessary and sufficient conditions of therapeutic personality change. 1957. Journal of Consulting and Clinical Psychology, 60(6), 827–832. Sweeney, D. S. (1997). Counseling children through the world of play. Wheaton, IL: Tyndale House. United Nations General Assembly. (1990). Adoption of a convention on the rights of the child (U.N. Doc. A/Res/44/25). New York, NY: Author. Retrieved from http://www.ohchr.org/EN/ProfessionalInterest/ Pages/CRC.aspx VanFleet, R., Sywulak, A. E., & Sniscak, C. C. (2010). Child-centered play therapy. New York, NY: Guilford Press.

19 Mindfulness in Counseling Cheryl L. Fulton

OVERVIEW OF MINDFULNESS The past two decades have marked the rise of mindfulness both as a therapeutic intervention for clients and as a means to promote counselor wellness (e.g., Shapiro, Brown, & Biegel, 2007) and effectiveness (Buser, Buser, Peterson, & Seraydarian, 2012; Fulton, in press; Fulton & Cashwell, 2015; Grepmair et al., 2007). Although not a panacea, mindfulness has been associated empirically with a wide array of physical and mental health benefits (Baer, 2014). As a result, mindfulness-based interventions (MBIs) have garnered the attention of mental health professionals seeking to incorporate mindfulness into their therapeutic work. In this chapter, I provide an overview and history of mindfulness, its benefits to clients and counselors, how it works, ways to develop it, and how it can be integrated into counseling. Mindfulness involves purposefully paying attention in the present moment without judgment (Kabat-Zinn, 2013) and requires compassion, kindness, openness, curiosity, and warmth, or as Kabat-Zinn (2012) aptly described it, an “affectionate attention” (p. 53). In other words, being mindful requires not only that we pay attention, but also involves how we pay attention. Germer (2006) echoed this idea noting that if a client increases his or her awareness of unpleasant thoughts, feelings, and sensations without the support of a warm, friendly, compassionate attitude, it may be counterproductive. Accordingly, mindfulness training often includes both mindfulness (awareness) practices and compassion practices (Schmidt, 2004). Mindfulness may also be understood as a set of skills that reflect how we relate to our present moment experience including the ability to observe, describe, act with awareness, not react, and not judge the experience (Baer, Smith, Hopkins, Krietemeyer, & Toney, 2006). When we are mindful we become attuned to our own thoughts, feelings, and sensations; we gain insight and compassion for ourselves, which can, in turn, lead us to be compassionate toward others. Mindfulness enables us to be fully present regardless of whether the present moment involves positive, negative, or neutral experiences (Germer, 2013). We are able to “be with” our experience without overly identifying with, reacting to, or elaborating on the meaning of it. Buddhists describe this as “bare attention” (Cardaciotto, Herbert, Forman, Moitra, & Farrow, 2008, p. 205); we are simply a witness, not a judge, to our waxing and waning thoughts, feelings, and sensations. Therefore, mindfulness is a skill that can change the way we relate to our experience, reducing our suffering and increasing our sense of well-being (Germer, 2013).

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FOUNDATIONS OF MINDFULNESS IN COUNSELING Mindfulness meditation dates back 2,500 years in Buddhist history (Germer, 2006), although most major world traditions include some form of contemplative practice (e.g., Christian contemplative prayer, Jewish meditation, Hindu transcendental meditation). Shapiro (2009) suggested that despite its Buddhist beginnings, the phenomenological nature of mindfulness fits with most world traditions, Western thinking, and psychological schools. In fact, Buddhism has influenced Western psychotherapy for nearly 100 years (Kelly, 2008); however, mindfulness did not attain significant interest or legitimacy in the West until the 1970s with the work of Jon Kabat-Zinn (Baer, 2003). Kabat-Zinn stripped mindfulness of its religious dogma and developed the Mindfulness-Based Stress Reduction (MBSR) program, initially as a treatment for those with chronic conditions (Kabat-Zinn, 2013). The program is an 8-week course that includes education regarding mindfulness and stress as well as meditation practices, yoga, body scan, and mindful eating exercises (Kabat-Zinn, 2013). Although patients could not eliminate their pain, with mindfulness training they learned to change their relationship to the pain, thereby reducing their suffering. Since the inception of MBSR, more than 720 mindfulness-informed programs have emerged across hospitals and clinics in the United States and abroad (Kabat-Zinn, 2013). Following Kabat-Zinn’s work, mindfulness informed several “third wave” cognitive behavioral counseling approaches such as dialectical behavioral therapy (DBT; Linehan, 1993a, 1993b), acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999), and mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002, 2012). Linehan (1993a) initially developed DBT for individuals with borderline personality disorder hypothesizing that mindfulness would aid clients in their ability to regulate emotion and choose more productive behaviors. Segal et al. (2002) created MBCT, a blend of cognitive behavioral therapy (CBT) and mindfulness, to prevent depression relapse among recurrent depressed individuals. Mindfulness helps clients notice depression-related thoughts and feelings, without ruminating or elaborating on them, so they do not escalate and invoke a depression relapse. Lastly, mindfulness is a vital aspect of ACT which has been successfully used to achieve a broad range of positive client outcomes (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). Based on ACT, mindfulness and acceptance processes help reduce rigid, avoidance strategies that inhibit commitment and behavioral change processes that lead to a values-oriented, fulfilling life. MBSR and MBCT have been delivered primarily via group or class format, while DBT has both group education and individual counseling components, and ACT is delivered in individual or group format. Many adaptations of MBCT and MBSR have been developed to address specific client concerns. For example, mindfulness-based eating awareness training, which integrates elements of MBSR and CBT with guided eating meditations, is used to address binge eating disorder (Kristeller & Hallett, 1999). Mindfulness-based relapse prevention was developed for substance use disorders (Bowen, Chawla, & Marlatt, 2011) and mindfulness-based relationship enhancement helps couples develop greater relationship satisfaction, closeness, and acceptance (Carson, Carson, Gil, & Baucom, 2006). Thus, over time, mindfulness has become an integral part of diverse counseling work and mental health. It is important to note that self-compassion also emerged as an important concept (and practice), somewhat parallel to mindfulness. Although it is unclear whether self-compassion is a component of mindfulness or an outcome of it (Baer et al., 2006), researchers often include study of both mindfulness and self-compassion as they can be differentially or synergistically related to outcomes (Fulton & Cashwell, 2015; Hollis-Walker & Colosimo, 2011). Self-compassion involves having feelings of concern for one’s own suffering and approaching one’s shortcomings with kindness, non-judgment, understanding, and awareness

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that shortcomings are part of the common human experience (Neff, 2003). Neff and Germer (2013) created the mindful self-compassion (MSC) program, which includes mindfulness training as part of teaching self-compassion; they found their program enhanced self-compassion, mindfulness, and well-being. BENEFITS OF MINDFULNESS Mindfulness and MBIs have been studied widely across disciplines producing a vast body of support for its positive effect on numerous physical and mental health outcomes (Baer, 2014). More recently, researchers have explored how mindfulness might benefit clients indirectly by using it to improve a counselor’s performance, as well as how mindfulness might support the counselor directly (e.g., decreased stress and improved wellness). Client Benefits Regarding specific mental health benefits, innate mindfulness has been associated with greater joy, hope, well-being, and life satisfaction and less stress, anxiety, and depression (Greeson, 2009). Based on a systematic review of 21 published random controlled trials of MBSR (17) and MBCT (4), researchers found that MBSR was useful for improving mental health and reducing symptoms associated with stress, anxiety, and depression, while MBCT was effective as a means of relapse prevention for recovered, recurrently depressed individuals (Fjorback, Arendt, Ornbol, Fink, & Walach, 2011). Further, mindfulness has been associated with improvements in many health-related behaviors such as sleeping, substance use (Greeson, 2009), and disordered eating (Kristeller & Hallett, 1999), as well as health conditions such as cancer, HIV infection, and type 2 diabetes (Greeson, 2009). Additionally, there is an emerging body of neuroscientific study supporting the positive effects of mindfulness practice on brain structure and functioning (e.g., Farb et al., 2010; Hölzel et al., 2011). Both formal mindfulness training programs (e.g., MBSR) and brief meditation practices among novices have been found to influence areas of the brain involved in regulating attention, awareness, and emotion (Greeson, 2009). Further, compassion meditation was found to enhance brain structures associated with empathy among expert versus novice meditators (Lutz, Brefczynski-Lewis, Johnstone, & Davidson, 2008). Similarly, Lazar et al. (2005) found increased thickness in regions of the brain associated with care giving and compassion in experienced meditators as compared with a matched control group. Hölzel et al. (2011) found that 8 weeks of meditation training, including 30 minutes of daily meditation practice, positively changed gray matter density in brain structures associated with learning and memory, self-awareness, emotion regulation, empathy, stress, and anxiety, as compared with a control group. Further, Farb and colleagues (2010) found that participation in an 8-week mindfulness training program decreased neural activity in response to watching a sad film as compared with a control group and from baseline. The researchers concluded that because the mindfulness training participants still reported feeling sad, mindfulness meditation increased their ability to regulate emotion (less reactivity to the sad film) without necessarily avoiding or detaching from it. In sum, there is strong evidence that MBIs can be beneficial to a broad array of client concerns. Counselor and Counseling-Related Benefits Mindfulness appears to benefit the counselor both professionally and personally, and, in turn, benefit the client. For example, a number of researchers have explored mindfulness as a means

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to improve development of the therapeutic relationship. Specifically, counselor mindfulness was associated with greater client-perceived empathy (Fulton, in press), client-perceived positive regard (Greason & Welfare, 2013), counselor self-reported empathy (Fulton & Cashwell, 2015; Greason & Cashwell, 2009), and observed development of the therapeutic relationship (Buser et al., 2012). Mindfulness has also been associated with greater ability to use counseling skills such as silence (Newsome, Christopher, Dahlen, & Christopher, 2006), ability to strategically control attention during counseling, counselor self-efficacy (Greason & Cashwell, 2009), and multicultural awareness and knowledge (Ivers, Johnson, Clarke, Newsome, & Berry, 2016). Fulton (in press) also found that mindfulness and self-compassion were negatively associated with experiential avoidance (affect tolerance in the positive form of the term) and self-compassion positively associated with greater ambiguity tolerance. Both affect tolerance and tolerance of ambiguity are purported to be important to empathic ability and effective counseling (Bien, 2004; Levitt & Jacques, 2005). Specifically, affect tolerance may be important to empathy as counselors are confronted with clients’ painful emotions for which they must be present, and with which they must empathize, without personal distress, overidentification, or avoidance (Bien, 2004; Rogers, 1957). Ambiguity tolerance is important as counselors must tolerate complex client situations without pushing for a premature solution, becoming apathetic, or sharing in the client’s despair (Bien, 2004; Fulton, in press). Perhaps most important regarding counselor mindfulness, in one randomized controlled study, mindfulness training for counselor trainees was associated with positive client outcomes (Grepmair et al., 2007). An ongoing mindfulness practice, therefore, may be useful for maintaining a counselor’s overall effectiveness. Mindfulness also may positively impact the counselor personally. Although counseling work can be immensely rewarding, it can also be emotionally demanding and self-care is considered vital to personal wellness and counseling performance. Greater self-reported mindfulness has been associated with lower anxiety among counselors (Fulton & Cashwell, 2015). Further, counselor participants in an MBSR course reported reduced stress, state and trait anxiety, and negative affect and rumination as well as increased empathy, positive affect, and self-compassion (Shapiro et al., 2007). Mindfulness practice was also found to be associated with greater self-care among counselors (Christopher & Maris, 2010). Mindfulness, therefore, appears to have many personal and professional benefits to counselors and their clients. HOW DOES MINDFULNESS WORK? Despite ample support for the salutary effects of MBIs, the specific mechanisms responsible for achieving positive outcomes remain unclear. Generally, there is support that MBIs increase the ability to approach daily experiences mindfully, and that mindfulness skills in turn yield improvements in mental health (Baer, 2014). There are, however, many other proposed mechanisms of change. For example, reperceiving has been implicated in the positive outcomes achieved with mindfulness practice. Reperceiving involves the ability to view a thought as a passing mental event rather than as a reflection of the self that is true or has real meaning. Reperceiving is not equivalent to detaching or disengaging, but rather is a means to connect more deeply with one’s experience without elaborative thinking and rumination (Shapiro, Carlson, Astin, & Freedman, 2006). In other words, clients can more objectively witness their experience as opposed to blindly letting it initiate a cascade of negative feelings or behaviors. Exposure has also been identified as a potential mechanism of mindfulness (Germer, 2013). MBIs teach individuals to attend to all stimuli, including aversive stimuli; thus, individuals learn to have exposure to experience, without avoidance, so a different relationship with the experience can be created over time. Individuals must also be able to observe that there are no catastrophic outcomes of the exposure for it to yield desensitization (Baer, 2003). In this regard, MBIs are similar to

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other “exposure” techniques such as systematic desensitization, because it is similarly designed to increase one’s ability to tolerate aversive stimuli over time (Labbé, 2011). Linehan (1993a) incorporated mindfulness into dialectic and behavioral therapy (DBT) for the treatment of borderline personality disorders positing that fear and avoidance of intense emotions were an underlying intrapersonal dynamic in a person diagnosed with the disorder and that prolonged exposure without avoidance would increase the individual’s ability to tolerate and cope with aversive emotional states more effectively. There is also evidence that positive outcomes associated with mindfulness may be the result of neurophysiologic effects, or changes in the brain structure or function (e.g., Farb et al., 2010; Hölzel et al., 2011; Lutz et al., 2008). Generally, supported neurological mechanisms include improved attention regulation, body awareness, emotion regulation, reappraisal, exposure, and flexible sense of self (Germer, 2013). Tang, Hölzel, and Posner (2015) pointed out that although the underlying neural mechanisms of mindfulness that produce positive clinical outcomes are still unclear, there is tentative evidence that mindfulness meditation can produce positive changes in the structure and function of brain regions, particularly those involved in regulation of attention, emotion, and self-awareness. Finally, there is also support that MBI outcomes may result from increased self-compassion (e.g., Hölzel et al., 2011). Whether self-compassion is an aspect of mindfulness, or an outcome of it, it is related to many benefits such as decreased depression, anxiety, rumination, and perfectionism and increased empathic concern, optimism, and emotional intelligence (Neff & Germer, 2013). DEVELOPING MINDFULNESS Mindfulness is considered a basic human capacity that can be developed further by engaging in both formal and informal practices (Brown & Ryan, 2004). Informally, one can invoke a mindful state at any time and during any activity such as taking a moment to focus on the breath or giving an activity (e.g., washing the dishes) one’s full attention, in the present moment, without judgment (Hahn, 1975). This level of practice is, perhaps, the type that most readily translates to counseling work with clients (Germer, 2004). Formal mindfulness practice involves an activity designed to cultivate mindfulness such as sitting meditation, walking meditation, or yoga (Baer, 2003). Mindfulness scholars have proposed that novice meditators learn it in two stages: first, individuals utilize concentration practices such as focusing on the breath (or word or phrase) to increase attentional abilities, and second, they use mindfulness practices, or open monitoring of thoughts, feelings, and sensations, to increase awareness and insight (Brown & Ryan, 2004). Attempting open monitoring (sometimes called “choiceless awareness”) can be highly challenging without first developing an attentional anchor. Mindfulness practice also includes loving-kindness and compassion meditations that involve focusing on a specific intention and they may be supported with written meditations or exercises designed to foster kindness, compassion, and joy toward one’s self and others (Germer, 2013). Individuals can develop mindfulness independently or via mindfulness programs such as MBSR; the support of a teacher or group may be particularly helpful for some individuals. INTEGRATING MINDFULNESS INTO COUNSELING The preponderance of mindfulness research has been based on MBSR, MBCT, and similar “manualized” group-format MBIs; therefore, empirical study of the application of these mindfulness programs to individual counseling is less established. Yet, as evidence of the positive effects of mindfulness grows, a number of clinician-authored sources on ways to integrate mindfulness into therapeutic work have emerged (e.g., Baer, 2014; Geller & Greenberg, 2012;

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Germer, Siegel, & Fulton, 2013; Labbé, 2011; Pollak, Pedulla, & Siegel, 2014); these sources include chapters outlining ways to use mindfulness with specific populations and client concerns. The term “mindfulness-oriented psychotherapy” has been offered as a way to describe a range of approaches to integrating mindfulness in counseling (Germer, 2013). Generally, there are four potential ways in which a counselor can integrate mindfulness into counseling. First, counselors can more formally integrate mindfulness into their therapeutic work by developing expertise in a mindfulness-based approach such as ACT, DBT, MBSR, or MBCT. Not only is mindfulness inherent within these approaches, but they also offer many mindfulness exercises that can be utilized in individual counseling (Pollak, 2013). MBSR and MBCT involve the client engaging in formal and informal mindfulness practices, some of which can be long (45 minutes), while DBT and ACT involve shorter, less formal mindfulness activities (Baer, 2014). Proponents of ACT and DBT do not require, but encourage, that counselors engage in their own mindfulness practice as part of their competency in utilizing a mindfulness-based program. MBSR and MBCT have greater requirements for use such as personal practice, peer supervision, and training (Segal et al., 2012). Similarly, Germer (2013) proposed using mindfulness as a theoretical frame, based on the practice and study of mindfulness, integrating Buddhist and Western psychology, and using an approach where the therapeutic relationship is viewed as central to the change process. Using this approach, referred to as “mindfulness-informed psychotherapy,” mindfulness is not formally taught to clients, but rather it is conveyed through subtle microcommunications (e.g., voice tone, facial expression). Mindfulness-informed work involves attention to the ways clients resist thoughts and emotions and how they may bring awareness and acceptance to those experiences. Second, because mindfulness is compatible with most major theoretical approaches, and arguably similar to some of their associated techniques (Germer, 2013), a counselor may employ specific mindfulness techniques to address a particular therapeutic need. There are many sources of clinical guidance and mindfulness exercises for specific groups such as parents and children (e.g., Goodman, 2013), couples (Carson et al., 2006), and those with addictions (Brewer, 2013). A third way to integrate mindfulness is for counselors to develop their own mindfulness practice toward enhancing therapeutic presence, or a way of being, with clients that fosters the therapeutic relationship and process (Geller & Greenberg, 2012). As detailed earlier, there is growing evidence that counselor mindfulness benefits clients. Lastly, counselors can directly teach mindfulness to clients, encouraging practice and individual study (Pollak, 2013). There are numerous online and self-help books on mindfulness available (e.g., see Germer, 2013 for a summary) to aid clients in developing mindfulness independently or as an adjunct to counseling. Some clients may resist the term “mindfulness,” may prefer traditional talk therapy, or may have misconceptions about mindfulness practices. Therefore, it is important for counselors to be patient with clients, make mindfulness terms accessible (e.g., attention training), and consider the clients’ values, needs, and willingness to learn as part of their clinical judgment regarding the use of mindfulness (Pollak, 2013). Counselors wishing to integrate mindfulness into their work using one of the above approaches must also consider how to use mindfulness with diverse populations. The major mindfulness-based approaches have been translated into many languages for use in diverse countries. Although there is evidence that mindfulness has been used effectively with diverse populations and settings, this area of study is still nascent. Masuda (2014) offered a thorough discussion of cultural issues and the use of MBIs with specific attention to cultural competency. EXAMPLES OF MINDFULNESS PRACTICES/INTERVENTIONS There are general and specific interventions that can be used in counseling and knowing when and how to use them is key. Germer (2013) offered a general intervention, breath meditation,

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to enhance the skill of focused attention, which is a helpful foundational exercise for open monitoring meditation. Focused attention can be practiced with any internal (e.g., breath, word, or phrase) or external (e.g., candle flame) object. Clients start by sitting in a relaxed, upright posture in a quiet space and allowing the eyelids to close, fully or partially. Next, they explore where in their body they most readily feel their breath (e.g., nostrils, chest, or abdomen) and then allow themselves to feel the physical sensation of breathing in and out. Communicate to the clients that the body knows how to breathe naturally, so there is no need to attempt to control or change it. When the mind wanders, as it will, they gently redirect their focus back to feeling the breath again. Focused attention can be utilized in counseling by helping clients anchor their minds to an object (e.g., the breath) when difficult emotions or thoughts are present. Brewer (2013) shared a population-specific mindfulness technique, RAIN (Recognize/ Relax, Allow/Accept, Investigate, and Note), for use with those struggling with addiction. RAIN helps clients “urge surf,” a craving much like a surfer rides a wave in the ocean. Clients recognize the craving is coming and relax into it. Then they allow or accept the wave (craving) as it is, without trying to ignore, distract, or react to it. Clients can identify helpful phrases such as “this is it” or “okay, here we go,” as a tool to allow and accept. The client investigates the wave as it builds asking, “What is the mind aware of now?” or “What is happening in my body right now?” noticing what arises as opposed to searching for anything in particular. Lastly, the client notes the experience in their body using a word or short phrase (e.g., rising sensation, clenching, wanting). If they become distracted, they return to investigation. If they fall off of the wave or it becomes unmanageable, they focus their attention to a safe part of the body (e.g., the feet), ducking this wave, and getting ready for the next. The wave is followed until it completely subsides (ridden to shore). These exercises offer a glimmer of how mindfulness works in a practical sense; counselors are encouraged to explore developing their own mindfulness practice as well as the many ways mindfulness can be integrated in counseling. CONCLUSION Given the large and growing body of support for the benefits of mindfulness, coupled with the development of several mindfulness-based counseling approaches, it appears mindfulness has been adopted by diverse mental health professions. Mindfulness not only provides a robust approach for addressing a wide array of client concerns, but there is growing support that it also improves the counseling process itself. Further, mindfulness may be a valuable means of counselor self-care, and, in turn, promote career longevity and overall effectiveness. The above clinician-authored sources on mindfulness in counseling are written by well-versed proponents of mindfulness and are a wonderful start for counselors on the journey of adopting mindfulness into their work. REFERENCES Baer, R. A. (2003). Mindfulness training as a clinical intervention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125–143. Baer, R. A. (2014). Mindfulness-based treatment approaches: Clinician’s guide to evidence base and applications (2nd ed.). San Diego, CA: Elsevier. Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13, 27–45. Bien, T. (2004). Quantum change and psychotherapy. Journal of Clinical Psychology/In Session, 60, 493–501. Bowen, S., Chawla, N., & Marlatt, G. A. (2011). Mindfulness-based relapse prevention for addictive behaviors: A clinician’s guide. New York, NY: Guilford Press. Brown, K. W., & Ryan, R. M. (2004). Perils and promise in defining and measuring mindfulness: Observations from experience. Clinical Psychology: Science and Practice, 11, 242–248.

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Buser, T., Buser, J., Peterson, C. H., & Seraydarian, D. G. (2012). Influence of mindfulness practice on counseling skill development. Journal of Preparation and Supervision, 4(1), 20–36. Brewer, J. A. (2013). Breaking the addiction loop. In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 225–238). New York, NY: Guilford Press. Cardaciotto, L., Herbert, J. D., Forman, E. M., Moitra, E., & Farrow, V. (2008). The assessment of present-moment awareness and acceptance: The Philadelphia Mindfulness Scale. Assessment, 15, 204–223. Carson, J. W., Carson, K. M., Gil, K. M., & Baucom, D. H. (2006). Mindfulness-based relationship enhancement (MBRE) in couples. In R. A. Baer (Ed.), Mindfulness-based treatment approaches: Clinician’s guide to evidence base and applications (pp. 309–331). San Diego, CA: Elsevier Academic Press. Christopher, J. C., & Maris, J. A. (2010). Integrating mindfulness as self-care into counseling and psychotherapy training. Counseling and Psychotherapy Research, 10, 114–125. Farb, N. S., Anderson, A. K., Mayberg, H., Bean, J., McKeon, D., & Segal, Z. V. (2010). Minding one’s emotions: Mindfulness training alters the neural expression of sadness. Emotion, 10, 25–33. Fjorback, L. O., Arendt, M., Ornbol, E., Fink, P., & Walach, H. (2011). Mindfulness-based stress reduction and mindfulness-based cognitive therapy: A systematic review of randomized controlled trials. Acta Psychiatrica Scandinavica, 124, 102–119. Fulton, C. L. (in press). Mindfulness, self-compassion, and counselor characteristics and session variables. Journal of Mental Health Counseling, 38(4), 360–374. Fulton, C. L., & Cashwell, C. S. (2015). Mindfulness-based awareness and compassion: Predictors of counselor empathy and anxiety. Counselor Education and Supervision, 54, 122–133. Geller, S., & Greenberg, L. (2012). Therapeutic presence: A mindful approach to effective therapy. Washington, DC: American Psychological Association. Germer, C. (2004). What is mindfulness? Insight Journal, 20, 24–29. Germer, C. (2006, Jan./Feb.). You gotta have heart. Psychotherapy Networker, 30(1), 54–59. Germer, C. K. (2013). Mindfulness: What is it? What does it matter? In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 3–35). New York, NY: Guildford Press. Germer, C. K., Siegel, R. D., & Fulton, P. R. (2013). Mindfulness and psychotherapy. New York, NY: Guildford Press. Goodman, T. A. (2013). Working with children. In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 239–258). New York, NY: Guilford Press. Greason, P. B., & Cashwell, C. S. (2009). Mindfulness and counseling self-efficacy: The mediating role of attention and empathy. Counselor Education and Supervision, 49, 2–18. Greason, P. B., & Welfare, L. E. (2013). The impact of mindfulness and meditation practice on client perceptions of common therapeutic factors. Journal of Humanistic Counseling, 52, 235–253. Greeson, J. M. (2009). Mindfulness research update: 2008. Complementary Health Practice Review, 14, 10–18. Grepmair, L., Mitterlehner, F., Loew, T., Bachler, E., Rother, W., & Nickel, M. (2007). Promoting mindfulness in psychotherapists in training influences the treatment results of their patients: A randomized, double-blind, controlled study. Psychotherapy and Psychosomatics, 76, 332–338. Hahn, T. N. (1975). Miracle of mindfulness (M. Ho, Trans.). Boston, MA: Beacon Press. Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, process and outcomes. Behaviour Research and Therapy, 44, 1–25. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance and commitment therapy. New York, NY: Guilford Press. Hollis-Walker, L., & Colosimo, K. (2011). Mindfulness, self-compassion, and happiness in non-meditators: A theoretical and empirical examination. Personality and Individual Differences, 50, 222–227. Hölzel, B. K., Carmody, J., Vangel, M., Congleton, C., Yerramsetti, S. M., Gard, T., & Lazar, S. W. (2011). Mindfulness practice leads to increases in regional brain gray matter density. Psychiatry Research: Neuroimaging, 191, 36–43. Ivers, N. N., Johnson, D. A., Clarke, P. B., Newsome, D. W., & Berry, R. A. (2016). The relationship between mindfulness and multicultural counseling competence. Journal of Counseling & Development, 94(1), 72–82. doi:10.1002/jcad.12063 Kabat-Zinn, J. (2012). Mindfulness for beginners. Boulder, CO: Sounds True. Kabat-Zinn, J. (2013). Full catastrophe living: Using the wisdom of your body and mind to face stress, pain, and illness (Revised). New York, NY: Bantam Books. Kelly, B. D. (2008). Buddhist psychology, psychotherapy and the brain: A critical introduction. Transcultural Psychiatry, 45, 5–30. Kristeller, J. L., & Hallett, C. B. (1999). An exploratory study of a meditation-based intervention for binge eating disorder. Journal of Health Psychology, 4, 357–363.

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Labbé, E. (2011). Psychology moment by moment: A guide to enhancing your clinical practice with mindfulness and meditation. Oakland, CA: New Harbinger. Lazar, S. W., Kerr, C. E., Wasserman, R. H., Gray, J. R., Greve, D. N., Treadway, M. T., . . . Fischl, B. (2005). Meditation experience is associated with increased cortical thickness. Neuroreport: For Rapid Communication of Neuroscience Research, 16, 1893–1897. Levitt, D. H., & Jacques, J. D. (2005). Promoting tolerance for ambiguity in counselor training programs. Journal of Humanistic Counseling, Education and Development, 44, 46–54. Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press. Linehan, M. M. (1993b). Skills training manual for treating borderline personality disorder. New York, NY: Guilford Press. Lutz, A., Brefczynski-Lewis, J., Johnstone, T., & Davidson, R. J. (2008). Regulation of the neural circuitry of emotion by compassion meditation: Effects of meditative expertise. PLOS ONE, 3, 1–10 doi:10.1371/ journal.pone.0001897. Masuda, A. (2014). Mindfulness and acceptance in multicultural competency: A contextual approach to sociocultural diversity in theory and practice. Oakland, CA: Context Press. Neff, K. D. (2003). The development and validation of a scale to measure self-compassion. Self and Identity, 2, 223–250. Neff, K. D., & Germer, C. K. (2013). A pilot study and randomized controlled trial of the mindful self-compassion program. Journal of Clinical Psychology, 69(1), 28–44. Newsome, S., Christopher, J. C., Dahlen, P., & Christopher, S. (2006). Teaching counselors self-care through mindfulness practices. Teachers College Record, 108, 1881–1900. Pollak, S. M. (2013). Teaching mindfulness in therapy. In C. K. Germer, R. D. Siegel, & P. R. Fulton (Eds.), Mindfulness and psychotherapy (pp. 133–147). New York, NY: Guilford Press. Pollak, S. M., Pedulla, T., & Siegel, R. D. (2014). Sitting together: Essential skills for mindfulness-based psychotherapy. New York, NY: Guilford Press. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–103. Schmidt, S. (2004). Mindfulness and healing intention: Concepts, practice, and research evaluation. The Journal of Alternative and Complementary Medicine, 10 (Suppl. 1), S-7–S-14. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2002). Mindfulness-based cognitive therapy for depression: A new approach to preventing relapse. New York, NY: Guilford Press. Segal, Z. V., Williams, J. M. G., & Teasdale, J. D. (2012). Mindfulness-based cognitive therapy for depression (2nd ed.). New York, NY: Guilford Press. Shapiro, S. L. (2009). The integration of mindfulness and psychology. Journal of Clinical Psychology, 65(6), 555–560. Shapiro, S. L., Brown, K., & Biegel, G. M. (2007). Teaching self-care to caregivers: Effects of mindfulness-based stress reduction on the mental health of therapists in training. Training and Education in Professional Psychology, 1, 105–115. Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of mindfulness. Journal of Clinical Psychology, 62, 373–386. Tang, Y., Hölzel, B. K., & Posner, M. I. (2015). The neuroscience of mindfulness meditation. Neuroscience, 16, 213–225.

20 Sandplay Therapy Suzanne Degges-White

OVERVIEW OF SANDPLAY Sandplay is a therapeutic intervention that allows individuals to articulate their current concerns or problems in a symbolic, nonverbal manner. As its name implies, sandplay involves the use of a tray of sand and the placement of small figurines into the sand by the client. This form of therapy relies on a client’s intuitive knowledge and the counselor’s belief that clients enter the counseling process already possessing the solution to their concerns although they may not yet be aware of this.The process of sandplay is typically likened to the archetypal “hero’s journey” (Campbell, 1973) in which an individual travels an unfamiliar and foreboding route into a place of transformation. In 1911, H. G. Wells wrote a book, Floor Games, which described the activities in which he and his children involved themselves while playing together on the floor with small toys. This was the basis for some of the earliest sandplay practitioners. Early professionals who used such a method include Dora Kalff, Margaret Lowenfield, Charlotte Buhler, and Erik Erikson (Mitchell & Friedman, 1994). Through a friendship with C. G. Jung’s daughter, Kalff began work with Jung and this influential collaboration defined Kalff as the first Jungian sandplay therapist. She believed that through sandplay, the unconscious could be made conscious. Jungian sandplay therapists view the “hero’s journey” as a trip into the deepest level of the unconscious where clients are able to create a “constellation of self ” tray and then travel back up to the everyday world of reality and life (Mitchell & Friedman, 1994). This process is seen as the vehicle through which healing through sandplay occurs. Kalff (1980/2003) described this process as a three-part journey in which clients would create trays that followed this pattern: (a) animal–vegetative, in which the figures chosen reflected a primal world; (b) conflict/battle, in which a confrontation occurred between the figures chosen; and (c) conflict resolution, the final stage in which the client created a “constellation of the self ” and experienced a “birth” of his or her ego, similar to individuation, and then made his or her way back to the “real world” or “collective.” The process of the journey itself is believed to promote emotional and psychological healing. MATERIALS The minimum basic materials needed for sandplay include a container to hold the clean sand and a collection of figures to be placed in the sand. The ideal size of sandtray is 30 in. × 20

315

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in. × 3 in., with the bottom and sides painted blue. Although sandtrays may be ordered from specialty vendors, counselors may also make use of repurposed plastic storage bins of the appropriate size. The selection of figures should encompass as many ethnicities, races, gender, and religious belief systems as possible for diverse clients to successfully choose the most relevant figurines to express their thoughts and feelings. Depending on the setting in which a counselor is working, the therapist can offer clients objects representative of that particular milieu (i.e., adhesive strips and syringes if you work at a hospital or medical setting; miniature desks, and blackboards in a school setting, etc.). As a minimum, objects and figures should include the following categories: animals (wild, forest, domesticated, prehistoric, fantasy, and farm); birds; insects; sea creatures; half-human/half-animal (mermaids, centaurs); reptiles and amphibians; monsters; eggs and food; fantasy figures (witches, wizards, kings, and queens); plants; rocks, shells, and fossils; mountains and caves; volcanoes; buildings; barriers; vehicles; people; fighting figures; spiritual (e.g., priests, Buddha, crucifix); and any additional figures you would like to add (Amatruda & Simpson, 1997). A camera should also be available to record each sandtray created by a client over the course of therapy. THE PROCESS Both adults and children can benefit from this adjunctive therapy, which calls on the active imagination to express with symbols what is difficult to express in words. Sandplay has been compared with the dream process in that the images that appear are not the product of conscious thought. Sandplay techniques allow clients to explore issues at their own speed and without having to use direct verbal exploration of the concern. This benefit is especially appreciated when younger clients do not have the necessary vocabularies to discuss their concerns or feelings. Children who are victims of various types of abuse can use sandplay figures to directly, or indirectly, act out their feelings and trauma. Even adults who are struggling with communicating deep-seated feelings, conflicts, and experiences successfully use this type of therapy to explore these issues. Clients typically create a new tray each session and their creations reflect their progress through symbolic selection and placement of the figures used. As the counselor first introduces clients to this medium, they are shown the figurines and the sandtray and invited to “create a world in the sand.” As a client works, it is important that the counselor merely acts as witness to the process—it is not advisable to ask questions regarding the client’s choice or placement of figures as he or she works. The first tray created by a client often holds not only part of the problem, but also part of the solution (Amatruda & Simpson, 1997). It is important to reflect on all the materials that the client presents during each sandtray, both by verbal communications and nonverbal. For instance, counselors should note which objects go in first, which are removed before the tray is set, and which objects are picked up, considered, and placed back on the shelf. Much information can be gleaned from the client’s physical movements as well as his or her activity level during the creation of his or her tray. Some practitioners suggest not asking a client direct questions about his or her finished creation, whereas others invite clients to tell them about their work as they create the tray or when they have completed it. Children frequently narrate their activities and the activities of their figures as they create their trays. After a client leaves the session, it is useful to take a photograph of the tray, in addition to any sketching of the tray done during the session so that a record of the client’s work exists. It is also essential that the client’s tray not be disassembled until after the end of the session and after the client has departed. The image reflects the “work” the client is doing, and to disassemble the tray in front of the client is perceived as undoing the work of the client’s session.

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Because the process of creating each sandtray is perceived as the therapeutic process, it is not necessary to interpret each sandtray created. In fact, interpretation of a sandtray can be as multifaceted as there are counselors. It is wise to remember that our own interpretations are just that—our own interpretations and they may not necessarily reflect the client’s meaning or intentions. As the counselor reviews photos of a particular sandtray, new understandings and symbolism of particular elements of the tray may arise. There are numerous books available on symbolism (e.g., Cirlot’s [1971] A Dictionary of Symbols) to help with interpretation of sand work, but the process itself can lead the client to transformation without outside interpretive works being consulted (Amatruda & Simpson, 1997). Some clients may use the sandtray as an anchor for the counseling process and return to it at each session, whereas others may simply create a single sandtray at the start of their work. It provides a space for depth work and metaphor to arise and allows even the most nonverbal clients a means of communicating from a deeply personal level. CONCLUSION Sandtray is an excellent medium for introducing the expressive arts into a counseling session in an easy and nonthreatening manner. Encouraging clients to utilize the miniature figures to represent both concrete and abstract forces in their lives facilitates creative expression and gets clients to rely on communication skills beyond verbal language. Sandtray invites both nondirective and directive work with clients and provides a lasting image of their inner worlds. REFERENCES Amatruda, K., & Simpson, P. H. (1997). Sandplay: The sacred healing: A guide to symbolic process. Taos, NM: Trance*Sand*Dance Press. Campbell, J. (1973). The hero with a thousand faces. Princeton, NJ: Princeton University Press. Cirlot, J. E. (1971). A dictionary of symbols (2nd ed.). New York, NY: Barnes & Nobles. Kalff, D. (1980/2003). Sandplay: A psychotherapeutic approach to the psyche. Cloverdale, CA: Temenos Press. Mitchell, R. R., & Friedman, H. S. (1994). Sandplay: Past, present & future. New York, NY: Routledge. Wells, H. G. (1911). Floor games. London, UK: Palmer. (Reprinted 1976. New York, NY: Arno Press)

Appendix: Summary Chart of Expressive Arts Activities

The following chart lists all of the activities within this book, organized by expressive art modality and then by chapter, so the reader can quickly find all activities involving art, bibliotherapy, drama, and so forth.

Expressive Art Modality

Theory Chapter

Name of Technique

Art

Adlerian theory

Life map accordion book

(Chapter 2)

Seeing the client’s world through images and collage

Page No.

Semi-structured early recollection drawing technique Structured multiple-domain family drawing technique Tissue paper collage Solution-focused therapy

Drawing a solution

(Chapter 3)

Family superpowers

Every little step you take “If it does not challenge you, it does not change you” New chapter pamphlet stitch book Race car identification

Cognitive behavioral therapy

A thousand words: cognitive behavioral phototherapy

(Chapter 4)

Catastrophe comic book Day in life without the disorder Felting with family Mental health toolbox Reversal moves for problematic thinking Tucked away

Choice theory (Chapter 5)

“Fashion statements are a fashion choice” activity

319

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Appendix

Expressive Art Modality

Theory Chapter

Name of Technique

Existential theory

Bridging the gap of self-awareness

(Chapter 6)

Collecting meaning: the shadow box as existential reflection Feelings landscape Identity-by-numbers Reframing with mat boards Restoring and linking meaning in life

Feminist theory

Altered books and changed lives

(Chapter 7)

Photovoice mapping: empowerment through a visual development history Woman craft embroidery hoop

Person-centered therapy

Client mirror

(Chapter 9)

Double-sided masks to improve congruency Dreamcatcher creation: a process of becoming Family of origin bouquet Feeling sculptures made from garbage Floratherapy: a garden of dreams Love your selfie (a self-reflection and affirmation activity) Magic wands Personality zoo Postcard poetry slam Therapy timeline Using metaphor in facilitating self-awareness Wall of images Writing your own sequel

Narrative approaches (Chapter 10)

Trauma-informed counseling

Cherokee gourd painting (as taught by Momfeather Erickson from Marion, Kentucky) “Externalizing the problem” sculpture and processing Fractions of colors Multilevel timeline My metaphor Yakima time ball Emotions with emoji Sensory memory book

(Chapter 11) Family counseling (Chapter 12)

My needs, your needs, our needs The same but different Together in this world Semi-structured strengths sorter

Clinical supervision

A picture and a thousand words

(Chapter 15)

Bridge of life Collage (case) conceptualization

Page No.

Appendix

Expressive Art Modality

Bibliotherapy

Theory Chapter

Name of Technique

Adlerian theory

A structured discovery bibliotherapy technique

(Chapter 2) Drama

Cognitive behavioral therapy (Chapter 4)

Acting out: paradoxical intention Cognitive behavioral therapy drama in two acts Day in life without the disorder Yes, and you understand

Choice theory

Choice-mobile activity

(Chapter 5) Gestalt theory (Chapter 8)

“Empty bear” technique: using puppets with adults Shadow party The boardroom Unpaid bills

Trauma counseling

Acting out the trauma

(Chapter 11)

Sensory memory book

Clinical supervision

“Finding my voice”

(Chapter 15) Expressive writing

Solution-focused therapy (Chapter 3) Cognitive behavioral therapy

New chapter pamphlet stitch book “If it does not challenge you, it does not change you” Catastrophe comic book The teapot transition

(Chapter 4) Feminist theory

Altered books and changed lives

(Chapter 7) Person-centered therapy

Empowerment over hurtful words

(Chapter 9) Narrative approaches (Chapter 10)

“Externalizing the problem” sculpture and processing Coconstructed stories My metaphor The statement of us

Trauma counseling

Sensory memory book

(Chapter 11) Clinical supervision

Creating a found poem

(Chapter 15) Floral art

Choice theory

Floral arrangements depicting quality world

(Chapter 5) Person-centered therapy Games

Family of origin bouquet

(Chapter 9)

Floratherapy: a garden of dreams

Existential theory

Interpersonal Jenga

(Chapter 6) Family counseling (Chapter 12)

Built to last

321

Page No.

322

Appendix

Expressive Art Modality

Theory Chapter

Name of Technique

Imagery/ visualization

Cognitive behavioral therapy

Reversal moves for problematic thinking

(Chapter 4) Person-centered therapy

Postcard poetry slam

(Chapter 9) Intermodal

Integrative theory in the expressive arts

Animal medicine/strength shields

(Chapter 13)

Music-inspired poetic sharing

Box of the self Naming and claiming the body

Adlerian theory (Chapter 2) Movement/ dance

Adlerian theory

Transforming lifestyle with dancing mindfulness and the expressive arts

(Chapter 2)

Transforming lifestyle with dancing mindfulness and the expressive arts

Choice theory

The peer pressure cooker (“taking a stand”)

(Chapter 5) Gestalt theory

E-motion, e-motion shield

(Chapter 8) Person-centered therapy

Wall of images

(Chapter 9) Music

Existential theory

Musical dialogues

(Chapter 6) Feminist theory (Chapter 7)

A musical chronology and the emerging life song Therapeutic community drum circle

Person-centered therapy Photography

Play

Empowerment over hurtful words

(Chapter 9)

Postcard poetry slam

Cognitive behavioral therapy

A thousand words: cognitive behavioral phototherapy

(Chapter 4)

Photovoice mapping

Adlerian theory (Chapter 2)

Show me your family in the dollhouse activity

Existential theory

Interpersonal Jenga

(Chapter 6) Puppetry

Gestalt theory (Chapter 8)

Sandplay

Solution-focused therapy

“Empty bear” technique: using puppets with adults Discovering solutions in the sand

(Chapter 3) Narrative approaches

Narrative sandtray with clients

(Chapter 10) Clinical supervision (Chapter 15)

Using sandtray in supervision

Page No.

Index

acceptance and commitment therapy (ACT), 306, 310 Adler, Alfred, 9–11, 13 Adlerian counselors, 9, 11–14, 17, 19–23 Adlerian theory bibliotherapy, 13 expressive arts intervention bibliotherapy technique, 14–15 dancing mindfulness, 25–27 doll house activity (play therapy), 20–21 images and collage, 17–18 life map accordion book, 16–17 semi-structured drawing (visual art), 19 structured multiple-domain family drawing, 22–23 tissue paper collage, 24 foundations, 9 goals and process, 11 individual psychology, 10–13 inferiority complexes, 10 multicultural competencies, 11–12 notion of superiority, 10 personality development, 9–10 play therapy, 12 psychological well-being, 10 unity of personality, 10 adult therapy, 302 adventure therapy client tasks, 288 components, 288–289 counselor, 288–289 definition, 287–288 foundations, 287 holistic counseling, 289 theory and practice, 289 affectionate attention, 305 Alzheimer’s disease, 4, 254–255 ambiguity tolerance, 308 American Art Therapy Association, 2 American Dance Therapy Association, 3

American Music Therapy Association, 2, 4 animal-assisted therapy (AAT) acknowledgment, 294–295 assurance, 295 checking in, 295–296 comfort, 295 foundations, 291–294 greeting, 294 integration of human interactions, 294 interpretation, 295 neurobiological aspects, 296–297 psychodynamics, 291 speculation, 295 anthropological theory, 237 anxiety, 1, 31, 52, 55, 93–96, 116, 138, 141, 156, 209–210, 212, 222, 261–252, 264–265, 278, 289, 292–293, 307–309 art modality interventions choice theory, 85–86 cognitive behavioral therapy, 59–60, 63–68, 70–71 existential theory, 99–102, 104–105, 112–113 family counseling, 233–235 feminist theory, 122–123 narrative therapy, 191–192, 197–199, 205–206 person-centered therapy, 158, 161–162, 167–168, 174, 177–180, 182–184 authenticity, 95 autism, 4, 63, 302 autism spectrum disorder (ASD), 63, 254 Axline, Virginia, 299

Bateson, Gregory, 222–224 Beck, Aaron, 49–50, 52 Berg, Insoo Kim, 29 bibliotherapy Adlerian theory, 13 structured discovery, 14–15

323

324

Index

Bowen Center for the Study of the Family, 222 Bowen, Murray, 222 Bowenian theory, concepts, family counseling, 222–223 brain, structure and system, 252–253 breath meditation, 310 Brief Family Therapy Center, 29–30, 40 Buddhism, 305–306, 310 Bugental, James, 93 Buhler, Charlotte, 315

calming signals, 294 child-centered play therapy (CCPT) foundations, 299–300 healing relationship, 301–302 importance of play, 300–301 issues and concerns, 302 overview, 299 person-centered therapy, 299 personality structure person, 300–301 phenomenal field, 301 self, 301 population diversity, 302–303 therapists, 299–303 child-centered playrooms, 303 choice theory core concepts human nature, 76–77 mental health, 77–78 quality worlds, 77 counseling goals, 80–81 counselor, 78–81, 87, 89 expressive arts interventions drama-based intervention, 83–84 fashion statements are a fashion choice activity (visual art), 85–86 floral arrangements (floral art), 87 peer pressure cooker (movement-based intervention), 88–91 foundations, 75–76 multicultural considerations, 81 role of creative arts, 81–82 total behavior, 78–79 wants, direction and doing, evaluation, and planning (WDEP) system, 79–80 way of conduct, 78–79 choiceless awareness, 309 clinical supervision, Gestalt approach art-based supervision, 263–264 clay, 264–265

drawing, 264 role play, 265–266 use of objects, 266 core principles, 260 counselor, 259, 261–266, 268, 274–275, 277–282 experiential activities, 261 expressive arts interventions bridge of life (art), 270–272 collage (case) conceptualization (art), 273 creating a found poem (art), 274 finding my voice (art), 275–276 picture and a thousand words (art), 268–269 using sandtray, 277–282 limitations, expressive art intervention, 263 multicultural considerations, 266–267 overview, 259–260 purpose, 260–261 role of creative art, 261–263 supervisee, 259–267, 270–271, 273–282 supervisor, 260–267, 270, 273–275, 277–282 cognitive behavioral therapy (CBT) behavioral interventions, 51–52 cognitions composition, 50 core concepts, 49–50 counseling process, 51 counselors, 49–54 empirical support, 52–53 expressive arts interventions catastrophe comic book (art and writingbased intervention), 59–60 collage making, 55–57 drama-based interventions, 58, 61–62, 72–73 felting with family (art), 63–64 mental health toolbox (visual art), 65–66 photography, 55–57 reversal moves for problematic thinking (art and visualization), 67–68 teapot transition (expressive writing), 69 tucked away, difficult/stuck situation (art), 70–71 foundations, 49 mindfulness, 306 multicultural considerations, 53 cognitive development, theory of, 301 cognitive distortions, 50–52, 55, 59 cognitive therapy, 49 REBT comparison with, 49–51 collaborative empiricism, 51 collage, 37–38

Index

confluence, 138 core, conditional, or compensatory beliefs, 50 corrective life experiences, 288 creative arts, 1–2, 4 Adlerian counseling, 12 creative license, 137. See also Gestalt therapy

dance/movement therapy, 3 dance/movement-based intervention life-style transformation, 25–27 De Shazer, Steve, 29–30, 33, 35, 39, 42, 44 depression, 1, 31, 49, 52, 78, 116, 139, 156, 187, 212, 254, 289, 306–309 depressive symptoms, 53 dialectical behavior therapy (DBT), 306, 310–311 Digital Anatomist Atlas, 251 dollhouse activity, 20–21 drama-based counseling interventions cognitive behavioral therapy, 61 role in counseling practices, 3–4 trauma, 213 drawing technique multiple domain, 22–23 semi-structure, 19 for solution, 35–36 dysfunctional thoughts, 51, 70

Ellis, A, 49–51 Epston, David, 187, 197 Erikson, Erik, 315 existential guilt, 95–96 existential theory concerns, 96 core concepts death, 94 freedom, 94 isolation, 94–95 link to anxiety, authenticity, and guilt, 95–96 meaninglessness, 95 counselors, 97–98, 113 expressive arts interventions bridging gap of self-awareness (art), 99–100 collecting meaning (art), 101–102 identity-by-numbers (art), 104–105 interpersonal Jenga (game), 106–109 musical dialogues (music therapy), 110–111

325

reframing with mat boards (art), 112 restoring and linking meaning in life (art), 113 foundations, 93–94 multicultural considerations, 97 role of creative arts, 97–98 theme identification, 97–98 experiential family theory, 224 expressive arts interventions Adlerian theory, 14–23 choice theory, 83–91 clinical supervision, 268–282 clinicians, 1–4 cognitive behavioral therapy, 55–73 existential theory, 99–113 family counseling, 226–237 feminist theory, 122–133 Gestalt theory, 141–152 integrative theory, 241–248 key modalities, 2 narrative therapy, 191–206 overview, 1–2 person-centered therapy, 158–184 solution-focused therapy, 33–45 therapeutic modality, 4–5 trauma, 213–217 expressive writing, 2–4 narrative therapy, 203–204 person-centered therapy, 163–165

family counseling Bowenian theory, 222–223 counselors, 222, 224–225, 230, 236, 238 experiential family theory, 224 expressive arts interventions built to last (game therapy), 226–227 one’s needs (narrative, visual arts), 228–229 semi-structured strengths sorter (expressive art/visual art), 230–4, 236–237 the same but different (art), 233 together in this world (art), 234–235 Haley’s theory, 223 versus individual counseling, 221 Minuchin’s theory, 223 multicultural considerations, 225 role of creative arts, 224–225 Satir’s theory, 224 strategic family theory, 224 structural family theory, 224 family super powers, 39–41

326

Index

feminist theory concerns evidence based research, 118 philosophical grounds, 118 core concepts advocacy, 118 flexibility, 118–119 gender roles, 116–117 hierarchical relationship, 117–118 oppression issues, 117 power issues, 117 counselors, 115–119, 121, 124–125, 131 developmental thinking, 115–116 experiential techniques, 119 expressive arts interventions altered books and changed lives (art), 122–123 drum circle (music therapy), 126–129 musical chronology (music therapy), 120–121 photovoice mapping (visual arts), 124–125 woman craft embroidery hoop (visual arts), 130–133 multicultural considerations, 119 multiple identities, 119 role of creative arts, 118–119 versus traditional theories of counseling, 116 waves, 115 floral arts interventions choice theory, 87 person-centered therapy, 166, 169 Freud, Anna, 115 Freud, Sigmund, 9, 115–116

game therapy existential theory, 106–109 family counseling, 226–227 Gestalt theory channels of resistance, 138 clinical supervision, 259–260 core concepts, 137–138 counselor, 138, 144, 149 expressive arts interventions boardroom (drama), 148–149 e-motion (dance and movement), 144–145 empty bear technique (puppetry and drama), 141–143 shadow party (drama), 146–147 unpaid bills (psychodrama), 150–152 foundations, 137 multicultural considerations, 139

nature heals, 138 research base, 139 role of creative arts, 139–140 Glasser, William, 75–81, 83, 85 Goodman, Paul, 137 guided discovery, 51

Hahn, Kurt, 287 Haley, Jay, 223 Human Validation/Satir Model, 224 human–animal relational process (HARP), 292, 296–297 human–animal relational theory (HART), 291–292, 296–297 human–animal relational therapeutic impact (HARTI), 292, 296

images and collage, counseling session, 17–18 individual psychology, 10–13 core principles, 10–11 intergenerational family process, 223 integrative theory core concepts, 238 counseling and psychotherapy, 237 counselors, 238, 243, 245, 247 expressive arts interventions animal medicine/strength shields (intermodal expressive arts), 241–242 box of self (intermodal expressive arts), 243–244 music-inspired poetic sharing (intermodal expressive arts), 245–246 naming and claiming the body (intermodal expressive arts), 247–248 foundations, 237–238 issues, 238–239 role of creative arts, 239 intergenerational family process., 223 intermodal expressive therapy, 2 isomorphism, 29

Kabat-Zinn, Jon, 305–306 Kalff, Dora, 315

life map accordion book, 16–17 Lipchik, Eve, 29 Lowenfield, Margaret, 315

Index

May, Rollo, 93–94 mindfulness counseling client benefits, 307 counselor benefits, 307–308 counselors, 305, 307–308, 310–311 definition, 25–26 description, 305 formal and informal practices, 309 foundations, 306–307 general and specific interventions, 310–311 positive outcomes, 308–309 therapeutic relationship, 309–310 training, 306–308, 310 mindfulness-based cognitive therapy (MBCT), 306–307, 309–310 mindfulness-based interventions (MBIs), 305, 307–310 mindfulness-based stress reduction (MBSR), 306–310 mindful self-compassion (MSC) program, 307 modes, 2, 50, 51, 251 Minuchin, Salvador, 223 Molnar, Alex, 29–30, 32 movement therapy choice theory, 88–91 in counseling practices, 3–4 trauma counseling, 211 multiculturalism, 119, 124 music-based interventions existential theory, 110–111 feminist theory, 120–121, 126–129 neuroscientific perspectives, 255–256 person-centered therapy, 163–165 role in counseling, 2–4

narrative therapy concerns, 188–189 core concepts, 187–188 expressive arts interventions Cherokee gourd painting (art), 191–192 co-constructed stories (writing), 193–194 fractions of colors (art), 197 multilevel timeline (art), 198–199 my metaphor (visual art), 200 narrative sandtray (sandtray), 201–202 sculpting of concern/problem (sculpture), 195–196 statement of us (expressive writing), 203–204 Yakima time ball (art), 205–206 multicultural considerations, 189

327

role of creative arts, 189–190 National Association for Drama Therapy, 3 National Association for Poetry Therapy, 3 National Institute of Mental Health, 222 Navajo healers, 1 neurological disease, 254 neuroscience, 251–254, 256 neuroscientific perspectives core principles, 253 foundations, 251–252 general applications, 253–254 music therapies, 255–256 role of creative art, 254–255 selfbox technique., 255 theory and components, 252–253 new chapter pamphlet stitch book, 44–45 nondirective play therapy, 299, 302 nonverbal methods, 238

outward bound model, 287–289. See also adventure therapy

Palo Alto Group, 224 Peller, Jane, 29 Perls, Frederick (Fritz), 137, 259–260 Perls, Laura, 137, 259 person-centered therapy applications, 156 clinical supervision, 260 counselors, 156, 159, 163, 164, 168–169, 171, 177–180, 183 expressive arts interventions client mirror (art), 158 double-sided masks (visual art), 159–160 dreamcatcher creation (art), 161–162 empowerment over hurtful words (music and expressive writing), 163–165 family of origin bouquet (art/floratherapy), 166 feeling sculptures made from garbage (art), 167–168 floratherapy, 169–170 love your selfie (visual art), 171–172 magic wands (art), 173 personality zoo (art), 174 postcard poetry slam (music), 175–176 therapy timeline (art), 177–178 using metaphor (art), 179–180 wall of images (movement therapy), 181–182 writing your own sequel (art), 182–184

328

Index

person-centered therapy (continued) foundations, 155–156 multicultural considerations, 156–157 role of creative arts, 157 personal power, 115, 117 philosophical theory, 237 physical disabilities, 4 play therapy Adlerian theory, 12, 20–21 Gestalt approach, 259 nondirective play therapy, 299, 302 poetry therapy, 3 posttraumatic stress disorder (PTSD), 52–53 powerlessness, 117 psychological theory, 237 psychosomatic problems, 138 psychotherapeutic care, 2 psychotherapy, 237–238 existential, 93–98 hierarchies in counseling and, 117–118 mindfulness-informed, 310 Western practices, 241, 306

race car identification, 46 rational emotive behavior therapy (REBT), 49 counseling process, 49–51 counselor, 49, 51 reality therapy, 75, 79 recognize/relax, allow/accept, investigate, and note (RAIN), 311 relational cultural theory (RTC), 119 retroflection, 138 Rogers, Carl, 155–158, 299–301

sandplay therapy, 33–34 basic materials, 315–316 benefits, 316–317 clinical supervision, 277–282 counselors, 315–317 narrative therapy, 201–202 overview, 315 solution-focused therapy (SFT), 34 symbolism, 317 therapeutic process, 316–317 Satir Growth Model, 224 Satir, Virginia, 222–225 self-compassion, 306–309 significant human–animal relational moment (SHARM), 292, 294–297. See also animal-assisted therapy

solution-focused behavioral therapy (SFBT), 30–31, 39 solution-focused therapy (SFT) collaboration, 31 community, 31 competence, 31 context, 31 core concepts, 30 counselors, 30–32 critical consciousness, 31 efficacy, 31 foundations, 29 implications for counseling, 32 multicultural considerations, 30–31 specific techniques, 30–31 expressive arts interventions drawing a solution, 35–36 family super powers, 39–41 new chapter pamphlet stitch book, 44–45 sand tray therapy, 33–34 use of inspirational quotes (visual/writing art), 42–43 strategic family theory, 224 structural family theory, 224 substance use, 306–307

tag team role-playing, 266 tissue paper collage, 24 transformational systemic theory, 224 trauma coping strategies, 209–210 counselors, 209–214 ethical counseling, 211–212 expressive arts interventions acting out (drama therapy), 213–214 emotions with emoji (visual art), 215 sensory memory book (multimedia), 216–217 negative effects, 209 self-care, 211–212 treatment goals, 210–211 traumatic brain injury (TBI), 251, 254

Virginia Satir Global Network, 224 visual art modality interventions Adlerian theory, 19 choice theory, 85–86 cognitive behavioral therapy, 65–66

Index

choice theory, 85–86 cognitive behavioral therapy, 65–68 family counseling, 228–232, 236–237 feminist theory, 124–125, 130–133 narrative therapy, 200 person-centered therapy, 159–160, 171–172 role in counseling practices, 2, 4 solution-focused therapy, 42–43 trauma therapy, 215

329

writing art, 42–43 writing-based interventions cognitive behavioral therapy, 59–60, 69 narrative therapy, 193–194, 203–204 person-centered therapy, 163–165, 182–184 role in counseling, 2–3 solution-focused therapy, 42–43 Western psychotherapy, 306 White, Michael, 187, 197