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Differentiation of self through the lens of mindfulness

By Kevin Foose and Maria Cicio February 7, 2018

A few years ago, while teaching a course in family therapy, a particularly bright and insightful student named Maria lingered after class one day and asked, “Isn’t differentiation of self similar to mindfulness?” I hadn’t quite thought of it like that before, but it certainly seemed plausible. “Let’s set aside some time to talk,” I suggested. With that single question began many months of conversations.

In 2015, a continuation of those hours of exploration transformed into an “anti-presentation” that was awarded “Best of Show” at the Louisiana Counseling Association Annual Conference. The examination continued the following spring at the American Counseling Association Conference & Expo in Montréal. In the end, it was inquiry rather than answers that animated our informal lyceum. Quest and question are born of a common root. And teaching is thin soup if only the student grows. The current work is an attempt to extend the spirit and tone of those many fruitful hours of meeting.

Attempting to define differentiation

Differentiation of self (DoS), since first being introduced by Murray Bowen in the early years of the family therapy movement, has remained a lofty, elusive and often misunderstood concept. As Bowen’s colleague, Michael Kerr, pointed out, differentiation contains so many unique conceptual facets that it defies simple definition.

Bowen himself, persistently mystified by the consistent misinterpretation of differentiation, noted late in his life in one of his more cantankerous moments that he wished he’d never “discovered” it in the first place. Anthropologist Gregory Bateson once said of Charles Darwin that he didn’t discover evolution, he made it up. The same may be said of DoS. Viewed through this lens, DoS becomes a story (the point of which is to communicate its creator’s intent) steeped in a deep faith in science and the relatively recent emergence of the Western nuclear family.

If we are to accept the premise that differentiation does indeed defy simple definition, or at the very least is so subtle and nuanced that it is open to numerous interpretations, the initial question that emerges is: What in the world are we actually talking about when we talk about differentiation?

Michael Cowen, one of my colleagues at Loyola University New Orleans, provides a useful foundation from which to launch this conceptual ship with his interpretation of differentiation as “the capacity to be aware of one’s own unique pattern of feeling, valuing and thinking, and to decide and act in ways that remain faithful to that awareness.” Cowen’s definition shifts the focus of differentiation away from some thing that one is or has or even does, toward a description of understanding and action. It is a process that, at its core, allows individuals to make distinctions between thoughts and feelings and to remain calm in highly emotional situations. It is the ability to be both a part of and apart from significant relationships, and it places a high premium on the ability to behave rationally. It is not, however, a call for a Spock-like hyper-rationality nor a ringing endorsement of the ruggedly individualistic American mythology.

For the sake of moving forward with consensus, nebulous as it may be, I (Kevin) am inclined to give Bowen the final say in the construction of a working definition of differentiation as “a way of thinking that translates into a way of being.” So the story goes.

If that description of differentiation is to be accepted, the question then becomes, how is one to cultivate such “a way of thinking?” And who might act as a reliable translator? This is the point at which the teaching of the Buddha, in general, and mindfulness, specifically, can offer a helpful perspective from which to view perceptions and human experience.

At first glance, Bowen and Buddha may seem to be a strange pairing. After all, Bowen’s search for understanding led him back to the tumult of his family of origin, whereas Buddha left home seeking transcendence and never returned. Logistically, Buddha’s eightfold path provides a different road map toward liberation and understanding than does Bowen’s eight interlocking theoretical concepts. But the wisdom gained beneath the Bodhi tree may not be as divergent from the family tree as one might think. When differentiation is examined through the prism of mindfulness, significant conceptual convergences begin to emerge. The potential implications for personal growth, insight and clinical practice merit a pause, perhaps a deep breath, and further contemplation.

Mindfulness

Mindfulness is essentially the act of being present. Anchored in continuous awareness of each emerging moment, it is the cultivation of a calm, dispassionate state in which experience can be examined with acceptance and nonjudgment. Mindfulness, not unlike DoS, is a process that provides the possibility of escaping the trappings of emotional reactivity.

In an excellent article examining mindfulness (“Mindfulness: A Proposed Operational Definition” in the September 2004 issue of Clinical Psychology: Science and Practice), a group of Canadian academics, led by Scott R. Bishop, pointed out that the insight that emerges through disciplined contemplative practice creates an open “space between one’s perception and response, ultimately making it possible to respond and interact more reflectively (as opposed to reflexively).” Rather than becoming tangled up in “ruminative, elaborative thought streams about one’s experience and its origins, implications and associations, mindfulness involves a direct experience of events in the mind and body,” wrote Bishop and his colleagues

In other words, we are able to stay tethered in the present, experiencing our life with courage and composure as it actually unfolds in our midst. In this awakened state, our mind is freed from anger, attachment to desire and misperception. Providing an alternative to being swept away in a flood of emotionality and elaborate misinterpretation, we are able to resist the urge to flee into ideations of the imagined future clouded by the residue of the past, or compulsively bend reality to meet idiosyncratic needs.

Mindfulness is the antidote to fear, confusion and anxiety. It is a practice and process that tethers us to the immediacy of our lives with the insight to see “relationships between thoughts, feelings and actions and to discern the meaning and causes of experience and behavior” (as described in “Mindfulness: A Proposed Operational Definition”). Essentially, mindfulness cultivates the ability to interact rather than react.

The greatest hurdle in defining a self or sustaining mindful attention is emotional reactivity. When emotions escalate beyond a critical threshold, a state of mind emerges in which rational thinking evaporates and agitation hijacks the cognitive process. It is impossible to differentiate in such an agitated state. We become prisoners to automatic emotional responses saturated in fear.

Buddha referred to this reactive state as “monkey mind,” in which fear becomes much like a loud, drunken monkey frantically screeching the alarm bells of danger in our brains. The ability to quickly regain composure and quiet the monkey mind is the cornerstone of both differentiation and mindfulness.

The quiet mind is fertile ground for exploring what Buddha called “store consciousness.” Long before Sigmund Freud proposed his theory of the unconscious (again, see Bateson above) or Bowen began his examination of psychobiological cognitive-emotional processes, Buddha was wandering about preaching the Dharma, teaching practices aimed at liberating people from misperception and attachment to mental formations that seemed to be just beyond the reach of everyday awareness.

Vietnamese Buddhist monk Thich Nhat Hanh writes in the introduction of Cultivating the Mind of Love: “In our store consciousness are buried all the seeds, representing everything we have ever done, experienced or perceived. When a seed is watered, it manifests in our mind consciousness. … The work of meditation is to cultivate the garden of our store consciousness.”

Getting back into harmony with our lives

Whatever we “attend” to will grow. And what we don’t attend to will tend to grow out of control without insight into content and coping strategies buried deep in our store consciousness. For multigenerational family systems theory, the seeds in the soil are the early experiences in the family of origin. Differentiation allows for a bit of psychic “weeding” to occur so that intimacy and integrity may grow.

Buddha, too, was attuned to the influence that family members have on one another. Perhaps more poetic, but no less prophetic, a Buddhist teaching examines the importance of the emotional climate of filial bonds, invoking the image of the garden again: “A family is a place where minds come in contact with one another. If these minds love one another, the home will be as beautiful as a flower garden. But if these minds get out of harmony with one another, it is like a storm that plays havoc with the garden.”

It is precisely in those moments when one finds oneself in the “I” of the storm where mindful intention allows the well-differentiated self to stay calm and sift through frenetic cognition that often causes impairment in our lives. The ability to sit in the midst of the tempest and remain present, self-aware and in close emotional contact with others is the essence of what Soto Zen monk Shunryu Suzuki calls “imperturbable composure.”

The well-differentiated self exhibits radical acceptance to what Jon Kabat-Zinn calls the “full catastrophe of living.” In this way, we remain open and curious to the actual events of our lives as they unfold, freeing ourselves from endless cycles of suffering and automatic reactivity. Whether we call this mindfulness or differentiation becomes an exercise in semantics.

Through work and practice, we become available to the full reality of our lives, with the insight and courage to quietly slip through the cracks of our conditioning and allow our ego-cramped consciousness to release its grip on our battered psyche. Quite simply, DoS and mindfulness bring us back into harmony with our lives.

For Buddha, the ultimate act of enlightenment is to wake up. The Dharma teaches that it is possible for any of us to awaken at any moment in our lives. Much like achieving a fully mindful present state, people often find embarking on the path of defining a self to be a daunting task.

Bowen was clear and consistent in his insistence that the fully differentiated self is a theoretical concept that is practically unattainable. It is a guiding light rather than prescription. However, with much work and practice, it is possible to increase one’s level of differentiation. Bowen pointed out that if we can “control the anxiety and the reactiveness to anxiety, the functional level will improve.” The task at hand becomes “getting beyond anger and blaming to a level of objectivity that is far more than an intellectual activity. … The overall goal is to be constantly in contact” with emotional issues involving ourselves and others.

A common thread

Although Bowen and Buddha’s conceptualization of the “self” superficially seems to be the point at which the Venn in the Zen between DoS and mindfulness begins to diverge, it is through interdependence that the deepest synthesis actually occurs. Whether one adopts a scientific or a spiritual perspective, the influence that each of us has upon the other is the thread that ties mindfulness and differentiation together.

Bowen was certain that the self exists. Buddha sent his disciples out into the world in search of the self and sat patiently waiting for the report back. Ralph Waldo Emerson, with his ever-present, transcendental wisdom, offered this: “All that is said of the wise man by Stoic or Oriental or modern essayist … describes his unattained but attainable self.”

Both Buddha’s and Bowen’s philosophical views were undergirded by a belief in the profound effect that each of us has upon one another. Bowen believed that successfully differentiating oneself within the system could have significant influence on all others in that system. He noted that if one is able to successfully define a solid sense of self and defend against requests from others to change back to old ways of being, then the entire system can catapult forward into higher levels of functioning.

The Dharma teaches that when one is awakened with compassion and wisdom, all are touched by the light. In Cultivating the Mind of Love, Hanh examines Buddha’s teachings, exploring the ways in which the Dharma opens each of us to the possibility of deeper understanding and more intimate connection. In his introduction, Hanh invites us to become fully present, and “the rain of the Dharma will water the deepest seeds of your store consciousness. If the seed of understanding is watered … the fruits of love and understanding will grow.”

Examining the teaching of interbeing and the delusion of separateness falsely constructed in the mind, Hanh concludes: “We must vow to practice for everyone, not just for ourselves. … Because of our ignorance and habit energies, we usually perceive things incorrectly. We are caught in our mental categories, especially our notions of self, person, living being and life span. We discriminate between self and nonself. … When we see things this way, our behavior will be based on wrong perceptions. Our mind is like a sword cutting reality into pieces, and then we act as though each piece of reality is independent from other pieces. If we look deeply, we will remove these barriers between our mental categories and see the one in the many and the many in the one, which is the true nature of interbeing. … Everything is touching everything else. … To bring relief to one person is to bring relief to everyone, including ourselves. This insight brings about the kinds of actions that are truly helpful.”

These are hopeful thoughts for troubled times. What is called for in this moment, if one is to view differentiation through the lens of mindfulness, is a “way of thinking that translates into a way of being in the world” that accurately perceives the deep connection that we have with the world surrounding us and the profound effect that each of us has upon one another. So the story goes.

Compassionate listening

Counseling is a reciprocal process of story and interpretation. As a conversational intervention, much attention has been given to the narrative telling of the tale — the “talk” in talk therapy. Often lost in the reciprocity is the transformative power of listening. As Hanh points out, when we listen to another deeply and compassionately, we help that person to suffer less. “One hour like that can bring transformation and healing,” he teaches.

If listening in this way does indeed, as we believe, lead to the alleviation of suffering, the question becomes, how does one engage in the process of compassionate listening?

The calm that accompanies the differentiated self, and a mindful stance tethered in the present, provide a helpful perspective from which to enter into another’s story. It allows one to avoid judgment without abandoning discernment and concern. This way of being allows the counselor to bear witness to the tumultuous content of clients’ troubled narratives without becoming overwhelmed. We can tolerate intense emotion without needing to flee for safety and care without getting carried away.

Deep listening contains the seeds of empathy. The calm that accompanies a well-differentiated presence opens up the space to create the distance necessary to examine problem-saturated narratives. The practice of active listening artfully folds the story continuously back upon itself, returning the client to present-moment awareness. The acceptance that accompanies awareness invites the client to slow down, resist the impulse to avoid the suffering and instead examine the story with compassion. The wisdom to accept that which is beyond our control paradoxically generates the flexibility necessary for transformation to occur.

Pragmatically speaking, compassionate listening is rooted in language. To listen in this manner, it is essential to remain firmly planted in the present, gathering content without getting lost in the labyrinth of past suffering or anxious projections of the future. When listening to stories of suffering, it can be easy to lose sight of the fact that the actual experience is the retelling of the tale here and now, not what occurred there and then. It is imperative to honor our clients’ suffering while also uncovering their strength.

The task is to attend to the content of the client’s story while staying deeply connected to the person. Listening in this way allows us to wonder what the client is trying to communicate about his or her struggle through the story. What meaning is seeking to be understood? What are the relational and emotional elements recurring in the client’s words? Compassionate listening is the conduit into the deepest sense of clients’ experiences. It asks, how can we be present to the struggle and help our clients confront the frustrating and most frightening moments of their lives?

At its core, compassionate listening holds the therapeutic space. It widens the client’s interpretation just a bit. It uses the client’s language, symbols and metaphors. It sees as well as hears, deconstructing the story, searching the margins for what has been edited out, pulling the thread of seemingly disjointed pieces and reflecting it back in recognizable form. This way of listening is ultimately a path toward healing that allows for safe passage through suffering. As American Buddhist nun Pema Chödrön points out, mindfulness allows us to choose an alternative course for our lives. A process such as DoS requires us to first notice the true nature of our experience, then disrupt our habitual patterns and do things differently and, finally, practice again and again, one moment at a time.

A client suffers and a change is necessary. The struggle often comes with not knowing how to manifest a healthy change. The client has likely been avoiding, wrestling with and running away from anxiety for years, creating deeply ingrained habits. In the space created by deep listening, the client can experience something different. Clients may be able to look at their anxiety for the first time with compassion and understanding. The paradox is that once they are able to sit with their struggle instead of avoiding it, anxiety loosens its grip on their lives.

DoS, viewed through the lens of mindfulness, creates the clarity and compassion for transformation to occur. Mindfulness aids in the process by creating awareness of our mind-body interaction so that we can become more skillful in our interpersonal, and intrapersonal, relationship(s).

Just as the counseling process makes space for emotions, thoughts, ideas and stories in session, mindfulness creates a similar space for our internal experience to occur. This is the “deep listening” to our own process. Mindful awareness allows for attunement, not only with our clients but with ourselves. It creates systemic and intrapsychic awareness to the ways that we get hooked into metanarratives and mental confines. Emotions no longer run amok, and we are available to be in relationship with others. As clinicians, we must first listen deeply to the mystery and history of our own stories before making contact with someone else’s.

The Beat Zen of Richard Brautigan leads us to a quiet place to begin in his poem “Karma Repair Kit: Items 1-4”:

1. Get enough food to eat,/ and eat it.

2. Find a place to sleep where it is quiet,/ and sleep there.

3. Reduce intellectual and emotional noise/ until you arrive at the silence of yourself,/ and listen to it.

4. ???

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Kevin Foose is an assistant professor in the Department of Counseling at Loyola University New Orleans. He maintains a private practice that focuses on couples and adult individuals. Contact him at kjfoose@loyno.edu.

Maria Cicio is a graduate of the Loyola University New Orleans master’s in counseling program, class of 2015. A licensed professional counselor, she is currently working in community mental health in rural Oklahoma.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Creating comics with clients

By Devlyn McCreight February 1, 2018

Academic and clinical interest regarding the intersection of comics and health care is high right now, which is no surprise to readers of Counseling Today. The July 2017 issue of Counseling Today featured a cover story titled “‘Cultured’ counseling” that provided perspectives on the clinical utility of integrating pop culture (such as video games, movies and comic books) into counseling practice. Similarly, both the American Psychological Association and the American Medical Association have devoted time and journal space to covering the topic, signaling that mental health counselors are not alone in wanting to explore the positive impact that comics can have on delivery of services.

Case in point: The 2017 Comics & Medicine Conference was held this past June in Seattle. An eclectic cross section of cartoonists, medical doctors, mental health professionals, teachers, students and librarians from across the globe attended. The conference theme, “Access Points,” explored how comics can open new gateways to health care “because of its ability to provide a platform for marginalized voices.” Because this worldwide chorus of marginalized voices often includes people with mental health diagnoses and comorbid disorders, comics can also help bridge the gap between client and counselor when utilized correctly.

As the body of literature regarding the therapeutic value of comics grows, the question is raised: Can comics be used as an intervention apart from traditional bibliotherapy? The focus of this article is to explore the rationale for creating comics with clinical clients, gain guidance from practitioners who use comic creation as a direct intervention and provide resources for those who are interested in learning more.

Beyond bibliotherapy

In the fourth edition of the American Counseling Association’s Counseling Dictionary, the intervention bibliotherapy is defined as “generally understood to be the reading of selected literature to help individuals gain a better understanding of themselves and others as well as to produce at times a healing or helpful catharsis.”

The bulk of recent literature regarding comics and mental health has fallen squarely into the realm of bibliotherapy, focusing on using graphic novels and memoirs to help clients better understand their own challenges. Although strong clinical evidence exists to support using existing commercially available materials to help articulate client experiences, a growing number of health services practitioners are advocating that patients and clients begin writing and illustrating their own stories.

Ian Williams, a comics artist, writer and physician who co-founded the Graphic Medicine movement, has suggested that revisiting trauma using sequential art can provide a form of catharsis for the creator, citing examples of prominent figures in the graphic memoir field such as Art Spiegelman (Maus) and Katie Green (Lighter Than My Shadow). His assertion is that the combination of visual art and narrative structure allows clients to reauthor their experiences in ways that simply talking through them do not.

This same hypothesis was the driving force behind the Defense Advanced Research Projects Agency (DARPA) using graphic novel software to assist combat veterans in dealing with symptoms of posttraumatic stress disorder. This initiative led to DARPA commissioning California-based software developer Kinection to design the Warrior Stories Platform for use with veterans.

Similarly, several public schools across the country have begun using online comic-creation software to help address ongoing behavioral issues for children with special needs. In addition, educators and social science researchers alike are using comic creation to help children tackle difficult real-world issues (such as making positive choices in the face of peer pressure), develop a more robust understanding of historical events (such as the Holocaust) and cultivate sound safety habits when interacting with friends and strangers.

As professionals from a multitude of disciplines create comics with others to help bridge the gap between educational content and personal experience, clinical mental health counselors can do the same with their clients.

The therapeutic act of creating comics

Scott McCloud, renowned cartoonist and educator, once defined comics as “images deployed in a sequence to tell a story graphically or convey information.” Given that comics are a storytelling medium, it is perhaps not surprising that the therapeutic act of creating comics falls under the scope of narrative therapy.

Narrative therapy is primarily concerned with the stories that clients have within them — those internalized beliefs formed by clients’ interactions with the various familial, social and cultural forces throughout their lifetime. Narrative therapies also place primary emphasis on the act of externalization of client issues. As Michael White and David Epston, the primary developers of narrative therapy, once famously surmised, “The person is not the problem, the problem is the problem.”

Externalization is used to help clients who overidentify with their problematic symptoms (“I am depressed”) begin to understand these experiences as distinct from their core self (“I am dealing with a really difficult depressive episode right now”). When I interviewed Katharine Houpt, an artist, licensed clinical professional counselor, board certified art therapist and lecturer at the School of the Art Institute of Chicago, she shared that the main strength of creating comics with clients is that it fosters the externalization process: “The idea is that experiences can be overwhelming and can take up so much space that it’s helpful to externalize them, and [creating comics] literally puts a container around those experiences so you can put them away on a shelf, so to speak, and [the problems] are separated from the person.”

Having a physical representation of an internal experience can be valuable because the idea of containment is extremely important when dealing with sensitive parts of a client’s experience. Each panel in the comic sequence functions as a figurative container for potentially overwhelming psychic material, allowing clients to approach the issue with a feeling of control or mastery that might elude them otherwise. The comic format also allows clients to represent themselves, others and even their disorders pictorially through the creation of avatars.

Working with clients to graphically depict interactions between themselves and problematic symptoms can help them uncover new insights. As with any other type of therapeutic intervention, it is important to choose comic-making directives that reflect an understanding of individual clients, their struggles and what resources they bring to the situation. “An example of something I’ve done recently is ask a client to create characters to have a dialogue based on the person’s conflicting thoughts when trying to make a decision,” Houpt says. “But again, this was done with careful consideration of the person’s history, possible responses, coping tools, motivation, ability, etc.”

Suggestions and considerations

Possessing a clear sense of best practices when creating comics (or any other type of art) with clients can help clinicians avoid therapeutic pitfalls and unintended confidentiality issues and create a safe space for the creative process. What follows are suggestions and considerations for therapists who are interested in beginning to integrate comic creation into clinical practice.

Create a functional space. Rebecca Bloom, a board-certified art therapist and licensed mental health counselor who practices in Washington state, suggested that clinicians try making art themselves in client spaces before introducing any interventions into practice. “I tell everyone that comes to my workshop, ‘Sit where the client will sit and try and make art in that spot.’ People inevitably come back and say, ‘Oh, well, it’s impossible to make art there.’ So I respond, ‘Great, now figure out how it would be more possible. Do the art supplies need to be closer? Do you need a lap desk? Do you need a coffee table that’s easy to use?’”

If the space available is not amenable for making art, this might require an investment in additional furniture that could be cost prohibitive. If an existing space and furnishings can be rearranged to accommodate the activity, it is also important to think through whether the space can remain in that configuration for clients who are not making art. If it can’t, it might be necessary to reserve time to reset the office between client sessions.

Remember, art is messy. Another consideration in determining whether a space is appropriate for incorporating any art making is whether the space is shared with other practitioners. “Art takes a little thinking through,” Bloom explained. “In some settings, it’s really hard, like for people who are in institutional settings. … Art is really messy. So, if there’s no way to be messy where you are, that’s going be a little problematic for art making.”

This holds true for comic creation too. India ink can be spilled, markers can be dropped onto couches, and erasers can leave behind rubberized crumbs. The reality of potential messes requires that practitioners be thoughtful about what materials they are willing to use during a session.

“Also, there need to be limits around time and mess,” Bloom said. “I stop the art-making process 10 minutes before the session ends because I want to make sure the people are back in their conscious process. I want to make sure we have time to clean up. [There are] materials that I don’t use. I don’t use paint in my office because it’s so easy to get out of control. I do spend money on fancy Copic markers with brush tips so you can have that experience of painting but without the mess.”

Invest in quality materials. Investing in quality materials will allow clients to stay focused on the therapeutic process instead of struggling to work with dried-out markers, inkless pens, stubby crayons or dull pencils. Additionally, having a selection of higher-grade media to choose from can signal clients that you are taking the art-making process seriously and being thoughtful about the materials with which you are asking them to work. “Clients can take a bad art-making experience personally,” Bloom observed.

Try it yourself first. Another common mistake clinicians sometimes make when using art directives during session is believing that instruction alone will inspire a client to make therapeutically meaningful art. “The only thing I hate for clients is when a therapist says, ‘Draw your darkest fear,’ and the client looks at them like, ‘You try that first. You try drawing your darkest fear,’” Bloom said. “You don’t want to ask anybody to do something that didn’t work for you, because you’re not going to be able to sell it very well, and you’re not going to be able to take care of somebody if it doesn’t go right. And you’re not going to understand the resistance in not wanting to do it.”

This also holds true for comic creation. If the counselor has never drawn a comic, then it will be difficult to understand client process from an artistic and therapeutic standpoint. One practice that can be helpful for therapists new to comic making is to try working with their own “daily comics journal.”

Kurt Shaffert, a fellow in applied cartooning at the Center for Cartoon Studies, located in White River Junction, Vermont, endorsed this practice, acknowledging that he has used it himself. “The basic idea is to sit down every morning and draw a simple three- to four-panel cartoon that captures where you are in that moment,” he said. “It was very helpful for me when I was going through some difficult personal circumstances. And when I began sharing them with my friends and family, they began to have a better understanding of what was happening with me during
that time.”

Houpt also uses the daily comics journal exercise to help temper the high emotions and excitement that can accompany working with comics. “I always emphasize the importance of pacing with clients,” Houpt said. “I think people can get really excited about comics and want to get really deep really fast. So something that I’ve done a lot with folks is ask them to keep a daily comics journal with just six panels per page. It puts a little bit of structure around it so that the experience doesn’t become overwhelming. And that practice has been really helpful for people to identify problems and solutions in their lives, to start recognizing themes, patterns and alternative stories about who they are through their personal artistic languages.”

There are also many opportunities for clinicians to gain firsthand experience with art therapy and comic-making interventions by utilizing local resources. Many art therapists, including those interviewed for this article, offer community-based workshops for clinicians and laypeople alike. Connecting with local therapists who regularly use art-based interventions can also provide valuable networking opportunities and potential ongoing clinical support as counselors begin to integrate art into their practice.

Read comics … and talk about them. If you are reading this article, chances are that you have some interest in the medium of comics, which exists apart from the therapeutic value of making comics. Exposing yourself to a wide range of commercially available comic books and graphic novels can help expand your understanding of what comics are — or ultimately can be.

Cultivating a broader understanding of what is considered a comic can help the therapeutic process in the long run. “I do find that I have to explain comics in many different ways to people,” Houpt said. “Sometimes I won’t call them comics. Sometimes I’ll say, ‘stories using words and pictures,’ or I will talk about something they might be familiar with, like the Sunday cartoons. … There’s all kinds of different interpretations. So, I just use that and make that part of the process of making comics with the client because, same as any other identifier about a person, it will mean a different thing to each individual.”

Talking with clients about their own beliefs regarding the medium can put them more at ease, which might allow them to experience greater gains from creating comics as part of the therapeutic process.

Be aware of the ethics regarding client art. There are additional ethical considerations that accompany counselors asking clients to make art for a therapeutic purpose. “I definitely think that all kinds of people can do some basic art therapy directives,” Bloom said. “I produce books that have those directives in them. Lots of people do. One of the major differences between people [who] are trained as art therapists and people who are not is what happens to the art after [it has] been made. It’s very common that people who are not trained as art therapists will put the art right up on the wall. Whereas art therapists believe that’s a private clinical conversation and that the client either takes that artwork home with them, or they keep it in the client’s file, or maybe the client destroys it. But it’s not up for public view.”

Another unintended consequence is that if a client walks into a room filled with client art, this might unknowingly set the expectation that all client art will be displayed, which can be problematic. As Bloom explains, “The idea within art therapy is that you might release something on the page that is unattractive that you don’t want anybody [else] to see. … If you go into an environment that has people’s art up on the walls, people will make less revealing art, most likely.”

Additionally, displaying client art might unintentionally create a false standard of how comic-making interventions “should look” for clients. Because some clients are more artistically inclined than others, certain clients might be reluctant — or even outright refuse — to create art because of insecurity around their abilities.

Self-portraits drawn by Kurt Shaffert (top) and Katharine Houpt.

“I also like to talk with clients about what MK Czerwiec discusses in her chapter in the Graphic Medicine Manifesto, which is the ‘fourth-grade slump,’” Houpt says. “That’s the idea that before fourth grade, everybody raises their hand when the teacher asks, ‘Who in here is an artist?’ And then starting in fourth grade, everybody points to the one kid who draws the best. So, why do we do that to ourselves? Why should we limit this outlet for joy and expression in our lives just because we think we’re not the best at it?”

Allowing clients to create comics without the pressure of comparison is essential for therapeutic work to occur, and that should be the goal of any intervention used with clients. Counselors should also know that any art created during a therapy session receives the same protections under HIPAA (the Health Insurance Portability and Accountability Act) that any other physical media (such as audio recordings and written materials) would.

Resources

It can be difficult for those who aren’t art therapists to begin working with a medium such as comics because the sheer amount of available materials can be overwhelming. The following list serves as a brief primer on texts that might be useful when beginning to integrate comic making into an existing practice. These recommendations were provided by the clinicians interviewed for this article and are grouped into separate categories for clarity.

General art therapy

  • Art Is a Way of Knowing: A Guide to Self-Knowledge and Spiritual Fulfillment Through Creativity by Pat B. Allen
  • Square the Circle: Art Therapy Workbook by Rebecca Bloom
  • The Art Therapy Sourcebook by Cathy Malchiodi
  • Materials & Media in Art Therapy: Critical Understandings of Diverse Artistic Vocabularies by Catharine Moon

Comics and Cartooning

  • Cartooning: Philosophy and Practice by Ivan Brunetti
  • Comics and Sequential Art by Will Eisner
  • Cartooning: The Ultimate Character Design Book by Christopher Hart
  • Understanding Comics and Making Comics by Scott McCloud

Conclusion

Although interest regarding the intersection of health services delivery and comics is at an all-time high, empirical research regarding the efficacy of comic creation as a direct intervention is largely absent. This might dissuade practitioners from introducing comic making into their therapeutic work, but it is important to remember that every testable intervention begins with a theoretical question, moves to the gathering of qualitative/anecdotal evidence and then transitions to quantitative outcome measurements.

This article has briefly addressed the narrative frame of comic creating while also sharing anecdotal insights from practitioners who use the intervention directly. The next step for helping make comic creation a more widely accepted and accessible intervention is to conduct rigorous research regarding outcomes. For social science researchers, these pursuits do not have to be conducted in isolation. That is reassuring for therapists such as Houpt: “I think that’s part of what was so exciting to me [about going] to the Comics & Medicine Conference this year. It was my first one. And to see people from so many different fields … different silos, who are doing similar work with different frameworks, different approaches, but arriving at similar outcomes. So, there has to be something there, and I wonder if part of the answer is more interdisciplinary collaboration.”

 

Author Devlyn McCreight, LMHC, draws a comic at his art desk. Photo by Sarah McCreight.

 

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Devlyn McCreight is a licensed mental health counselor and owner of McCreight Psychotherapy & Clinical Consulting LLC. Contact him at devlyn@mccreightpsychotherapy or through his website at drdevlyn.com.

Letters to the editor: ct@counseling.org

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