Monthly Archives: February 2018

Fried chicken, watermelon, addiction and Appalachia

By Gerard Grigsby February 8, 2018

Hearing jokes about watermelon and grape Kool-Aid. Hearing someone talk about their “half-colored” nephew’s “nappy” hair. Being called “boy.” This is what I experienced over the year that I led an addictions process group in rural Appalachia.

After working in the area for almost four years, I had grown accustomed to hearing these types of comments, but the straw that broke the camel’s back was a response made in group after one member shared that she was dating outside of her race for the first time.

This particular group member said that she was no longer interested in “full-blooded white men.”

“Yeah, you like him now, but wait until he blacks your eye,” another group member commented.

We were gathered outside on a warm, sunny spring day, but a storm cloud of mixed emotions swept over me as I sat there in disbelief. As the leader of the group and the only person of color among a group of eight, I was at a total loss for words. I had no idea how to address what had been said, and I was too overwhelmed to convey exactly what I thought or felt in that moment.

I knew I felt invisible. I knew I felt voiceless. But without any guidance, I struggled to determine what my response should be or whether it would even be appropriate to share what I was feeling. Ultimately, I chose to remain silent and let the moment pass as if nothing had happened, but the weight of what had transpired lingered with me long after our group meeting had ended.

By the time I arrived home that evening, my initial shock and disbelief had transformed into anger and disappointment. I had been really fond of the group member who made the offensive comment, so it stung to hear him perpetuate such a harmful stereotype about people of color. It didn’t help that he had made this comment after I had worked so hard to be understanding and sensitive to the needs of the group, especially considering that many members perceived that their backgrounds made them targets for judgment and mistreatment by law enforcement, family, friends and even other counselors.

I had also worked very hard not to perpetuate stereotypes about people who are in recovery from addiction, and I had avoided repeating the derogatory language that is often used to describe the people of Appalachia. What made matters worse is that just months prior, there was general consensus among the group that no one liked being called a “junkie” or an “addict,” especially by someone who has never used drugs. Clearly, these members knew what it was like to feel marginalized, so how could they allow someone in the group to make such a racially insensitive comment and not challenge him?

I went to bed that night still upset about what had happened and woke up the next day feeling even angrier. In fact, I thought about that incident for several days. I consulted with my supervisor and processed what it was like for me to have led the group that day. I shared the details of the incident with my colleagues in a separate supervision group. I spent hours brainstorming different ways to confront the group about what had happened. I thought to myself, “Maybe I should compile a list of derogatory terms, share them with the group and ask members what they think about culturally insensitive language. Maybe I should stop being so careful with my words and ask members how they feel when they’re on the receiving end of microaggressions!”

These ideas came from a wounded place in me. I had worked hard to protect my group members, and it hurt having to accept that they had not been as protective of me. Thankfully, ongoing self-examination helped me set aside my own baggage and reminded me that it would be harmful and unethical to prioritize my own needs over those of the group.

Instead, I did some more processing and eventually decided it was less important for me to get retribution and more important for me to leave the members with greater insight than they had before joining the group. I wanted to do something that would be meaningful and impactful for everyone in the group, including myself.

The next week, I sat everyone down and implemented a new group rule: Please be mindful of the diversity represented within the group. Without my having to confront him directly, the group member who had made the offensive comment the week before knew immediately why I had made this request and, to his credit, apologized for what he had said. Although I did not take the opportunity to share with the group exactly how his words had impacted me, the act of advocating for myself and others in the group was healing enough.

In fact, addressing diversity issues that day served as a critical moment for the group and opened the door for continued discussions about race, culture, sexual orientation and other aspects of multiculturalism. Just a few weeks later, for example, a group member made a comment about fried chicken, to which I lightheartedly responded, “Is this another racist joke?” To my relief, the group laughed, and we went on to have a productive conversation about ethnicity, regional diversity and similarities between Appalachian culture and African American culture.

In hindsight, I don’t know if I used the best approach to address diversity issues in my group, but I can look back and appreciate how that first challenging experience (there were others afterward) helped to shape my counseling philosophy and improve my group counseling skills. It taught me when and how to address diversity issues in groups, and it served as a reminder that multicultural issues are always relevant, even in an addictions process group in rural Appalachia.

My recommended resources

If you have been in a situation similar to mine, or would simply like more guidance on addressing diversity issues in addiction counseling groups, check out the following books:

Group Exercises for Addiction Counseling by Geri Miller (2012)

Miller describes two activities that can be used to address diversity issues in addiction counseling groups. My favorite of the two, “Sharing Culture,” is a dynamic group activity that facilitates engagement, information sharing and processing. I won’t provide any spoilers if you haven’t read the book, but just know that this activity involves yarn and sounds like a lot of fun.

Group Work Experts Share Their Favorite Activities for the Prevention and Treatment of Substance Use Disorders, published by the Association for Specialists in Group Work (2015), and edited by Christine Bhat, Yegan Pillay and Priscilla Selvaraj

This book is full of engaging activities for anyone interested in group work, but one activity in particular may be useful for practitioners who want to address diversity issues in group. Submitted by Beverly Goodwin and Lorraine Guth, this activity requires group participants to identify what they know about their own ethnic, racial or cultural group, and then consider how different aspects of their identity impact their recovery.

My own spin on this activity would involve an initial discussion about drug culture — its norms, unspoken rules, daily practices and common beliefs of which people may be unaware. I see this as a helpful way to set the stage for a broader discussion about culture and diversity. I also think it would be a useful way to help group members process the fact that they are indeed giving up certain aspects of a valued cultural system when they decide to start their recovery. This context can help enrich subsequent discussions about culture, assimilation and acculturation as members discuss the process of letting go of drug culture and embracing aspects of other cultural systems that may be less harmful.

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A version of this article was originally published in the December e-letter of the Association for Specialists in Group Work, a division of the American Counseling Association, and is used here with permission.

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Gerard Grigsby is a fourth-year doctoral student in the counselor education and supervision program at Ohio University. He is licensed as a professional counselor in Ohio and has worked in college counseling and community mental health settings. Currently, he works at a substance use treatment clinic, where he has the privilege of serving and learning from individuals in recovery. Contact him at ggrigsby@hrs.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.

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.

Ethics, religion and diversity

By Gregory K. Moffatt February 5, 2018

Tears streamed down her face. Kaylah (not her real name) was a 21-year-old woman struggling with a romance in trouble. I’d seen it many times, even though I’d only been in the field for a few years at this point. My heart broke for Kaylah as I saw the same old story played out in the same old way — only the names and a few of the details were new.

Kaylah had been psychologically mistreated and her relationship was in serious trouble. Her partner demonstrated what social psychologists call the principle of least interest. This principle teaches that the person in any relationship — work, friendship, marriage — who has the least interest in maintaining it possesses the most power. My client’s partner treated her well on occasion but at other times humiliated her in front of others, exploded at her or ignored her for days on end. Kaylah tolerated these behaviors because she was desperate to maintain the relationship.

Kaylah’s partner’s emotions ran hot and cold. One day, they were talking about starting a family; the next, Kaylah’s partner threatened to leave, causing Kaylah to feel confused, hurt, angry and torn. Like most abused women, at times Kaylah felt surges of confidence that she should leave the relationship and never look back. Then, as if someone had flipped a switch, she was overwhelmed with love, hope and compassion for her relationship. In this phase, Kaylah made excuses for the pitiful way she was treated and assumed all the responsibility for their relationship troubles. It was classic battered woman syndrome.

What readers also need to know about Kaylah is that she was a lesbian. She was also a staff member at a church. Her lover, a member of the pastoral staff, was also Kaylah’s boss, which created a serious power issue (and a significant ethical issue too). For obvious reasons, the relationship was a carefully guarded secret. Kaylah had no one to talk to because her family wasn’t receptive to her lesbian lifestyle and she didn’t feel she could confide in her friends in the religious community. She also worried that if anyone found out, her partner would terminate the relationship — the thing Kaylah feared most in the world. Exposure might also mean that Kaylah could lose her job, her family and the few friends she had. She was totally isolated. What a mess.

One last thing that I need to tell readers: I am a person of religious faith, and until I met Kaylah, I hadn’t been forced to clarify the place for my religious beliefs in the counseling profession. That day, the decision I faced became crystal clear to me.

No room for debate

It was around the time that Kaylah entered my world that I taught my first college course overseas. As I was preparing to teach a marriage and family course in India, it dawned on me that our two cultures were very different. I worried that my knowledge would be so based in American culture that it wouldn’t translate well into Indian culture. But without denying our vast differences, my host reassured me. “Dr. Moffatt,” he said, “problems are problems.”

How right he was. Hurting relationships are the same regardless of culture, age, religion or sexual orientation.

In some ways, I can’t believe that equity for LGBTQ clients even remains a topic for debate. I remember when the AIDS epidemic first became public in the 1980s. Some people of religious faith actually stated that AIDS victims deserved the outcome as punishment for their lifestyle. I hope that even the most cold-hearted person today wouldn’t utter such nonsense. Even in those uncertain times when we didn’t know much about the disease, doctors served these men and women because it was their professional duty to do so, regardless of their personal opinions on homosexuality, drug use, multiple partners or other factors. Today, many nonprofit counseling agencies are run by faith-based agencies specifically for those who have HIV/AIDS. Thank goodness.

How, then, could there still be any possibility of debate in the 21st century over whether we should discriminate against our clients? Our concept of human rights as counselors is that all people deserve the same treatment, regardless of worldview, religion, gender, age or creed. Our modern view of equality has been evolving for decades, yet even counselors have not yet perfected it in practice. Just in the past decade or less, there have been several highly publicized court cases in which graduate students have refused to work with gay clients and suffered academic consequences because of their beliefs. These include Julea Ward in 2009 at Eastern Michigan University, Jennifer Keeton in 2010 at Augusta State University and Andrew Cash in 2014 at Missouri State University.

Supporters of these students lauded their bravery and commitment to their religion. Even though I am a person of faith, I cannot see why this type of irresponsibility to clients should be lauded. Interestingly, Christian tradition teaches that Jesus spent most of his time with the outcasts of his culture, not with the religious upper echelon, and he didn’t abandon people simply because they behaved in ways that were contrary to Jewish teachings. Gandhi and Mother Teresa also demonstrated a seeming lack of interest in religious pedigree. Instead, they helped the people who came to them.

Sadly, the three lawsuits from academia that I noted are just the ones that made the news. I suspect that many more therapists are practicing discrimination without the public becoming aware. “I’m not culturally competent to work with those issues” is a common argument that I hear among some in the profession to justify their referral of LGBTQ clients. In fact, the real reason is often a personal belief system rather than a question of competence. There is no way to tell how much of this type of referral or redirecting of client goals happens in our profession, but if my anecdotal experiences as a clinician, supervisor, professor and public figure in the field are any measure, the answer is a lot.

This clearly violates our ACA Code of Ethics. Under Standard A.4.b., we are clearly called to “seek training in areas in which [we] are at risk of imposing [our] values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.” Notice that it says seek training, not refer. In fact, Standard A.11.b. specifically prohibits referring solely on the basis of a conflict between the counselor’s values and the client’s values.

This culture war hit home for the American Counseling Association in 2016 when the Tennessee Legislature passed a bill that the state’s governor subsequently signed into law making it legal for counselors and therapists to discriminate against their clients if the client’s “goals, outcomes or behaviors … conflict with the sincerely held principles of the counselor or therapist.” This legislation clearly contradicted the ACA Code of Ethics. Consequently, ACA moved its planned 2017 annual conference from Nashville to San Francisco.

It should be noted that before we even get to the standards in the ACA Code of Ethics, our association’s mission statement directs that we exist to “promote respect for human dignity and diversity” through the profession. The key word here is not diversity but rather promote. We are actively to promote diversity, not actively run away from it.

A common base for truth

For any reader who thinks that I am not sensitive to the importance of religion, please bear with me. Religion does indeed matter, and many religions have clear teachings on a variety of subjects — sex, marriage, work, the roles of men and women — that are central to people’s faith and shouldn’t be ignored. But we must also recognize that many discriminatory traditions have their roots in religious teachings. Even in my short lifetime, I can remember a relative of mine excusing the discriminatory practices of his all-white church, saying, “God didn’t intend for the races to mix.” He then proceeded to use Bible verses to justify that belief. He made similar comments about mixed-race marriage, again justifying them weakly through religious teachings. Refusing to see clients based simply on sexual orientation is no different.

Some religious therapists have defended discriminatory practice by arguing that equating racism with clinical treatment of gay couples is comparing apples and oranges. The argument goes that if a counselor’s religious views teach that, for example, the heart of a couple’s problems is directly related to homosexuality — something the counselor’s religion teaches is inappropriate — then helping these clients maintain the very relationship that is causing their grief would be problematic if not unethical/immoral. I’ll address this argument momentarily. But, first, a brief tangent.

It would be disingenuous to say that counselors never force a worldview on a client. Of course we do. For example, one of the goals we almost always have for clients who are addicted is that they stop doing their drug of choice, even if they don’t want to stop. The difference between this worldview and that of the anti-gay worldview, however, is that this worldview is based on objective research, not moral code or religious teaching. Using methamphetamine destroys tooth enamel, leads to degenerative behaviors and can eventually kill the user. Alcohol abuse changes brain structure, destroys the liver and leads to degenerative lifestyle and potentially death, not to mention a host of other social ills.

As for a religious argument against homosexuality, there is no scientific evidence that being gay, transsexual, bisexual, etc., is clearly linked to any social or physical issue that is not also present among the heterosexual population. We must have a common base for “truth,” and that base is research, not religion.

Many years ago, a religious group, knowing I am a person of faith, asked me to do a seminar addressing why homosexuals would not be good parents. I refused because there is absolutely no evidence that one’s sexual orientation has anything to do with quality of parenting. It would be unethical to promote such a baseless argument. Academic integrity demands that as professional counselors, we pursue what we know. We must be driven by facts, not opinions and preferences.

Make a choice

Empathizing and working with a diverse population does not mean that a counselor must sacrifice her or his own position. We are free to think what we want, engage in our own religious practices and beliefs, and live our lives as we choose.

For many years, I’ve spent part of my year in the United States and part of the year in Chile, my second home. During this time, I have also traveled the world. Whether I’m in a clinic in India, the Philippines, Peru or Mexico, I still think like an American/Chilean. But when I’m in those varied cultures, I try to see the world through the eyes and culture of the people I encounter. I can easily do that without making any value statement about the culture itself, and even though I have personally adopted many customs and preferences from around the world, I have done so voluntarily. I would still be a competent counselor in those cultures if I hadn’t. My preferences are irrelevant when working in another country.

Our professional ethic simply means that we will not thrust our belief systems upon our clients any more than we would try to sell our clients a car, recruit them into a political party or manage their retirement accounts. What we cannot do is make choices that are at odds with wanting to work as a counselor, such as simultaneously wanting to function as a missionary who proselytizes clients into our personal belief system.

I occasionally work with individuals who have been mandated to treatment. Some of them have drug issues. I’ve heard all the arguments:

“Why is weed illegal? It’s a dumb law.”

“Who cares what I do in my own home?”

“Smoking weed doesn’t affect my job or my personal life, so why should I have to go to addiction counseling?”

My response is always the same. You can do anything you want — but all behaviors have consequences. If you want to smoke weed, go ahead. But if you don’t want to risk arrest, being fired from your job or kicked off your athletic team, don’t smoke weed. You can’t have it both ways.

To our profession, I make the same suggestion. If you are a pastor or priest, be a pastor or priest. Nobody is trying to stop you. But do not attempt to be a pastor while you are a counselor. If your religion teaches that you must proselytize in the workplace, then the counseling profession is not the best fit for you. There is nothing wrong with being a pastoral counselor in which your focus is pastoring, not counseling. But don’t pretend to be a counselor who is religious when, in fact, you want to function as a pastor who is also a counselor.

As counselors, our job is to help the hurting. We cannot — we must not — attempt to evaluate who we think is worthy of our help. Whether our clients are gay or lesbian, battered women or batterers, abused children or abusers, we don’t pick and choose who we help. Our ethical standards determine when we refer or step away, but our personal feelings — whether driven by religion, morals or anything else — have no role in our decision to help. Pain is pain. The pain of Kaylah’s relationship was no different than the pain from any other relationship. The fact that she was a lesbian was, in some ways, irrelevant.

Diversity includes people of faith

History hasn’t always been friendly toward people of faith. We hardly need to be reminded of the many wars and episodes of genocide that have been perpetrated against various religious groups throughout history. Even today in different places around the world, including the U.S., Christians, Jews, Muslims and others are persecuted for their faith. Television mogul Ted Turner brashly claimed in 1990 that Christianity was a “religion for losers.” These were thoughtless words from one who knew nothing of the religion. Jewish men, women and children are still isolated in many parts of the world. And I can’t imagine how difficult it must be to live as a Muslim in the U.S. Sadly, the words “Muslim” and “terrorist” are sometimes used interchangeably these days.

The field of psychology has not always been friendly to people of faith either. Sigmund Freud proposed that neurosis and religion were closely related and that religious people were weak and in need of a dominant father figure. In the 1950s, Alfred Kinsey despised religion, claiming it repressed “healthy sexual desires.” And as a graduate student, I was taught that we should never talk about religion in session, even if our clients brought it up, because it would only distract from more important issues. Really? Faith can be a central part of a person’s existence, influencing almost everything, from food, dress and marriage to job choice and child rearing. Yet I was taught that this was somehow unimportant and distracting.

About 20 years ago, I was presenting an ethics seminar for professional counselors. One of the case studies the seminar participants were supposed to discuss involved religion. The concise version of the question I posed was, “If your client was a person of religious faith, would it be acceptable to include that person’s religion in your therapeutic process?” Every single one of the 75 or so participants said no. Apparently, they had the same training I had.

I have personally witnessed bias within the counseling profession against people of faith. At professional conferences, I have heard comments in hallways and elevators openly disrespecting people of various religions. One clinician, wearing her conference name badge, rolled her eyes as the elevator door closed and said to another attendee, “Oh, God, this hotel is crawling with Christians. Heaven help us!” To which her friend snickered and nodded consent, as if Christians, Jews or Muslims were some sort of infestation.

At a past ACA annual conference, I attended a workshop on gay and lesbian issues. In the workshop, the leader subtly condescended to people of faith — something Derald Wing Sue calls microaggressions — and the audience openly jeered, laughed and mocked Christians in their public comments. No one said a word about the overtly biased, thoughtless and hurtful commentary. Although I certainly didn’t fear for my safety, I didn’t feel comfortable confronting this bigotry. And even though I agreed with the position presented by the session leader, I have never felt more discriminated against in my life.

The heckling I witnessed was the same thing that those in the LGBTQ community have rightly fought against in times past. It was the same behavior — only the target had changed. People of faith should be as welcome as members of any other group in a professional meeting.

I might also argue that people of religious faith can make outstanding counselors. Many religions teach the inherent value of all humans, creating a natural empathy among the religious for a hurting world. Although there are individuals who have used religion to pursue their own selfish agendas, there is no scientific evidence that people of faith are less intelligent, weaker or any less capable of working in the helping professions than are nonreligious individuals.

Conclusion

In a public presentation many years ago, Albert Ellis, a man known widely for his aggressive approach to his clients, littered his address with profanity. Visibly upset, several participants in the room eventually made an overtly public statement by storming out. The only remark Ellis made about it was this: “Counselors should never be upset with what people say.”

I have never forgotten those words. Whether or not Ellis was right, the message I took away was that, as counselors, we treat those who need help. In that regard, our clients’ words, sexual orientation, religion, age, gender, race, criminal history and socioeconomic status have no relevance. We help. That is what we do.

Many people in the counseling profession are also, in their personal lives, deeply committed to their faith. These counselors see clients daily without issue and function at the highest level of ethical conduct. But the few who feel they are called to change the profession, rather than to accept the profession as it is or to move on to another line of work, give us a black eye. Even worse, these counselors leave clients hurting — and perhaps discourage them from ever seeking help from another counselor again. It is always about the client.

Counselors using their religion as an excuse to refer clients or to force their ideas about sexuality upon their clients can deceive themselves into thinking they have ethical grounds for doing so. You don’t. Period. You must seek training to work through this issue (Standard A.4.b.) rather than perpetually referring LBGTQ clients.

As a footnote, I saw Kaylah in counseling off and on for a little over a year. During that time, her relationship went through various ups and downs. When we terminated, her daily functioning had improved significantly, but she was still nursing her seriously troubled relationship.

Months after termination, I happened across Kaylah in a shopping center. She was with her mother. Meeting clients on the street always makes me nervous, but when our eyes met from a distance, she beamed and ran toward me, towing her mother along by the hand.

Kaylah introduced me to her mother and, in turn, her mother’s face brightened. She stepped forward and hugged me tightly. When she stepped away, she had tears in her eyes. “I don’t know what all you did, but I know you saved my daughter,” she said. “Thank you for helping my baby.”

These were the most sincere and heartfelt words of gratitude I have ever received. I’m positive I did the right thing by my client, and I can’t imagine a world in which my religion would have allowed me to tell Kaylah to move along because I don’t work with clients who are gay.

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Gregory K. Moffatt is a professor of counseling and human services at Point University in Georgia. He is a licensed professional counselor and certified professional counselor supervisor. Contact him at Greg.Moffatt@point.edu.

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

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Other pieces written by Gregory K. Moffatt, from the Counseling Today archives:

“The healing language of appropriate touch” https://wp.me/p2BxKN-4D9
“Recognizing and managing deception in the therapeutic relationship” https://wp.me/p2BxKN-4nu
“Case study: The critical need to conduct thorough child assessments” https://wp.me/p2BxKN-3PU
“Working with sexually abused children” https://wp.me/p2BxKN-3fI

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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.

Nonprofit News: Dostadning (death cleaning) your program and home can bring new life and promote growth

By “Doc Warren” Corson III February 2, 2018

The longer you‘ve been in a space, the more time you’ve had to collect things. Some of these things allow you to work more creatively and effectively or simply make your space more appealing to the eye. But sometimes your collection can lead to clutter that causes you to lose efficiency and can stunt the productivity you long for. Most folks have little trouble throwing away things that are clearly broken, but when an item is still good but no longer in service, it can be harder to let go. Add decades in the same space, and your eclectic office may resemble a low-rent rummage sale where there is little room to walk let alone do your job.

Dostadning is a concept from our friends in Sweden that means “death cleaning,” which is the practice of removing unnecessary clutter from your home to make it easier for your loved ones after you pass away. Over time, the term has evolved a bit, and its use has been employed by younger, healthier folks as a way to declutter not only their physical space but to improve their emotional and mental outlook as well. Whereas it may have once been unheard of for anyone below 50 to do any dostadning, adults of all ages engage in it. What works for people, can also work with programs, so this mindset is worth considering for programs of all sizes, be they one room or thousands of square feet, clutter collects easily, especially in our consumer-based society.

When the program I founded purchased its largest location, the space came with a mixed bag of treats, treasures and plain old junk. Previously a farm that had been in the same family since at least 1860, you can bet there were many items set aside for a later date. The family had also rented space to several companies over the years, leaving behind a collection of amazing breadth and depth. Farmers learn not to throw much away as money is tight, repairs are often and ingenuity is king. That old bedframe may be cut and welded onto a broken trailer; that cot may make a great gate for an animal pen. You get the idea.

Our main building was mostly full of items from many lifetimes. Though a bit under 8,000 square feet, in much of the building there was little more than enough room to walk through. A lot of it was junk, but some of the items intrigued us, so we bought the building, all contents included. This meant moving tons of items many, many times as we sorted, remodeled, staged and built. It may have been easier to simply have started with an empty building and then shop for cool items to furnish it with later, but we wanted an authentic look and felt that nothing would be more authentic than using items that had been here for generations. So we were left with an array of old kerosene lanterns, hand cut nails, old lumber and other antiques to furnish our new offices, but we also had a few thousand square feet of cluttered chaos and new shops and multipurpose areas to build. We had tag sales and hauled away dumpsters full of items until we were left with what we felt was the “good stuff.” However, we simply had far too much of the good stuff to be able to function. That’s where dostadning would save the day — and our programming.

Many of you may have have tried and possibly failed at cleaning out the store room of your own office. On one side you have the coworker who wants to toss everything – from the boxes of old toner cartridges up to and including the ashes of the founder of the program. On the other, you have the coworker who wants to keep everything, including not only the stale donuts in the breakroom but also that box of broken Christmas ornaments that was meant to make the office look more festive but instead caused a trip to the ER for stitches. And in the middle, you have the more level-headed coworkers who want to keep things that are useful and throw the rest away. This works—unless, of course, you have a lot of useful items that you don’t actually use. That’s when you need dostadning the most.

Dostadning embodies the idea that an item can be good but not need to stay with you. Here are some ideas for deciding what to do with the unneeded useful things in your program, home and life:

Have you used it in the last six months, a year? Do you have clear and solid plans to use it soon (such as seasonal items)? If not, it should probably go.
Start with the obvious areas –those with the clutter long forgotten– and thus easiest parted with, like storage closets, junk drawers and that old outbuilding that you have not gone into since fuzzy car dice were still a thing.
Make three piles, one for throw away/recycle, one for keep and one for giveaway/donate. Try to make the “keep” pile the smallest.
If the space is large, consider getting a dumpster so once you have elected to throw away items they are immediately out of sight. The longer it stays, the bigger the chance that it moves to the saved pile.
Do try to involve folks that may need items you are getting rid of. Is there a colleague that is just starting out that has a large need but limited funds? If so, ask them to help and to let you know whenever they see things they can use. Knowing an item has a home and a use can make it easier to part with. Just make sure they take it right away, otherwise you may become their de facto storage place.
Speak with other programs to see if anyone has a posted wish list. If so, offer any of your extra items that are on the list — a great way to help them as you help yourself.
If you have an empty room, consider moving good but not needed items to it for a time-limited (1-2 weeks) “take what you need” event where you invite the public to come take a look and take whatever they can use (you can include a donation can if you wish in case some folks want to make a monetary donation for an item). When the event is over, however, it all goes to a donation center or dumpster — this is about cleaning, not opening a shop.
Use social media to offer items for free (or in some cases, for sale). Programs like Freecycle can prove invaluable but do set firm timelines for pick up.

As you clear away the clutter, you will clear some space—and hopefully, some pressure. By removing items, you may be able to help others as well and also highlight the key items that you kept, transforming a mass of stuff into selectively staged, unique eye-catching displays.

In our case, the dostadning continues. We’re working on our latest dumpster—parting with potential treasures, but clearing up some much-needed space: 1,000 square feet that will soon be 1,600. This space will eventually be a multipurpose room that will host community meals, talent shows, classes and other events. By removing the unneeded, we are bringing new life into once dead space while also lessening the burden on those that will come after us. Death cleaning enables new life and growth, which is what we in the nonprofit sector are all about. I’m rooting for ya.

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Nonprofit News looks at issues that are of interest to counselor clinicians, with a focus on those who are working in nonprofit settings.

Dr. Warren Corson III

“Doc Warren” Corson III is a counselor, educator, writer and the founder, developer, and clinical and executive director of Community Counseling Centers of Central CT Inc. (www.docwarren.org) and Pillwillop Therapeutic Farm (www.pillwillop.org). Contact him at docwarren@docwarren.org. Additional resources related to nonprofit design, documentation and related information can be found at docwarren.org/supervisionservices/resourcesforclinicians.html.

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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.

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