Tag Archives: narrative therapy

Enhancing the genogram to incorporate a narrative perspective

By Les Gura March 11, 2021

The first time I watched my internship supervisor use a genogram, I became enamored. Here was a tool that instantly created dialogue between counselor and client as they reviewed family history, dynamics, health, socioeconomic data and more.

But a funny thing happened when I began incorporating the genogram into my own work as an intern. Although the genogram helped promote conversation, I found I couldn’t always use the information gathered to help connect the issues presented by clients.

So, as I’ve often done since beginning my second career as a clinical mental health counselor after 35-plus years as a journalist, writer and editor, I put on my critical thinking cap. Might there be a way to do more with a genogram — a way to put my narrative experience into it?

I began to think about how writers create a cohesive narrative in fiction or nonfiction.

In America’s Best Newspaper Writing, Christopher Scanlan and Roy Peter Clark of the Poynter Institute note that when writers write in chronological order, they invite readers to enter a story and stick with it.

Phoebe Zerwick, director of journalism at Wake Forest University and a columnist I worked with when I was metro editor for the Winston-Salem Journal, refers to chronologies not just as a way to organize stories, but as a way to understand stories. “Once you have the events laid out on a timeline, you can pinpoint the most meaningful ones for the purpose of telling a story,” Zerwick told me in an email conversation. “That story is a series of ‘scenes.’ The timeline helps identify the scenes to draw out. Other events might be summarized or ignored. But without an understanding of the underlying chronology, the meaning of the story falls apart.”

So, why wouldn’t helping clients develop chronologies — along with a genogram — create a more cohesive story for my clients? To be sure, chronologies are not something new to practitioners and social service agencies as a means of tracking incidents relevant to a presenting client. In genogram work, chronologies have typically been used as a side tool to flush out connection between family occurrences and a specific presenting problem.

When I started working full time in September 2019 for CareNet Counseling as a licensed clinical mental health counseling associate, I decided it was time to merge chronology and genogram. My goal was not just to seek connection with specific family relationships or occurrences, but to allow clients to themselves identify and discuss the reasons behind key moments in their life — the “dominant narrative” that brought them to counseling — that may or may not be connected to their family history.

Thus was born the “geno-chronology.”

How a geno-chronology works

One of the principal jobs of a therapist is to help create moments of insight for clients. Toward that end, when I work from a narrative perspective, one of the first things I do is encourage clients to identify a “three-word dominant narrative” that brought them to counseling (see my previous article “Counseling from an editor’s perspective”).

I typically ask clients to do this as a homework assignment at the end of an initial assessment session. At our next meeting, we discuss the client’s identified three-word narrative to learn more details about current feelings and how things got to this point. When clients recognize and understand their dominant narrative, they often send signals — by their excitement or impatience — that help me decide to begin the geno-chronology.

As with the three-word dominant narrative, building the geno-chronology usually starts with a homework assignment. The purpose is to continue to engage the client in the process of therapy between sessions. Already in my career, I’ve observed that clients typically are more eager to get into work if they’ve done a homework assignment.

The assignment for the geno-chronology asks clients to identify “key moments” in their life — as few as two or three, or as many as 20 or more. What qualifies as a key moment? I typically use my own life as an example: I tell clients about the devastation I felt when my father died unexpectedly when I was 22, the joy of being the person to deliver my daughter (also unexpected) 10 years later, and the transformation I began after being fired at age 51 and recognizing that my life’s work as a journalist was over. In other words, key moments can represent triumph, failure, fear or any other emotion. If the moment is something that lingers in a client’s mind, it’s probably for a reason that’s worth discussing in therapy, regardless of whether it becomes part of the chronology.

Sometimes, based on the sessions that take place before the geno-chronology work begins, I might ask clients to pay particular attention to moments related to a specific issue — depression in their life or times when they felt overwhelmed, or devastating or traumatic incidents, for instance. For most clients, however, it’s a broader canvas from which they choose.

A fictional case study

Let’s use a fictional case study to illustrate how a geno-chronology provides therapeutic value.

Rob is a single white man, 34 years old, who initiated counseling when he was experiencing depression. Rob is a marketing manager, which is his first leadership role since graduating from a state university. Despite what appears to be a burgeoning career, Rob says he has been sleeping late and even called in sick to work twice in the past three weeks. He says he is not drinking any more than usual, he is not suicidal and he continues to maintain good physical health, although he has been eating out more frequently; he says he has been too lazy to cook.

From our earlier work, Rob’s three-word narrative was “life bores me.” I also know the basics of Rob’s upbringing: He is the middle child of three, with a high-achieving older sister who is a corporate attorney and mother of two, and a fun-loving younger sister who is a freelance writer and the darling of the family. Rob’s parents divorced when he was 16; his father is recovering from alcoholism. Both of his parents continue to work, and neither has a current romantic relationship.

I’m going to use a large artist’s pad for the geno-chronology, just like we would use for a traditional genogram. I usually turn the pad horizontally and draw a line across the bottom with an arrow pointing forward. I have only one instruction for Rob when I ask him to share his key moments: “Don’t necessarily go chronologically, even if that’s how you thought of them. Just begin with the moment that most stands out in your mind, and we’ll go from there.”

The late journalist Don Murray wrote about this idea for chronologies in his book The Essential Don Murray. “Do not start at the beginning, but at a moment of intensity,” he advised. Murray noted that readers understand the demands of chronology and know that when the timeline ends, they will have reached a heightened level of understanding. Similarly, counselors can make more sense by ascertaining the level of urgency when a story begins at a moment the client chooses rather than simply starting at the beginning.

Rob indicates that he’d like to begin with the first depressive moment he recalls — being a college sophomore, when he would lie around in his dorm room and miss class. He says he was bored and wound up spending hours playing video games and noshing on junk food, ignoring invites from his roommates and fraternity brothers to go out. Rob stops at that point, and I recognize the story needs to be fleshed out.

Scanlan and Clark note in their book that good editors help reporters unfreeze time in a story, often turning flat explanation into action. Questions for reporters include: When did that happen? Tell me the story of how that came to be. Do you know the history of this problem? As a counselor, I’m going to take that same approach, gently coaxing more detail from Rob by using the common narrative therapeutic practice of questioning.

I ask Rob if anything happened in his family at that point. “No,” he responds. “In fact, despite the divorce, things were getting a little better at that time because Dad finally sobered up, and when I saw him, he was great.”

Yet Rob’s grades were plummeting. “So, how did you get out of this funk?” I ask him.

His eyes light up. “Well, a professor in my major pulled me aside, basically, and told me he knew I was better than this and that if I accomplished even half of what he believed I could, I’d have a great career ahead of me.”

Rob says he went back to his room, tossed out some unopened bags of chips and hit the books for that day. He also began accepting invites to parties. It was the end of his depressive period, which had lasted a month. “To tell the truth, I’d almost forgotten about that period until you gave me this assignment,” he says. “But it was the first time I can remember being in that kind of funk.”

That is a lot of information to process, and I file it away knowing there is more to Rob’s story. But first, there are other key moments to consider.

Rob goes on to report two other “funks” between that incident and what he’s experiencing now. One of those depressive periods lasted six weeks. It began when his older sister got married; he couldn’t get a date, and that made him look at his life, where he had few friends and wasn’t socializing. The second depressive period lasted about three months and had occurred only a year and a half ago. That incident centered on breaking up with a girlfriend of four months after another wedding; she told him the event made her realize she had no interest in a long-term relationship with him.

I go back to the beginning, a question I often use at the start of my initial counseling assessment: “Why are you sitting in that chair, right here, right now?”

“Well,” Rob says, “I suppose this latest episode began when I saw my baby sister had an article published on HuffPost. I felt really proud of her. And yet that night, I got hammered.”

Once again, I know there is more to investigate. So, in the sessions that follow, Rob and I build a traditional genogram above the chronology. I begin to see a pattern, although I keep it to myself. It feels to me that Rob’s key moments of depression are closely tied to a perception of inadequacy, especially fed by the achievements of his siblings and a lack of connection with his parents, or both.

I ask him whether, as a middle child, he’s ever felt lost. He acknowledges he has, saying his mother bonded closely with his sisters, but he felt he hadn’t been able to have that type of close relationship with his father because of the alcoholism. In fact, Rob admits he resents that his dad got sober only after Rob was in college and his parents’ marriage had collapsed.

The conversation has Rob intrigued. He can look at the geno-chronology and see his key moments, which include both the “what” of the incident in question and the “significance” of it as he described it to me and I jotted notes next to the entry. Rob eventually brings up his resentment of his sisters and what he believes is his own lack of achievement in his personal and professional life. He thinks about his father, who bounced from job to job during his drinking years, always earning but never establishing a career of which to be proud. Rob feels that his marketing career is like that — enough to pay the bills but nothing that cultivates a sense of pride. And he doesn’t even have a family of his own.

The key moments of Rob’s chronology in this case have direct ties to his genogram. Rob is ready to talk in more detail about his lack of self-esteem, which, it turns out, was his true dominant narrative all along, hiding behind what was, in effect, the bravado of “life bores me.” Rob considers this and eventually recasts his three-word dominant narrative to “Failure overwhelms me.”

The addition of the chronology to the traditional genogram provides a visual cue for Rob to see the connection of the identified key moments in his life to the family system in which he was raised. Although it takes some time, the process prepares Rob, with a more accurate, self-identified dominant narrative, to begin the work of moving away from that dominant narrative and toward a preferred alternative narrative that he will identify in sessions to come.

Chronology and connection

Each incident that a client considers a key moment should be given weight during therapy. I’ve had entire sessions built around one key moment, as clients delve into a trauma they suffered in childhood, the story of the death of one of their children or how they made a life-changing decision. When clients are prompted by proper questions, these moments become a way to help them bring context to the stories of their lives, both in the period in which the moments occurred and in the present day.

In her book The Genogram Journey, Monica McGoldrick notes that “even the worst and most painful family experiences — alcoholism, sexual abuse, suicide — are part of our accumulated identity.” She goes on to write that “only by understanding what led to those behaviors can we begin to understand the dark side of ourselves and learn to relate more fully to others.”

The strength of the geno-chronology is that in today’s more fragmented immediate families, “the dark side of ourselves” often presents when clients have long separated — physically, emotionally or both — from their nuclear family. Adding good and bad life incidents to a genogram forms a more complete picture for clients and thus creates more opportunities for insight.

My ultimate goal in using narrative interventions is to help my clients identify a “preferred narrative” that will replace their dominant narrative. We use the same three-word approach. Clients have latched on to the concept by this point in therapy because during the building of the geno-chronology, I have asked them to develop three-word narratives for different points in their life. Looking back at past narratives identifies character traits that have developed through their families and relationships and have come into play during their key moments — all of which are conveniently on display in the geno-chronology. In the fictional case study I have presented, Rob might eventually settle on a preferred narrative of “Rob craves more.”

When clients identify a preferred narrative, we have a rich foundation from which to understand how character traits become magnified, lost or strengthened. We can have conversations about the process of gaining better awareness and control of character traits, enabling clients to move away from the dominant narrative and toward the preferred narrative. Rob might learn to recognize that despite his perception of self-failure, he can identify successes in his life, such as his ascension at work to a managerial role. We can discuss the traits that helped him achieve that, and he can learn to use those traits in other areas of his life.

Ultimately, the geno-chronology is a story-building tool that adds a narrative element to the classic genogram.

One of the things I have enjoyed most about becoming a counselor after a lifetime of writing and editing is letting go of my own concept of story. As a writer, my job was not just listening, but also absorbing the information from interviews and research and then determining the story to be told. As a counselor, I have the privilege of listening, absorbing and then allowing the chips to fall, with minimal guidance from me. I have ideas, and I can share those ideas, but the client is the protagonist of their own story.

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Les Gura is a licensed clinical mental health counselor associate and national certified counselor based in Winston-Salem, North Carolina. He works for CareNet Counseling, where he is part of a two-year residency program and also serves as director of communications. Contact him at lgura@wakehealth.edu.

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

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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.

Starting post-college life in a pandemic

By Bethany Bray August 3, 2020

Spring 2020 college graduates have emerged into a world turned upside down by COVID-19. The job prospects and post-college lifestyles these graduates were imagining for themselves just a few months ago are today largely nonexistent.

Unprecedented seems to be the buzzword of the season, notes Roseanne Bensley, assistant director of New Mexico State University’s (NMSU’s) Center for Academic Advising and Student Support. The coronavirus pandemic has affected everything from relationships to career planning for new graduates.

“It’s not one part of their life, it’s every part of their life,” Bensley says. “Employers have uncertainty and don’t know, day to day, when things will lift. … No one has enough information to give answers. This is new territory for employers and job searchers.”

However, Bensley would like to add a second buzzword to the class of 2020’s lexicon: resiliency. As she points out, these students, many of whom had to unexpectedly finish their senior year coursework online, can claim an advantage when it comes to adaptability and comfort with technology.

Because of COVID-19, “New jobs and new ways of doing business are opening up. This is going to cause a new wave of change, and [employers] may not be going back to the way it was,” Bensley says. “These students are ahead of the curve. … They will be resilient with what they’ve learned.”

At a loss

Licensed professional counselor (LPC) Patricia Anderson recently worked with a new college grad who was experiencing a resurgence of anxiety this past spring during the pandemic. The young woman had switched jobs, and the restrictions associated with COVID-19 meant that she was unable to meet any of her new co-workers in person. Her entire hiring and onboarding process had been completed via video and electronic communication. She had also recently moved into her own apartment and begun living away from her family for the first time.

The client was stressed out, anxious, and struggling with her self-confidence, recalls Anderson, an American Counseling Association member who has a private practice in the Georgetown section of Washington D.C. In working through her feelings in counseling, it became clear that the young woman — an extrovert by nature — was experiencing grief over the large-scale absence of social connection, both at work and in her personal life.

During the pandemic, the client had stopped using an online dating platform. This resulted in her experiencing a sense of loss regarding opportunities to meet people and a decrease in the confidence she normally gained through interacting with dates and new relationships. Anderson worked with the client to establish a self-care plan that included making time for hobbies and exercise, as well as maintaining social contacts and reconnecting with friends with whom she had lost touch.

Anderson also focused on boosting the client’s confidence and equipped her with strategies for keeping her self-talk from becoming self-critical. In addition, Anderson helped the client recognize that what she was feeling was grief, which can arrive in waves. Together, they connected some of the client’s feelings to family-of-origin issues that were contributing to her stress.

Anderson also helped the client focus on the reality that her current situation wouldn’t last forever. “We talked about things she can look forward to in the future: going back to online dating, figuring out a new normal, looking forward to meeting colleagues face-to-face, planning a trip, and working on another business opportunity,” Anderson says. “Time spent away [from dating] had eroded the confidence she once had and had kicked up her anxiety. Staying ‘in the game’ can be beneficial for some [clients]. It’s a way to get to know themselves and push themselves socially.”

Many of Anderson’s clients are young professionals, current college students or recent graduates. Throughout the spring and summer, many of these clients have been wrestling with feelings of loss, she says. This includes the loss of rites of passage such as graduation ceremonies and in-person celebrations, the loss of internships and immediate job prospects and, for some, the seeming loss of entire career plans.

“Their world and their [sense of] structure have been upended, and they’re not really knowing which direction to move in,” Anderson says. “Some days, they feel like, ‘OK, I got this,’ and then other days, they have doubts about ‘Where am I going?’ The floor dropped out of what they thought was going to happen. … They have anxiety over the fact that everything got pulled out from underneath them, and now they don’t have a road map.”

It is vitally important that counselors first help these clients process their feelings of loss before trying to guide them to reconsider their job options or life path, Anderson says. Among the most consequential actions counselors can take are to listen to, validate and normalize the emotions that these young adults are feeling in the wake of COVID-19.

“Be with the client where they are,” Anderson says. “If they’re unable to go with a job that didn’t happen or was rescinded, really sit with them in that space before opening up and looking at the possibilities of ‘what else?’ It’s difficult to do that until they know that you understand them and where they’re coming from.”

All feelings of loss should be treated as real and valid, Anderson says, even if clients themselves express guilt over feeling that way or dismiss those feelings as being trivial when the world is facing weightier issues. For example, some graduates may still be dealing with disappointment that they missed out on a final chance to take a spring break trip with friends or weren’t able to study abroad because of the coronavirus. Counselors should reassure these clients that it is OK to have these feelings and then give them space to talk about it, she emphasizes.

“[Help them] know that they’re not alone and that it totally makes sense to struggle right now. They also may be scared at feeling unsettled, which may be a new feeling for them,” explains Anderson, who does contract work for the QuarterLife Center, a Washington, D.C., therapy office that specializes in working with young professionals in their 20s and 30s.

In addition to normalizing feelings, Anderson has been providing clients with psychoeducation on self-care, the nonlinear aspects of grief, and the importance of maintaining social supports and a structured daily schedule. She checks with clients to ensure they are staying connected with friends and family via technology and that they are equipped with coping mechanisms such as meditation and self-reflection exercises. She also asks if they are eating well, engaging in physical activity, getting outside, and taking part in other wellness-focused activities.

As Anderson’s clients talk in sessions, she listens for hopeful language that might indicate they are ready to rethink their futures. “I try to help them broaden their scope a little, if they’re ready for it. I let them talk about what they need to talk about, but then spend some time looking at other pieces of what else might be possible. [I] try and get them out of their heads just a little bit,” Anderson says, “because if I [as a client] always thought I was going to be a dentist, and come to find out that I’m not going to be a dentist, I have to grieve. But at the same time, maybe there are some things that free me up about not being a dentist.”

“If you can create a trusting relationship with a [client],” she says, “they know that you understand them, and we can explore all kinds of things, whether they [previously] seemed unrealistic or not.”

Rethinking career plans

Flexibility must be the watchword for recent graduates who are looking for jobs, says Lynn Downie, associate director of career and professional development at Presbyterian College in South Carolina. In her work with undergraduates and alumni of the small, rural college, Downie is finding that those who had a “hard and set, defined path” in mind, such as entering the health care or hospitality industries straight out of school, are struggling most.

Those who are currently seeking jobs can benefit greatly from the guidance and encouragement provided by a counselor, says Downie, who recently finished a two-year term as president of the National Employment Counseling Association (NECA), a division of ACA. “Give them reassurance that things haven’t changed completely. Highlight [the idea] that pathways to a particular goal aren’t always the same. There are other distinct pathways,” she says.

Downie is helping her clients identify workarounds as they adjust their perspectives to become more flexible and less discouraged by rejection letters or the idea of taking a job that might not have appealed to them previously. Some of her clients have readjusted their career plans to take entry-level or short-term work in positions or fields they wouldn’t have considered six months ago. Others have pivoted to opportunities in national service programs such as AmeriCorps.

Downie, a member of ACA, also reminds recent graduates that they just need to find a fit for right now. That doesn’t mean their long-term career goals have to change. “Help [these clients] realize that they’re not making a choice for the rest of their lives when they choose a job, or [especially] their first job,” she says. “Their life is going to be full of all kinds of pivots. Some are planned and some are unplanned and forced. There is a big arc from 18 to 65 or retirement age. … You can [still] have aspirational goals that are for down the line.”

Downie has worked with several business students who had hoped to go into health care administration, but because the industry is so in flux currently, there aren’t many administration jobs open at the entry level. With these students and graduates, Downie has focused on ways that their administration skills could be used in alternative settings, such as nonprofit, community development or public health organizations. Another tactic is taking lower-paid medical aide or assistant jobs in settings that are currently short-staffed (such as nursing homes) and that do not necessarily require special certification. As Downie points out, even working as a contact tracer as part of the COVID-19 virus response — a job that didn’t exist six months ago — could help these new graduates gain experience.

Similarly, a job in pharmaceutical or medical sales could provide these graduates with valuable exposure. “They would still be interacting with those in the medical field, instead of applying for jobs that don’t exist,” she points out.

Bensley notes that going with a “Plan B” job in a field or setting that a graduate didn’t originally intend to work in can demonstrate to other potential employers that the graduate possesses a good work ethic and thinks outside the box. She also urges students and recent graduates to widen their searches to consider temporary, freelance or even gig work instead of focusing solely on full-time employment.

“[A first job] may not be professional, but it’s work, and [the individual] can be introduced to people through that work,” Bensley says. “It also tells a [future] employer that you’re a hustler and not waiting for the golden egg to show up.”

When counseling clients who are rethinking their career plans, Downie finds it helpful to have them identify a theme they feel drawn to and then consider various types of work that fit that theme. For example, a graduate who enjoys building relationships can use that skill in any number of job settings. They might start out in sales but advance to building teams as a manager or even pivot to cultivating client relationships as a professional counselor.

“Find a theme for your life — that one thing you cling to, what you’re good at,” Downie tells her clients. “You can work on that in all types of settings. A core skill can translate into different fields, and sticking with it will give you a sense of continuity and purpose.”

Networking during a pandemic

Bensley often tells students at NMSU to think of how professional athletes are handling the pandemic: Their season may be on hold or even canceled, but they’re continuing to stay in shape.

“Just because the competitive side of their sport has stopped, they’re not watching Netflix for 10 hours a day. They are still keeping their skill set up, working out, training and preparing,” Bensley observes.

That same philosophy should apply to career planning during the pandemic, she emphasizes. Now is the time for job candidates to put even more energy into enriching themselves and expanding their professional networks.

“Don’t limit your strategy to just sending out résumés and waiting for a response,” urges Bensley, an instructor for the global career development facilitator credential through NECA. “While employers may have slowed down their original hiring plans, it does not mean that a candidate should also slow down. If anything, it means you might need to work harder at following employers on LinkedIn, reviewing their homepages and [thoroughly] reading job postings to determine if you have the skill set that employers require.”

Bensley suggests it is also the perfect time for recent graduates to flip the usual dynamic and reach out to interview professionals who are already working in their desired field. Job seekers can identify contacts through LinkedIn or other networks and ask if these professionals have 20 minutes to talk about their job or industry.

Bensley urges students and recent graduates to start with professors and mentors whom they already know or have worked with. They can then use those connections to secure introductions to other professionals in their desired field. Those professionals can recommend still others they would recommend connecting with, and so on, in a widening circle, Bensley says.

Professionals are especially open to such requests right now because many are working from home and are free from in-person meetings, conferences and business travel engagements. In many ways, motivated students and recent graduates currently have a “captive audience,” she says.

“This shows curiosity and a desire to learn about your craft, gets your name out there, and helps you evolve and have insights on what they [professionals] consider to be important,” Bensley says. “If an employer said, ‘We really value teamwork,’ there’s a hint: Everything [you might say in a job interview] should be focused on teamwork. Instead of saying, ‘I did X,” say, ‘We did X.’ That can be the small percentage you need to get ahead — understanding the value system of the employer because you’ve talked to them about it.”

Forward vision

As counselors offer support and reassurance to recent graduates and young professionals struggling to adjust to personal and professional lives upended by COVID-19, here are some important points to keep in mind:

>>  Focus on listening. Downie urges counselors to slowly ease in to therapeutic or career work with these clients. She often opens her sessions with a question: “What do you want to talk about today?” With so many concerns currently weighing on these clients, their answers might be unexpected and diverge entirely from the topics they have discussed in session previously, she says.

“Give them the floor to talk about whatever they want. We [counselors] always have to be good listeners, but now as we’re isolated, there’s a real temptation to give advice,” Downie says. “What is needed now, during this crisis, is to listen — listen more and not give advice. That’s been essential. Students who were slow to open up to begin with now need additional time to be comfortable. We need to build [therapeutic] relationships but also step back and allow for quiet. Right now, there’s so much chatter, [clients] need time to catch their breath before speaking.”

>> Consider the whole picture. College students and recent graduates may unexpectedly find themselves living at home and navigating family stressors, Downie notes. Regardless of the presenting issue that brings these clients to counseling, counselors should ask questions that will help them understand clients’ situations in full. Downie says she has worked with students who have needed to finish college coursework while sharing a computer with family members or to conduct their entire job search on a cellphone. Others found themselves scrambling to secure temporary work — long before they expected to start a career — to supplement household income because their parents had been laid off.

“When students went home and courses went online, family structures were being upended,” Downie says. “It took an emotional toll. … The level of stress has been enormous, even from day one” of the pandemic.

Some students and recent graduates have expressed feeling pressure from parents about their job searches or life choices (even if parents haven’t necessarily voiced those concerns) that they wouldn’t have felt living on campus. Counselors should be mindful that living at home adds an entirely new dynamic to these clients’ experiences, Downie says.

Administrators at Presbyterian College, including Downie, split up the student body roster and called every student to check in through the spring semester. This endeavor confirmed a saying that Downie had been hearing from colleagues: “We’re all in the same storm but not in the same boat.” The needs and stressors that students were experiencing varied widely, depending on their circumstances, she says.

“Really quickly, I realized the truth of that saying. For some, doors opened that weren’t there before. There were some who found themselves with new opportunities, yet their best friends were experiencing a very different [reality],” she explains.

>> Make clients the authors of a story in progress: Tina Leboffe, an ACA member and a counselor pursuing licensure under supervision at a therapy practice in Douglassville, Pennsylvania, uses narrative therapy with clients, many of whom are college students concerned about finding a job after graduation. “I see my clients as the meaning-makers in their own lives. When working with loss [related to the COVID-19 pandemic], I feel that it is important to walk with the client as they tell the story of their experience, while supporting their exploration of what they want this loss to mean for their life story. This can look like allowing space for the client to be present in feeling the emotions caused by loss and also to look forward at what they want their lives to look like as a result of the loss,” says Leboffe, an associate addiction counselor.

“When working with a client to refocus and reimagine their future, we can listen as they add context to their story,” she says. “Despite the setting of their story shifting, the client is still the author. We can support our clients as they integrate a new reality into their life story by asking questions that refocus on the client being the expert of their life. As counselors, we might not be able to change the job market, but we can guide our clients in an exploration of what they want their life to look like given the changes that have occurred. We can assist them in identifying decisions they want to make in the face of change.”

>> Seize the opportunity to explore identity: Leboffe and Anderson both note that while this is a time of stress and upheaval for young clients, it can also afford opportunities for personal growth. Counselors can help support and encourage that process.

“This is a good time for them to learn about themselves, learn about what their values are and what is important to them. … [It is] a time to explore their internal world and let them find out what their 22-year-old self is like,” Anderson says. “How are they with stress? How do they handle ambiguity? How are they capable and able to move forward and readjust in such a difficult time? Giving them space to talk allows them to process [these things].”

“In my experience working with young adults and recent grads — and being one myself not long ago — I have found that this time in their lives can be filled with identity exploration and transition,” Leboffe says. “They may be faced with new levels of independence and responsibility that can evoke questions like ‘What do I want my life to look like?’ or ‘Who do I want to be?’ This can be important to keep in mind as we work with or parent recent grads because it can serve as underlying context to help us be empathetic to their lived experiences while they are developing their sense
of identity.”

>> Remember that productivity is relative. Anderson has found it helpful to remind young clients that even though they’re spending much more time at home, they may need to temper their expectations about productivity.

“This shouldn’t be a time when you plan to be super productive. That’s hard to do when you’re going through something so emotional and so taxing,” Anderson tells clients. “It’s not a time to learn six new languages, clean your entire house or finish a major art project. Instead, focus on what works for you. What are things that calm you and help you [that] you can do routinely? Be less hard on yourself. At the same time, it’s a great time to try something new if you have the motivation to.”

>> Build confidence. Bensley urges counselors to focus on the positive when communicating with college students and recent graduates during the pandemic. “The No. 1 thing we can do for clients is help build their confidence,” Bensley says. “The tone of my emails has been, ‘Hey, you’ve got this. I’m cheering you on.’ I’m trying to use my language to be that [needed] encouragement, even if they don’t ask for it or seem to need it.”

>> Take them seriously. Transitioning to adulthood is hard enough without the added concerns and stresses of COVID-19. Validation from a counselor is pivotal during this time of life, Anderson says.

“Take their concerns seriously. We know in general that people will land on their feet and things will turn out OK as they make their way in the world. [But] they need to be held in the emotional space where they are right now,” Anderson says. “Moving into adulthood is really hard. It can be a very tumultuous time — and one that promotes growth.”

“[These clients’] struggles and needs are serious,” she continues. “Figuring out dating, jobs and social stuff — it’s all important. Stay with them in their space and create that [trusting] relationship. Know that their concerns are valid, even if we have all the confidence in them in the world that they’re going to figure this out. They really are worried that they’re not going to figure this out in the right way. And that’s valid [because] they haven’t been here before.”

 

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Entering the counseling profession amid COVID-19

Graduates from counseling programs certainly aren’t immune to the stresses and uncertainties that 2020 graduates in other fields are facing.

Darius Green graduated from James Madison University (JMU) with a doctorate in counselor education in May. Green says that he and many other counseling graduates feel the pressure of finding jobs that can provide financial stability “rather than being able to choose what positions best fit [our] personal and professional goals.”

I do not come from a background of financial privilege, so this rose to the top of my priorities,” says Green, a member of the American College Counseling Association, a division of ACA. “I [have] noticed a mix of success and difficulty among some of my peers in the job search process. For those who started early and found a position that matched what they were looking for, the process seemed easy. For my peers who had not been able to start searching early or just had not found the ideal position, there seemed to be more difficulty. … I struggled with finding a position that I wanted and carried out my job search longer than I had planned.”

This summer, Green is living in Harrisonburg, Virginia, where JMU is located, holding down both a full-time instructional faculty position with JMU’s Learning Centers Department and working part time as a counselor with the ARROW Project, a community mental health organization roughly 30 miles away in Staunton.

Green hopes that in this time of crisis, professional counselors who are already established will remember the role they play as advocates for the profession and will look out for new counseling graduates trying to enter the field.

“I think that counselors who are already working can be aware and sensitive to how stressful being in such a position [graduating during a pandemic] can be. I also feel as if counselors can advocate within their agencies or communities to do our part in making sure that existing opportunities are made known to recent graduates,” Green says. “That could include reaching out to counseling faculty members to share information or even connecting with colleagues who may know of new counseling graduates in need.”

“One thing that I would want [counselors] to keep in mind is that not everyone has connections to others in the counseling profession and other mental health fields,” he continues. “Some students come from backgrounds that may have lacked opportunities for networking or that may not value the mental health professions. I think it would be important to pay particularly close attention to those students so that they do not fall through the cracks or face another layer of oppression.”

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@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.

Counseling from an editor’s perspective

By Les Gura November 6, 2019

When I was a newspaper editor and reporters would tell me they had writer’s block, I sometimes used a technique championed by Pulitzer Prize–winning journalist Jon Franklin in his book Writing for Story. “Tell me your story in three words: subject, action verb, object,” I’d say.

After thinking about it, the reporter would deliver the initial three-word narrative, which would in turn ignite reporter-editor dialogue. Eventually, we would settle on the true narrative the writer was trying to tell, and off the writer would go to craft the full story.

When life brought me to graduate school for counseling, it was no coincidence that I found myself drawn to narrative therapy. To me, it made obvious sense to learn and understand client stories — a centerpiece of narrative therapy, according to its founders, Michael White and David Epston. Their book, Narrative Means to Therapeutic Ends, describes the power that story — and the maladaptive meaning often ascribed to it — has in people’s lives.

White and Epston explain how narrative therapy is about finding a client’s dominant narrative, externalizing the problem central to that dominant narrative, and identifying alternative narratives. But how does a professional counselor do that? Is what the client tells you the true dominant, or problem-saturated, narrative? Or might a presenting issue mask something deeper?

As I read more books, absorbed more information on narrative therapy, and began my internship in my final year of school, I recognized something. Clients don’t automatically understand the concept of a “dominant” narrative. Sometimes, they’re not even sure why they have come for counseling, other than a vague sense that something is not right.

It is the conversation between client and counselor that can elicit story. And that reminded me of my old editor’s trick — the three-word narrative.

Initial exploration

Thirty years as a journalist will garner you some skills, especially when your orientation is investigations and narrative writing. As I learned more about narrative therapy, I saw the parallels to my journalism past and went into the attic to fetch my old narrative writing materials, including Writing for Story and excerpts on writing techniques from the Poynter Institute. What I quickly realized was how easily and effectively the techniques of narrative writing could be adapted as part of the narrative orientation in counseling.

Today, I have made my background as a writer and editor a centerpiece of my professional disclosure statement because I find it a great way to kick off a conversation with most clients. Talking about my past eases clients’ anxieties about coming to see a counselor and lays the groundwork for future narrative work.

When conversation turns to why clients have come to counseling, I usually give them a homework assignment to return to the next session with a three-word narrative that answers the question: Why are you here? The exercise itself invites conversation, just as it did with “blocked” writers.

In journalism, the writer and editor chat after the former returns from the three-word exercise with the headline “Council Approves Budget.” The editor might ask the reporter, “Is that all there is?” Was it simply a vote? Who are the winners and losers of this budget approval? During the ensuing discussion, the reporter reveals that the new budget will cut taxes for the first time in 10 years. The reporter now has a more accurate three-word narrative from which to frame the story: “Taxpayers Win Relief.”

Now let’s apply the three-word narrative to counseling with a fictional client named John, a 65-year-old who presents at his first counseling session with sadness at the death of his wife of 43 years, Sarah. His initial three-word narrative about why he has come to counseling is “Grief overwhelms John.”

The counselor explores the concept of “overwhelm” with John. What is that like? Does it have a physical effect? Is John able to sleep at night? This conversation allows John to explore the nature of his dominant narrative. It turns out that the “overwhelm” John feels may have its roots in grief, but he is actually worried about what comes next.

Passive vs. active

There is a specific intent in using the three-word narrative’s subject–action verb–object format that has to do with how we perceive the stories of our lives. It’s all about passive versus active.

Inevitably, when I use the three-word narrative with my clients, they initially place themselves in the “object” position of the three-word narrative, just as John did in the example (“Grief overwhelms John”). Clients perceive that something is happening to them beyond their control, and they don’t like it. Being the “object” puts them in the passive position.

In narrative therapy as described by White and Epston, a central goal is to externalize the problem, to help clients see a problem as outside of themselves. Clients are asked to name the dominant narrative, and that becomes how it is thereafter referenced. Often, the action verb or object point toward the name of the dominant narrative. In the fictional case, we might try to externalize John’s dominant narrative by calling it “overwhelm.”

That is not an easy concept to externalize, however, because it is outside of John’s control; he has put himself in the passive position of his narrative. Using another narrative therapeutic intervention called questioning, John and the counselor spend time better defining the dominant narrative. John eventually recognizes that what brought him to counseling isn’t so much being overwhelmed but rather fear of the future. Hence, through dialogue with his counselor, John reconstructs his dominant narrative to “John fears loneliness.”

In this new version, John is now in the active position of the three-word narrative; he is the “subject.” This allows him to better see his role in the dominant narrative and gives him the insight to externalize his dominant narrative, which for this example can be named “lonely.” On a subsequent visit, the counselor can simply inquire of John, “How are you handling ‘lonely’ this week?” John can respond in the context of how he has responded to that issue, his dominant narrative.

The side benefit of this approach is that by John viewing himself as the subject, he is better equipped to “act” in terms of moving away from his dominant narrative or simply seeing it for what it is — an immediate situation outside of himself that is causing him problems. Again, as White and Epston would say, John is not the problem; the problem is the problem.

Indeed, that insight will be the means by which John and the counselor collaborate on strategies to identify alternative narratives in John’s life. They will eventually move toward those alternatives and away from “lonely.”

Going deeper

In her textbook Theories of Counseling and Psychotherapy: A Case Approach, Nancy Murdock says that narrative therapy can be described as “where the client tells the therapist a story, the therapist listens, and the two make what they can out of it.” Indeed, narrative therapy is a social constructive theory and typically considered a shorter term approach to counseling.

Using the three-word narrative approach, however, allows counselors the flexibility to go deeper than identifying and working to change the dominant narrative. For example, I have found that the three-word narrative approach pairs well with the construction of a genogram, which is a diagram of family relationships and behavior patterns. Once clients have identified a dominant narrative in their lives, I will spend some time with them constructing a genogram to help us both see and begin to understand their more complete life story.

Genograms allow clients and counselors to gain insight into how clients perceive the strengths, issues and relationships in their lives. I often ask clients to devise three-word narratives that describe their lives at different ages and moments. This allows us to contextualize how stories change; more importantly, it helps clients see where personal strengths lie during periods in which their stories were not problem-saturated.

Seeing life as a progression of narratives also encourages clients to begin thinking about two things: 1) alternative narratives to the dominant one that has brought them to counseling, and 2) how to use their strengths to build a path to achieve the alternative, just as they see they have done in the past.

The approach can work for a variety of presentations. The fictional examples that follow show how a counselor might work with a client on the issues of grief, depression, trauma and anxiety. Each example includes the identification of the initial three-word narrative, the reconstructed dominant narrative after client-counselor discussions, the externalized name for the presenting issue and, ultimately, the alternative narrative identified by the client.

Together, client and counselor will identify and form the path — using client strengths as well as other interventions — to move toward the alternative narrative.

Subject: Grief

Initial three-word narrative: Grief overcomes John

Reconstructed three-word narrative: John fears loneliness

Externalized name: “Lonely”

Alternative narrative: John conquers life

Subject: Depression

Initial three-word narrative: Hopelessness overwhelms John

Reconstructed three-word narrative: John destroys relationships

Externalized name: “Doubt”

Alternative narrative: John enjoys friends

Subject: Trauma

Initial three-word narrative: Abuse wounded John

Reconstructed three-word narrative: John trusts nobody

Externalized name: “Distrust”

Alternative narrative: John builds relationships

Subject: Anxiety

Initial three-word narrative: Indecision surrounds John

Reconstructed three-word narrative: John despises decisions

Externalized name: “Decision hater”

Alternative narrative: John relishes choices

Three-word narrative versatility

The beauty of the three-word narrative is both its simplicity and its ability to mesh with other interventions, in short, creating an integrated approach.

In addition to three-word narratives and genograms, I have used interventions such as reframing, motivational interviewing, mindfulness, wellness, and even harm reduction. All of these can help propel clients toward insights about themselves or the first baby steps to envisioning preferred narratives.

More simply, three-word narratives invite further exploration and conversation in an effort to go deeper. Understanding a client’s narrative — in the moment, in the context of the past, and to gain a sense of a preferred future — requires push and pull between client and counselor.

I have found my journalist experience to be most useful in asking questions. Not the rapid-fire style that is something of a cliché in journalism, but the more thoughtful, open-ended questions that show empathy. Not surprisingly, the most effective journalists are the ones who show their sources empathy and seek to fully understand a story. That’s even more true, obviously, for counselors using narrative techniques.

Narrative therapy as embodied in the three-word narrative technique has two other positive aspects worth noting. First, the three-word narrative is a transparent technique, which is typical of narrative therapy in general. It requires the counselor to openly explain the technique and its goals from the start, which has the benefit of also engaging the client in the work of therapy. By discussing my own background from the first meeting with a client, I am modeling the art of storytelling. This type of sharing promotes a two-way dialogue with clients.

Second, three-word narratives, as with many other aspects of narrative therapy, work well in a multicultural context. A counselor who seeks to understand life narratives is promoting the unconditional acceptance of a client’s family, culture, influences and environment in the shaping of those narratives. This promotes trust in the therapeutic relationship and the promise of collaboration.

As I move forward with my career in counseling, I anticipate finding other parallels with my former life and putting those ideas to work. The goal? To help clients recognize the narratives of their lives — past, present and future.

 

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Les Gura has been interested in narratives his entire life. After 35-plus years as an award-winning journalist, writer and editor, his own narrative took a turn in 2016 when he entered graduate school to become a clinical mental health counselor. He earned his master’s degree from Wake Forest University in the spring and joined CareNet Counseling in Winston-Salem, North Carolina, in September. He is a national certified counselor and a licensed professional counselor associate. Contact him at lgura@wakehealth.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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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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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.

Stories of empowerment

By Lindsey Phillips September 26, 2017

In 2009, writer Chimamanda Adichie gave a TED Talk on the danger of reducing people to a single narrative, using her own personal stories to illustrate the complexity of individuals. In one of those stories, she revealed how her college roommate in the United States had a single understanding of Africa — one of catastrophe. Adichie, a middle-class Nigerian woman, did not fit this single-story narrative. To her roommate’s surprise, Adichie spoke English, listened to Mariah Carey and knew how to use a stove.

Adichie points out that people are impressionable and vulnerable in the face of a story. Stories are powerful, she says, but that power is dependent on who is telling the story and how it is told. “Power is the ability not just to tell the story of another person, but to make it the definitive story of that person,” Adichie says.

Storytelling can also be used to empower people, which is one of the primary functions of narrative therapy. In many ways, the story of narrative therapy began in the late 1970s through shared stories and conversations between Michael White and David Epston. This counseling approach assumes that culture, language, relationships and society contribute to the way that individuals understand their identities and problems and make meaning in their lives.

The narrative approach also separates the person from the problem — a technique that allows clients to externalize their feelings. “The spirit of externalizing the problem is so that the client doesn’t see that as something that they can’t change,” says Kevin Stoltz, an American Counseling Association member who is an assistant professor of counselor education at the University of New Mexico. Moreover, this approach places clients as the experts in their own lives (see sidebar, below).

Don Redmond, an associate professor of counseling at Mercer University in Atlanta and director of the university’s Center for the Study of Narrative (CSN), points out that White and Epston’s original vision of narrative therapy was not prescriptive. “It really is in some ways theoretical, even though there are specific techniques that you can learn. It really is about celebrating and appreciating each person’s unique story and helping them frame it in a way that is more self-affirming and less self-defeating,” he explains.

(Re)writing memories

Narrative therapy can help clients release the burden of painful memories. Cheryl Sawyer, professor of counseling at the University of Houston–Clear Lake, started using narrative therapy in part because of an aha moment she experienced while watching a scene in the movie Harry Potter and the Goblet of Fire. In the scene, Hogwarts headmaster Albus Dumbledore shows Harry the Pensieve, an object that stores thoughts and memories.

Sawyer specializes in trauma counseling and often works with children who are refugees or who have been abused. She wanted to help her child clients release their traumatic memories, so she created a narrative project in which children create memory books. As Sawyer explains, the memory books operate like the Pensieve, allowing the children to unpack their trauma and give it a safe place to live.

Children do not narrate the episodes of their lives chronologically, Sawyer notes. Instead, their level of trust determines where their stories begin. If they trust the counselor, she says, they will reveal more intimate details (e.g., “I was beaten up at my birthday party”) rather than offering only the generic version (e.g., “I received presents”).

Because children’s narratives typically are structured but not sequential, it can be hard to discern cause and effect, says Sawyer, a member of ACA. To overcome this, counselors can have child clients place events from their stories on a timeline. This technique allows clients to see the cause and effect, understand their own behavior and possibly project what might come next based on the patterns they notice.

In Stoltz’s experience, Adlerian theory and early recollections (an Adlerian process in which counselors instruct clients to remember actual events from their early life) work well with narrative therapy. This is because they help people understand their self-concept and self-identity and make meaning out of the experiences embedded in their lives.

In a classical Adlerian sense, early recollections are defined as memories before age 10, Stoltz says. “The time frame … is somewhat artificial in some aspects, but in other aspects, it’s good to understand the very core of when those first experiences started to come out for people — what they remember, what they really think is poignant that … shapes their beliefs and their worldview,” he says. Childhood memories are often distorted by one-dimensional thinking because people’s perception in childhood is different than in adulthood, he adds. Re-storying involves recalling these early memories and reinterpreting them with an adult mindset that is capable of higher cognitive exploration.

Stoltz is currently applying guided imagery to career narrative stories. As he explains, clients often have a fictional or real-life person they admired when they were young because the person’s traits or behaviors matched the way they thought the world should operate. Often, they used this hero narrative to move through life, Stoltz says.

For example, with one client who presented a heroic memory of Spider-Man, Stoltz noticed a pattern: The client kept using the word conflict in his narrative. In discussing this pattern, they discovered that the client no longer wanted to let his responsibilities be an excuse for shying away from conflict. So, they worked together to determine how the client handled conflict currently, how the client wanted to handle it in the future and how the client’s role models handled conflict.

“Guided imagery is a way of projecting that hero data onto a future career decision or a career transition. And it makes it more lifelike in the session for the person. It begins to allow them to purposefully imagine and really begin to apply that self-concept to the next step in their career,” Stoltz says.

Stoltz uses narrative data from the career construction interview to develop individualized scripts, including ones focused on supporting client identity, meaningfulness of work and aspects of adaptability and skills. “The narrative approach is always about writing the next chapter, and this is a way of applying the next chapter to an imagined world, a daydream,” he explains.

Pictures worth a thousand words

Words can sometimes fail clients. If clients cannot or will not articulate their stories with words, counselors must be creative and find another way for clients to express themselves, Redmond says. “The more versatile a counselor can be, the better,” he adds.

Sawyer works with some clients who possess limited vocabularies because they have lived on the streets from an early age and haven’t been exposed to higher levels of language. For example, a child might say, “I’m really mad,” but that statement is insignificant compared with what he or she is actually feeling.

When children don’t have all the words they need to express their thoughts, Sawyer relies on pictures. She asks clients to draw pictures, find pictures on the Internet or even go out and take pictures that support the deeper level of emotion in their personal stories. Often, she will take a series of pictures into the counseling session and ask clients if any of the pictures express how they feel that day and why that image best exemplifies what they are feeling.

Technology is providing yet another avenue for clients to communicate their stories. Sawyer finds that children and adolescents are often more comfortable texting than talking, so she has started using technology as a tool in storytelling. She creates digital narratives by typing the clients’ stories into PowerPoint slides. Then, she gives clients the option of adding music, images or art to depict how they feel. For example, one client added a picture of his father’s death certificate, and another client added a picture of a pair of shoes she was going to send her sister before her sister was murdered.

Redmond also combines technology and narrative therapy. At Mercer University’s CSN, counseling students interview people in the community and then convert these interviews into digital narratives (approximately five-minute videos) by selecting pictures, art and music to complement each person’s narration of his or her own story. One woman whom Redmond interviewed painted and sang to express her story, and both aspects were incorporated into her digital narrative. Pairing descriptions of her artwork with actual images of it captured her essence more fully than if she had been only interviewed, he adds.

These digital narratives allow individuals not only to rewatch their stories but also to share their stories with others. In fact, one of Redmond’s goals for CSN is to create a digital library that will help individuals going through a difficult time to realize that they aren’t alone.

Taking a back seat

Narrative therapy falls under postmodern theory. “One of the hallmarks of the postmodern approach is embracing the fact that there is subjectivity with an individual’s perception and what they’ve been through and not having the counselor come in and be the expert,” Redmond says. With narrative therapy, he explains, clients are the ones verbalizing the new or modified narrative of their lives, and counselors only paraphrase or mirror what clients are saying.

Because narrative therapy is client driven, it is more important for clients to understand how they are feeling than for the counselor to understand it, Sawyer says. “[Counselors are] the tool that [clients are] using, the base that they’re using, to tell their stories for themselves,” she explains. Clients must be provided with a safe space where they can share their stories and learn to express their feelings about what happened.

As a volunteer with Bikers Against Child Abuse, Sawyer often attends court cases involving children who have been abused, and she has observed children’s frustration when lawyers interrupt or guide their stories in answer to a specific question. For Sawyer, this observation further underscores the importance of allowing clients, not counselors, to direct and narrate their stories. As she points out, counselors are facilitators for the client’s story, so their job is to listen and help the client structure the order of the story, not the content.

Stoltz has found that the process of deconstructing and reconstructing the elements of a client’s story is often challenging, particularly for counseling students. To demystify this process, in 2015, Stoltz, along with Susan Barclay, published a guidebook, The Life Design ThemeMapping Guide, that provides counselors with a process for deconstructing narrative data, developing specific themes for the career construction interview and helping clients reauthor their stories. For the past five years, Stoltz has used this technique to train students to deconstruct and theme elements together.

Taking a back seat and allowing clients to guide the session can be particularly difficult for new counselors because they want to feel that they are accomplishing something, Stoltz says. They want to sense that the client has made a decision and is moving in a direction. Drawing on James Prochaska and Carlo DiClemente’s Stages of Change model, Stoltz reminds counselors that they’re “raising awareness now. You’re in the beginning of the change model. You’re in the contemplation stage or precontemplation stage. You’re not looking for movement. You’re looking for insight or awareness, the aha moment.”

A voice for marginalized, multicultural populations

With narrative therapy, clients inform counselors about their world, values and beliefs. In fact, early recollections provide counselors with an inside view of the client’s culture, Stoltz says.

Within this dynamic, a counselor’s culture and values may differ from the client’s, but counselors should not place cultural judgment on what clients have done, Sawyer says. For example, clients might disclose that they have offered sex in exchange for food, or they may use profanity in telling their story, but counselors must refrain from passing judgment, even if they think this act or language is hideous or immoral based on their own cultural perspective. Clients must feel safe to use their own language and words to freely tell their stories, Sawyer adds.

Redmond agrees that narrative therapy is compatible with cross-cultural environments because narrative counselors do not presume to know and tell clients about their problems. He also realizes that too often, the stories of marginalized individuals remain unheard. One of Redmond’s inspirations for creating CSN was StoryCorps, an oral history project that allows people to record their stories in a studio by having a family member or friend interview them. The recordings are then archived at the Library of Congress. Through CSN, Redmond expanded the project to include marginalized populations (e.g., people who are homeless, refugees) who do not readily have someone available to interview them and record their stories.

Redmond believes the community plays a significant role in narrative therapy. Therefore, CSN’s purpose is both to allow counselors to practice their listening skills and to provide a service to the community by letting people who are marginalized know that they are valued. Even though the CSN interviews are not considered official therapy, most people would agree that the simple act of telling one’s story can be therapeutic, Redmond says.

Redmond’s personal story also played a role in the creation of CSN. Besides the fact that he has always enjoyed stories, Redmond had two professional experiences that strengthened his belief in the power of narrative therapy. First, in his role as a supervisor at Hillside in Atlanta, a facility that serves children with severe emotional behavior disorders, he discovered that the children with the most severe behaviors and who had been at the facility the longest also possessed the most strengths. This observation made an impression on him, especially considering all the negative messages directed at these children, many of whom had been abused and were in and out of foster care.

The second experience occurred when Redmond was an access clinician at a community services board. Many individuals were at this facility under court order or because they were dealing with mental health issues. While conducting intake interviews, Redmond amused himself by writing down the clients’ strengths (e.g., intelligent, strong work history, sense of humor, family support). At the end of the interview, he would tell the clients the strengths he had jotted down and then would ask if they wanted to add anything. He often witnessed powerful reactions from the clients, including those who cried and said no one had ever told them that they had strengths.

These two experiences reinforced Redmond’s belief that “people start creating negative self-stories, and they start to only believe the negative images, and then they forget about the strengths that they have.” Therefore, Redmond advises counselors never to forget to account for the strengths of their clients, no matter the difficulty of the case.

The cultural awareness gleaned from narrative therapy also applies to clients, allowing them to question their own cultures. Often, Stoltz says, the difficult part is relating the memories and stories back to the client’s present life. Some clients grasp this concept more easily than others, and some struggle to understand how childhood events are still affecting them as adults. The latter scenario is challenging. “Early memories really are a good tool to have to be able to talk to people from different cultures because [there are] stories in every culture. … Memories are a story, and [they are] a way of relating that whole story back to the person,” he says.

Validating narrative therapy

Critics of narrative therapy often question how counselors objectively measure narrative techniques, which are subjective. “I think we’re in the infancy of starting to measure these kinds of things. I think we’re just beginning to rediscover some of the things that have been helpful in mental health counseling, and we’re applying those as new techniques to the career narrative area,” says Stoltz, who served as chair of the research committee for the National Career Development Association, a division of ACA. At conferences, counselors are discussing how the narrative approach works, and they are doing outcome research that says it works, but they are not yet validating the process, he adds.

“You cannot quantify emotion,” Sawyer acknowledges. She and her colleagues attempted to measure narrative approaches by administering a pretest and posttest to children who had suffered trauma. They found a valid instrument and administered it in the children’s native language, but the formality of the instrument and the fact that the counselors had not yet established a relationship with the clients caused some clients to leave prematurely. Based on this experience, Sawyer decided not to administer the posttest and concluded that sometimes narrative therapy is not about research; it is about clients and their needs.

The best method Sawyer has found for measuring the success of narrative therapy involves having clients point to shapes (e.g., small, medium and large circles) to indicate how big their problems are both before and after counseling sessions. Using this method, she has found that narrative therapy has a positive effect because for most children, the representative shape decreases in size at the end of the counseling sessions. However, because counselors cannot account for all variables — if court is over, if the client is living in a home with 14 other children, if the client has learned to speak English and so on — it is impossible to know whether clients have improved strictly because of narrative therapy, she points out.

Redmond is a proponent of mixed-methods research because quantitative research (e.g., a Likert-type scale) provides more breadth than depth, whereas qualitative research provides the depth. In addition, they complement each other: Quantitative research can provide counselors with great ideas for qualitative research and vice versa. Redmond recommends first using quantitative research, such as a survey, because clients find it less threatening and less personal, but it will still get clients thinking about their experiences. Then, counselors can ask clients the magic question: “Is there anything you haven’t discussed that you would like to talk about?”

Stoltz has discovered that finding thematic codes for categorizing narrative data is one way to measure narrative techniques. For example, people who engage in storytelling about traumatic events in their lives tend to integrate these life events into meaningful stories and report higher life and career satisfaction.

“Preliminary evidence is beginning to show that when trained people read these stories, they come to the same conclusions,” Stoltz says. “That’s an important first step in validating …
this process.”

In addition, digital narratives may provide opportunities to quantify narrative interventions in the future, Redmond says.

Integrating narrative practices

Narrative therapy is not for the lightweight, and it is not as easy as it sounds, Sawyer says. In fact, self-doubt can prevent counselors from using narrative techniques, she points out. To avoid this, counselors need practical experience. Just taking one course or workshop or reading a book on the topic won’t mean that counselors will know how to use the approach correctly. Instead, Sawyer argues that counselor training should involve a holistic approach in which counselors expose themselves to the topic not only through courses, books and articles but also by practicing under supervision and processing all along the way.

Also, some counselors are hesitant to incorporate mental health-based approaches if their training is in another specialty such as career counseling. Stoltz, however, stresses the importance of taking an integrated perspective because people have multidimensional experiences that are not mutually exclusive. “Career counseling is often seen as limited to the career dimension, but it is really counseling with a career goal in mind,” he says.

For Stoltz, it makes sense to apply narrative therapy to career counseling because there is always a story behind one’s career. Furthermore, many people spend eight to 10 hours working every day, and work stress is a significant contributor to a person’s well-being or absence of well-being, he says. Despite this, counselors are generally not incorporating work aspects into mental health, he points out.

Thus, Stoltz argues that counselors “need to rethink [their] specialization construct.” Unfortunately, it is easy for counselor educators to design courses that address a certain standard (e.g., a career counseling course, a trauma course, a multicultural course). However, when counselor educators create stand-alone courses, students often move from one course to another without integrating those courses, Stoltz says. To avoid this, he incorporates basic counseling skills alongside career counseling because students must learn to respond to content and meaning before they can help a client deconstruct a story.

Sawyer’s counseling program at Houston–Clear Lake integrates narrative therapy into the curriculum by introducing narrative therapy as a counseling tool and working narrative techniques into multiple courses. “It is not the only way to counsel but … like how everybody knows how to do Rogers, everybody knows how to do Gestalt … all of my students know how to do CBT [cognitive behavior therapy] and trauma-focused CBT, and they all know how to do narrative counseling,” she says.

Stoltz agrees with expanding counseling areas, but he also worries that as counseling training becomes broader, counseling programs are finding it difficult to retain depth. Counseling students need to understand both the academic jargon and the practical training associated with those terms, he stresses. “Re-storying needs to be accompanied with a practical, pragmatic application of what that looks like and what that process is,” he says.

Stoltz is helping to bridge this gap by incorporating experience work in his classroom, which is a technique modeled after Mark Savickas’ pedagogical practice. For example, a counseling student might do a case study and follow someone through a career intervention, or a career story, and present this constructed story to the class.

Redmond finds that counseling students infrequently have many opportunities to train specifically in narrative therapy or narrative studies. Currently, students in his program are introduced to narrative therapy under the umbrella of postmodern approaches in a counseling theories course, but his goal is to have students do more specialized work in narrative therapy in the future. As a step toward achieving this goal, he will be working this fall on a proposal for a narrative certificate program.

Authoring the next chapter

Stoltz acknowledges that misinterpretation or a unitary interpretation of a client’s story is one of the pitfalls of narrative therapy. “[Counselors] feel like [we’ve] got the inside track on this because [we] have this psychological knowledge, this counseling knowledge, and [we] have to be careful with that,” he warns.

Often, counselors will make up their mind about what the story means to the client. But the counselor’s job is to test, not to interpret, Stoltz says. Counselors should make the client aware of what they see and test that theme or theory with the client while still respecting that it is the client’s story, he explains. The client is the one who has to live the life and rewrite the story; the counselor’s job is to help the client accomplish this.

Adichie reminds us that “stories can break the dignity of a people, but stories can also repair that broken dignity.” Narrative therapy provides clients with a safe space to tell their stories. With a counselor’s guidance, clients can slowly reject the negative stories and stereotypes that create an incomplete or inaccurate representation of who they are as individuals and replace them with stories that empower them to take control of their lives and regain their humanity.

Stories are powerful, but the person holding the pen is the one who controls the story. Revision is key when writing a novel, and this holds true in narrative therapy as well. People first have to understand and narrate their stories in order to rewrite them and become the authors of their next chapter.

 

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Narrative approaches

As explained in the fifth edition of Counseling and Psychotherapy: Theories and Interventions, edited by David Capuzzi and Douglas R. Gross and published by the American Counseling Association, narrative therapy is based on the following beliefs:

1) Clients are not defined by problems they present in counseling.

2) Clients are experts on their lives, so in counseling, judiciously seek their expertise.

3) Clients have many skills, competencies and internal resources on which to draw when impacting change and growth.

4) Therapeutic change occurs when clients accept their role as authors of their lives and begin to create a life narrative that is congruent with their hopes, dreams and aspirations.

 

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Lindsey Phillips is a freelance writer and UX content strategist living in Northern Virginia.
She has 10 years of experience writing on topics such as health, social justice and technology. Contact her at lindseynphillips@gmail.com or through her website at lindseynphillips.com.

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.