Tag Archives: Creativity

Creativity

Fostering healing and community through an art and wellness magazine

By Russ Curtis, Lisen Roberts and Merry Leigh Dameron September 29, 2021

As a nation, we have faced several grim statistics in the past few years. Suicide rates have increased more than 30% in half of the states in the U.S. since 1999, and the opioid crisis has become an epidemic. In addition, adverse childhood experiences will likely rise because of the increased isolation and lack of school support services during the COVID-19 pandemic. These statistics are further troubling considering that mental health and addiction issues often begin in adolescence and lead to long-term disability, failure to achieve one’s highest potential and premature death.

Thus, it’s paramount to reach young people using multivariate, systemic and effective outreach methods. Using social media and other online venues can be more effective in reaching larger audiences than using simple public awareness messages, and this method is particularly salient during times requiring social distancing. With grant funding from the Jackson County and North Carolina Arts Councils, the Western Carolina University (WCU) counseling program collaborated with local public schools throughout western North Carolina to create an online art and wellness magazine called Masterpeace. We invited K-12 students to submit art for consideration in this publication, which was designed to do the following:

  • Create an engaging online (and print) magazine that celebrates local student art
  • Build university-school partnerships
  • Collaborate with counseling graduate students to provide mental health and wellness education to children, adolescents, parents, teachers and counselors
  • Destigmatize mental health issues
  • Increase conversation among parents, students, faculty and community members about the importance of seeking help for mental health needs

Healing through art

Coupling art with wellness information is particularly advantageous because research indicates that creating and appreciating art is therapeutic. Creating art elicits similar brainwave activity to what is observed in people while meditating. Art therapy is effective in helping clients who have experienced domestic violence, trauma, depression, personality disorders and schizophrenia.

Artists are visionaries who follow their hearts, not crowds, and are regularly at the forefront of societal change. Often it is music, paintings, graffiti or murals that bring much-needed awareness of inequality and oppression to the public. The aim of this art and wellness magazine is to encourage and nurture students’ creative genius to inspire others to instill a more collaborative and just society.

Expanding the reach

An online magazine can be an effective tool because 95% of teens have access to a smartphone, 89% of them are online multiple times every day and 40% say they prefer to receive health information online versus face-to-face medical visits. In addition, accurate online health information decreases anxiety and depression and increases stress management, healthy relationships and academic achievement. Evidence suggests that online health education is particularly salient for stigmatized topics that adolescents would typically avoid in face-to-face settings.

The WCU counseling program tested the efficacy of including art with mental health information on the university’s social media platform. First, we placed suicide prevention information on the counseling program’s Facebook page. Then, the next day we included student art with the same suicide information post. Adding art to the post increased the reach of the suicide prevention message: 46 more views (168 total), 152 more engagement (165) and 11 more likes (17).

Strengthening university, school and agency relationships

Masterpeace magazine enhances our university, agency and school partnerships by providing an engaging way for students, parents, counselors and teachers to interact during a period of social isolation. The teachers have told us how much they appreciate having the online magazine to discuss with their students and inspire them to create art. For instance, a middle school counselor was working with a student who was new to the school and struggling to fit in. He suggested she join the art club, so she did. And one of her artworks was published in Masterpeace. The counselor said it significantly improved her attitude and school engagement. Another art teacher told us that one of her talented high school student’s intermittent depression was visibly improved after their art was published in the magazine, and the teacher also believed that this publication would increase the student’s chances of receiving college scholarships. It may sound cliché but helping even one student thrive is well worth this publication.

Excitement for the magazine was evident from the number of students and schools that participated. There was a 100% increase in the number of students and a 27% increase in the number of schools that contributed art between the 2020 and 2021 editions. To date, the first two issues of Masterpeace have been viewed over 4,700 times, a reach that is significantly more than faculty could have accomplished by speaking to schools and community groups.

We hope that collaborating with community schools and agencies will also increase their involvement in counseling student field placements, service-learning opportunities, internships, practicums and other partnerships.

Another benefit of this project is that it involves counseling graduate students using what they learn in classes about mental health wellness and prevention to provide salient information throughout the magazine. In turn, this project benefits both graduate and K-12 students because it encourages counseling graduate students, who will become future counselors, to apply course material so that K-12 students will understand and use it in their lives.

Honoring the foundation of the counseling profession

We believe this magazine has a broader and more nuanced purpose. The counseling profession was founded on prevention and wellness principles, and it has increasingly been a leader in the behavioral health field on diversity, social justice and equality issues. The beauty and originality of art are emblematic of the counseling profession’s desire to honor the truth and uniqueness of everyone and allow them to express themselves in their own way. Much like the vision and imagination it takes to generate art, we believe this magazine speaks to the ethos of the counseling profession by honoring the varied and meaningful ways we all contribute to the world, creating an ever-evolving and highly complex beautiful tapestry of humanity.

 

Enjoy flipping through the 2020 issue and the 2021 issue of Masterpeace, and follow us on Instagram @masterpeace.artmag.

“The New King of the Jungle” by Marina Mace, the cover art for the 2021 issue of Masterpeace magazine (published by Western Carolina University in collaboration with the Jackson County and North Carolina Arts Councils)

 

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Russ Curtis is a licensed clinical mental health counselor and a professor of counseling at Western Carolina University. Contact him at curtis@wcu.edu.

Lisen Roberts is the department head of human services and an associate professor of counseling at Western Carolina University, where she oversees 10 academic programs. She continues to be involved in school counseling, counseling ethics and social justice issues. Contact her at lroberts@wcu.edu.

Merry Leigh Dameron is a licensed school counselor and assistant professor of counseling at Western Carolina University. Her research interests include social justice in education, alternative education and school counselor cultural competence. Contact her at mdameron@wcu.edu.

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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.

Yes, and … improv can be therapeutic

By Lindsey Phillips September 7, 2021

Two of the main rules of improv are that you must agree with the other person and add to the conversation. One of the most commonly used improv games “Yes, and …” illustrates these principles. 

Two people face each other. One person starts by voicing a single statement. The other person accepts this idea and builds on it by responding, “Yes, and …” For example, if someone says, “The lake is full of alligators,” the other person could respond, “Yes, and one of them is swimming toward us.” 

“In a lot of ways, improv is like a therapist,” says Andrea Baum, a licensed professional counselor (LPC) in Texas. “It’s giving that unconditional positive regard but also reflecting, tracking, and conveying empathy and understanding.” 

Baum discovered improv when she started looking for more playful counseling modalities. She decided that to enhance her role-playing, which she was using with clients, and to help herself focus more on being in the moment, she would take an improv theater class. In the process of having fun, she also observed several parallels with counseling. 

“I noticed that what I was trying to teach my clients to do, improv was organically doing,” she says. “Things like keeping them in the present moment, accepting themselves, finding their voice, expressing their authentic selves [and] connecting with other people. There were so many risks people were taking because they felt safe in [the improv] environment.”

Later, she learned about how improv could help caregivers better communicate with their loved ones, and this hit home for her. When Baum was 15, her father suffered a brain injury, which led to early onset dementia. Improv now served another purpose for Baum: “I started using these techniques that I had learned in improv with my dad, and our entire relationship just completely changed for the better. It was life-changing.”

Her experience with improv inspired her to partner with an improv educator and open Stomping Ground Comedy Theater in Dallas. She serves as the director of Improv for Life, a series of therapeutic improv classes and workshops that she designed for several populations with unique needs. 

Building connections 

In preparing to transition his counseling practice online a couple of years ago, Gordon Smith, a licensed clinical mental health counselor with a virtual private practice based in Asheville, North Carolina, began researching ways to build intimacy more effectively and efficiently in online spaces. His search led to him taking improv classes at the comedy club Second City. After participating in four online sessions, Smith was hooked. Immediately thereafter, he signed up for an improv group for counselors at the Improv Therapy Group, an organization that provides improvisation training with the goal of improving mental health. 

“I was immediately struck by how this modality allowed for practically instantaneous levels of trust, intimacy, risk-taking and laughter among total strangers,” Smith says. “I realized that I’d found what I was hunting for and was also having a really good time cutting up with a bunch of therapists.” 

Smith, who now serves on the Improv Therapy Group’s advisory board, has created improv groups tailored to working with gifted adolescents, adults and families. In a recent improv group, many of the participants reported that they felt mirrored and seen in the group in a way they didn’t often experience in their daily lives as neurodiverse individuals.   

Improv can also help disrupt toxic patterns in relationships, Smith says. He once worked with a family whose members all felt unheard and unseen by one another. The dynamic was so toxic that the family constantly argued in session, Smith recalls. While counselors can try to engage family members in therapeutic activities during therapy sessions, these activities may elicit only eye rolls or hurtful comments when the relationship is so badly damaged, Smith observes. He finds that the spontaneity of improv activities often interrupts these toxic patterns and opens the possibility of the relationship looking different. 

“All it takes is that first moment of spontaneity where something new happens and toxic patterns are disrupted, if only for a moment, which is what we’re going for in family therapy,” Smith says. Family members can explore how their relationship might look different by breaking out of an assumed role such as “mean mom,” for example. The mom can instead pretend to be “fun mom” for a few moments. Improv allows clients to play with the family narrative and “break” it in fun, nonthreatening ways, Smith explains.

Baum points out that mirroring is a great way to teach empathy and for people to connect with others. One of the first games she uses, especially when working with caregivers of people with Alzheimer’s disease, is having group members introduce themselves by saying their name and doing a silly gesture that expresses themselves in some way. The rest of the group then repeats this gesture three times before moving on to the next person.

When introducing improv games to clients, clinicians need to provide sufficient detail for how to play and show examples from across the spectrum. With the gesturing game, a counselor could exhibit both a small way to gesture, such as barely raising one’s hand, and a big way, such as jumping up and down and waving. 

“It seems like a simple icebreaker, but really we’re giving people the experience of being silly, being themselves, and then everybody accepting and supporting that by mirroring them,” Baum says. “There’s so much that benefits us when we mirror one another. We naturally mirror people when we’re connected to them. It helps us to listen and stay in the moment … and it’s a type of empathy … [to] really listen and repeat what you’re hearing.” 

Caregivers can also apply this skill in their own work, Baum says. They can mirror the ones they are caring for, matching their tone and volume of voice and what they are doing nonverbally. “That can help you connect and create mutual trust quickly,” Baum explains.  

Improv can also be a fun way to end a difficult processing session, says J. Claire Gregory, an American Counseling Association member who is an LPC and a licensed chemical dependency counselor in Texas. She presented on how improv can foster connection with clients and counseling students at ACA’s Virtual Conference Experience this past spring. 

One game she sometimes uses at the end of a process group is “Place, Hobby and Reason to Leave.” The game involves two people acting out a scene. One of the two leaves the room, while the others in the group determine a place (e.g., Texas), hobby (e.g., ballet) and reason to leave (e.g., stinging bees). The first individual returns to the room, and the second person acts out the place, hobby and reason to leave using only gestures and gibberish. The point of the exercise is to get the clients laughing and end the group on a fun note, Gregory says.   

Incorporating improv into counseling 

Comedic improv itself can be beneficial because it teaches communication, connection and acceptance in a supportive environment. So, counselors could recommend that clients who are struggling with social anxiety, confidence issues, self-esteem or relationship issues take a general improv class, Baum says. 

Therapeutic improv, however, differs in two ways: 1) It tailors the improv games to address a specific mental health need or population, and 2) it allows participants to process and apply the skills they learn in the games to their own lives. 

Alison Sheesley, an LPC and play therapist with a private practice in Denver, uses improv to create experiential activities that help group members learn skills needed to overcome some of the mental health issues confronting them. Although general improv classes are about being present, listening, being receptive, building connection and having fun, they are not as focused on helping participants connect what they do in class with their own personal lives, she explains. That’s one of the biggest differences between general improv and therapeutic improv. Sheesley’s focus is never on having clients be funny. She uses improv as a method for imparting life skills, but the humor often still happens intrinsically.

At Stomping Ground Comedy Theater, Baum has created therapeutic improv programs focused on anxiety, autism, caregivers, dementia/Alzheimer’s, kids and anxiety, health care professionals and physicians, and stress management. When working with an improv therapy group, Baum selects or adapts improv games based on the needs of the group population. 

One game she often uses for clients with social anxiety is to have them create a character — either someone they know or have made up — and imagine that character’s most distorted thought about themselves or the world. For instance, maybe the thought is “I’m stupid.” The person then acts out a scene with another person in the group who is also thinking their character’s most distorted thought. For example, the person whose character thinks they’re “stupid” may order a cup of coffee at Starbucks from the other person’s character, who is thinking, “The world is out to get me.” The first person may act nervous while ordering and stumble over their words, while the other person eyes them suspiciously.  

After acting this scene, Baum teaches the group how thoughts, emotions and behavior influence each other. They also learn to reframe thoughts using cognitive behavior theory. Baum asks the group how the characters could change their thoughts to neutral ones. They aren’t allowed to create a new thought, she explains. Instead, they must reframe the current one. The two members of the group assume these new, neutral thoughts and replay the same scene, noticing how things flow differently. 

Improv games such as this one have real-world benefits, Baum says. They give clients tools to communicate so that they won’t feel so lost or self-conscious, she explains. In the process, clients learn how to express themselves or how to position their hands or eyes when they first meet someone.

Monkey Business Images/Shutterstock.com

Baum has also used improv games to help people with dementia or Alzheimer’s learn how to better express their emotions. After playing the game, she briefly processes with them by asking, “How did that game make you feel? What did you learn from it? How could you use this in your life?” Her goal is to have clients come up with their own conclusions because then they are more likely to apply these lessons outside of session. 

Improv games are similar to techniques that many counselors already use, Smith observes. For example, clinicians may have clients externalize their feelings: “If your feeling could talk right now, what would it say?” That is a form of improv, he points out. This activity helps clients consider how their experience can go differently depending on subtle changes in how they think or act, he explains, which is in line with cognitive behavior theory.  

Reducing anxiety

Improv games work well with people who have anxiety, especially social anxiety, Sheesley says, because it allows them to lean into their social discomfort in a safe — and often humorous — way. Sheesley and her colleagues discussed how comedic improv therapy can treat social anxiety through group cohesiveness, play, exposure and humor in a 2016 article published in the Journal of Creativity in Mental Health. 

Sheesley, an ACA member who holds a doctorate in counselor education and supervision, runs a therapeutic improv comedy group in Denver that incorporates skills from acceptance and commitment therapy (ACT). At the beginning of a recent group session, she explained the concept of defusion, an ACT skill that involves creating space between a client’s sense of self and their thoughts and feelings to lessen their negative impact. This skill helps empower clients to make choices that align with their life values. Sheesley then asked group participants to identify a self-critical thought that contributed to their feelings of social anxiety so they could work on defusing it. In a circle, they repeated the self-critical thought multiple times using different silly voices, which is a well-known ACT defusion technique, Sheesley notes. 

However, she had the participants take it a step further by incorporating aspects of improv. They created characters to represent this self-critical thought and acted out how these characters spoke, walked, dressed and interacted with others. After getting comfortable in these roles, group members performed improvised scenes of inviting these self-critical characters to a party. One person pretended to be the self-critical character, while another person pretended to be the “self” that is negatively affected by this character. Sheesley instructed them not to reject the character but to treat it with acceptance, kindness and empathy. If she noticed a group member was not fully in the moment or was making a T sign (a sign Sheesley taught them to use when they needed a timeout), she would pause the improvisation to allow group members to process their feelings using a feelings chart. At the end of this exercise, group members told Sheesley they were able to view their self-critical thoughts and feelings through a different, more helpful, lens.

Improv can also help reduce anxiety among gifted individuals. This population often lives
in a state of overwhelm because of all the cognitive, sensory and emotional information they are processing, which can cause them to be more guarded and less trustful of the moment, Smith says. 

“The improv space allows for the rule for the room [to be] spontaneity and presence,” he notes. “It allows [gifted individuals] to come into the present and learn more about trusting … and feeling safe in the present. … They have time to practice going with their intuitive sense … and seeing how it works out in a no-stakes way.”

Smith once worked with a 13-year-old client who, like many gifted individuals, presented with asynchronous development (uneven intellectual, physical and emotional development). The client would overthink social situations, and by the time he figured out what to say, the moment had passed. His peers judged him negatively for his awkward and delayed responses. 

When the client first came to see Smith, these rejections had caused him such anxiety that he found it difficult to even open his mouth to speak. Their first few sessions together were only 20 minutes long because it was so painful for the client to talk. “His anxiety was so high,” Smith recalls. “I could see him so bottled up and having difficulty getting words out.” 

Smith knew the client enjoyed playing games, so he asked the client if he would play a game with him. The client agreed. Smith chose the improv game “Energy Ball” because he was also working on building the client’s emotional vocabulary. The game involves passing a ball that can transform into any feeling. Smith began the game by pretending to hold a ball of despair in his hands. Then, he threw it to the client. 

At first, the client played it safe by naming emotions such as happiness or fun, Smith recalls. He would also describe a feeling when he wasn’t sure of the emotional word, and Smith would “catch” the ball and name the appropriate feeling. But after about eight or nine passes of the energy ball, the client relaxed and started talking.

After playing this and other improv games, the client started doing hourlong sessions and grew confident enough to attend summer camp, where he made several friends. 

In improv, “everything that happens is a gift to be taken … and built upon versus some sort of threat. It’s just opportunity after opportunity after gift after gift,” Smith says. “And that can be a cognitive shift: The story I’m telling of what others are expecting of me or how they’re judging me … [changes] to ‘Well, here’s what they’re giving me.’”

Creating a safe space 

Counselors also need to cultivate a safe, supportive space when using improv. Baum and Gregory recommend establishing clear guidelines at the beginning. Gregory makes it clear that inappropriate or offensive words are not allowed, and she tailors her guidelines to the population. When she runs groups for individuals dealing with addiction, for example, she asks participants to avoid referencing drugs or drug use. 

The Stomping Ground theater has an oops/ouch policy, Baum says, that encourages group members to let others know if they are uncomfortable or offended by another’s actions or words.

“With improv, you can’t prepare for all things,” acknowledges Gregory, a doctoral candidate of counselor education and supervision at the University of Texas at San Antonio. “There’s going to be times where maybe a client gets over-triggered, but that can turn into an individual session” or learning experience, she says.

Smith had his own awkward moment in which he felt he crossed a line when acting out a scene in his personal improv group. The game involved group members destroying fear with an imaginary object. Smith picked up a “lamp” and proceeded to aggressively beat the fear out of it. At the end of the scene, he worried he had been a little too violent and may have triggered another group member, so he asked the group, “Was that too much?” 

The improv teacher responded in a supportive way, Smith recalls. She acknowledged that the performance could have been triggering, and she advised him to redo the scene in slow motion, which took the threat out of it. So, the group laughed while he slowly replayed the scene. 

Smith recommends that counselors also apply the “Yes, and …” principle to situations that create discomfort in their sessions. Acknowledge what the client was doing, he says, and show them another way to approach it to ensure that others feel safe. 

The need for proper training 

To successfully incorporate improv into their practice, Baum recommends that counselors take several improv classes and get training. She also stresses the importance of partnering with a highly skilled improv instructor. 

“The person who’s leading the group has to be able to build rapport and trust really quickly and in a playful way to get the buy-in,” she says. “If a therapist tries this once for the first time [without training], it could flop very quickly.” After doing improv for seven years, Baum says she just now feels she could lead a class by herself.

It was through an improv class that Sheesley met Stephanie Jones, an experienced improv coach and therapeutic improv consultant. Sheesley decided to partner with Jones and start an improv comedy play-based therapy group for social anxiety. Jones leads the improv activities, and Sheesley operates as a group facilitator, observing the group through a therapeutic lens. 

Before Gregory started using improv techniques with her in-patient group, she spent time training and discussing the ethical implications with her clinical director. She also sought consultation with other mental health professionals, all of whom advised her to continue learning by going to improv and psychodrama workshops. 

Smith has learned a substantial amount from Improv Therapy Group’s trainings, which allow him to play improv games with other mental health professionals and reflect on how best to use them with clients. Later in training, clinicians learn to create their own games tailored for the populations with which they work, he says. 

What counselors can learn from improv

Sheesley was working in a coffee shop in New Orleans when she first learned about improv from a friend. She started going to the local comedy theater and immediately loved it. Later, when she entered a master’s in counseling program, she noticed the parallels between the two. She recalls thinking, “Improv is exactly what we’re learning in my counseling classes about being receptive and present, listening and responding in the moment.”

She believes improv has also improved her skills as a counselor because it has given her confidence in her ability to handle whatever arises in session. “I’m much more accepting and less reactive to whatever comes up because I’ve practiced that in improv,” Sheesley says.

Smith agrees that in many ways, clinicians are already using improv skills by actively listening and being present with clients. Counseling sessions unfold naturally just like an improv scene, he says. In fact, some of the things he loves about both improv and counseling are “the immediacy, intimacy, uncertainty [and] mystery of how things are going to unfold,” he says.

Smith has also benefited from improv because he now has a deeper vocabulary to explain counseling concepts. He constantly uses “Yes, and …” with clients to build on what they are saying in session. Improv also allows him to crystallize therapeutic language in a casual way. For example, he can talk about “being in the moment” through these games and not from a Gestalt, psychoanalytic perspective. 

Baum thinks improv classes have made her more perceptive. “I’m able to read people really well nonverbally and verbally and pick up on cues. My intuition has improved on what might be going on with someone,” she explains. 

Gregory often found herself in her own head in sessions. She feared saying the wrong thing, and her focus on adhering to a specific counseling theory sometimes caused her to feel less connected with the client. Improv taught her how to step aside from that strictly clinical, structured mindset, she says.

Learning to be spontaneous and in the moment has allowed her to move past her own anxieties and fears to focus more on what her clients need. Spontaneity in improv “doesn’t mean being impulsive,” she adds. “It’s about being tuned in and being authentic to yourself and to the group.” 

Improv has also taught Gregory how to “fail.” She once tried an improv activity with a group, and it completely fell apart because no one wanted to participate. She had the group sit in silence for a few moments while she collected her thoughts about how to proceed. Finally, she asked the group what had happened, and she discovered some tension existed between two group members. 

“You’re going to fail with it,” Gregory admits. “There’s going to be times where you will try [an improv game] … and [clients] are just not really into it. And that’s OK because it leads to a different conversation, which can be therapeutic in itself.”

Learning to laugh again 

Gregory, Sheesley and Baum all agree that improv is a form of play therapy for adults. “At some point when we are becoming adults, we become self-conscious, and we stop playing. We stop expressing ourselves, and we start hiding parts of ourselves,” Baum says. “Improv is helpful because it’s a type of play that adults and children can have to express themselves.”

Sheesley finds that counseling frequently revolves around theories, mainly developed by white men, that are serious and often unapproachable. This isn’t the type of therapy that she wants to cultivate with her clients. She wants to make counseling a safe, playful space. “Laughter is just as therapeutic as crying, and yet we focus so much on crying as the ultimate cathartic expression,” she observes. She argues there is room for both. 

Smith recently led an improv workshop at a Supporting Emotional Needs of the Gifted mini-conference. He noticed one woman who looked like she wanted to participate but kept hesitating. So, he invited her to play in the next game. She reluctantly said yes, but a few minutes after playing, she was cracking herself up. 

Later, when they were processing the game with the group, she admitted that it was the first time she had laughed since her husband died two years earlier. “And it wasn’t because we were doing grief work,” Smith points out. “We were just playing and being supportive.” 

“Part of our job is helping people become aware of their own patterns, habits, scripts and narratives. … And improv is a way to disrupt those habits and patterns in a very safe way that allows for new perspectives,” Smith asserts. “So much of our work as therapists is just trying to help clients grow and broaden their perspectives on their own lives and to see opportunity and possibility. And that’s what [improv] is.”

People often think counseling must be serious all the time. They incorrectly assume that “if it’s fun, it’s suspicious somehow; if it’s fun, it’s not ‘real’ work,” Smith says. “We need to go to those other places that are sad and scary. [Yes,] those things can happen, and we can play.”

 

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Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@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 outside the box

By Bethany Bray February 25, 2021

Clients bring an unending range of presenting issues, personalities, life histories and challenges into counseling. Fortunately, counselors also have an infinite supply of tools for forging therapeutic bonds, meeting clients’ needs and helping clients tell their stories.

Counselors need only flex their creative muscles to find approaches that can bolster trust with clients and speak to each person’s unique life experiences and worldview. Exploring a client’s interest in skydiving as a metaphor for self-awareness and trust? Discussing a favorite dish or recipe as a prompt to get a client talking about family-of-origin issues? Assigning a client to play video games online with peers as a first step toward addressing social anxiety? The sky’s the limit.

Counseling Today contacted several counselors who are using interesting, fresh or different approaches to help their clients and students. We hope that you will be inspired by their ideas and possibly use them as a jumping-off point to think outside the box in your own work.

Sparking connection with photos

As the adage goes, a picture is worth a thousand words.

American Counseling Association members Brandee Appling and Malti Tuttle believe the truth of this saying holds up even in counseling settings, especially in the age of smartphones, when photography is ubiquitous. Why not leverage that by asking clients to bring photos and images into sessions, they reasoned. Prompts such as “bring in an image that represents you feeling happy” or “bring in an image that represents your family” can be eye-opening for clients and clinicians alike, Appling and Tuttle say.

The duo, former school counselors who met while working as co-coordinators of the school counseling program at Auburn University, have found that “phototherapy” can encourage dialogue and boost empathy and connection in counseling. This can be especially true in group settings, with child and adolescent clients, and with individuals who struggle with speech or whose primary language is not the same as the counselor’s.

Photos and images introduce “another mode of communication” in counseling, says Tuttle, a licensed professional counselor (LPC) who is an assistant professor and school counseling program coordinator at Auburn.

“Photographs can bring insights into someone’s life that we might miss when talking — things that the client can’t verbally express or doesn’t think to,” adds Appling, an LPC and approved clinical supervisor who is now an assistant professor in the Department of Counseling and Human Development Services at the University of Georgia. “It helps to break down walls [in session] and makes it easier for the client to talk about something that’s concrete rather than [topics] that are in the air, so to speak.”

When Tuttle and Appling have used this approach in school settings, students have often been able to display photos on their cellphones. If students don’t have access to a cellphone, they may be able to check out digital cameras from the school, or the exercise can be widened to include printed images such as postcards or magazine clippings, the counselors say.

The counselor’s role is to prompt conversation by asking questions about the client’s image and then allowing the client to reflect and speak. The counselor should never try to interpret the image or impose their feelings about it, Appling stresses.

“This is not to be used to diagnose [clients]. This is not meant to be a stand-alone tool but part of a range of counseling tools,” Appling notes. “It’s one thing that we would use, but it’s not the only thing we would use. It should be part of the therapeutic process, one tool to use in an interrelated system.”

In group settings, an assignment to bring in an image that “represents you” can help participants get to know one another, build connection and create a sense of belonging, Tuttle says. Asking group members to explain why they chose their image can prompt meaning-making, empathy and recognition of others’ viewpoints and perspectives. It can also provide the group leader a glimpse into each group member’s personality and emotions.

The exercise “builds a sense of universality and connection with one another, [prompting] conversations that might not happen organically,” Tuttle adds.

She suggests spurring dialogue in sessions (whether individual or group) by asking open-ended questions such as:

  • Why did you choose to bring this particular photo?
  • What meaning does it hold for you?
  • What would you title this photo, and why?

Appling has used this approach with a group she ran for students who were going through family transitions (e.g., divorce, a death in the family, living in foster care). When asked to share an image that represented the changes they were going through, one student brought in a photo they had taken of a unique seashell.

The seashell “was a representation, for them, of where they had been,” Appling recalls. “It looked very different than any other seashell that I had ever seen, and I initially didn’t recognize the image as a seashell. We talked about how water had changed it and eroded it. The seashell represented [the student] but also the growth and change they were experiencing.”

This intervention can also be flipped, with the counselor bringing in a photo for clients and students to discuss. When presenting on this intervention at conferences and trainings, Appling and Tuttle use an image of an aging set of concrete steps with vegetation growing through the cracks. They ask participants:

  • What do you think this image means?
  • What emotions does it elicit?
  • What does this photo remind you of in your own life?

Despite being shown the same image, participants typically share a wide range of thoughts, reactions and associations regarding the picture, Tuttle and Appling say. Some people see resiliency and growth in the vegetation, whereas others see decay and despair in the cracked steps.

“It’s really interesting to be able to see the perspective of each participant,” Appling says. “It’s a lesson that we all see things very, very differently and that it depends on the things we have been through, our different lenses. It’s a lesson that we all bring different experiences and viewpoints.”

 

Walking (and running) the walk

Counselors can use a seemingly unlimited number of running-related metaphors to encourage clients: It’s a marathon, not a sprint. Keep putting one foot in front of the other. Focus on the mile, not the marathon. You have to learn to walk before you can run.

But for Natae Feenstra, an LPC with a private practice in Smyrna, Tennessee, this approach goes beyond the metaphorical. An experienced runner who has completed multiple marathons, she sometimes conducts outdoor counseling sessions with clients as they run and talk, side by side. As a counselor who specializes in “running therapy,” Feenstra offers running sessions for clients who are comfortable with and interested in donning their sneakers and hitting the trail with her.

“For the client, it’s first and foremost a counseling session,” says Feenstra, who is working on a dissertation on running as a therapeutic treatment for trauma as part of a doctorate in counselor education and supervision through the University of the Cumberlands in Kentucky. “A goal to get to a certain number of miles is never part of a client’s treatment plan. The goal is improvement of mental health, and running is a tool for that.”

Counselors have long known the benefits that movement and exercise can have on mental health, including stimulating the release of endorphins, dopamine and other brain chemicals. Engaging in movement and exercise also offers opportunities for processing thoughts and mindfully focusing on one’s breath and stride.

“Natural bilateral stimulation — that’s all that running is. Rhythmic movement of large muscle groups, and we know that can bring amazing benefits to our brain,” explains Feenstra, a former school counselor who recently transitioned into private practice. Running therapy also offers the built-in ecotherapy component of enjoying sunlight, fresh air and views of nature as she and the client run and talk, she adds.

Feenstra’s approach is individualized. If a prospective client requests running sessions, Feenstra agrees only after having at least one consultation to get to know the client and their presenting concerns and determining whether the approach would be a good fit. She also offers walking and walk/run sessions, as well as traditional, stationary counseling sessions.

During the COVID-19 pandemic, Feenstra is conducting all of her traditional counseling sessions via telebehavioral health. She continues to offer in-person running therapy for clients who are comfortable doing that, while following health guidelines concerning physical distancing as much as possible.

Above all, she suggests running only if the client is comfortable with it. She points out that clients don’t need to be experienced runners to engage in this approach. She modifies each session to the client’s ability and comfort level. “It’s never about the pace or distance of the run. It’s about the movement, going alongside the therapeutic conversation,” says Feenstra, a member of ACA.

Feenstra has seen significant improvement in clients presenting with anxiety and depression who engage in running. Her clients have also self-reported boosts to their self-esteem, self-efficacy and overall wellness.

In addition to the mental health benefits that running provides on it own, these mobile sessions can help strengthen the counselor-client bond and support clients who might otherwise struggle to open up in a more traditional therapy setting, says Feenstra, who is also a certified running coach with the Road Runners Club of America. “Some people are intimidated by eye contact or other aspects of face-to-face sessions, or being in an office with a power differential. For some people, [running during counseling] can help them speak more freely,” Feenstra says.

This was recently the case for an adult male client on Feenstra’s caseload who presented with severe depression and anxiety. During the COVID-19 pandemic, his condition had worsened to the point that he was no longer leaving home.

When Feenstra and the client began meeting, counseling sessions were the only time the man ventured out. They eventually transitioned to mobile sessions, beginning with a walk/run mix to fit the man’s comfort level. Within a few sessions, his anxiety and depression had lessened so that he was leaving his house more frequently and beginning to reengage in hobbies and activities that he had enjoyed previously.

“The platform of running therapy was what prompted him to leave the comfort zone of his house. A telehealth platform would not have made him leave his house, and he was not interested in pursuing [therapy in] an office environment,” Feenstra says. “In this case, the running therapy was what helped him pursue counseling services. I think it was the running piece that was intriguing [to him], and it was so helpful to get him outside to conquer his anxiety.”

Running therapy “is not a miracle treatment, of course, but there are cases where it can make a difference, just like any therapy,” she adds. Running therapy, pioneered by American psychiatrist Thaddeus Kostrubala, has been around since the 1970s, she notes.

For running sessions, Feenstra meets the client in a park, on a trail or in another public place that she is familiar with or has checked out ahead of time. She begins by warming up with the client and chatting as they stretch. After completing a run or walk, they finish by cooling down and reflecting on the session together.

Feenstra acknowledges the potential lack of confidentiality when holding counseling sessions in a public place. She addresses this with her clients ahead of time, both with detailed language in her informed consent forms and verbally, explaining that they can pause their conversation whenever another person is within earshot.

“I let the client dictate,” she says. “I let them know that [they] can choose to lower their voice, stop talking or continue talking if they are comfortable.”

While many counselors may not be runners themselves, they could have clients who enjoy running. Practitioners don’t have to offer running therapy to leverage running’s benefits for their clients, Feenstra points out. She sometimes incorporates running by assigning clients to run outside of session (again, only if they are interested and able) and then uses that to prompt counseling work in their next session together. Running provides an opportunity to relieve stress, tap into the subconscious and process thoughts away from the distractions of life, Feenstra explains.

Clients may find it helpful to keep a journal to record their thoughts, questions and discoveries made while running. This can be used as a self-development tool or as something the client brings into sessions, Feenstra notes.

“Since the run time is often prime time for thinking, clients and counselors can discuss [in sessions afterward] how the run went and what their thought process was like on the run,” Feenstra says. “Also, since running has an innate mindfulness component, this [aspect] can be used as a counseling tool. The counselor might give the client a thought to ponder or a mindfulness activity to meditate on during their run time.”

 

Movies and moral development

One of Justina Wong’s clients had served a long military career as a sniper with a special forces unit. His experiences in service, including multiple deployments overseas, had left him with posttraumatic stress disorder and a relative inability to show or express his emotions. When he did, it often manifested as anger. His relationship with his wife and family was becoming increasingly strained, and one of his children was beginning to fear him.

In counseling, what clicked for this client was Wong’s suggestion that he watch two movies that, on the surface, were geared toward children: Charlotte’s Web and Inside Out. Wong’s client was able to see himself — and many of the emotions he was having trouble identifying and expressing — in the moral arc these movie characters experienced.

“The response that he had was very powerful,” says Wong, who completed an internship at a nonprofit that serves military veterans and their families as part of her master’s in counseling program at the Chicago School of Professional Psychology. As they processed the movies together in session, “We talked about healthy coping skills and unhealthy coping skills. He began to open up more about what he saw and experienced in the military. He had a very hard time differentiating [between] feeling angry and feeling sad, which is common among this population. Feeling angry is accepted, but feeling sad is seen as [a] weakness or being undependable.”

Cinematherapy, or using movie storylines, characters and themes as a therapeutic tool, can be particularly helpful with child or adolescent clients and those who struggle with depression, trauma, loss or social anxiety, Wong says. It’s also useful for individuals who might not respond well to more traditional counseling interventions and those who have trouble opening up to a counselor, she adds.

Clients can observe and learn from movie characters’ struggles, growth and perseverance in the face of challenges throughout their story arcs, explains Wong, a member of ACA. Clients “can feel like they’re not alone because someone else [a movie character] is going through a similar thing. They can see a character’s unhealthy behavior, coping skills and what they did or didn’t do to manage. It can help clients communicate and voice their emotions and understand what their values are.”

A counselor can either assign a client to watch a particular movie (that the practitioner has vetted) outside of session, or the counselor and client can watch film clips together in session. Either way, the important part of the intervention involves the therapeutic discussion afterward, Wong says.

Wong, a recent graduate of the Chicago School, prompts dialogue with open-ended questions. For Inside Out, these include:

  • Which emotions do you consider to be positive, and which do you consider to be negative?
  • Tell me about a time when you suppressed a particular emotion and, as in the movie, your “island” started falling apart.
  • What islands do you have in your life?
  • What role do joy, sadness, anger, fear and disgust have in your life?
  • Describe a time you felt embarrassment, shame or guilt regarding something from your childhood.

Wong stresses that cinematherapy must be individualized when used in counseling. Practitioners should carefully consider whether the approach is a good fit for each specific client and appropriate for their presenting concerns and therapeutic goals. She uses only movies that she is very familiar with and has prescreened. Her list includes About Time (2013), Mulan (1998 animated version), Yes Man (2008), The Lion King (1994 animated version), Eternal Sunshine of the Spotless Mind (2004), Toy Story 3 (2010) and others.

“You really want to do your due diligence and make sure you’re using this intervention to the benefit of the client,” says Wong, a certified trauma professional. “If you don’t, it [watching movies] just becomes a recreational activity.”

The therapy goals of Wong’s veteran client included mending his relationship with his family and being able to have conversations without becoming triggered and angry. As a grown man and hardened military veteran, he initially bristled at the idea of watching children’s movies. But when he began to understand how they could help him strengthen his family relationships, he agreed. He watched Inside Out with his entire family and discussed Wong’s therapeutic questions afterward with his wife.

When Wong suggested he watch Charlotte’s Web, she warned him about the movie’s sad ending because he had never seen it before. Even so, Wong recalls, he was very upset in the following counseling session. As they began discussing the movie, the client realized that he identified with Wilbur’s feelings of isolation and loneliness. The pig’s friendship with the spider, Charlotte, reflected the camaraderie he felt and the bonds he had formed with the soldiers in his unit, some of whom had not made it home alive.

“He put two and two together and understood that when Charlotte dies, she couldn’t return home with Wilbur, and he [the pig] was angry, sad and in despair. [The client] had served in special forces and had lost many friends and was trying to bury and push away his troubles. … After processing it [in therapy], he understood why I chose that movie for him to watch,” Wong says. “The lightbulb turned on for him when Charlotte and Wilbur have a conversation in the movie and she tells the pig that she can’t return home with him.”

Wong talked these issues through with the client, supporting him as he processed, during which he began to show emotion and cry — a major breakthrough for someone who had appeared emotionless and “very by the book” at intake, according to Wong.

The movie discussion spurred the client to open up to Wong. He disclosed that during one of his deployments, several soldiers he was in charge of had died as they worked to secure and occupy an area. The area was eventually retaken by insurgents, and the client wrestled with feeling that his comrades had “died for no reason,” Wong says. He struggled with moral conflict and felt frustrated and betrayed by his commanding officers and the government. “It was powerful progress. He was able to talk about that, which he had never [done] before,” she says.

When used intentionally, cinematherapy can be a powerful tool, Wong notes. She was inspired to explore the approach after hearing Samuel T. Gladding, a past president of ACA and a professor of counseling at Wake Forest University, present on a range of creative interventions, including cinematherapy, at the International Association of Marriage and Family Counselors conference in January 2020. “It’s up to the counselor to be as creative — or not — as they want to be,” Wong says. “I never thought of myself as a creative counselor, but when I heard Dr. Gladding’s presentation … I guess I’m more creative than I thought I was.”

 

Once upon a time

As a doctoral candidate at North Dakota State University, Robert O. Lester recently taught a class on group counseling to first-year, master’s-level counseling students. Most students, Lester notes, came into the class with an innate understanding of empathy, but as the class neared its end, he looked to delve deeper, teaching empathy in an applied manner.

He turned to fairy tales. Lester asked students to write a tale that illustrated some of the challenges they had encountered and the personal growth they had experienced over the span of the class. The assignment had just two requirements: Begin the story with “Once upon a time …” and don’t make fun of any tale shared in class.

The exercise succeeded in opening students’ eyes to a greater understanding of empathy while spurring the growth of their professional identities. It also equipped them with a creative intervention that can be used with clients in counseling sessions. Going through the “imaginative labor” of observing one’s self in unfamiliar places or scenes expands our concept of what is possible, Lester explains.

“Many students began with ‘I don’t have a story to tell,’” says Lester, a school-based counselor and ACA member. “You don’t need to have gone through some great suffering; you just need to be up close to your own desire and belief. It’s the distance of suffering that empathy can’t cross. It was an assignment to bridge the distance between ourselves and others by keeping the desire and suspending the disbelief. It’s about a willingness to let other worlds be possible. This is the initial move of empathy.”

Weaving one’s experiences into a fairy tale can be a helpful exercise for counseling students and clients alike because the stories are compact and give the writer the satisfaction of identifying a coherent story arc and conclusion, even if it’s not a happy one, Lester says.

Writing fairy tales “is expressive, playful and may surprise you. It can loosen the tongue for serious talk. Letting people become a little more enchanted and surprised with themselves would have a lot of possibilities [in counseling]. Then, it would be on the counselor to facilitate a good discussion afterward,” says Lester, who is now living in California and working as a counselor at an alternative-education high school while he completes his doctoral dissertation. “One of my favorite things about this [intervention] is when we surprise ourselves. … It can certainly break some of the narrative ruts we can get into.”

In counseling sessions, prompting clients to express themselves through fairy tales could be a good fit for “any situation where you want someone to begin trying on differences,” Lester says. “Organizing our experiences into an imaginative story — a story where there’s room for enchantment, and the marriage of emotion and imagination — [can be beneficial] for clients who operate with a lot of constraint in their life, either self-imposed or imposed by culture or external forces, especially if they’re having trouble imagining themselves otherwise.”

Fairy tales offer students and clients a chance to cast themselves in new roles, organize their experiences into a sequence, and reflect on the challenges they’ve overcome and how they’ve grown from start to finish, Lester explains. In turn, they gain an appreciation for their belief of what they’re up against and their desire for how they go on.

This benefit was magnified when Lester invited his counseling students to share and discuss their fairy tales in class. This enabled them to see how different each of their journeys were.

“At the deepest level, I was hoping the fairy tale project would be a hermeneutical project [and] part of their professional identity development — marrying your own worldview into the profession [and] taking the feelings of others seriously and compassionately, especially those who don’t experience the world as we do,” Lester says. “They are just beginning in counseling and have to learn to honor others’ worldviews. This fairy tale [assignment] was a compact way to help them begin by rendering their own experiences as unusual and in need of close reading.”

One of Lester’s students wrote an impactful fairytale about a protagonist named Mia. She lived in an idyllic village where everyone knew one another and worked according to their talents — except for Mia, who spent much of her time alone, reading. Although she liked her fellow townspeople, Mia felt something was missing in her own life, Lester says. She harbored an intense curiosity and sense of imagination that many of her neighbors did not share.

Her story took a turn when some creatures from the outlying forest visited her and asked for her help. An ancient well where they lived, deep in the forest, had dried up. The well was the source of the creatures’ magical powers.

Kindhearted Mia knew she had to help and journeyed into the forest, where she found the well in shambles. Her heart broke for the forest creatures, and at a loss for what to do, Mia began to cry. As her tears flowed, they filled and restored the well. Mia’s compassion had saved the day. Not only had she revived the creatures’ source of magic on her quest, she had also discovered her own sense of purpose.

In class discussions afterward, the student who wrote Mia’s tale talked about feeling alienated in the small town where she grew up. Everyone in town seemed to know how they fit into the fabric of the community, but this student was never able to find her niche, Lester says.

Her fairy tale was a beautiful description of this concept. “She [Mia] is looking for a world where her tears have a place and can do something on behalf of others,” Lester explains. This paralleled the student’s own struggle to find her way and cultivate her professional identity.

“We all go through growing up and forming identity, but her fairy tale elevated the experience,” Lester says. “Suddenly, Mia’s tears could do work and were life sustaining. I find that incredibly moving — that language of having permission to cry, because you don’t know what wells your tears might replenish. To me, that’s a whole other order of coming to apply empathy. [Learning empathy] begins with ourselves and becoming empathic with some of the pain and beauty of growing up. … There’s something poetic in that everydayness.”

 

Culinary therapy

Each of the elements in chef Samin Nosrat’s 2017 cookbook, Salt, Fat, Acid, Heat, can be used as therapeutic metaphors in counseling work with clients, suggests Michael Kocet, a professor and chair of the Counselor Education Department at the Chicago School of Professional Psychology.

If a dish doesn’t have enough salt, it can be bland, but if the cook oversalts the dish, it becomes inedible. “One little [extra] pinch of salt can ruin a dish,” Kocet says. “Talk that through with the client: In life, what do you have that’s not enough or too much? What in your life is that extra pinch of salt? Is it unleashing an opinion on a family member? How can we control that?”

Similarly, acid is very powerful and must be wielded correctly, as in ceviche, in which citrus juice is used to cook the dish without heat. Continuing the metaphor, a counselor can ask a client about the “acid” they have in their life. “Maybe their sarcastic humor is biting. Talk about when that can be useful and when it can be hurtful,” advises Kocet, a licensed mental health counselor and approved clinical supervisor who provides pro bono counseling at the Center on Halsted, an LGBTQ community center in Chicago.

Food, eating and cooking are so intertwined in most people’s life histories, perspectives and preferences that they can become beneficial tools when leveraged in counseling, says Kocet, who taught a course on “culinary therapy” when he was a professor at Bridgewater State University in Massachusetts. Although he no longer teaches that class, he continues to weave culinary elements into his work with clients and students in Chicago and has provided workshops and trainings on the topic.

In addition to tapping into a bountiful supply of culinary-related therapeutic metaphors and conversation starters, counselors can consider giving clients the assignment (when appropriate) of cooking a dish at home and debriefing in session afterward. The dish doesn’t need to be anything complicated, Kocet emphasizes. It could be a peanut butter and jelly sandwich or a simple salad, he adds. Cooking or preparing food mindfully, no matter the recipe, can prompt reflection. Tracking experiences in a cooking journal may also benefit clients who respond well to this approach.

“Food is often a binding element,” Kocet explains. “If I have a client who is struggling in a relationship, I might have them cook a recipe that represents their relationship and talk about that [in session afterward]. Or if a client and their partner are from two different cultures, I might have them cook a meal that incorporates elements from their two cultures. … One aspect to [help] forge cultural connection with clients is to discuss food: what they grew up eating and what was ‘celebration’ food. That’s one way to get to know the client a little more. Clients are often really proud of food and cultural traditions, and it’s one way to connect and break down barriers in a counseling setting.”

Assignments for a client to cook with a partner or family member can prompt bonding and offer a fun and creative way to work on healthy behaviors introduced in counseling, Kocet adds. Also, cooking “failures” don’t have to be failures when talked about and learned from in counseling. Perhaps a client forgot an ingredient or strayed from the recipe. How does that parallel the choices made and lessons learned in their life outside of the kitchen?

Even time spent cleaning up and washing dishes after cooking can serve as a mindfulness exercise, Kocet points out. Practitioners could suggest that clients take time to reflect on how they felt stepping outside of their comfort zone to try a new recipe as they clean up the kitchen and feel the dishwater on their hands.

Kocet has developed a culinary version of the genogram mapping tool that he uses with clients to delve into family issues. He keeps a small collection of cooking spices and a sleeve of mini paper cups in his counseling bag. As he begins the exercise, he lines all of the spice containers up on the table and asks the client to select a spice that represents them and other members of their family circle. The client pours a little bit of each person’s spice into a separate cup. Eventually, a constellation of spice-filled cups is displayed in front of them.

Kocet prompts the client to talk through why they chose that particular spice for each person. Cinnamon or red pepper flakes might signify either a warm personality or a hot temper, Kocet points out. The exercise encourages clients to talk through issues related to their own identity and helps the counselor better understand how the person views their family network, Kocet explains. Similarly, questions that invite discussion of traditions and memories surrounding food can encourage clients to reflect and open up, while giving practitioners additional context on clients’ families of origin and related emotions.

Kocet, an ACA member and a past president of the Society for Sexual, Affectional, Intersex and Gender Expansive Identities (SAIGE), a division of ACA, specializes in grief counseling. “If a client is missing someone they lost, such as a grandmother, it can bring comfort to cook a dish that she used to make,” he says. “Cooking uses all the senses — we can connect with loved ones through the tastes and smells [involved] in the act of cooking.”

As with any counseling intervention, practitioners must be mindful of the ethical ramifications of incorporating cooking and culinary elements into therapy and consider whether it is appropriate for each individual client, Kocet stresses. Clinicians should practice caution in using the approach with clients who struggle with disordered eating, and cooking assignments should not be given to clients who have a history of suicidal ideation or self-harm because knives and other equipment could be involved, he says.

Kocet plans to continue exploring the use of culinary elements in counseling and is in the early stages of a research study on therapeutic cooking as a coping tool for the isolation, anxiety and depression people have experienced during the COVID-19 pandemic.

 

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Staying within scope of practice

Practitioners considering the use of nontraditional approaches in client sessions must always keep the profession’s ethical guidelines in mind. Professional counselors’ licensure guidelines and scope of practice vary from state to state. Practitioners must ensure that any approach, whether a widely used talk intervention or one of many complementary methods such as aromatherapy, reiki, yoga, acupuncture and others, fall within their state’s scope of practice regulations before using them with clients or students.

In addition, counselors must consider the potential risks to client welfare, whether the approach is evidence-based (which is called for by the 2014 ACA Code of Ethics), and their own level of competency in using the method.

 

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Contact the counselors interviewed for this article:

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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.

Online role-playing games as group therapy during the COVID-19 pandemic

By Per Eisenman and Ally Bernstein February 18, 2021

During the challenging era of COVID-19, many young people are experiencing the sort of isolation that can interfere with healthy social development. This may be particularly true for young people who were already wrestling with significant mental health challenges before the pandemic. Telehealth group therapy that utilizes role-playing games offers a hopeful modality for facilitating individual growth in a group context.

Setting the stage

When one of us logs in to the Zoom session 10 minutes early, a picture of a cat immediately pops up. Martin has been waiting all morning for the group to start. He appears briefly and shows us his cat, Betty, sitting on his lap, before turning the video off so that only the photo of Betty is visible.

Gradually, everyone else joins and our game begins. Martin is committed to the group; he has never missed a session and is always early. In Dungeons and Dragons and other role-playing games, group members play fantastic adventurers, working together to overcome obstacles and gain rewards. The facilitator narrates a story, and the group members describe how their characters respond.

Martin plays an elf wizard named Sylvan who has a cat (also named Betty) as his magical animal companion. Martin was initially a bit shy but has integrated into the group and participates in collaborative decisions; he also loves to talk about Sylvan’s cat and backstory. Martin joined the group after the COVID-19 stay-at-home order in the spring of 2020, once we moved to a virtual environment. As is the case with some others in the group, this is Martin’s only social contact outside his family.

The therapeutic group allows for a structured social interaction — a place where people can connect, practice social skills, and modulate their inner and outer worlds. Many of the young people we work with experience social anxiety, depression or social skill deficits. The experience of a safe social setting where they can experiment with becoming someone else allows them to develop connections that can be both an antidote to loneliness and an opportunity for growth.

The COVID-19 pandemic has been a time of isolation. Young people especially are having fewer opportunities to develop socially, and schools are not able to provide as many opportunities for social contact. Telehealth group therapy using role-playing games creates opportunities for social connection and resiliency-building that may not be possible in person during the pandemic.

Collaborative creativity

Role-playing games hold a place in the pop-culture imagination as a niche interest, but their popularity has increased in recent years, and therapists have started implementing the games more widely as a group therapy modality for older children and adolescents. In role-playing games, one facilitator describes an imaginary world, and the participants (playing characters) describe their actions in that world. Sometimes success and failure are based on dice rolls, but players’ creativity and collaboration are also key in helping a group achieve its goals within the world. The game has many decision points, and each player can change the course of the story.

Martin’s character, Sylvan, has blasted open treasure chests with fireballs, duped goblins by pretending to be their grandmother, and hatched a dragon egg. Martin’s creativity influenced the world for himself and the other players, creating a new set of circumstances and changing the direction of the story.

During the game, the facilitator sets the stage: “You enter the pirate’s cavern. As you go in, you see a couple of pirates standing guard.”

The group members discuss how they would like to respond. Should they fight the pirates or try to sneak past them?

“Let’s trick them,” Maya suggests enthusiastically. Maya is shy in real life, but in the game, she plays a tough brute who likes smashing down doors. Martin’s character is cunning and enjoys deception. He likes the idea, and they work together to come up with a ruse.

Martin’s character says, “We are poor pirates who have lost our way in the tunnels. Could you tell us the way to the ship?” He rolls the dice to see whether he can convince the pirate guards to let them pass.

Traditionally, role-playing games are played in person, sitting around a table with maps of the adventure setting, rolling dice, and telling the story together. However, it is possible to play the games remotely through videoconferencing and the use of online platforms. In recent years, remote role-playing game use has increased dramatically. The virtual medium confers new benefits during the COVID-19 pandemic and in an era of physical distancing. It translates surprisingly well to a telehealth group therapy experience. Martin, who struggles with social anxiety, told facilitators, “I like playing online better. I can turn off my video.”

Emergence of change

In the many groups we have run with colleagues, we have observed the emergence of group dynamics and group member interactions that have influenced the choices members make and their participation in the group. Some group dynamics become apparent through the group members’ interactions with one another or from the progress of the group over the course of many sessions. Other patterns emerge in the development of individual group members and the impact they have on the group.

We were particularly struck by the memory of Kendra, who had a very clear vision of how she wanted the game to proceed. She wanted to control the narrative so badly that she soon began frustrating the other players.

“Can I roll the dice to persuade Maya that she should give me her gold?” Kendra asked. She prioritized stealing gold or impressing pirates controlled by the game master over helping the other characters.

This led to frustration among the other group members. Some members began to go silent. One spoke out angrily against Kendra, suggesting the group members’ characters fight Kendra’s character. The frustration of the group turned into a discussion, and Kendra ended up changing her character’s behavior entirely, deciding that her character needed to work with the group and eventually save them, sacrificing herself for the greater good.

She said, “I want my character to help the group, but the shift has to make sense for her character arc. She can’t just change overnight.” We had numerous discussions about what it might mean for her character to develop.

We asked the other group members what they valued about the game, and another member said, “Working together as a team.” The emotional message felt palpable. We were thrilled that the adolescent participants were able to lead this discussion themselves and process as a group with only minimal prompting from the adult facilitators.

Role-playing games involve the players describing the actions of their characters, while the game master describes the rest of the world and the people who inhabit it. The world is imaginary, and visual aids are optional. In a therapeutic group, this system allows for group members to explore identity construction and navigate group dynamics. Therapy groups for teens support the essential task of identity development in the context of relationships with peers and adults.

Much like with any good therapeutic group, what happens within the context of the game often reflects the members’ lives out-of-game. When the game master is also a therapist, questions such as “How are you similar or different from your character?” and “Why did your character make that decision?” make the game a clinical experience. The avatar of the character allows each group member a safe distance through which to explore, process, experiment, fail and succeed.

Group process as an adventure

Role-playing games have long been an effective group therapeutic modality, but creating a shared imaginary world presents unique opportunities during the COVID-19 pandemic, when we are unable to safely convene in person.

Every age has different developmental tasks to achieve, and during the pandemic, these tasks have either been interrupted or have required us to make notable changes in how we carry them out. With schools shifting the way education is delivered because of the pandemic, the amount of social interaction has been significantly reduced. On the whole, we are spending more time isolated from others, and young people are having fewer opportunities to develop socially. Role-playing games, a high-interest activity, allow for social experiences to happen through telehealth in a way that might currently be impossible in person.

Role-playing games feature goals, conflict, choices and relationships. Young people can do something together by completing tasks that require creativity and teamwork. Playing every week creates routine and ritual. Having a group means that young people have regular contact with adults and peers outside their immediate family.

Games can be adapted for different age groups and needs. Children and adolescents can develop executive function and practice resiliency. The technology necessary to play the game online can malfunction and lead to frustration, allowing participants to practice patience and engage in troubleshooting. Also, because the games are fun and silly and joyful, the fantasy setting can provide everyone with a much-needed break from the stress and grief of the current world (or a way to process grief and loss, because characters can die too).

This innovative form of group telecounseling provides an opportunity to engage young people who might not otherwise actively participate in a group process. It also provides an opportunity to support the cultivation of interpersonal relationships with group members in serious need of social skill development. Right now, during the pandemic, if we want to offer something that simulates living and striving in close proximity to others, we can. These challenging times call for innovation. Therapy can become exactly what kids need: a safe but exciting place to be challenged to grow. In other words, an adventure.

 

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Related reading, from the CT archives: “The power of virtual group therapy during a time of quarantine

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Per Eisenman (peisenman@csac-vt.org) and Ally Bernstein (abernstein@csac-vt.org) are community mental health counselors in the Youth and Family Services Program at the Counseling Services of Addison County in Middlebury, Vermont. They have been leading therapeutic groups for teenagers using role-playing games since 2015 and 2018, respectively. At the beginning of the COVID-19 pandemic, they transitioned these groups to telehealth.

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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.

Containment in restraints

By Erika Berger March 4, 2019

“The degree of civilization in a society can be judged by entering its prisons.” ― Fyodor Dostoevsky

 

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A group of young black men sit and interact before our weekly art therapy group. Some laugh and share stories of their children and loved ones. Others put their heads down and are silent. They discuss and debate song lyrics and current events.

One young man, freshly 18 years of age, bursts into laughter so deep, his eyes begin to tear up. He cannot wipe his eyes though because his wrists are handcuffed together. Those handcuffs are shackled to a small metal desk, which is chained to the floor. His feet are also chained together and shackled to the floor. This is the state of juvenile justice in the United States.

When I first began working in custody as a graduate student of art therapy, I ignorantly thought that juvenile detention centers were different than the adult prisons and jails that I frequented. I was wrong. Juvenile detention centers incarcerate adolescents ages 13-17 and house “adult inmates” until they are 21. Juvenile detention centers are no different than adult prisons in their daily operation, physical structure or philosophy of detention.

From my perspective, a more accurate name for such centers would be “child prisons.” More than 60,000 youths are incarcerated in these prisons on any given day. The majority of these young people are black. This does not include the numbers of children incarcerated at adult prisons. Many children are tried and sentenced as adults. Episode 8 of the new season of NPR’s Serial podcast takes an in-depth look at one such child prison in Cleveland.

 

Harsh juxtapositions

To think about therapeutic containment or the creation of a safe holding environment in the context of prison feels paradoxical at best. These young people are not safe in this environment, either physically or psychologically. Histories of trauma, coupled with the toxic stress and bigotry inherent to the prison system, often lead clients to feel utterly psychologically uncontained while completely physically restrained.

This kind of harsh juxtaposition defines the clinical environment I work in. Weekly group art therapy is the only therapeutic support that my clients receive. Art therapy is one of four hours out of the week in which these clients are let out of their cells. Simply being in the presence of a group can be overwhelming to them. To open up too much emotional expression in therapy can be dangerous because these kids are left to cope by themselves.

How then does a clinician establish boundaries and a contained, safe therapeutic environment in a context defined by walls, chains and fences? Walk beside and begin with the art.

Walking beside clients in their therapeutic journey is to embody empathy. It is to see the clients as unique individuals while understanding the cultural and sociopolitical forces (racism, toxic masculinity and other forms of oppression) at work around them. It is to continually investigate my place in that oppression. It is to know and accept that my mere presence and vast privilege as a white, upper-class, free individual may be painful for clients. It is to be open to dialogue about our identities and to hold anger. It is to express my anger at the systems of oppression that shackle young people.

Empathic embodiment is indeed visceral. I strive to walk beside these clients with my heart and, as clinical and liberation psychologist Taiwo Afuape writes, to have my heart broken. I work toward deep therapeutic attunement that allows me to experience the unbearable feelings of clients while remaining grounded. These feelings are simultaneously bearable and unbearable. I stand in the eye of the storm. This position allows me to support clients in the processes of identification, digestion and integration of feelings and experiences.

 

Art making as resilience

We always begin with art making in sessions. The materials automatically become physical containers for emotions. The concrete nature of the art materials stands in opposition to the rampant, formless boredom of prison. Art therapy interventions have a beginning and an end that is client directed, while time in prison is endless.

Clients often verbalize their creativity and creations as acts of resilience and resistance: “I felt free when making this”; “I forgot I was in prison”; “They can’t take these ideas from me.”

Early on in group therapy, I often implement the “I am” format of sharing about artwork. Clients speak from the perspective of their pieces and work to use literal descriptions of the artwork that begin with “I am”: “I am colorful. I am dark and light. I am chaotic. I am beautiful. I am bound. I am peaceful. I am bright. I am vibrant.”

The continual process of naming and deepening who you are in prison is indeed an act of peaceful resistance. To claim presence is to erode the stereotyped, bigoted treatment by the system.

A drawing Erika Berger made to help her process her work with prisoners.

I know our therapy is progressing when the art making begins to be inspired by the clients’ personal passions. It can take weeks or months of rapport building for clients to share their dreams and goals in therapy. Leading up to these passion projects are long hours of walking with clients through self-doubt, self-hatred, anger, depression, anxiety, fear and shame. Creative writing in the form of poetry, short stories and rap is common during these stages. It is a medium and coping mechanism with which clients are familiar and comfortable.

Passion projects begin to subtlety shift the orientation of time from the present moment to the future, indicating growing resilience and hope. Clients are often more self-directed with these projects. As self-regulation increases, the use of materials generally shifts from two-dimensional to three-dimensional, reflecting a literal inner growth or expansion. Drawings, paintings and writings transform to creations such as folded paper boxes, sculpted figures and dynamic collages. In this place of creativity and visibility, we can approach pain with enhanced flexibility and perspective.

 

In summary, fostering therapeutic containment in the prison setting is about holding steadfast to attunement and empathy. It requires looking our broken justice system in the eye and allowing our hearts to be broken. Remain grounded in this brokenness and always stay connected to each individual client’s uniqueness, creativity and inner light.

 

 

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Erika Berger is a recent graduate of Pratt Institute’s master’s degree program in art therapy. For the past two years, she has worked to create and implement clinical art therapy programming in western North Carolina prisons. Prior to becoming an art therapist, she was a bilingual special education teacher in New York City public schools. Contact her at Erika.wallace.berger@gmail.com.

 

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Related reading, from Counseling Today: “Seeing people, not prisoners

Seeing people, not prisoners

 

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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.