Draw Me Your Thoughts: The Use of Comic Strips as a Cognitive Behavioral Therapy Intervention

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Journal of Creativity in Mental Health
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Draw Me Your Thoughts: The Use of Comic Strips
as a Cognitive Behavioral Therapy Intervention
Karina Therese G. Fernandez & Sofia Grace A. Lina
To cite this article: Karina Therese G. Fernandez & Sofia Grace A. Lina (2019): Draw Me Your
Thoughts: The Use of Comic Strips as a Cognitive Behavioral Therapy Intervention, Journal of
Creativity in Mental Health, DOI: 10.1080/15401383.2019.1638861
To link to this article: https://doi.org/10.1080/15401383.2019.1638861
Published online: 16 Jul 2019.
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Draw Me Your Thoughts: The Use of Comic Strips as a
Cognitive Behavioral Therapy Intervention
Karina Therese G. Fernandez and Sofia Grace A. Lina
Ateneo de Manila University, Quezon City, Philippines
ABSTRACT
Creating comic strips can be a viable mechanism when utilizing cogni-
tive behavioral interventions. Generating comic strips, which involves a
process of constructing sequenced panels and a story-narrative through
drawing, can reveal dysfunctional cognitions that can consequently be
addressed. The authors of this article discuss a qualitative case study of a
14-year-old high school boy who came for psychotherapy due to severe
anxiety during math tests. Creating comic strips was found to be ben-
eficial in externalizing problematic thinking processes, which were then
utilized for cognitive restructuring and behavioral modification. The use
of comic strips provided a concrete medium for analyzing maladaptive
thoughts and practices, leading the way for the emotional management
of anxiety with math.
KEYWORDS
Cognitive behavioral
therapy; comic strips; test
anxiety; math anxiety;
emotional management;
creativity in counseling
“Test anxiety is a combination of perceived physiological over-arousal, feelings of worry and
dread, self-depreciating thoughts, tension, and somatic symptoms that occur during test
situations” (Rajiah, Coumaravelou, & Ying, 2014, p. 68). Such an experience can be debilitat-
ing, as it can interfere with optimal output, underestimation of skills or learning ability, and
anxiety across a wide range of performance-evaluative contexts (Putwain & Daly, 2014).
Seligman and Ollendick (2011) survey of 40 studies that examined CBT for anxiety
symptoms and anxiety disorders among the youth reveals that Cognitive Behavioral
Therapy (CBT) is the only evidence-based treatment for children with anxiety disorders.
However, Morris (2014) states that CBT can be challenging in that it may be difficult for
clients with lower verbal skills or who utilize more concrete thinking. Previous studies have
addressed this by successfully integrating art practices into cognitive behavioral interventions
(Czamanski-Cohen et al., 2014; Morris, 2014). One such approach in making CBT more
appropriate for children is through the incorporation of the creation of comic strips.
Test anxiety and youth
Anxiety is a state wherein one feels excessive fear in anticipation of a future event
(American Psychiatric Association, 2013). Although it is typical to experience anxiety
symptoms, anxiety reaches a clinical level when it causes significant distress, is persistent,
and excessive (American Psychiatric Association, 2013). Test anxiety is a common form of
CONTACT Karina Therese G. Fernandez [e-mail] Ateneo de Manila University, Quezon City,
Philippines.
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/wcmh.
JOURNAL OF CREATIVITY IN MENTAL HEALTH
https://doi.org/10.1080/15401383.2019.1638861
© 2019 Taylor & Francis

anxiety among school children but, unlike General Anxiety Disorder (GAD), test anxiety
occurs in a specific situation or context wherein performance is evaluated. Test anxiety has
detrimental effects on performance and academic appraisal (Putwain & Daly, 2014).
Furthermore, test anxious students can experience psychological distress as well as aca-
demic amotivation (Rajiah et al., 2014). High levels of anxiety are debilitating outside the
academic areas as well, affecting self-esteem and impairment in relationships (Yen, Liu, &
Yang, 2013).
Cognitive behavioral therapy and children
Cognitive behavioral therapy is one treatment approach in dealing with anxiety disorders.
CBT is based on the premise that psychological problems are caused by dysfunctional
cognitions that influence feelings and behavior (Czamanski-Cohen et al., 2014). The CBT
model involves changing the content of thoughts, inferences, interpretations, and biases
while also changing the frequency of problematic behavior (Lorenzo-Luaces, Keefe, &
DeRubeis, 2016).
CBT for anxiety disorders generally comprise several techniques, among them are
cognitive restructuring, guided imagery, and coping skills instruction (Joyce-Beaulieu &
Sulkowski, 2015). Cognitive restructuring involves identifying and disputing maladaptive
thoughts that occur in anxiety provoking situations. Guided imagery involves invoking
mental images to achieve a particular goal. Coping skills instruction can include manage-
ment techniques, problem-solving strategies, and self-talk to manage anxious thoughts
and regulate behavior.
A critical review by Gibby, Casline, and Ginsburg (2017) of the long-term efficacy of
CBT for youth treated with anxiety disorders revealed that there were beneficial effects
maintained after a mean of 5.85 years. Their comprehensive study of several databases
identified 21 published reports where positive outcomes were maintained between 2 to
19 years of follow up. A meta-analysis of 56 randomized control trials using CBT found
47.6 to 66.4% complete recovery for children and adolescents across different anxiety
disorders (Warwick et al., 2017). With such evidence lasting across developmental periods,
CBT has been highly recommended as an effective treatment for children with anxiety
disorders.
For CBT for children to work, research suggests flexible, clinical sensitive, and
developmentally appropriate applications. Therapists must be creative in applying the
content and process of CBT and possess the ability to adapt these to the child’s needs
and interests (Podell et al., 2013). Hirshfeld-Becker et al. (2008) suggest examples of
adapting CBT for children by incorporating particular interventions such as stories,
puppet play, and role-play, to engage younger clients in learning and formulating
cognitive behavioral strategies. In a study that utilized CBT in a school-based interven-
tion for test anxiety, learning points and cognitive-behavioral skills were delivered
through child-friendly picture charts, activities, and handouts (Yeo, Goh, & Liem,
2015). By adapting and tailoring therapy’s content, materials and approach, CBT
becomes more effective and accessible to children of different levels and abilities
(Lickel, MacLean, Blakeley-Smith, & Hepburn, 2012).
2 K. T. G. FERNANDEZ AND S. G. A. LINA

Comic strips and cognitive behavioral therapy
Integrating art with cognitive behavioral techniques offers clients the opportunity to
express and learn skills through visual, linguistic, and tactile routes to decrease maladap-
tive cognitions (Morris, 2014). Traditionally, CBT is verbal and linguistic for the most
part; thus, art integration complements CBT by including imagery and creative expression
to articulate thoughts. Morris suggests that clients can be invited to create visual repre-
sentations of their thoughts, which could later be used to cognitively restructure irrational
or negative thoughts into more realistic and rational cognitions.
Creating comic strips are one such form of art therapy. It involves a process of creative
expression of one’s inner world, allowing children to actively and concretely examine and
understand their abstract and complex experiences, cognitions, feelings, and behaviors.
With the process of children actually making comic strips themselves, children are able to
actively engage in making sense of their problems or experiences. Notably, comic strips go
beyond the limits of static art, as they have a formal structure that consists of sequenced
panels, imagery, narrative, and sometimes dialogue, that gives children the opportunity to
holistically and serially process their thoughts and feelings (Johansson & Hannula, 2014).
A survey of literature of the utilization of comic strips for CBT revealed that there were
no studies integrating the two. In fact, research regarding creating comic strips to under-
stand children’s internal experiences was also limited. Much of the literature on comic
strips in therapy involves using published comic strips or graphic novels to help students
address personal issues and challenges (e.g. Gavigan, 2012). Johansson and Hannula
(2014) presented a case study, which explored how children’s moral expressions differed
depending on the mode of the narrative: comic strip versus written narrative. The data
from 4 third grade children were presented, and the findings suggest that children express
their morality more strongly through comic strips, as comic strips offered a more versatile
means of expressing morality, by combining a pictorial with an action format. A study by
Laba (2015) introduced the use of comic strip conversations to shape social behavior in
children with autism. Comic strip conversations is a technique that involves creating
comic strip illustrations while talking and utilizes symbols for different communication
skills such as thinking and talking. Using a quasi-experimental design in which a pre-test
and post-test was conducted on one group, it was found that comic strips were an effective
tool for looking at a problem and finding appropriate solutions.
Method
This study utilized a qualitative case study design, describing and analyzing the data from
the course of therapy with a 14-year-old high school boy who came for treatment due to
severe anxiety during tests for mathematics. According to Nock, Michel, and Photos
(2007) using a case study design is often a tool of choice of clinicians. First of all, this
design does not prescribe control conditions or comparison groups. As such, case studies
can easily be incorporated into therapy without disrupting the flow of the sessions.
Furthermore, the lack of a stringent structure provides the opportunity to observe
naturally occurring behavior. Finally, case studies are useful for the development of new
treatment strategies. Case studies provide the flexibility for crafting and honing novel
approaches for intervention.
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