Draw Me Your Thoughts: Comic Strips as CBT Intervention

This report, "Draw Me Your Thoughts: The Use of Comic Strips as a Cognitive Behavioral Therapy Intervention," published in the Journal of Creativity in Mental Health, explores the application of comic strips within a CBT framework to address anxiety, particularly in adolescents. The authors, Karina Therese G. Fernandez and Sofia Grace A. Lina, present a qualitative case study of a 14-year-old boy experiencing severe test anxiety. The intervention involved creating comic strips to externalize and analyze maladaptive cognitions, which were then addressed through cognitive restructuring and behavioral modification. The study highlights the benefits of this creative approach, providing a concrete medium for managing emotions related to anxiety. The report emphasizes the importance of adapting CBT techniques to suit the needs and interests of the clients, particularly those with limited verbal skills. The authors discuss the theoretical background of CBT, test anxiety, and the integration of art-based interventions, referencing previous research and studies. The report concludes that creating comic strips can be a viable mechanism when utilizing cognitive behavioral interventions. This assignment is available on Desklib, a platform that provides AI-based study tools for students.

Journal of Creativity in Mental Health
ISSN: 1540-1383 (Print) 1540-1391 (Online) Journal homepage: https://www.tandfo
Draw Me Your Thoughts: The Use of Com
as a Cognitive Behavioral Therapy Interv
Karina Therese G. Fernandez & Sofia Grace A. Lina
To cite this article: Karina Therese G. Fernandez & Sofia Grace A. Lina (2019): D
Thoughts: The Use of Comic Strips as a Cognitive Behavioral Therapy Intervention
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;
emotionalmanagement;
creativity in counseling
“Test anxiety is a combination of perceived physiological over-arousal, feelings of wo
dread,self-depreciating thoughts,tension,and somatic symptoms thatoccur during test
situations” (Rajiah, Coumaravelou, & Ying, 2014, p. 68). Such an experience can be d
ing, as it can interfere with optimal output, underestimation of skills or learning abilit
anxiety across a wide range of performance-evaluative contexts (Putwain & Daly, 201
Seligman and Ollendick (2011)survey of40 studies thatexamined CBT for anxiety
symptomsand anxiety disordersamong theyouth revealsthat CognitiveBehavioral
Therapy (CBT) is the only evidence-based treatmentfor children with anxiety disorders.
However,Morris (2014) states that CBT can be challenging in that it may be difficult fo
clients with lower verbal skills or who utilize more concrete thinking. Previous studies
addressed this by successfully integrating art practices into cognitive behavioral inte
(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 isa state wherein one feelsexcessive fearin anticipation ofa future event
(American Psychiatric Association,2013).Although itis typicalto 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 fo
CONTACT Karina Therese G.Fernandez [e-mail] 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 anxie
detrimentaleffectson performance and academic appraisal(Putwain & Daly,2014).
Furthermore,test anxious students can experience psychologicaldistress as wellas 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, L
Yang,2013).
Cognitive behavioral therapy and children
Cognitive behavioral therapy is one treatment approach in dealing with anxiety disor
CBT is based on the premise thatpsychologicalproblems are caused by dysfunctional
cognitions that influence feelings and behavior (Czamanski-Cohen et al.,2014).The CBT
modelinvolves changing the content of thoughts,inferences,interpretations,and biases
while also changing the frequency ofproblematic behavior (Lorenzo-Luaces,Keefe,&
DeRubeis,2016).
CBT for anxiety disordersgenerally comprise severaltechniques,among them are
cognitive restructuring,guided imagery,and coping skills instruction (Joyce-Beaulieu &
Sulkowski,2015).Cognitive restructuring involves identifying and disputing maladaptive
thoughts thatoccur in anxiety provoking situations.Guided imagery involves invoking
mental images to achieve a particular goal.Coping skills instruction can include manage-
menttechniques,problem-solving strategies,and self-talk to manage anxious thoughts
and regulate behavior.
A criticalreview by Gibby,Casline,and Ginsburg (2017) of the long-term efficacy of
CBT for youth treated with anxiety disorders revealed that there were beneficialeffects
maintained after a mean of5.85 years.Their comprehensive study ofseveraldatabases
identified 21 published reports where positive outcomes were maintained between 2
19 years of follow up.A meta-analysis of 56 randomized controltrials using CBT found
47.6 to 66.4% complete recovery for children and adolescents across differentanxiety
disorders (Warwick et al., 2017). With such evidence lasting across developmental pe
CBT has been highly recommended as an effective treatmentfor children with anxiety
disorders.
For CBT for children to work,research suggestsflexible,clinicalsensitive,and
developmentally appropriate applications.Therapists mustbe creative in applying the
content and process of CBT and possess the ability to adapt these to the child’s need
and interests (Podellet al.,2013).Hirshfeld-Becker etal. (2008) suggestexamples of
adapting CBT for children by incorporating particular interventions such as stories,
puppetplay,and role-play,to engage youngerclientsin learning and formulating
cognitive behavioral strategies.In a study that utilized CBT in a school-based interven-
tion for testanxiety,learning pointsand cognitive-behavioralskills were delivered
through child-friendly picturecharts,activities,and handouts(Yeo, Goh, & Liem,
2015).By adapting and tailoring therapy’scontent,materialsand approach,CBT
becomesmore effectiveand accessibleto children of differentlevelsand abilities
(Lickel,MacLean,Blakeley-Smith,& Hepburn,2012).
2 K. T. G.FERNANDEZ AND S.G.A. LINA

Comic strips and cognitive behavioral therapy
Integrating artwith cognitive behavioraltechniquesoffersclientsthe opportunity to
express and learn skills through visual,linguistic,and tactile routes to decrease maladap-
tive cognitions (Morris,2014).Traditionally,CBT is verbaland linguistic for the most
part; thus, art integration complements CBT by including imagery and creative expre
to articulate thoughts.Morris suggests that clients can be invited to create visualrepre-
sentations of their thoughts, which could later be used to cognitively restructure irrat
or negative thoughts into more realistic and rationalcognitions.
Creating comic strips are one such form of art therapy. It involves a process of crea
expression of one’s inner world, allowing children to actively and concretely examine
understand their abstractand complex experiences,cognitions,feelings,and behaviors.
With the process of children actually making comic strips themselves, children are ab
actively engage in making sense of their problems or experiences. Notably, comic str
beyond the limits of static art,as they have a formalstructure that consists of sequenced
panels, imagery, narrative, and sometimes dialogue, that gives children the opportun
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 w
no studies integrating the two.In fact,research regarding creating comic strips to under-
stand children’s internalexperiences was also limited.Much ofthe literature on comic
strips in therapy involves using published comic strips or graphic novels to help stude
addresspersonalissuesand challenges(e.g.Gavigan,2012).Johansson and Hannula
(2014) presented a case study,which explored how children’s moralexpressions 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 ex
their morality more strongly through comic strips, as comic strips offered a more ver
means of expressing morality, by combining a pictorial with an action format. A study
Laba (2015) introduced the use of comic strip conversations to shape socialbehavior in
children with autism.Comic strip conversationsis a technique thatinvolvescreating
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 eff
toolfor looking at a problem and finding appropriate solutions.
Method
This study utilized a qualitative case study design, describing and analyzing the data
the course of therapy with a 14-year-old high school boy who came for treatment due
severe anxiety during testsfor mathematics.According to Nock,Michel,and Photos
(2007) using a case study design is often a toolof choice ofclinicians.First ofall,this
design does not prescribe control conditions or comparison groups.As such,case studies
can easily be incorporated into therapy withoutdisrupting the flow ofthe sessions.
Furthermore,the lack of a stringentstructureprovidesthe opportunity to observe
naturally occurring behavior.Finally,case studies are usefulfor the development of new
treatmentstrategies.Case studies provide the flexibility for crafting and honing novel
approaches for intervention.
JOURNAL OF CREATIVITY IN MENTAL HEALTH 3

The participant
Lucas (a pseudonym) is a 14-year-old boy who studies in an exclusive school for boys
the older of two brothers and loves to draw. Lucas was recommended for therapy for
reasons namely,very low grades in math and significant manifestations of anxiety durin
quizzes and tests (i.e.,repeated head scratching,leg shaking,quickened breathing,missing
out on/not reading/forgetting instructions, mistakes in copying numbers from the boa
test paper). Furthermore, at home he would hide his quizzes from his mom. Examina
quizzesand long testsrevealed inconsistency in math achievementsuggesting thatthe
problem was not one of a learning disability or low aptitude in the subject.
Ethical considerations
During the intake interview, the client and his mother were informed of the code of e
that is practiced by the counseling center.In particular,the therapistdiscussed the
contents of the informed consent document crafted by the center and provided to cli
which outlines the various ethical considerations reflecting universal guidelines of pro
sionaland responsible values and standards to be practiced by the therapist,in order to
enhance the psychologicalgrowth and well-being ofthe client.Severalpointsin the
document were discussed in detail.First of all,the clients were told that,given that the
center was part of a teaching institution, the information they provide could be utilize
research,training,and education purposes.Secondly,they were informed thatpersonal
information would remain confidential,and that efforts would be taken to protect their
privacy and obscure any identifying information in any form of reporting. They were a
informed of their right to disallow the use of their information for research,training,or
education purposes.The client’s mother signed the contract of informed consent.
The Ethics Review Committee of the researchers’ university affiliation had done a p
hoc evaluation ofthis study and,on the basis ofthe information provided,found the
research procedures to be ethically sound. The ethics review was done after the stud
conducted as there was no established research ethics committee at the time of the
Procedure
An intake interview wasconducted with theclient’smotherto obtain information
regarding family background,developmentalhistory,and the client’s currentproblem
and symptomatology.There were two therapists working with the client,one was the
senior psychologist,with a PhD in ClinicalPsychology,while the other was a graduate
student taking her internship. Each therapist took turns taking the lead across the se
as partof the graduate student’s training.Each therapisttook notes separately during
therapy,which covered the client’s behavior and observed themes.
Several cognitive behavioral therapy techniques were used namely, cognitive refra
visualimagery,and problem solving.These techniques involved the creation ofcomic
strips to better understand the client’s thoughts and behaviors.Specifically,the sessions
included the following activities namely:outlining the scripts in the math testtaking
experience,and identifying more effective thoughtsand behaviorsto regulate anxiety
symptoms.
4 K. T. G.FERNANDEZ AND S.G.A. LINA

The firsttwo sessions with the clientinvolved rapportbuilding and discussing the
client’s perception of his problem. The process of creating comic strips began in the t
session and wenton for 5 sessions.In the course ofthese sessions,Lucas created five
illustrations. With each comic strip, the client and his therapists discussed the output
subsequent comic strips were created based on these outputs.
Data analysis
Hermeneutic inquiry was utilized as the framework for analyzing the data.Hermeneutic
inquiry isa practice ofinterpretation,which uncoversmeaningsunderlying the text
(Crotty,1998).Hermeneutic inquiry begins by accessing data abouta phenomenon,in
this case the experience and repercussions ofmath anxiety.Data was collated from the
intake interview process,behavioralupdates between sessions (particularly from math
class),sample quizzes from math class,and the comic strips from therapy sessions.Then,
the nextstep is the creation ofa shared understanding (Koch,1999).This was done
through the discussion and dialogue ofthe therapists and clientregarding the client’s
output,and the therapists’discussion of the output during case conferences.Finally,the
therapists engaged in synthesizing the whole phenomenon,based on how the various
outputs contributed to the whole (Crotty,1998).This involved moving repeatedly from
the interpretation of the parts of the comic strip outputs to an emerging understandin
the experience oftest anxiety.This was done through a series of open dialogue in case
conferences,revisiting the materialseveraltimes.
Case study
In the third session,Lucaswasasked to create comic stripsof a typicalmath test
experience.His outputshowed thathis conceptualization ofhis problem included his
thinking process before,during,and after the math test.His comic strip revealed that his
stress began with the announcement of the test (see Figure 1). It then showed how h
sensitive to the days between the announcement and the test itself and included dra
of him studying in classand athome.The therapistsnoted the focuson time and
numbers.
Based on the output of the first comic strip,the therapists invited Lucas to draw his
experience during the math test itself (see Figure 2). This comic strip output illustrate
cognitive bias on time and on numbers.The therapists also asked him to include in a
“calmnessand worry thermometer” to supplementthe successive comic strip entries.
Notably,his artrevealed thatcalmness and worry are two separate feelings.For Lucas
while calmness is high at the start, it goes down, then up again. On the other hand, w
is low at the start, and increases in the end, and is actually highest when he is hoping
he passes.
Lucas was also asked to create an “after the test” comic strip (Figure 3).This output
revealed Lucas’experience when the test is given back. What is most notable is that Luc
is most worried when the teacher makes the statement “at least 10 boys failed” (see
scale of calm and worry on the right of the comic strip). Interestingly, the story ends
Lucas passing and a feeling of calm with little worry.
JOURNAL OF CREATIVITY IN MENTAL HEALTH 5

The outputs from the firstsetof comic strips led the therapists to instructLucas to
create a series of drawings of the experience of the brain when one was anxious or n
anxious.First,he drew what he labeled as a “chaotic brain” (see Figure 4).He also drew
what he considered an “orderly brain” (see Figure 5).While these are not in comic strip
Figure 1.This drawing illustrates how stress begins once the test is announced.
6 K. T. G.FERNANDEZ AND S.G.A. LINA

form, they areincluded herebecausethey helped furtherillustratehis textanxiety
experienceand weresourcesfor his final output.When discussing thesedrawings,
Lucas explained thatduring tests,his brain was “chaotic and dark,like whathappens
when you mix allthe colors together.” He said thatcolors representinformation and
Figure 2.This drawing illustrates how stress begins once the test is announced.
JOURNAL OF CREATIVITY IN MENTAL HEALTH 7

feelings, that when he took a test, they all got mixed up. This mix included thought o
pressure to pass,feelings ofanxiety thathe would fail,and trying to remember allthe
things that he had studied.He said that “everything gets so mixed up that I can’t think
anymore.” Under the paint,he had drawn people running around with pieces of paper,
Figure 3.This drawing illustrates how stress begins once the test is announced.
8 K. T. G.FERNANDEZ AND S.G.A. LINA

trying to get to a processing machine.There was a man standing on a platform shouting
orders, and an alarm and a clock. On the other hand, an orderly brain shows mostly c
clean lines – there are no paints covering the work, which shows a line of people who
carrying the information Lucas has studied.They are putting their pieces of paper in the
processing machine.There is no man standing on a platform – instead there is a Public
Address system where there someone telling him whatto do, but thatperson is not
pressuring.Notably,there is no alarm,no clock,and no numbers.
The therapists’main realization was that,for Lucas,test anxiety was not an experience
during testing only.For him,testanxiety began atthe announcementof the test.This
Figure 4.This drawing illustrates how stress begins once the test is announced.
Figure 5.This drawing illustrates how stress begins once the test is announced.
JOURNAL OF CREATIVITY IN MENTAL HEALTH 9

finding was discussed with the client, and in the sessions that followed, Lucas was as
identify coping strategies that he could use from the beginning stages of his test anx
the end,and to practice them.Relatedly,the findings revealed the rising and falling of
panic in the course ofthe anxiety experience,suggesting to Lucas when he needed to
utilize these strategies.He also became cognizant on the need to focus his attention on
staying calm,rather than on time.
The finalcomic strip (Figure 6) reveals a step-by-step process of the cognitive beha
vioral strategies that Lucas had learned and begun to practice.First,Lucas became aware
of some rising negativeemotions.When he did, he calmed himselfwith breathing
exercises.He was also cognizant ofhis thoughts when he was about to sleep and what
he needed to do.Prayer was coping strategy that Lucas felt he could use,and to utilize it
during the course of the test anxiety experience,so that he felt so he feels calm.During
testing, he started the behavioral strategy of staying calm by practicing breathing ex
He also included the practice of calming himself down after the test,also through deep
breathing.Because he was aware that he stillexperienced apprehension after testing,he
saw the need to keep calm.
Figure 6.This drawing illustrates how stress begins once the test is announced.
10 K. T. G. FERNANDEZ AND S.G. A. LINA

Discussion
The resultsof this case study suggestthatcomic stripsare a usefulmechanism for
cognitive behavioraltherapy goals.The use of comic strips allows a client to externalize
and concretize the mental processes,emotions,and behaviors of an experience through a
dynamic artistic output.Furthermore,the use of comic strips allowed the therapists and
the client to see the temporal schema of a psychological experience, which would ha
been uncovered if art therapy was limited to static symbols.Moreover, comic strips break
up cognitionsand behavioralexperiencesinto discrete blocks,specifically the blocks
created by each comic strip panel.By scrutinizing the blocks,and the distinctions of
each block,the clientis able to identify where particularproblematic thoughtsand
behaviors are arising. In addition, these blocks are seen as interconnected, further al
for the client to observe the flow from one block to another. In doing so, the client is
to observe associations,cause and effect,or change.Finally,the use of comic strips helps
the client see the experience as more manageable, rather than overwhelming, leadin
increased capacity to manage thoughts,emotions,and behaviors in a healthier way.
In particular,in the course of 5 sessions,aided by the comic strip output,Lucas was
able to become aware ofdysfunctionalcognitionsthatwere influencing hislevelof
anxiety.He became aware ofhis sensitivity to time,for example.It is likely thathis
focus of attention being invaded by thoughts of schedules or deadlines, created feeli
tension,further dysfunctionalthoughts,and physicalexhaustion.Moreover,it impeded
his ability to focus more attentional resources on learning and understanding his sub
His focus on time might also be explained by the Looming Vulnerability Model of anxi
which suggests that anxious patients have a distorted sense of rate of change in term
threat,where events seem to be coming at the self very quickly,compressing the psycho-
logical distance from the stressful object (Riskind, Rector,& Taylor, 2012).In this theory,
awareness of one’s perception of threat is a crucialstrategy.
The creating of comic strips allowed Lucas to become cognizant of his emotional st
For example, he was able to describe his experience of anxiety. In doing so, Lucas wa
able to describe an alternative state,which became histargetstate in modifying his
behavior.This awarenessparallelsSiegel’s(2014)argumentaboutthe importance of
identifying and labeling emotionsin order to modify emotionalreactionsadaptively,
particularly in the contextof anxiety and stress.Furthermore,Lucas was able to gain
insight that these emotions, and states they triggered, changed across the experienc
anxiety disorders,noticing change in emotionalstates can be very helpful.Leahy (2012)
discussesthe importance ofunderstanding one’semotionalschema,which refersto,
among others,the belief about the duration of emotions when working with anxiety or
depression.
Another benefit of creating comic strips was that Lucas realized that his Math anxie
was a larger experience than simply the actualtesting situation.He saw that his anxiety
began with the announcement of the test and went on until the test was given back.The
awareness ofthis bigger picture was found to be especially essential,as it made Lucas
realize the need for behavioralstrategies and adjustments throughoutthe larger event.
Relatedly, comic strips allowed for identifying particular interventions at particular st
Specifically,Lucas was able to see how he needed to rest and sleep well during the nigh
before the test,and the benefits of breathing exercises and calming thoughts throughou
JOURNAL OF CREATIVITY IN MENTAL HEALTH 11

each stage – before,during,and after the test.Studies on cognition and anxiety suggest
that improved problem solving are essentialfor treatment (Hogendoorn et al.,2014).It
can then be suggested that,when Lucas was able to identify the problem-solving space
more accurately,he was better equipped to dealwith cognitive and behavioralglitches.
Conclusion
Cognitive Behavioral Therapy is an evidence-based intervention that focuses on iden
ing dysfunctionalthoughts and behaviors in dealing with anxiety disorders.This study
explored creating comic strips as a way to deal with test anxiety. The technique allow
client to concretize such problematic thoughts and behaviors.Just as importantly, the use
of comic strips allows for the identification of such thoughts and behaviors across a la
and sequential orientation, leading the way for more effective management and chan
anxiety symptoms.
ORCID
Karina Therese G.Fernandez http://orcid.org/0000-0002-4475-0570
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