This article was downloaded by: [78.97.129.

246]
On: 22 July 2015, At: 04:06
Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered
office: 5 Howick Place, London, SW1P 1WG

Journal of Creativity in Mental Health

Publication details, including instructions for authors and
subscription information:
http://www.tandfonline.com/loi/wcmh20

Innovative and Brain-Friendly Strategies

for Building a Therapeutic Alliance With
Adolescents
Gail K. Roaten

Texas State University , San Marcos, Texas, USA

Published online: 16 Dec 2011.

To cite this article: Gail K. Roaten (2011) Innovative and Brain-Friendly Strategies for Building a
Therapeutic Alliance With Adolescents, Journal of Creativity in Mental Health, 6:4, 298-314, DOI:
10.1080/15401383.2011.630306
To link to this article: http://dx.doi.org/10.1080/15401383.2011.630306

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the
Content) contained in the publications on our platform. However, Taylor & Francis,
our agents, and our licensors make no representations or warranties whatsoever as to
the accuracy, completeness, or suitability for any purpose of the Content. Any opinions
and views expressed in this publication are the opinions and views of the authors,
and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content
should not be relied upon and should be independently verified with primary sources
of information. Taylor and Francis shall not be liable for any losses, actions, claims,
proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or
howsoever caused arising directly or indirectly in connection with, in relation to or arising
out of the use of the Content.
This article may be used for research, teaching, and private study purposes. Any
substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,
systematic supply, or distribution in any form to anyone is expressly forbidden. Terms &
Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions

Journal of Creativity in Mental Health, 6:298314, 2011

Copyright Taylor & Francis Group, LLC
ISSN: 1540-1383 print/1540-1391 online
DOI: 10.1080/15401383.2011.630306

Innovative and Brain-Friendly Strategies for

Building a Therapeutic Alliance With
Adolescents
GAIL K. ROATEN

Downloaded by [78.97.129.246] at 04:06 22 July 2015

Texas State University, San Marcos, Texas, USA

Brain growth and change are key factors in adolescent

development and influence cognitions, emotions, and behavior.
Much of the research on the adolescent brain is fairly recent,
and mental health practitioners working with adolescents must
have knowledge about these changes to more effectively engage
their young clients in therapy. The therapeutic relationship is
paramount in counseling with all ages and is particularly important with adolescent populations. Use of innovative and creative
strategies such as sand tray and art therapy are suggested as means
to establish the therapeutic alliance with teens in processes that
engage their developing brains effectively.
KEYWORDS innovative strategies, counseling, adolescents,
therapeutic alliance, art therapy, sand tray, creativity

There has been an explosion of research on adolescent brain development

in recent years (Steinberg, 2011). Anecdotally, adults have often blamed hormones alone for what is typically considered the normal adolescent angst.
Adolescence is an evolution, and research suggests that brain growth and
change are major factors in teens development (Spinks, 2000). The field of
psychotherapy has lagged in incorporating this research (Divino & Moore,
2010). Mental health practitioners working with adolescents must be aware
of current research to be effective. As Gorman (2006) stated,
You cant change whats physically happening within a teens brain, but
you can use this information to change how you react and respond by

Address correspondence to Gail K. Roaten, CLAS Department, Texas State University,

600 University Dr., San Marcos, TX 78666, USA. E-mail: gr17@txstate.edu
298

Innovative Strategies

299

Downloaded by [78.97.129.246] at 04:06 22 July 2015

developing a method for working with teens thatll help them rather than
send them racing out the door. (p. 34)

Counselors cannot treat adolescents as mini adults; the developmental differences are critical in appropriate treatment strategies. Youth must feel safe
to participate in therapeutic work (Eyrich-Garg, 2008; Straus, 1999). To feel
safe, the counselor must engage their young clients in therapy through the
establishment of a therapeutic relationship. The quality of the therapeutic relationship is clearly tied to outcome (D. G. Martin, Garske, & Davis,
2000). The single most important factor in effective therapy is the empathetic
capacity of the therapist (Horvath & Symonds, 1991; Hutterer & Liss, 2006);
this is especially true when working with adolescents (Morris & Nicholson,
1993; Reinecke, 1993; Sommers-Flanagan & Sommers-Flanagan, 1995). Due
to brain dynamics during this critical period, counselors must seek creative, brain-friendly strategies to engage with the young clients early in the
relationship-building phase of counseling.

THE ADOLESCENT BRAIN

No other period of development, other than the first 3 years of life, is
characterized by more dramatic brain changes than adolescence (Steinberg,
2011). Due to improved technologies such as magnetic resonance imaging (MRI) and, more recently, functional MRIs (fMRI), scientists now have
the capability to see inside the teen brain. Research suggests that the cognitive, affective, and behavioral change in adolescence is largely due to
synaptic reorganization (Blakemore & Choudhury, 2006). A new neurobiological model has emerged; Siegel called this period a reconstruction
zone (Codrington, 2010). Experiential input is critical to the development
of both executive function and social cognition (Blakemore & Choudhury,
2006); counselors are offered the unique opportunity to provide experiential
stimulation through the use of art and sand tray with adolescents.
While 95% of brain development takes place before age 5 or 6, a
second wave of development takes place during adolescence, typically
from age 11 or 12 through approximately 24 (Jensen, 2010; Spinks, 2000;
Yurgelun-Todd, Killgore, & Young, 2002). A second overproduction of neurons, dendrites, and synapses takes place in teen years. As overproduction
takes place, the brain selectively strengthens neuron pathways, while others
that are unused are eliminated. This process, known as synaptic pruning, is
based on activity and stimulation. As an adolescent has internal and external
experiences, synapses are formed, interconnecting neurons into pathways
and carrying energy and information throughout the brain (Badenoch, 2008).
Myelin begins to insulate and cover the neurons and pathways. Myelin is

Downloaded by [78.97.129.246] at 04:06 22 July 2015

300

G. K. Roaten

released in stages and is dependent upon age, environment, and genetics.

The more extensive the myelination, the faster information flows. This
makes the brain efficient; it allows the brain to organize circuitry. It also
means that . . . all aspects of an experience tend to gather into a neural
net that encodes a representation of an event. This is called remembering (Badenoch, 2008, p. 9). This means that thoughts, feelings, images,
relational values, and other factors related to an experience tend to clump
together and create what Badenoch called a super highway (2008, p. 10).
Every life experience can impact change in these connections. Function also
appears to be related to experience. A recent study using fMRIs found an
increased flow of blood to the social part of the brain, the hypothalamus and
amygdala, when teens were shown pictures of angry or frightened faces
(Hariri, Bookheimer, & Mazziotta, 2000). Repetition and relational experience strengthen connections in this part of the brain (Badenoch, 2008).
Adolescents attending counseling often have some level of anxiety. When
this anxiety and fear, often emanating from remembering other relational
experiences in the social part of the brain, are met with empathy, kindness,
and brain-friendly therapeutic strategies, new synapses form. So counseling
may actually stimulate the growth of new neurons while also sending blood
to more soothing parts of the brain, changing function. A model of healing
stemming from the therapeutic relationship emerges (Badenoch, 2008).

Neurotransmitters
During this period of vast brain development, synapses increase in complexity. Chemical neurotransmitters including dopamine, epinephrine, noradrenalin, and numerous others, become more excitable (Bronson, 2002;
Jensen, 2010). These excitatory neurotransmitters react more strongly to
stressors; neurons are actually seen in MRIs to spark and fire as messages
sprint across teen synapses. Jensen (2010) stated, Nature made the brains
of adolescents excitable. Their brain chemistry is tuned to be responsive
to everything in the environment. Thats what makes them susceptible to
thrill-seeking (p. 1). Risky behaviors, such as experimenting with drugs
and having unsafe sex appear to be driven by dopamine and other excitatory neurotransmitters (Cohen et al., 2010). Cohen et al. (2010) found
that the dopamine system appears to be the final pathway to all addictions
and begins in the adolescent brain. What was once thought to be choice
now appears to be teen hardwiring. A recent study found that when a
teen is anxious, has self-doubt, or is not confident, some neurotransmitters
such as noradrenalin are flowing into the synapse, basically shutting them
down. Conversely, when the teen feels confident and generally anticipates
challenges, dopamine, serotonin, and other neurotransmitters flow into the
synapse causing the message to fire through quickly and smoothly (Reyna &

Innovative Strategies

301

Farley, 2006). This new insight suggests how negative emotions impact teen
affect and behavior.

Downloaded by [78.97.129.246] at 04:06 22 July 2015

Limbic Region
The limbic area of the brain, or the midbrain, is centered in the head cavity. Two important structures here are the amygdala and the hippocampus.
The amygdala, which sits atop the brain stem, interprets input and regulates emotions; it readies the body for action when it perceives a negative
stressor. The hippocampus, located behind the amygdala, classifies memory
input; it selects, classifies, and stores experiences and learning into memory.
Explicit recall, the earliest type of memories, is known as factual memory
(Siegel & Hartzell, 2003). Later, children and adolescents develop autobiographical memory, which begins to generate connections from the limbic
area to the prefrontal cortex. Empathy and relational experiences are key
factors in this very important process. If the adolescent does not have early
empathetic experiences, this wiring is incomplete. Counseling with an empathetic counselor using art or sand tray presents new and unique experiences
for teen clients; the therapeutic relationship may cause the formation of new
connections and create more positive outcomes (Badenoch, 2008). These
include regulation of emotion, empathy, insight, intuition, fear extinction,
and moral development (Badenoch, 2008).

Prefrontal Cortex
The prefrontal cortex, the section of the brain that controls planning, organization, insight, and reasoning, and serves as mood modulator, does not
fully mature until age 24 or 25 (Giedd et al., 1996). Appearing sluggish,
the prefrontal cortex is the last section of the brain to receive myelin.
While adults rely on their prefrontal cortex to react logically to input,
adolescents rely more on the amygdala when making decisions; they will
revert to emotions and instinct (Yurgelun-Todd et al., 2002) and will bypass
the prefrontal cortex altogether. This process, coupled with the excitatory
neurotransmitters, leads teens to poor decisions and risk taking. Jensen
(2010) aptly stated, Its not that they dont have a frontal lobe. And, they
can use it, but they are going to access it much more slowly (p. 1). Insight
requires a fully connected prefrontal cortex; thinking about the impact of
ones behavior on others requires insight. So teens will often appear to
others as being self-centered (Jensen, 2010).
The prefrontal cortex plays a major role in adolescent affect. The right
side may be activated by negative feelings, while the left side controls positive feelings; most of the time, the two work in sync. The left side of the
prefrontal cortex receives and filters information from the amygdala. If the
amygdala sends a message of danger, the left prefrontal cortex processes

Downloaded by [78.97.129.246] at 04:06 22 July 2015

302

G. K. Roaten

this and sends a message back to the amygdala either reinforcing the danger
signal or instructing the amygdala to calm down. If the left side decreases
in activity, the amygdala may run wild (Feinstein, 2009, p. 105). The inactivity of the left prefrontal cortex leads to dominance by the right side; thus,
the teen becomes overwhelmed with negative feelings. Adolescents often
get stuck in negative emotions; this phenomena may lead to the development of depression. There does seem to be a link between the workings of
the left and right prefrontal cortex in depression, but there is no causeand-effect relationship (Feinstein, 2009). Depression does impact other
parts of the brain, especially the hippocampus. Through MRIs, researchers
have found that the hippocampus decreases in volume during a long-term
depression, primarily due to death of neurons (Thomas & Peterson, 2003).
Malfunctioning of the hippocampus impacts short-term memory and the
adolescents ability to process emotion and information. Plasticity once again
comes to the rescue, and when depression lifts, the hippocampus grows
new synaptic connections (Thomas & Peterson, 2003). Adolescent depression is more complex than simple neuroscience; numerous internal and
external factors are involved. Better understanding of the heart of adolescent
depression is critical for counselors engaged with this population.
The prefrontal cortex is also the province for language, and language
production in adolescence is difficult (Feinstein, 2009). Language production
shifts in function as the frontal lobe develops, and young adolescents have
more difficulty generating words and expressing themselves than do their
older counterparts (Sowell, Thompson, Holmes, Jernigan, & Toga, 1999).
This explains youthful answers such as, I dont know, Whatever, and
other vague responses. Such comments can be frustrating for counselors
trying to do talk therapy. Using expressive therapies such as sand tray
and art bypass the use of words and language and thus may be more
developmentally appropriate for teens.
Counselors working with adolescent populations must become familiar
with recent neuroscience literature on adolescents and how brain development impacts affect, cognition, and behavior. Counselors also need to have
an understanding of what is happening (or not) in the prefrontal cortex.
Promoting neural integration into counseling, creating a safe environment,
and building an empathetic therapeutic alliance using creative strategies
that are likely to engage youth in brain-friendly ways are important for
counselors who counsel adolescent clients.

THE THERAPEUTIC RELATIONSHIP

Many teens coming in for counseling do not understand their own adolescent experience, and they feel frightened and helpless (D. G. Martin, 2003).
Others, after getting in trouble for risky behaviors, may be mandated into

Innovative Strategies

303

counseling by well-meaning parents. Treating adolescents requires a good

relationship and creative and flexible use of techniques aimed at meeting
adolescents unique developmental experience (D. G. Martin, 2003).

Downloaded by [78.97.129.246] at 04:06 22 July 2015

Importance of Therapeutic Alliance

Adolescent clients are very different from adults or children, and the formation of the therapeutic alliance is critical. As D. G. Martin (2003) stated, All
of the brilliantly understood knowledge in the world will not make a clinician effective with adolescent clients unless he or she is able to form good
relationships with those clients (p. 2). Others have defined the therapeutic
relationship as the relational, emotional, and cognitive connection between
the youth client and a therapist (e.g., bond, trust, feeling allied, and positive
working relationship; Karver et al., 2008). This definition is echoed by D. G.
Martin: The ability to build a relational, emotional, cognitive connection
with teens is critical in successful therapy (2003, p. 14). A positive relationship between the adolescent client and the therapist also promotes teens
involvement in therapeutic work (Shirk & Russell, 1996), and the establishment of the alliance quickly is of great importance (Fitzpatrick & Irannejad,
2008). D. G. Martin (2003) and Katz (1990) suggested that, for adolescent
clients, even the first few minutes can be critical.
The therapeutic relationship is often the most powerful tool available to
counselors. Teens desperately need a safe and trustworthy relationship with
a counselor who understands their experience (Straus, 1999). Counselors
working with youth often disregard or are uninformed about research on
adolescent development. Specifically, they lack information regarding how
brain development might impact their work (Badenoch, 2008). Due to lack
of enlightenment, some adolescent counselors operate on what Straus (1999)
called five child-unfriendly assumptions (p. 26) based on their treatment
of adults:
1.
2.
3.
4.
5.

Talking is the most natural way to exchange information.

Talking about problems leads to solutions.
Getting in touch with bad feelings is beneficial.
Talking in therapy leads people to have more control over their lives.
The prospect of feeling better through talking is inherently motivating
(Straus, 1999, p. 26).

Adolescent clients are developmentally different from adults. D. G.

Martin (2003) emphasized this fact by stating, Adults and adolescents
are members of different cultures who barely share the same language
(p. 3). D. G. Martin (2003) suggested that two frequent mistakes made by
counselors treating teens are (a) thinking of adolescent behavior in terms of
what they themselves would/should do, and (b) using the adults inevitably
distorted memories of how he/she was as a teen (p. 3). In counseling,

Downloaded by [78.97.129.246] at 04:06 22 July 2015

304

G. K. Roaten

adolescents must feel deeply known and accepted; a personal bond must
be formed. This includes personal warmth, empathy, and acceptance (D. G.
Martin, 2003). Often, counselors begin the first session by asking teens questions such as, What brings you in for counseling? or Can you tell me a
little about yourself? They usually receive responses from teens such as,
I dont know, or Uh huh. As previously stated, teens frontal lobes may
not be engaged; they may have difficulty expressing themselves and may
have a hard time putting thoughts and feelings into words (Feinstein, 2009).
Traditional talk therapy often mirrors a teens real-life experience of adhering
to adult rules and expectations for behavior (Straus, 1999). Many adolescents
feel that adults do not listen to them; they have strong expectations that
an adult therapist will provide corrective advice or at least some judgment
or value on the part of the therapist (DiGuiseppe, Linscott, & Jilton, 1996;
D. G. Martin, 2003). For the relationship between adolescent and counselor
to be different, this control issue must be addressed. Giving youth some
control in sessions can be a critical component for counseling; without a
sense of ownership and responsibility, teens may not benefit any change
(Straus, 1999). Working together collaboratively, with both the adolescent
and the counselor in agreement about where they are going in counseling,
builds collaborative commitmentanother quality that D. G. Martin (2003,
p. 15) identified as critical to building the therapeutic alliance. Eyrich-Garg
(2008) expanded this idea, stating that counselors need to present themselves to their clients as partners rather than authorities in meeting teens
need for freedom and control. This need for control and freedom is a consequence of what is going on in the teen brain, a combination of changes in
cognitive abilities and affect (Sylwester, 2007). A commitment to the mutual
work and goals of counseling can be gained by using creative strategies to
engage adolescent clients in the relationship-building stage of counseling.

Counselor Qualities
Little research exists related to qualities sought by adolescents in people
from whom they might seek help; most studies were conducted with adults
(Eyrich-Garg, 2008). One study focused on pretherapy adolescents perspectives on desired therapist qualities (J. Martin, Romas, Medford, Leffert, &
Hatcher, 2006). The top three adult qualities identified by the adolescents
in this study were respect, time shared, and openness. Additional results
from J. Martin et al.s (2006) study indicated that adolescents like adults who
view them as mature, capable, and aware. Similarly, Everall and Paulson
(2002) found three alliance themes in their study: therapeutic environment,
uniqueness of the therapeutic relationship, and therapist characteristics.
Teens need to feel valued by adults, even though they may appear to be
self-centered or emotional. Adolescents are developing thoughts, beliefs,
and interests. This is a time of opportunity for counselors to plug into the

Innovative Strategies

305

adolescent drive for employing excitatory neurotransmitters in counseling

through use of stimulating experiential activities.

Downloaded by [78.97.129.246] at 04:06 22 July 2015

CREATIVE STRATEGIES FOR BUILDING

THERAPEUTIC ALLIANCE
Counseling with adolescents begins at the moment of initial contact (D. G.
Martin, 2003). One study recently found that the first counseling session is a
crucial time for engagement (Eyrich-Garg, 2008), and counselors must show
respect for their young clients. Kids rely more on what adults do, their tone
of voice, body language, past experiences, degree of fun, and expectations
to gain information (Straus, 1999). Teens infrequently hold sustained oneon-one conversation, either with adults or peers (Straus, 1999). In fact, Straus
said, This may even be a bizarre idea for themthe most unnatural way to
exchange information (1999, p. 27). Understanding teens intended meanings and validation of experience is critical for the development of empathy.
Making an adolescent feel understood often requires far more than talking, as Straus (1999) said, Psychological formulations and insights are the
hallmark of good adult work, but abstraction undermines what needs to
happen in a child therapy session (p. 49). Adolescents may be more likely
to engage in the process if it is embedded in interesting, stimulating, brainengaging activities. Well-chosen strategies employing expressive therapies
can become the . . . vehicle needed for making clients comfortable, engaging them in treatment, and giving them a way to express themselvesto
talk, explore, and let themselves be known by you (D. G. Martin, 2003,
p. 40). Further, Grey (2010) proposed, Because of the brains limitations,
counselors must incorporate multisensory learning to incite areas of the
developing brain that are prepared to aid in healing (p. 57). D. G. Martin
(2003) suggested that one fundamental principle that must be conveyed to
young clients from the outset was that these activities were not for fun or
friendship, but rather were part of the treatment process. Two innovative
strategies for engaging youth in the alliance-building phase are suggested
here. Sand tray and art stimulate the limbic region by sending sensory input
and processing the data into what Badenoch called emotionally meaningful
context (2008, p. 221). This information then engages the prefrontal cortex, spanning both hemispheres of the brain and integrating the body and
whole brain in therapy (Badenoch, 2008). Both counselors and therapists
are drawn into sharing this powerful experience, therefore enhancing the
bond between the mental health practitioner and client (Badenoch, 2008).
Young people may find therapeutic benefit from experiential approaches
using art or some other form of metaphoric communication (Draper, Ritter, &
Willingham, 2003). Both approaches are identified to be best practices in
working with youth.

306

G. K. Roaten

Downloaded by [78.97.129.246] at 04:06 22 July 2015

Sand Tray/Metaphors
Metaphors are powerful ways to show understanding and can help adolescents express complicated meaning in ways that words cannot (Cirillo &
Crider, 1995). A definition of sand tray therapy is an expressive and projective mode of psychotherapy involving the unfolding and processing of intraand inter- personal issues through the use of specific sand tray materials as a
nonverbal medium of communication, led by the client(s) and facilitated by
a trained therapist (Homeyer & Sweeney, 2011, p. 4). Sand tray is one way
to get to work quickly in an engaging activity involving the concrete use of
metaphors and symbols, thus circumventing initial resistance. Sand tray, or
sand play, refers to the therapeutic technique of using miniatures to create
a picture or sand world in a box of sand (Draper et al., 2003). Adolescents
may benefit from sand tray, as it is not dependent upon verbalization; the
process also transcends cultural boundaries. The experiential, metaphorical communication utilized through sand tray also fosters self-direction and
growth in teens, as it acknowledges their capability of learning experientially how to rely on their inner resources through the process (Kottman,
Strother, & Deniger, 1987; Landreth, 1994).
Counselors from a variety of theoretical orientations use sand tray as
an opportunity to engage in symbolic or metaphorical communication, and
different theories may be integrated into the actual processing (e.g., personcentered, Adlerian, solution-focused brief therapy, and others). Using sand
tray presents adolescents with the opportunity to create concrete representations of emotionally laden issues. Teen clients are provided an experiential
opportunity to make a vast number of choices during a single session
beginning with what they want to create; they are in control over what
is represented in their sand world. The child may become engrossed in the
process, or not; the counselor must be wary of how much or how little to
process verbally with the client while they are delving into the sand. The
focus of the work is on the metaphors, and teens may gain immediate insight
as the meaning of their created worlds emerges.
In the first session, the counselor may briefly introduce themselves,
explain confidentiality, and explain the miniatures and sand. Counselors may
choose to give no direction or very minimal direction to clients; this allows
the client to interact with the sand on their own (Homeyer & Sweeney,
2011). Some teens may need more structure, so prompts such as Create
your world, Create your world at home, and Create a scene may be
used to direct the experience. The counselor must be fully present during the
process, and very limited dialogue is necessary or wanted in the beginning
(Homeyer & Sweeney, 2011). As the child creates their world, they may naturally begin to share. Even if the teen does not talk, they are sharing symbolic
speech. Tracking, empathizing, encouragement, connecting/linking, and
even limit setting may be used by the counselor during the session with teens

Downloaded by [78.97.129.246] at 04:06 22 July 2015

Innovative Strategies

307

who have difficulty exploring the sand on their own. Tracking connects
the counselor with the teen and lets them know that the counselor is fully
present and empathetic with the adolescent (Landreth, 1994). Empathizing
is the art of feeling what another is feeling and communicating that to the
teen. It is especially important for adolescents to make guesses about what
they might be feeling as they may not be able or willing to put into words
their emotions; this is critical in meeting the teens developmental needs by
helping them access and use their frontal lobes. Encouragement focuses on
identifying the adolescents strengths, abilities, and resourcefulness; noticing
these traits and finding ways to build their confidence and competence is
profoundly important (Draper et al., 2003).
In sand tray, teens may be encouraged for making decisions and even
working hard. Examples of encouraging statements include: You figured
that out; You decided to do it that way; or You know just what you want
to do; you have a plan (Landreth, 1994). Some teens choose to stay with the
sand rather than using any miniatures. The tactile sensory experience acts
as a soothing regulation that is therapeutic (Badenoch, 2008). In placing the
miniatures in the tray, the teen is assembling a largely right-brained narrative based on previously unconscious themes (Badenoch, 2008, p. 223).
Through the process, the counselor and client become linked interpersonally, and a strong empathetic relationship grows. Sand tray experience
actually activates the prefrontal cortex for both the counselor and the teen
(Badenoch, 2008). Connecting, linking, and finding creative ways to interpret themes found in the teens sand tray are processed by the counselor. For
example, when noticing use of fences, walls, or imposing figures surrounding the miniature they have chosen to represent themselves, the counselor
might make a statement such as, I notice you have included ways to stay
safe or be protected in your world.
At the end of a sand tray session, the counselor may present the client
with two more choices. The first involves whether or not the teen would like
a photo of the sand world they have created; this memorializes the story.
The counselor may also ask for a photo for their files, while explaining confidentiality of the photo. The final choice is posed in the form of a question
to the adolescent: Would you like to remove the miniatures from the sand
tray, or would you like for me to remove them after you leave? Some might
have a hard time destroying what they have created; this powerful experiential activity may have stirred the brain to process powerful themes previously
not understood (Badenoch, 2008). Some teens will not have a problem with
leaving the tray; the choice leaves control with the young person.
Sand tray can be magic for an adolescent. Use of sand tray in the
first session allows for the use of metaphors instead of words and engages
teen brains in a way that talk therapy cannot. Angus and Rennie (1989)
have gathered evidence that suggests . . . a metaphor is typically embedded
within experiential networks of memories, incidents, images, and feelings

308

G. K. Roaten

constituting an associated meaning of context (p. 377). Not only does this
process engage adolescents in meaningful therapy, it also stimulates the
brain to create a unique therapeutic bond between counselor and client.

Downloaded by [78.97.129.246] at 04:06 22 July 2015

Art Techniques in Counseling

The roots of art therapy are grounded in psychoanalytic theory dating back
to the 1940s (Naumburg, 1973). Originally used as a free association interpretation of the subconscious, the goals of art therapy are to support the ego,
foster development of identity, and promote maturation (Kramer, 1979). Art
has long been acknowledged as a useful treatment modality with adolescents
(Coleman & Farris-Dufrene, 1996; Saunders & Saunders, 2000).
Art therapy is defined as a psychoeducational therapeutic intervention
that focuses upon art media as primary expressive and communicative channels (Shostak, 1985, p. 19). According to Davis (1995), the four main goals
of art therapy are: awareness, expression of energy and emotion, working
through a problem, and creativity and joy. Art therapists receive specialized training and pass a written examination for certification. However,
counselors may incorporate the use of art media and techniques into the
counseling process.
Through the use of art in counseling, an adolescent may explore
personal problems and developmental issues via nonverbal and verbal
expression. Through art, a teen may discover aspects about themselves not
easily accessed through verbal means (Finn, 2003). Art provides a nonthreatening means of exploring an affective response as a variety of emotions and
trauma can be accessed through various art media (Dalley, 1990; Rubin,
1988; Steele, 2009). Both the counselor and the teen may benefit through
the informal assessment the art process provides.
As with sand tray, art activities often activate the limbic of the brain, process the input through the experiential activity and stimulation it provides,
and enhance connections with the prefrontal cortex (Badenoch, 2008). Art
allows the counselor to enter the inner world of the teen and often provides
insight for both the teen and the counselor. Art techniques can be soothing
and relaxing and can allow for the child to cathart strong emotions. Art
is not dependent upon language, and it allows for a wide range of cultural
differences and backgrounds.
Much like sand tray, art can be easily incorporated into client-centered,
behavioral, cognitive, and solution-focused theories (Kahn, 1999). Kahn
(1999) states that art therapy is well suited for adolescents developmentally
and aids teens in accomplishing tasks of individuation and separation from
the family by (a) providing clients control over their expressions, (b) stimulating creativity through the process, (c) providing pleasurable experience,
and, (d) using media which depict personal and age/group symbols and
metaphors (p. 294). Because adolescents live in a world of images, they are

Downloaded by [78.97.129.246] at 04:06 22 July 2015

Innovative Strategies

309

comfortable with the therapy process utilized in images (Kahn, 1999). This
free expression, control, stimulation, and use of images and symbols engage
the limbic system through the senses (Badenoch, 2008; Kahn, 1999). Art
activities also provide permanence, objectification, a spatial matrix, and the
release of physical energy for adolescents (Wadeson, 1980). Objectification
is the process through which the adolescent externalizes threatening feelings
and ideas onto a neutral art form. The adolescent then has the opportunity
to gradually integrate these feelings as a part of self. Through objectification,
the teen has the opportunity to externalize negative emotions. Through
externalization, even resistant teens can begin to process and acknowledge the existence of potentially harmful feelings (Kahn, 1999; Wadeson,
1980). Art with teens may engage excitatory neurotransmitters and stimulate
synaptic connections from the limbic system to the prefrontal cortex.
If art techniques are used early in the alliance-building stage, teens may
be more likely to bond with the counselor. Use of images also takes talk
away from therapy, thus decreasing a teens defenses or resistances. Art
moves counseling to a nonverbal process; thus, the counselor is less likely
to be seen as an authority figure (Kahn, 1999).
From the outset, counselors must normalize the use of art in counseling.
Some teens prior experiences may move them away from art (Badenoch,
2008). Teens may be reminded that the process is about communicating
and expressing through a different media other than talk; it is not about
their artistic talent. Confidentiality regarding their artistic product needs to
be discussed and clarified for adolescents. Counselors need to reassure teens
from the outset that their artwork will not be seen by anyone else unless
they choose otherwise. Choice of materials and even paper should be given
to young clients; many may have issues with various media (Badenoch,
2008). Art stations would include paper, markers, pencils, pastels, paints and
brushes, magazines, cloth, buttons, clay, play dough, soap, shaving cream,
and other media. The selection of materials and appropriateness of their use
for each session is based on several factors including: a) students developmental level and abilities, b) session structure and purpose, c) degree
of control of materials, d) ease of use, and e) allotted time for setup and
cleanup (Kahn, 1999). In structured sessions, the counselor is purposeful in
selecting media and an activity. For less structured sessions, a wide variety
of materials should be available for use.
The counselors goal is to establish a therapeutic alliance and build
trust. Early on, they must convey the concept that art productions are a
vehicle for shared communication (Kahn, 1999) and reinforce through their
explanations and nonverbal behavior that the environment is accepting, nonjudgmental, and understanding. Using art can be a way for the counselor to
avoid early resistance or anxiety in their young clients through engagement
in the artistic process. Art activities are useful both as an activity that gives
the counselor and client something to do with their hands as well as a means

Downloaded by [78.97.129.246] at 04:06 22 July 2015

310

G. K. Roaten

of expressing thoughts and feelings that might be difficult to initiate simply

by talking (D. G. Martin, 2003). Kahn (1999) suggested that art directives in
the initial stages need to be open ended. The counselor may use a directive
that may reflect some of the adolescents problems, but the directive needs
to be viewed as safe by the adolescent (Kahn, 1999). Some directives in
the alliance-building stage might include, Draw a picture of you and your
friends doing something; Tell me a story about you; Illustrate your tale;
or Make a collage about who you are. Others might include, Create an
animal that stands for you; Create a collage that depicts your life story
(Riley, 1994, p. 85); or Make a scroll of your life story (Kahn, 1999, p. 296).
Counselors may choose to complete the art activity along with the adolescent, thus engaging their brains in the same way as their young client and
creating a more empathetic relationship. The counselor is not asking the
teen to do something they are not willing to do. This, again, takes away the
assumed authority position of the counselor, which the teen may be holding.
Interpreting or overprocessing needs to be avoided; it may actually hinder the relationship (Steele, 2009). In addition, there is the danger that the
counselor will be inaccurate in their interpretation (D. G. Martin, 2003). Simple
statements such as, Tell me about the collage, or Explain your animal to
me, should suffice. The counselors response to the art should always convey
interest and positive curiosity and should model behavior that encourages the
teen to expand self-expression throughout the process (Kahn, 1999). Even if
the adolescent produces artwork that is filled with hostility, anger, and defensiveness, the counselor needs to be accepting and nonjudgmental. Counselors
must trust the process; the adolescent will share at a pace that best fits them
(Kahn, 1999; Riley, 1994). Processing should always be paced with the teens
ability to integrate meaning, a brain function that allows for processing of
affect and cognition (Badenoch, 2008; Steele, 2009).
Ending a counseling session with art activities involves providing the
teen client with choices about their artistic product. Counselors may provide
teens with a choice about taking their product with them or leaving it with
the counselor. Never should a counselor display the art without the express
consent of the teen; this would violate confidentiality. If an adolescent offers
the artwork to the counselor, they should accept it graciously, making sure
the teen knows that it will be well taken care of (D. G. Martin, 2003, p. 43).

CONCLUSION
Beginning counseling can be terribly uncomfortable for adolescent clients,
many of whom have never had such an experience before. Some teens bring
with them expectations, anxiety, dread, and even hostility (D. G. Martin,
2003). Treating adolescents requires a good therapeutic alliance and creative
and flexible use of treatments that are developmentally appropriate (D. G.

Downloaded by [78.97.129.246] at 04:06 22 July 2015

Innovative Strategies

311

Martin, 2003). Counselors need to be creative and thoughtful about choosing experiential activities such as sand tray and art techniques for individual
teen clients. Employing expressive techniques in the beginning stages of
counseling may engage adolescents in treatment and begin a positive therapeutic alliance. Art and sand tray give teens the opportunity to talk, explore,
and let themselves be known by you (D. G. Martin, 2003, p. 40). Straus said,
What we do with kids makes them feel more successful and closer to us
(1999, p. 49).
The adolescent brain is both complicated and wondrous; counselors
must understand the developmental processes and provide counseling that
is brain appropriate. Providing stimulation through art and sand tray allows
teens the opportunity to develop neural pathways through experience; it
engages processes connecting affect, cognition, and behavior in positive
ways. Creative therapies such as sand tray and art also help adolescents
process emotions through the limbic system, which in turn stimulates the
development of neural pathways to the prefrontal cortex. The developmental functioning level of an adolescent and their natural energy to creatively
seek forms of self-expression and identity formation are captured through
creative processes such as art and sand tray (Kahn, 1999). Counselors must
stay attuned to adolescents emotions for alliance formation (Karver et al.,
2008). Understanding what emotions need to be expressed by a teen, choosing appropriate experiential activities such as art or sand tray, and processing
that enhances each adolescents understanding in a safe environment build
a therapeutic alliance. Art techniques and sand tray are empowering, effective, and brain-engaging means to build a positive therapeutic relationship,
thus increasing the likelihood of positive outcomes.

REFERENCES
Angus, L. E., & Rennie, D. L. (1989). Envisioning the representational world: The
clients experience of metaphoric expression in psychotherapy. Psychotherapy,
26, 372379. doi:10.1037/h0085448
Badenoch, B. (2008). Being a brain-wise therapist. New York, NY: W. W. Norton &
Company.
Blakemore, S. J., & Choudhury, S. (2006). Development of the adolescent brain:
Implications for executive function and social cognition. Journal of Child
Psychology and Psychiatry, 47, 296312. doi:10.1111/j.1469-7610.2006.01611.x
Bronson, P. J. (2002). Factors in neurotoxicity in adolescents. Journal of
Orthomolecular Medicine, 17, 141150.
Cirillo, L., & Crider, C. (1995). Distinctive therapeutic uses of metaphor.
Psychotherapy, 32, 511519. doi:10.1037/0033-3204.32.4.511
Codrington, R. (2010). A family therapists look into neurobiology and the adolescent
brain: An interview with Dr. Daniel Siegel. The Australian and New Zealand
Journal of Family Therapy, 31, 285299. doi:10.1375/anft.31.3.285

Downloaded by [78.97.129.246] at 04:06 22 July 2015

312

G. K. Roaten

Cohen, J. R., Asarnow, R. F., Saab, F. W., Bilder, R. M., Bookheimer, S. Y.,
Knowlton, B. J., & Poldrack, R. A. (2010). A unique adolescent response
to reward prediction errors. Nature Neuroscience, 13, 669671. doi:101038/
nn.2558
Coleman, V. D., & Farris-Dufrene, P. M. (1996). Art therapy and psychotherapy:
Blending two therapeutic approaches. Washington, DC: Taylor & Francis.
Dalley, T. (1990). Images and integration: Art therapy in a multicultural school.
In C. Case & T. Dalley (Eds.), Working with children with art therapy
(pp. 161198). New York, NY: Tavistock/Routledge.
Davis, C. B. (1995). The use of art therapy and group process with grieving children. In S. C. Smith & M. Pennells (Eds.), Interventions with bereaved children
(pp. 321331). London, England: Jessica Kingsley.
DiGuiseppe, G. M., Linscott, J., & Jilton, R. (1996). Developing the therapeutic
alliance in childadolescent psychotherapy. Applied and Preventive Psychology,
5, 85100. doi:10.1016/S0962-1849(96)80002-3
Divino, C. L., & Moore, M. S. (2010). Integrating neurobiological findings into psychodynamic psychotherapy training and practice. Psychoanalytic Dialogues,
20, 337355. doi:10.1080/1048 1885.2010.481613
Draper, K., Ritter, K. B., & Willingham, E. U. (2003). Sand tray group counseling
with adolescents. Journal for Specialists in Group Work, 28, 244260.
doi:10.1177/0193392203252030
Everall, B., & Paulson, B. (2002). The therapeutic alliance: Adolescent perspectives. Counseling and Psychotherapy Research, 2, 7887. doi:10.1080/14
733140212331384857
Eyrich-Garg, K. M. (2008). Strategies for engaging adolescent girls at an emergency
shelter in a therapeutic relationship: Recommendations from the girls themselves. Journal of Social Work, 22, 375388. doi:10.1080/02650530802396700
Feinstein, S. G. (2009). Secrets of the teenage brain: Research-based strategies for
reaching and teaching todays adolescents (2nd ed.). Thousand Oaks, CA:
Corwin Press.
Finn, C. A. (2003). Helping students cope with loss: Incorporating art
into group work. Journal for Specialists in Group Work, 28, 155165.
doi:10.1177/0193392203252189
Fitzpatrick, M. R., & Irannejad, S. (2008). Adolescent readiness for change and
the working alliance in counseling. Journal of Counseling & Development, 86,
438445.
Giedd, J., Snell, J. W., Lange, N., Rajapakse, J. C., Kaysen, D., Vaituzis, A. C., . . .
Rapoport, J. L. (1996). Quantitative magnetic resonance imaging of human
brain development: Ages 418. Cerebral Cortex, 6, 551560. doi:10.1093/
cercor/6.4.551
Gorman, M. (2006). The terrible teens. School Library Journal, 52(6), 34.
Grey, E. (2010). Use your brain: A neurologically driven application of
REBT with children. Journal of Creativity in Mental Health, 5, 5564.
doi:10.1080/15401381003627160
Hariri, A. R., Bookheimer, S. Y., & Mazziotta, J. C. (2002). Modulating emotional responses: Effects of a neocortical network on the limbic system.
Neuroreport: For Rapid Communication of Neuroscience Research, 11, 4348.
doi:10.1097/00001756-200001170-00009

Downloaded by [78.97.129.246] at 04:06 22 July 2015

Innovative Strategies

313

Homeyer, L. E., & Sweeney, D. S. (2011). Sand tray therapy: A practical manual
(2nd ed.). New York, NY: Routledge.
Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and
outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology,
38, 139149. doi:10.1037/0022-0167.38.2.139
Hutterer, J., & Liss, M. (2006). Cognitive development, memory, trauma, treatment:
An integration of psychoanalytic and behavioral concepts in light of current
neuroscience research. Journal of the American Academy of Psychoanalysis
and Dynamic Psychiatry, 34, 287302. doi:10.1521/jaap.2006.34.2.287
Jensen, F. (2010). The teen brain: Its just not grown up yet. [Interview by Richard
Knox, National Public Radio]. Retrieved from http://www.npr.org
Kahn, B. B. (1999). Art therapy with adolescents: Making it work for school
counselors. Professional School Counseling, 2, 291298.
Karver, M., Shirk, S., Handelsman, J. B., Fields, S., Crisp, H., Gudmundsen, G., &
McMakin, D. (2008). Relationship processes in youth psychotherapy: Measuring
alliance, alliance-building behaviors, and client involvement. Journal of
Emotional and Behavioral Disorders, 16, 1528. doi:10.177/1063426607312536
Katz, P. (1990). The first few minutes: The engagement of the difficult adolescent. In
S. C. Feinstein (Ed.), Adolescent psychiatry: Developmental and clinical studies
(v. 17, pp. 6981). Chicago, IL: University of Chicago Press.
Kottman, T. T., Strother, J., & Deniger, M. M. (1987). Activity therapy: An alternative
therapy for adolescents. Journal of Humanistic Education & Development, 25,
180186.
Kramer, E. (1979). Childhood and art therapy: Notes on theory and application. New
York, NY: Schocken.
Landreth, G. L. (1994). Play therapy: The art of relationship. Muncie, IN: Accelerated
Development.
Martin, D. G. (2003). Clinical practice with adolescents. Pacific Grove, CA: BrooksColeThomson Learning.
Martin, D. G., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic
alliance with outcome and other variables: A meta-analysis review. Journal of
Consulting and Clinical Psychology, 68, 438450.
Martin, J., Romas, M., Medford, M., Leffert, N., & Hatcher, S. (2006). Adult helping
qualities preferred by adolescents. Adolescence, 41, 127140. doi:10.1037/0022006X.68.3.438
Morris, R. J., & Nicholson, J. (1993). The therapeutic relationship in child and
adolescent psychotherapy: Research issues and trends. In T. R. Kratochwill &
R. J. Morris (Eds.), Handbook of psychotherapy with children and adolescents
(pp. 405525). Needham Heights, MA: Allyn and Bacon.
Naumburg, M. (1973). An introduction to art therapy: Studies of the free art expression of behavior problems of children and adolescents as a means of diagnosis
and therapy. New York, NY: Teachers College Press.
Reinecke, M. A. (1993). Outpatient treatment of mild psychopathology. In
P. H. Tolan & B. J. Cohler (Eds.), Handbook of clinical research and practice
with adolescents (pp. 387410). New York, NY: Wiley.
Reyna, V. F., & Farley, F. (2006). Risk and rationality in adolescent decision making:
Implications for theory, practice, and public policy. Psychological Science in the
Public Interest, 7, 144.

Downloaded by [78.97.129.246] at 04:06 22 July 2015

314

G. K. Roaten

Riley, S. (1994). Rethinking adolescent art therapy treatment. Journal of Child and
Adolescent Group Therapy, 4, 8197.
Rubin, J. A. (1988). Art counseling: An alternative. Elementary School Guidance and
Counseling, 22, 180184.
Saunders, E. J., & Saunders, J. A. (2000). Evaluating the effectiveness of art therapy
through a quantitative, outcomes-focused approach. The Arts in Psychotherapy,
27, 99106. doi:10.1016/S0197-4556(99)00041-6
Shirk, S. R., & Russell, R. L. (1996). Change processes in child psychotherapy:
Revitalizing treatment and research. New York, NY: Guilford Press.
Shostak, B. (1985). Art therapy in schools: A position paper of the American Art
Therapy Association. Art Therapy, 14, 1921.
Siegel, D. J., & Hartzell, M. (2003). Parenting from the inside out: How a deeper
self-understanding can help you raise children who thrive. New York, NY:
Tarcher/Putnam.
Sommers-Flanagan, J., & Sommers-Flanagan, R. (1995). Psychotherapeutic techniques with treatment-resistant adolescents. Psychotherapy, 32, 131140.
doi:10.1037/0033-3204.32.1.131
Sowell, E. R., Thompson, P. M., Holmes, C. J., Jernigan, T. L., & Toga, A. W. (1999).
In vivo evidence for postadolescent brain maturation in frontal and striatal
regions. Nature Neuroscience 2, 859861. doi:10.1038/13154
Spinks, S. (2000). Adolescent brains are works in progress, heres why. Nature, 404.
Retrieved from http://www.pbs.org
Steele, W. (2009). Drawing: An evidence-based intervention with trauma victims.
Reclaiming Children and Youth, 18, 2023.
Steinberg, L. (2011). Demystifying the adolescent brain. Educational Leadership, 68,
4146.
Straus, M. B. (1999). No-talk therapy for children and adolescents. New York, NY:
W. W. Norton & Company.
Sylwester, R. (2007). The adolescent brain: Reaching for autonomy. Thousand Oaks,
CA: Corwin Press.
Thomas, R. M., & Peterson, D. A. (2003). A neurogenic theory of depression gains
momentum. Molecular Interventions, 3, 441444. doi:10.1124/mi.3.8.441
Wadeson, H. (1980). Art psychotherapy. New York, NY: John Wiley & Sons.
Yurgelun-Todd, D. A., Killgore, W. D., & Young, A. D. (2002). Sex differences
in cerebral tissue volume and cognitive performance during adolescence.
Psychological Reports, 91(3), 743757. doi:10.2466/pr0.2002.91.3.743

Gail K. Roaten is an Assistant Professor in the Department of Counseling,

Leadership, Administration, and School Psychology at Texas State University,
San Marcos, Texas.