37 Graduate Student Journal of Psychology Copyright 2005 by the Department of Counseling & Clinical Psychology 2005, Vol. 7 Teachers College, Columbia University ISSN 1088-4661 A Case Study Illustration of Grief Therapy Using Culturally-Sensitive, Integrative Techniques Eavan S. Miles-Mason Fordham University This article is a case study detailing a therapeutic intervention conducted with a 12-year-old Afri- can-American girl who experienced behavioral problems following the death of her mother from drug abuse and AIDS. The intervention integrated several modalities and techniques to facilitate behavior change and the healthy grieving process; these included cognitive-behavioral techniques, psychodynamically-oriented art, and culturally-sensitive grief-focused therapies. This article seeks to elucidate the ways in which developing integrative techniques for African-American children and adolescents is a significant and worthy goal. This article is a case study detailing a therapeutic inter- vention conducted with a 12-year-old African-American girl who experienced behavioral problems following the death of her mother from drug abuse and AIDS. The inter- vention integrated several modalities and techniques to fa- cilitate behavior change and the healthy grieving process, including cognitive-behavioral techniques, psychodynami- cally-oriented art, and culturally-sensitive grief-focused therapies. Cognitive-behavioral therapy was implemented to reduce behavioral problems such as lying and physical aggression, while art therapy, in the form of poetry, was used as a form of psychodynamically-oriented grief ther- apy. The client wrote powerful, moving poems about her life experiences, including her mother’s death, her grief, and feelings of isolation. This part of the intervention had a strengths-based orientation and recognized the importance and power of spirituality within the context of the client’s racial-ethnic cultural heritage. The client’s interest in crea- tive and spiritual expression was used to fuel the interven- tion. The client demonstrated marked improvement at ter- mination in academic achievement, prosocial behavior, and emotional well-being. The effectiveness of interventions with African Americans that incorporate spiritual and re- ligious elements into the therapeutic process has been dem- onstrated in recent research (Davis-Russell, 2002). This case study offers an illustration of the integration of spiritu- ality and spiritual expression into a successful, culturally- sensitive intervention. Developing new therapeutic tech- niques that help African-American clients explore emo- tional problems and distress through their own spiritual and religious traditions should be an important pursuit for mul- ticultural counseling practitioners. Developing these types Correspondence concerning this article should be addressed to Eavan S. Miles-Mason; e-mail: milesmason@fordham.edu. of therapeutic interventions for African-American children and adolescents is an equally significant and worthy goal. Background Information Amy,1 a 12-year-old African-American girl was r e- ferred to a private mental healthcare agency last year be- cause of behavioral problems and academic underachieve- ment. Amy is originally from Oklahoma and grew up there until she moved to New Jersey in June 2003, soon after the death of her maternal grandmother. Amy’s mother, a drug- abuser (and most likely a prostitute, based on Amy’s ac- counts of her mother’s behavior), died of AIDS 2 years ago in Oklahoma. Amy has never met her father, who is also a drug user, and she has no idea of his whereabouts. Amy was born addicted to crack/cocaine, but her cognitive and physical development have followed a normal trajectory and appear to be unaffected by her mother’s drug use. An official evaluation of Amy’s cognitive functioning was not available; however, her teachers have reported that her aca- demic grades do not reflect her full intellectual abilities. As will be seen in the description of the intervention, Amy is very articulate and demonstrates a great capacity for ab- stract thought. Amy’s previous therapist reported that her mother had also taken Amy with her to random hotels where she would have sex with unknown men in front of her daughter (who was 9 or 10 years old at the time.) Amy did not explicitly say that her mother was a prostitute, but given the informa- tion presented, her previous therapist suspects that she was. Not only was Amy forced to witness her mother’s highly traumatizing, sexually deviant behavior, she was also made an unwitting accomplice to it; she was taught to lie to other family members and to keep her mother’s secret. Amy’s previous therapist, who worked with Amy for 8 months, 1 All names and identifying information have been changed to protect the privacy of the client. MILES-MASON 38 suspects that Amy may have been sexually abused due to some of the behavior she has displayed at school and the highly sexualized content of poems she was writing in ther- apy with him. Amy currently lives in New Jersey with her aunt who is a police officer. Amy and her aunt maintain close familial relationships with members of their extended family, who live in both New Jersey and Oklahoma. Amy’s current oppositional behavior is primarily lying to her family and teachers in addition to exhibiting aggres- sive behavior towards some of her peers. Teachers at Amy’s school have reported that she has displayed “inap- propriate,” sexually-suggestive behavior at school such as dancing provocatively and “grabbing at” boys in her class. (There have been no gross or serious instances of sexual assault or harassment.) Amy’s aunt, Annette who is em- ployed as a police officer, is her primary caretaker. Her aunt is a strict disciplinarian and often comes into conflict with Amy over her inappropriate behavior at school and contin- ual lying. In spite of the tempestuous nature of their rela- tionship, her aunt is solicitous of Amy’s welfare and, in Amy’s own words, “loves her,” even though she may not be overly affectionate or demonstratively nurturing. When Amy’s previous therapist initially evaluated her, she was diagnosed with Adjustment Disorder with Anxiety. Amy’s grandmother had been the powerful matriarch of their extended family and provided stability and continual care to Amy, as her mother was unreliable and often unable to function successfully. Until her death approximately one year after Amy’s mother’s death, Amy’s grandmother had been Amy’s primary source of stability and love. Not only was she grieving for her mother’s and grandmother’s deaths, but she was also forced to leave her home environ- ment (where she had lived all her life) and relocate to a foreign one—New Jersey. Shortly after the move, Amy began exhibiting oppositional behavior, primarily aggres- sion towards other students and lying. Amy currently lives in a mostly white middle-class community and it has been difficult for her to “fit in” with other students who have an entirely different cultural and socioeconomic background. In one of our initial sessions Amy expressed her feelings of inferiority, saying that she was not “up to” the other stu- dents (e.g., she did not have the same amount of money, clothes, etc.) and that she was often taunted at school. Amy did not admit this to her aunt because she was embarrassed by it and said she was trying to be “tough,” not letting any- one (including her family) see that she was hurt by the other students’ insults. I began working with Amy as a student intern in Janu- ary 2004. After having two sessions with Amy, it was evi- dent that she had not adjusted to her new environment and felt like an outsider at school. She expressed her desire to live in her old town in Oklahoma in the “projects” where she felt like she fit. A few days before our second session, Amy was sent home from school because she was wearing inappropriate clothing. Amy had been wearing normal winter clothing to school, but then changing into tight- fitting summer clothing when she got to school. She had also stolen her aunt’s boots and bracelet, but would not ad- mit that she had done so to her aunt. Her aunt, exasperated and deeply upset by Amy’s behavior, felt that Amy had no remorse about her wrongdoings. While it was difficult for Amy to admit that she had stolen items and disobeyed her aunt, in truth, she felt terrible about what she had done. Amy broke down in our session, saying that she wished she had not done those things and feels terrible when she lies. From Amy’s perspective, she was changing her clothes because she thought that they were “cooler” and would help her fit in. During this session, we came to a core issue un- derlying her emotional distress and behavior; Amy was able to verbalize that she missed her mom and felt misunder- stood by her cousin. Possibly, she was affection-starved. She told me she longed to live with one of her mother’s friends in Oklahoma and “be one of her children” because she was “softer” and less strict. Behavioral Observations Amy is an attractive, yet somewhat awkward and heavy-set girl. She is much taller and both physically and sexually more developed than most of her same-age peers. Amy often came to sessions looking a little unkempt, but clean and in good health. Amy was very receptive to the therapeutic process. Her willingness to share her feelings and experiences with the therapist as well as her advanced verbal abilities facilitated the therapeutic process. Conceptualization Because of all the tragic events Amy has experienced, she has several layers of psychological trauma that must be worked through. In an effort to prevent destabilizing any emotional well-being she had been able to sustain, it was important to work with one issue at a time, beginning with her mother’s death. Amy was grieving the loss of her mother. However, it appeared that she was not able to fully engage in the grieving process because of the great value her family places on strength and stoicism; her grand- mother, a devoutly religious woman, told Amy that one should not cry at someone’s death because that person is going to heaven to be with God. Her grandmother told her not to cry at the funeral and Amy said she was able choke back her tears even though she really wanted to cry. Her aunt espouses that same stoicism and consequently Amy has not been able to grieve openly or share her sadness with an adult figure. Amy was also experiencing complicated grief because of the nature of her mother’s lifestyle and subsequent death. Children whose parents or loved ones die from socially “taboo” causes such as murder, suicide, or AIDS often ex- perience what is known as complicated grief, wherein the natural process of grieving is inhibited because “the child is unable to express what happened” (Goldman, 2002, p. 8). Because of the social stigma and shame associated with CASE STUDY ILLUSTRATION OF INTEGRATIVE GRIEF THERAPY TECHNIQUES 39 AIDS, children coping with the loss of a loved one from AIDS are often denied the ability to grieve by other family members and are told not to discuss the death. These sup- pressed feelings can become self-destructive and “get pro- jected outwardly in the form of rage or inwardly in the form of the self-hatred” (Goldman, 2002, p. 8). Multiple deaths can also create complicated grief and the death of her grandmother and mother within 2 years must certainly compound her sense of loss. Validating Amy’s grief and allowing her a safe place to openly mourn her loss became a primary therapeutic goal. Helping Amy reduce her lying behavior was equally important, as it was jeopardizing her ability to function in the home and educational setting and damaging her relationship with her aunt. Her therapeutic intervention had to address both of these key issues. The main therapeutic goals became facilitating the grief process through psychodynamically-oriented therapy as well as employing cognitive-behavioral techniques to change Amy’s self-destructive behavioral patterns. Counseling Before therapy began, informed consent was obtained from Amy and from her aunt and the limits of confidential- ity were explained. A therapeutic alliance between Amy and the therapist was easily established because of Amy’s willingness to share her feelings and experiences beginning in the first session. As stated before, Amy was, in essence, taught to lie by obeying her mother’s wishes to conceal her sexual indis- cretions. Amy most likely (consciously or subconsciously) modeled her mother’s maladaptive lying behavior. From conversations with Amy and her aunt, I hypothesized that after her mother’s death, lying gradually developed into a coping mechanism for her, as it allowed her to suppress distressing emotions or cognitions about her mother, her family, and herself. A cognitive-behavioral intervention with the following underlying principles was designed to reduce her lying behavior: lying is not “innately nor always morally wrong…[and should not be] stamped out at all cost to the child” (Bernard, 1984, p. 250). However, if lying becomes pervasive, it is self-defeating because it serves as a means of avoiding reality and adopting maladaptive means of maintaining self-esteem (Bernard, 1984). In Amy’s case, the lying had become a maladaptive behavior that not only alienated her family members from her, but also threatened her development of a healthy self-concept. In order to help Amy maintain some level of emotional stability throughout the therapeutic process, eliminating the lying behavior had to be done gradually because it was functioning as a major defense mechanism against emotional distress. The ultimate goal of therapy was to help Amy achieve insight into the causes of her feelings and behavior, work- ing through all of her emotionally traumatic experiences, to answer the question: why does she lie? Achieving this ob- jective will require extensive, longer-term psychotherapy (which has been initiated), but Amy’s behavior also needed to be addressed and controlled in the short-term so that she could function successfully in her present environment. Albert Ellis, the founder of Rational-Emotive Behavior Therapy (REBT), would call this the “practical solution” as opposed to the more profound, “elegant” solution (Ellis, 1983). Cognitive-behavioral therapy techniques were em- ployed with the client; the antecedents, behavior, and con- sequences (ABCs) associated with her lying were identified (Bernard, 1984). Amy explained that she lied “to get out of trouble.” Telling her aunt that she had finished her home- work when she had not and saying that the bracelet she stole from her aunt belonged to a friend at school were both used as examples during discussion. When we discussed the consequences of her behavior, we concluded that while lying keeps her from being caught and punished in the mo- ment, it almost always backfires because the lie is discov- ered and Amy gets into even more trouble. In the past, this has led to Amy being grounded and prohibited from using any “electricity” (i.e., TV, radio, or phone). Because Amy feels very guilty when she lies, it was important to remove any sense of moral judgment from the discussion. Lying was presented as a “bad habit” in our sessions that was separate from her worth as a person or her “goodness” (Bernard, 1984). As stated earlier, Amy demonstrates a great capacity for abstract thought. This allowed for the use of the REBT/CBT technique of rational disputation to help her come to the conclusion that she was, in fact, a good person who had a problem that could be helped and hope- fully changed. A complementary aim that was coupled with this pursuit was an effort to bolster her self-esteem, to em- phasize her positive qualities rather than focusing exclu- sively on her maladaptive behavior. To this end, Amy com- pleted behavioral “worksheets,” adapted from Bernard (1984; see Figure 1).2 The format of the worksheets r e- quired her to list Figure 1. Amy’s behavioral worksheet. 2 Materials containing the client’s own words, writings, and drawings have been used with permission. MILES-MASON 40 many positive aspects of her life—her good qualities, pleasing experiences, or things that make her happy—and contemplate behavior she has to be “careful of” in order to raise her awareness of her maladaptive behaviors while withholding moral judgment of her actions. Frequent verbal praise was given during therapy sessions that emphasized the enormity of the losses she has experienced and the strength she has demonstrated in coping with them. Amy was also taught how to use other CBT-based techniques such as self-statements, guided imagery, and relaxation exercises to provide her with adaptive behaviors to employ in stressful and upsetting situations. Helping Amy change negative cognitions about herself, build ego strength, and bolster resiliency were conceived of as essential parts of the intervention during this painful yet ultimately healthy proc- ess of grieving. Amy’s previous therapist initially employed CBT in Amy’s treatment by asking her to keep a journal and re- count instances where she lied and how she felt about it. In my first session with Amy, I asked her about her journal and she replied that she did not like writing about daily events and instead preferred creative writing such as poems and stories. It became apparent that asking her to make a record of her undesirable behavior or transgressions was not intrinsically motivating and was in fact negatively rein- forcing. In order to scaffold off of her natural interests, the journaling activity was changed. Amy was allowed to write poems about her life experiences, emphasizing that the po- ems had to specifically express how she felt. In addition, because Amy perceived herself as a good poet, the activity served to highlight her natural ability and reinforce positive self-esteem. Although the activity did not directly address the need for her to “tell the truth,” expressing how she felt accessed her emotional reality and required her to honestly confront her emotions. Hence, art therapy was included in the intervention along with cognitive-behavioral techniques. Amy embraced this therapeutic technique, which tapped into her artistic, creative passion for expression and fueled the intervention. I presented the process to Amy as making a portfolio of artwork about her mother and her grieving process. At the end of the intervention, we would bind to- gether all of the work, making a book that she could then have as a tangible creation born of her life experiences. The portfolio-making process served as an “autobibliotherapeu- tic” technique for grief therapy. The emotional reality re- flected in Amy’s poems and drawings dealt with her grief over losing her mother, the endeavor to interpret her trau- matic life experiences, and consequently form her own identity. Empirical studies have shown that using art therapy in the treatment of bereaved children can facilitate a child’s grieving process by allowing for the expression of strong feelings of pain, sorrow, and anger (Fogarty, 1999; Gold- man, 2002). Artwork created in therapy sessions also pro- vides a medium or context for the dialogue between the therapist and the child (Allan, 1988). The use of art was particularly suited to this intervention because of Amy’s creativity and the “spiritual framework” through which she interprets life events. Amy naturally conceptualizes and expresses her feelings through symbolic language (poetry) or other means of artistic creation, including drawing and music. Amy’s perceptual processes and worldview are, in part, influenced by her cultural and familial experiences. Recent multicultural counseling research and theory have espoused a conceptual shift from a focus on the individual to a “self- in-cultural context” where the ethnic customs, values, and beliefs of the client are recognized and utilized in the thera- peutic process (Frame & Williams, 1996). Studies on coun- seling African-American populations have emphasized the importance of strong, Afrocentric spiritual and religious values that have existed since institutionalized slavery be- gan in the United States (Frame, Williams, & Green, 1999; Frame & Williams, 1996): “African spiritual and religious traditions form an enduring framework for expressions of spirituality in contemporary Black culture” (Frame & Wil- liams, 1996, p. 16). African spirituality has been expressed through numerous artistic endeavors throughout African- American cultural history, such as in Negro spirituals, blues, soul, jazz, fiction, poetry, and more recently in rap, R&B, and hip-hop. A sense of communalism and collective identity among kinsmen, neighbors, and community mem- bers is also an important part of the African-American ex- perience that must be acknowledged and can be incorpo- rated into therapeutic interventions (Frame, Williams, & Green, 1999; Frame & Williams, 1996). These issues of spirituality and culture were particu- larly relevant to Amy’s experience, as her family has owned and maintained a small farm in Oklahoma for many gen- erations. Amy not only discussed the religious Baptist be- liefs and experiences in her local church, she also described older customs and superstitions that she said went back to “the days of slavery.” Even though Amy may be at odds with other family members at the moment, she has a strong network of extended family relations and friends that lend her stability and a sense of identity. Amy also shows inter- est in African-American history and literature. Amy’s cul- turally-oriented values and beliefs, especially her passion for creative and (as will be shown) spiritual expressions, were incorporated into the intervention and served as pow- erful therapeutic tools. Expressing oneself through symbolic language and metaphor is an essential component of Afrocentric oral tra- ditions and, for Amy, is a means of interpreting and under- standing her experience. Amy’s use of a symbolic and spiritual framework to express herself is illustrated in the drawing in Figure 2, which fostered important therapeutic dialogue in the therapy session. Amy identified herself as the figure in the middle crying because she misses her mother. The hand and “sparkling light” stretching down from the sky represents God helping her through her sorrow and pain. The figure of the woman floating next to the 41 Figure 2. Amy’s use of a symbolic language. moon is her mother as an angel looking over her. The bro- ken heart symbolizes her profound sadness, and finally, the devil hiding behind it represents the struggle between good and evil that claimed her mother. The devil speaks to her perception of the presence of evil or pernicious forces in the world that can do harm, such as drug use. The symbol of the devil could also refer to the manner in which she died (from drug abuse and prostitution). Seen from this perspec- tive, the drawing also speaks to the difficulty (and perhaps conflict) children have processing grief from a stigmatized death (Goldman, 2000). The theme of the destructive power of drugs and violence manifest themselves in later pieces as well. The sequence of poems that will be presented here demonstrates Amy’s progress through a healthy grieving process. The process of grief for adolescents is broken down into the following stages: “1) accepting the reality of the loss; 2) experiencing the pain; 3) adjusting to an environ- ment in which the deceased is missing; 4) relocating the dead person within one’s life and finding ways to memori- alize the person” (Webb, 1999, p. 226). Presumably the first stage was completed before therapy began because she had already had 2 years to come to terms with the reality of her mother’s death and when she began therapy, she was able to discuss the death and its impact upon her. The second stage, experiencing the pain, can be seen in Figure 2, with Amy in the middle of the composition with tears streaming down her face. It can also been seen in a poem she wrote with a friend, “Angel in the Sky.” Angel in the Sky I lie in bed sobbing Hoping that my life won’t dred I slowly fall asleep In the night breeze I hear my mother with Her jingling keys Oh wait! I forgot, I don’t know why My mother is a MILES-MASON 42 Beautiful angel In the sky I look at the stars From my bedroom Wondering why she Had to die. Oh Lord, I hope She is O.K. I think about her Everyday. I wonder Why she had to pay I can’t wait for my day To pay the cost and then I won’t feel so lost. Here, her mother is once again “a beautiful angel” whom she misses dearly and with whom she wants to be reunited. Amy explained in therapy that there was a time when she thought about killing herself right after her mother’s death—“pay[ing] the cost so [she doesn’t] feel so lost”—but that she no longer felt that way. The line in the poem expressed how she had felt at that moment in the past. Through the poem, Amy was able to express the despera- tion and sadness she felt over losing her mother. In a dis- cussion of the piece, psychodynamically-oriented art ther- apy techniques were employed to generate insights into her feelings (Allan, 1988). Another positive aspect of this poem is that she wrote it with a friend who had also experienced a great deal of loss in her life. Being able to share one’s grief with another who empathizes with one’s experience is ex- tremely beneficial to the healing process (Goldman, 2002). This is explained in reference to adult/child grieving; how- ever, a friendship with a peer can also help the child feel supported and understood. The third stage, adjusting to the environment without the missing loved one, was very challenging for Amy. Amy felt that her aunt and the rest of her family did not under- stand her like her mother had. She was having difficulty successfully functioning in her environment, as demon- strated by poor academic performance, lying, and aggres- sive behavioral problems. At the beginning of the intervention, almost all of Amy’s privileges to leisure activities had been suspended as means of disciplining her, including visiting with friends, watching TV, and listening to the radio. Even though Amy still has difficulty with these issues, her misbehavior has lessened in frequency, and, more importantly, she has es- tablished a secure attachment to her aunt Annette. Over the course of the 3-month-long intervention, Amy and her aunt have become closer and currently express open affection for each other. While Amy still gets in trouble on a weekly, if not daily, basis (for small infractions), Amy has expressed her positive feelings about Annette, saying that she not only “loves” her aunt, she “likes” her too. Her adjustment to living in New Jersey with Annette is reflected in the poem “Wings,” which she dedicated to her family. Wings If I had wings…Wow! My world would fly! I’ll feel free. If I had power…Man! You would bet that Those who died Would live again. If I had a million dollars… Goodness! I would ask God For my mommy back. But..If I had you… That’s all I need. Dedicated to: My Family Amy still expresses her desire to be with her mother, to make her “live again,” but the poem does not contain the same sense of sorrow and loneliness, the willingness to give up her life just to be with her mother. When asked who she meant by “you” in the poem, she said her aunt Annette, , and the rest of her family in Oklahoma. While she still misses her mother, Amy now feels that having her loved ones’ support and affection are all she “needs” to “live and be happy.” The title “Wings” and the references to flying in the poem imply a new-found freedom and unburdening. She does not actually “have wings,” but she feels empow- ered by and connected to the loved ones in this world and to the ones who are in heaven watching over her who do, in fact, have wings.3 The final stage, memorializing her mother, has already begun to be reflected in Amy’s poems. Her mother appears in all her work as an “angel,” someone who has gone to heaven, achieved peace, and now watches over her as a benevolent spirit. In addition, when Amy discusses her mother in therapy, it is emphasized that she will always have the memories and love of her mother in which she can take comfort and joy. Outcome It should be mentioned that the intervention was cut short because Amy was moving back to Oklahoma to live with the rest of her family and there are many issues that will still need to be addressed. For example, Amy has not yet begun to discuss the ways in which her mother was not 3 Music was also used as means of expression during therapy. Amy would sing songs that she felt had great significance to her life and then we discussed their meanings. The songs’ themes focused on the need for love and healing. CASE STUDY ILLUSTRATION OF INTEGRATIVE GRIEF THERAPY TECHNIQUES 43 a good caretaker and put Amy in dangerous, inappropriate situations. In an effort not to overwhelm Amy and derail her progress, exploration of this issue must wait until a sta- ble sense of well-being has been achieved and sustained for a substantial period of time. It should be remembered as an important concern, however, as Amy moves further into adolescence and confronts issues of sexuality and sexual identity. When I first began working with Amy 4 months ago, she felt like she did not fit in at school and was taunted by other students. Both Amy and I have noticed a remarkable change in her confidence and self-esteem since that time. She has reported that she is now making some close friends, getting good grades in school, and getting along with her aunt Annette better. Amy has also slimmed down since the beginning of the year and seems to have more confidence in her body. Amy completed two Beck Depression Inventory (BDI- II) forms, as a source of anecdotal evaluation of the effi- cacy of her treatment. (I did not use the manual to interpret results.) I asked her to fill out one form representing how she felt in January and then one corresponding to how she felt now. Although this is not an objective measure of her psychological health, it is an indication of her self- perception, which is linked to her self-esteem. In comparing the two inventories, a global perceptual shift in her self- concept and her state of mind is evident. While she rated all items negatively on the inventory representing how she felt in January, her ratings of her current emotional state were overwhelmingly positive. When I asked Amy what had changed between then and now, she smiled and said “me,” noting that she had more self-confidence and was proud of the grades she was getting in school. Although these results are not empirically validated, I believe they do represent clinical validation of her perceptual and emotional reality and the progress she has made in adjusting to her new envi- ronment. This also corresponds with the positive messages in her latest poems about her family and mother. Amy completed the self-report form of the Behavior Assessment for Children (BASC). The report indicated that all of her indexes were in the “acceptable range.” Each of the infor- mal evaluations (i.e., positive theme progression of her po- etry, her current self-observations, my observations of positive changes she has undergone, grades at school) indi- cate that her self-esteem, quality of life, and ability to cope with her mother’s death have improved significantly. While Amy has made significant progress in her grieving process and adjusting to her new environment, she still occasionally lies and recently got into a serious physi- cal fight with a boy at school. Figure 3 shows another CBT worksheet that Amy filled out just before treatment was discontinued. Once again, the worksheet attempts to break down the ABCs of her actions so that she may better under- stand and eventually create systemic changes in her behav- ior. As may be seen in the figure, she did not answer the “why” question regarding lying, saying that it was a “hard one” and didn’t want to do it now. Coming to a full under- standing of the faulty cognitions causing her lying behavior and adopting new, adaptive cognitions represent primary goals for future therapeutic treatment. Figure 3. Understanding cognitions. Discussion Cognitive-behavioral therapy was used in this inter- vention to help Amy reduce lying and aggressive behaviors and gain insight into the underlying cognitions causing her maladaptive behavior. Amy was taught how to use self- statements, guided imagery, and relaxation techniques to help control impulses and maintain emotional well-being under stressful or emotionally charged situations. The long- term goal of REBT—to acquire a healthy belief system and a repertoire of adaptive behaviors (Ellis, 1983)—was not fully achieved during this intervention and Amy would benefit from further therapy that explores salient psycho- logical/emotional themes in more detail. It should again be noted that Amy has experienced highly traumatic events at a young and developmentally sensitive age and extensive therapy will be needed to fully address the impact of her life experiences. Although therapy was prematurely termi- nated, Amy felt comfortable ending therapy because she said was moving back “home” and would be with her fam- ily and could talk to them about any problems she was having. Psychodynamically-oriented art therapy was used to facilitate Amy’s healthy grieving process. Through sym- bolic language, in the form of poetry, Amy was able to work through many of her feelings of loss and sorrow. Her use of poetry still continues to reflect her emotional and MILES-MASON 44 psychological development. The following is a poem she wrote about her identity as an African American. Negroes Negroes…Negroes of the black history month of sea- sonal energy, those Who do not know the black ways is not Negro. Negroes….Negroes back then were whipped to the bone for us, yet, How do we repay these slaves of knowledge. Negroes…Negroes today, peace up A’s down, Eastside, Westside, down bottom. Ya’ll don’t know the real way of black coolness, yet, You still go by today’s hottest clothings. Ya minds are poisoned by the pimpness and gangastaness of rap and R&B singles. But I give you my props, for I am the same way. Negroes…Negroes in their cellas waitin’ Foe their day to die, each day They’re slippin’ from the soils of earth And into the hands of God. Negroes…Negroes who abuse and then accuse, baby daddies lookin’ for some other girl to get pregnant, drug attics who are lookin’ foe moe money just to put them back into devil’s paradise… Thug mansion, every thug Waitin’ foe their time. Negroes…Negroes of the world! In “Negroes,” one sees Amy grappling with her rela- tionship to the cultural and historical legacies of African Americans. She explained to me that many African Ameri- cans today do not appreciate the sacrifices made in past generations by people like Harriet Tubman, who fought for freedom and equality. Amy’s poem also expresses scorn or frustration with the “baby daddies” and “drug addicts” who are also part of her cultural identity and her personal expe- riences. Amy’s art therapy (in the form of poetry) was an ef- fective therapeutic vehicle for emotional expression, as well as a means of generating insight. Techniques drawn from several modalities—psychodynamic, cognitive-behavioral, art therapy, and grief-focused therapy—were all employed to create a more comprehensive, individualized, and effec- tive intervention. In addition, crafting a culturally-sensitive intervention which drew upon Amy’s natural interests and the spiritual traditions of her ethnic heritage allowed for the expression of profound emotion and psychological insight that facilitated her grieving and healing process. This case study illustrates the importance of conceptu- alizing the client as “the self-in-cultural context,” under- standing the interplay of familial, cultural, and racial factors that contribute to the client’s psychological, cognitive, and emotional processes. Recognizing and integrating spiritual- ity into interventions with ethnically diverse clients who maintain their own religious and spiritual belief systems is essential to providing effective and appropriate counseling to these minority populations. While there is a substantial body of research regarding the use of religion, spirituality, and church organizations in interventions for adult African Americans (Frame & Wil- liams, 1996; Frame, Williams, & Green, 1999; Querimit, 2003) less research and fewer programs have been imple- mented for African-American children and adolescents. This represents an area for future growth and development of therapeutic techniques that could be applied in multiple contexts for multiple psychological problems (aggression, depression, low self-esteem, etc.). Therapy using Afrocen- tric spiritual traditions comes from a strengths perspective and emphasizes positive cultural attributes, customs, and artistic pursuits. Therapeutic interventions designed to em- power African-American adolescents—helping them form solvent cultural and personal identities—have been effec- tively implemented in small community-based programs (Querimit, 2003). Another program, Assimilating Into Mainstream Society Economically (AIMSE), focuses on the spiritual and healing relationship of the therapist and has also been successfully implemented in interventions (Querimit, 2003). Further research and development of similar programs should be undertaken to both widen and refine the application of these techniques with African- American adolescents and children. References Allan, J. (1988). Inscapes of the child’s world: Jungian counseling in schools and clinics. Dallas, Texas: Spring Publications. Bernard, M. (1984). Rational-emotive therapy with children and adolescents. New York: John Wiley & Sons. Davis-Russell, E. (2002). Religiosity and racial attitudes: Clinically relevant factors in psychotherapy with African Americans. In E. Davis-Russell (Ed.). California school of professional psychology handbook of multicultural education, research, intervention, and training (pp. 263- 276). San Francisco: Jossey-Bass. Ellis, A. (1983). Rational-emotive approaches to the prob- lems of childhood. New York: Plenum Press. Fogarty, J. (1999). The magical thoughts of grieving chil- dren. New York: Baywood Publishing. Frame, M. W., & Williams, C. B. (1996). 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