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Experiences of Elementary School Counselors and Students in Using Reality Art Therapy to Address Chronic Conditions.

An emerging area of concern for students and schools is the provision of counseling services for students who are diagnosed with chronic conditions. Chronic conditions are defined as those that persist over time (a duration of at least 3 months) and result in an overall decrease in quality of life; they include medical and behavioral conditions such as asthma, attention deficit hyperactivity disorder (ADHD), and diabetes (Centers for Disease Control and Prevention [CDC], 2016, 2017; Merianos, Vidourak, King, & Nabors, 2015; Nabors et al., 2013). Approximately 25% of children in the United States are affected by a chronic condition, which can result in diminished academic performance, decreased school attendance, and poor social interactions (Emerson et al., 2015; Lum et al., 2017; Miller, Coffield, Leroy, & Wallin, 2016). If untreated, such issues can result in difficulties in school transitions and completion (Quach & Barnett, 2014). With such a high percentage of students facing chronic conditions, elementary school counselors are in a unique position to address their academic and psychosocial issues (Boles, 2017; Janin, Ellis, Lum, Wakefield, & Fardell, 2018; Merianos et al., 2015).

Although up to 97% of school counselors have reported working with students with chronic conditions, many often also report feeling unprepared to work with this population due to a lack of adequate training and appropriate interventions (Hamlet, Gergar, & Schaefer, 2011; Kaffenberger, 2006). Further, school counselors must be prepared to work with elementary students in ways that are developmentally and culturally appropriate (Kohn-Wood & Hooper, 2014; Ohrt, Limberg, Bordonada, Griffith, & Sherrill, 2016). Considering that the American School Counselor Association (ASCA, 2012) National Model states that a key aspect of responsive services is that school counselors are "prepared to recognize and respond to student mental health crises and needs and to address these barriers to student success by offering education, prevention, and crisis and short-term intervention" (p. 86), school counselors' preparation to use relevant and effective interventions in school settings with children with chronic conditions is paramount. School counselors provide developmentally and culturally appropriate complementary services that are individualized, creative, and student centered and that fit within established educational services provided under individualized educational plans (IEPs) and 504 plans for students with disabilities (ASCA, 2016b; Kohn-Wood & Hooper, 2014; Ohrt et al., 2016). Both reality therapy and art therapy show promise as innovative interventions for school counselors who work with elementary school students with chronic conditions and address the school-related problems that can result (e.g., attendance, academics, and social interactions).

Art and Reality Therapy in Schools

Art therapy has been identified as an effective, creative, and developmentally appropriate technique to help children explore situations that may be too painful or confusing to discuss while encouraging self-exploration, awareness, and growth (Cook, Mayorga, & Ball, 2016; Pielech, Sieberg, & Simons, 2013). In particular, art therapies have been shown to be effective in helping children facing chronic conditions reduce stress, enhance problem-solving skills, and develop a strong sense of well-being (Bastemur, Dursun-Bilgin, Yildiz, & Ucar, 2016; Beebe, Gelfand, & Bender, 2010; Bitonte & DeSanto, 2014; Palmer & Shepard, 2008). Further, art therapies fit well with the ASCA National Model for responsive services and lend themselves to combination with other counseling approaches (e.g., reality therapy) and application in school settings (Gonzalez-Dolginko, 2018; Losinski, Hughley, & Maag, 2016; Randick & Dermer, 2013).

A counseling approach often applied in schools is Glasser's (1998) reality therapy. With its focus on helping students make appropriate choices to effectively meet their basic needs for love and belonging, freedom, power, fun, and survival, reality therapy has been shown to be effective in areas such as perceived academic efficacy, self-esteem, and classroom behaviors (Mason, 2016; Mason & Dye, 2017; Mocan, 2013; Wubbolding, 2017). Although reality therapy has been widely applied in schools with older students, there is still a need for developmentally appropriate techniques for working with younger elementary school students based on this approach (Davis & Pereira, 2013). Fortunately, reality therapy blends well with creative interventions such as play therapy (Bradley, 2014; Davis & Clark, 2012; Davis, Pereira, & Dixon, 2015). Educators can easily explore reality therapy concepts including quality world and wants, doing, evaluation, and planning (WDEP; Wubbolding, 2000) through child-friendly creative arts mediums such as drawing to create visual maps for goals and plans for elementary school students to address behavioral and academic issues (Davis, 2011). Reality therapy also has been linked to effectively addressing stress-related issues for people with health problems (Pedigo, Robey, & Tuskenis, 2018).

Considering a call to meet the needs of students with chronic conditions in schools (Emerson et al., 2015; Losinski et al., 2016), developing and introducing targeted and innovative techniques for elementary school counselors is imperative. Another critical need is for counseling interventions that integrate easily into existing responsive service delivery and conform to best practices (ASCA, 2012). To date, only limited research has examined school counselors' interventions with children with chronic conditions. Authors (Beebe et al., 2010; Merianos et al., 2015; Nabors et al., 2013; Palmer & Shepard, 2008) of prior studies have proposed art therapies as an intervention for school-age students with chronic conditions, and reality therapy offers a toolbox of creative counseling ideas for school counselors. Therefore, we integrated art with reality therapy and created an innovative technique, reality art therapy (ReAT), specifically for counseling young children with chronic conditions in the elementary school setting. Then, we trained several school counselors in the new techniques and used a qualitative methodology to explore whether school counselors and students found the intervention helpful. The purpose of the current study was to examine the experiences of school counselors and students using ReAT to address chronic condition issues.


The purpose of this qualitative research study was to explore the perceptions of elementary school counselors and students following the implementation of ReAT counseling sessions to address elementary school children's chronic condition issues. We employed a constructivist approach in this qualitative study because it honors participants' understanding of their lived experiences and relates participants' perceptions of the ReAT intervention in a way that is meaningful and relevant to them (Grbich, 2007). In the current study, school counselor and elementary students' viewpoints were of interest. The following questions guided our research:

1. What are elementary school counselors' perceptions of implementing ReAT with students dealing with school-based chronic condition issues?

2. What are elementary school students' perceptions of participating in ReAT sessions with their school counselor to address school-based chronic condition issues?

3. What are school counselors' perceptions of how ReAT sessions helped students with school-based chronic condition issues (e.g., attendance, academics, and social interactions)?


Participants in this study included nine certified elementary school counselors and nine students (ages 8-12) identified as having a chronic condition (e.g., diabetes, asthma, ADHD) within a large Southeastern United States school system that employed 78 school counselors at the time of the study. School counselors referred elementary school students who had a chronic condition and a related school-based concern (e.g., attendance, grades, social interactions). In qualitative studies, the sample size needed is determined by the type of descriptive study and data analysis process, and nine is generally considered a sufficient number of participants (Creswell, 2013; Grbich, 2007). We recruited school counselor participants through the school district's supervisor for elementary school guidance, who asked for volunteers via e-mail requests sent out 3 times. All recruitment messages clearly stated that participation was voluntary; this was reiterated throughout the research procedures with the participants. All participating school counselors were female. However, the sample had a diverse distribution of ethnicities with five school counselors identifying as White, two as African American, and two as Latina. Participants' years of school counseling experience ranged considerably from 2 to 26 years.

Students who participated in the ReAT counseling sessions were selected by school counselors based on whether the children had chronic conditions and accompanying school-based issues. Parents or guardians were provided informed consent documents that outlined the nature of the research study. Each student was also provided with an assent statement to agree to participate in the study. Elementary students included five males (two White, one Latino, and two African American) and four females (two White, one African American, and one South Asian). Chronic conditions, as reported by school counselors, included diabetes (2), ADHD (3), conduct or behavior problems (2), asthma (1), and sickle cell disease (1). Students' ages ranged from 7 to 10 years. One child received outside counseling services and seven students had educational plans related to their conditions. School counselors and student participants were provided pseudonyms to maintain their confidentiality.


Approval was received from the university institutional review board and school district prior to the study. Researchers also followed the American Counseling Association (2014) and ASCA (2016a) ethical guidelines for proper treatment of human subjects.

Elementary school counselors participated in one 8-hr training conducted by the primary researcher and the graduate student assistant addressing the basic tenants and concepts of art therapy (definitions, techniques, and materials) and reality therapy (basic needs, quality world, and the WDEP method). Following the training, the school counselors implemented six 30-min individual sessions with students over the course of approximately 3 months during one semester (see Table 1). During the ReAT sessions, all nine students participated in the ReAT techniques to gain awareness of their wants and plans concerning their chronic condition and related school-based issues. The school counselors used art techniques to help the children explore the five basic needs, quality world components, and four aspects of the WDEP method. ReAT counseling sessions were supplemental to the students' educational program and designed for children to explore feelings and set goals for personal change.

Data Collection

We collected data using semistructured one-on-one interviews following the implementation of the six ReAT sessions. The semistructured interview questions were developed by the research team consisting of the principle investigator and coinvestigators who were a graduate student assistant and another faculty member. School counselors were interviewed individually for approximately 30-40 min and students for 10-15 min at their respective school sites. One student did not participate in the interviews due to absence. Using a constructivist lens, we were interested in the effectiveness of the ReAT intervention from the participants' perspectives. Questions for the school counselors included: (a) What are your thoughts on implementing the ReAT technique? (b) What are some of the outcomes of the experience for you? and (c) How will you continue to use this technique with students with chronic conditions? For students, questions included: (a) How did you feel when you were doing the drawings? (b) How did the drawings help you feel about your condition? and (c) What did you learn about yourself by doing the drawings? All interviews were recorded and transcribed verbatim.

Data Analysis

The three-person research team consisted of two White counselor educators (one male and one female) and one White female graduate student assistant. Both counselor educators have experience as practicing school counselors and as instructors in school counseling courses. The graduate student assistant has experience as a teacher and, at the time of the study, was completing her internship requirements for her school counseling program. The team members' varying levels of knowledge and experiences with chronic condition, school counseling, and education led to three unique perspectives regarding the research project, which strengthened our abilities to identify and challenge our biases and assumptions.

We conducted a six-step analytic process as outlined by Braun and Clark (2006): (a) becoming familiar with the data, (b) generating initial codes, (c) searching for themes, (d) reviewing the themes, (e) defining and naming the themes, and (f) producing a report of the results. The graduate student assistant transcribed each interview and the principal researcher reviewed all the transcripts before beginning the coding process. A list and brief description of potential codes that emerged from the data was generated and shared with the research team. The team discussed the codes to process, which held the most relevance to the study's research questions. Together, we created a list of initial codes and refined them as we revisited the interview transcripts. Saldana (2013) labeled this coding process as a first step to fully link the data to the research questions. The principal investigator then conducted a second cycle of coding to find thematic and conceptual similarity between codes, develop code categories, and combine code categories into primary themes (Saldana, 2013). A final set of themes was then created and provided to the research team for consensus. Last, themes were linked to the research questions.


We applied a variety of strategies to ensure credibility and rigor throughout the study period. As recommended in qualitative research, we continually examined potential biases and preconceived notions that could potentially affect the data collection and analysis (Creswell, 2013; Hays & Singh, 2012; Ohrt et al., 2016). For instance, we discussed the primary researcher's previous experiences with the development of reality therapy and art as a potential area of bias. We regularly used research team meetings, journaling, and reviewing of codes to set aside our assumptions as a means to enhance trustworthiness during the study. Prior to coding the interview data, the lead researcher reviewed all interview transcripts against the recordings for accuracy. Transcripts were reviewed several times as outlined by Braun and Clark (2006). Copious notes were taken and recorded as potential themes emerged from participants' interviews. No significant disagreements occurred among the research team during the data analysis process. Last, we used member checking by providing each participant with her transcribed interview and initial themes for review and potential edits (Hays & Singh, 2012).


The research team identified four broad themes in the school counselor participants' responses. Each theme also included sets of subthemes. The four themes related to school counselors' perceptions addressed the first and third research questions. Separate themes were related to school counselor's perceptions of the consequences of students' school-based chronic condition issues and how the ReAT intervention helped with those issues. The first theme was issues school counselors addressed with children with chronic conditions. Subthemes were (a) behavior/social/academic, (b) identification, and (c) social/cultural aspects. The second theme was related to school counselors' ways of working with children with chronic issues, with subthemes of (a) techniques and (b) intervention needs. The third theme addressed the school counselors' perceptions of the implementation of ReAT and included subthemes of (a) benefits and (b) difficulties related to counseling intervention. The final theme addressed future considerations with subthemes of (a) alternative formats/ applications and (b) adherence. Four themes also emerged from the interviews with the elementary students, which addressed the second research question related to elementary school students' perceptions of the ReAT intervention. Students' themes were (a) my condition, (b) my relationships, (c) using creativity, and (d) gaining insight.

School-Based Issues Related to Chronic Conditions

School counselors described behavioral, social, and academic issues for the students. They also discussed issues related to impact of the actual diagnosis of the conditions. Finally, the participants talked about social/cultural components of the school-based issues.

Identification of behavioral/social/academic concerns. The school counselors noted a variety of school-based issues that affected the students related to their chronic conditions. For instance, Dorothy noted both academic and social aspects for her student. She described one student as
   being behind academically, not being up-to-date in their social
   skills as far as getting along with people ... struggling to fit
   into the general population and feel like they're accepted and
   wanted and loved. Most of the kids tend to shun him because he's
   just so difficult to deal with so he has no people skills.

Similar condition-relationship issues were also discussed by Nancy who said, "Sometimes the problems are with classmates. If the classmate doesn't understand the condition or absenteeism problems and then their coping skills with some of these issues may arise." An observed lack of peers' understanding was also the case for Barbara's student. She shared, "I was really surprised because she's the sweetest little girl and I really thought that everybody understood in her classroom, but she still gets laughed at a lot" and "When it comes to her diabetes I think it's just more acceptance from peers is what she wants." Diana addressed her student's behavioral aspects regarding effective problem-solving or self-regulation: "She has a hard time identifying solutions. She just gets caught up in what happened before or what is always going to happen that she can't rationalize the solution for herself every time." Iris expounded on the academic aspects for her student stating:
   He's scoring Ds and Fs in class because he either was not here and
   wasn't doing make-up work or when he was here he slept the entire
   day. Literally the entire day. He would sleep the whole day and not
   get anything done.

Identification of the chronic condition. Outcomes related to the diagnostic process and subsequent school-based problems also emerged from the school counselors' interviews. For Iris's student, getting the diagnosis was a difficult process as noted in her comment: "It took a very long time to even get an ADHD diagnosis. He had to get a lot of tests and assessments done so he was missing school quite a bit. It was very difficult." Following identification, some students still had difficulties. Dorothy stated:
   I don't think he completely understands that he has an illness. I
   think that he just doesn't think that the world is the way it is
   supposed to be when it concerns him. He doesn't see himself as
   having a problem. He knows that people get on him for pushing and
   hitting and blaming things on other people, but he still doesn't
   see it as something he needs to change.

Finally, Leia discussed the fact that her school is "seeing a lot of anxiety from home" when it comes to dealing with the identification of a chronic condition.

Social/cultural issues as context. The school counselors noted social/cultural aspects that were associated with the students' chronic conditions and how they influenced school-related issues. For instance, Barbara discussed difficulties her student had with addressing his chronic condition within a family-community context: "This is a very low socioeconomic status (SES) area and so kids have a lot of home issues, so they truly have basic need issues." Dorothy shared a similar concern: "The fact that his mom was a single mom and doesn't have much family support ... all that plays in so he is definitely starved for attention." Anna also shared concerns related to how she viewed her student's family background:
   There was some drug abuse. Some serious domestic violence. I
   think they both ended up in jail at various points this year, so he
   was living with grandmother and grandfather and still is. He is the
   oldest of four, so he takes care of the younger ones. He feels
   responsible for them.

She further stated, "I think at home he had no structure. He had no voice or control." Iris echoed similar concerns:
   [the student] lives with his grandparents and we've gotten a lot of
   excuses over the years. It's never any responsibility placed on
   him. I don't think he feels empowered at all. He is powerless about
   the things that are going on around him and his attendance.

School Counselors' Use of Counseling Interventions for Chronic Conditions

School counselors shared current techniques they used when working with students with chronic conditions and school-based issues. Participants also discussed their needs for additional intervention options for counseling this population.

Current use of techniques. Participants discussed a variety of current interventions they employed in counseling their students, including the use of basic counseling skills when working with this population. For example, Leia uses "mostly just a lot listening. That kind of empathetic just being there. I mean what I do is so quick." Nancy shared her use of "calming techniques like breathing or listening to them. Giving them space and just waiting for them to deescalate. Avoid trying to reason with them whenever they are in crisis mode." For Iris, the use of "check-ins" was helpful to "talk about active listening skills." Two of the school counselors used group counseling. Dorothy shared that she used "more of a group approach rather than individual because the time constraints as a school counselor are almost impossible. I just don't have the luxury of that kind of time. So, I've done more social skills groups." Similarly, Anna said, "I tried small group counseling focused on issues like teaching them the skills they need." Further, Anna used information gained from the group sessions as a means of "giving teachers ideas, even giving them scripts of like what exactly to say." Barbara also incorporated classroom aspects: "I try to find a mentor in the school. It's usually their previous teacher. Some kids check in in the morning or afternoon. If that doesn't go well, they might need a midday check-in." She also shared the importance of having a plan in place:
   We have a plan for her next year. When she's in third grade, we're
   going to go in and she's going to teach her teacher what diabetes
   is about and then we're going to talk to the class. That's the plan
   she came up with.

Students' intervention needs. School counselors discussed a desire for more counseling applications to use when working with this specific population. For example, Nancy shared: "It's always good to have a tool and use new tools and then see how they work because then you just add them to your toolbox." Barbara also commented: "You're always trying to find answers that will work. They really need the help ... because it's not just elementary school. We're working towards high school graduation. That's the goal." An appreciation for art-based interventions emerged for the participants. Leia said, "I thought it would give me something different to do with the kids than what I usually do and they might be able to express themselves a little bit better through art than they are going to be verbally." Diana appreciated "the art element. Not all kids want to talk or write but many times you can get them to draw or paint or use some kind of artistic means to communicate." She addressed the lack of art in schools by sharing: "They're not allowed to draw. Drawing is almost removed from schools other than the art class."

Implementation of ReAT

School counselors described implementing the ReAT approach with their students. They discussed positive aspects that were beneficial in counseling the students. They also shared some of the difficulties in utilizing the ReAT techniques.

Benefits. The school counselors discussed several positive aspects of the ReAT techniques. For example, Leia commented:
   I really like drawing and it's usually a great way for them to calm
   down, but it was nice to have the theory behind what I've just been
   kind of guessing with on my own. To have the theory behind it was
   pretty helpful.

Leia also described the connection with her student using ReAT:
   I think that part [drawing] was really good for her to be able to
   talk about it and process it in a way that I don't think she would
   have. We wouldn't have gotten to the heart of everything if it had
   just been her and I talking. Her being able to draw and then
   explain to me what was in the drawing I think helped her get deeper
   than she would have if it were just her and I sitting in the

Nancy also shared the benefits of the approach from an information-gathering perspective:
   I thought it was kind of powerful, especially at the beginning
   because when we were doing the first steps of his quality world and
   he only included his mom.... I learned more later ... there was
   domestic abuse in the home and the dad was no longer living with
   them, so then I understood why he withheld anybody else in the
   picture and I was able to understand that he felt like he needed to
   protect his mom. That was an important point within the process.

For Barbara, the relationship aspect was of key importance. She said, "I think it's really important to create those relationships with students. It was rewarding. Understanding her better ... that connection and hopefully next year will be better." Similarly, Anna noted, "I really saw some positives out of it in that building the relationship and getting him to share things and to realize things and have some insights." She also stated:
   I think he felt heard and validated. He had a plan and he felt
   positive about that. In discussing what was going on with him I
   think that really helped build the relationship. He worked hard on
   it. He wanted to do well. He came up with ideas and was always
   excited to come back and say how it was working.

The depth of understanding school counselors had for their students also came to light in Diana's comment: "She would tell me many times that the picture she drew was staying in her brain. She could remember what she drew. Having the pictures that she drew independently hit home more than anything." Diana also shared an experience where her student
   drew an angel.... She said "I want to be calm like an angel." It
   just hit home so much. In that moment I understood what she meant.
   She was able to say what she wants is not to act out. She wants to
   be able to be calm but she doesn't know how to do that in the

Difficulties. The participating school counselors noted some difficulties in the implementation of the ReAT techniques. For some students, understanding and applying the reality therapy concepts were challenging, as demonstrated in Iris's comment: "I like connecting with him personally, but his scope is very limited. His ability to think beyond where he is is very, very small. It's just so hard for him. It's almost like he's afraid to dream." Dorothy also noted this difficulty in applying the concepts:
   He'll look at you and talk to you and absolutely say he understands
   he needs to change but then in his drawings he just doesn't feel
   that he's the one that needs to change. He feels like it's
   everybody around him that needs to change and so that's frustrating
   for me.

Nancy suggested using the ReAT approach when children are calm:
   I feel that when they are in crisis mode, it may not help. I would
   wait until he deescalates and then discuss the problem. When the
   child is calmer, using reality therapy or art therapy to come up
   with a plan and talk about the here and now.

Finally, Leia shared that she would like further training. She said, "It was really fun, but I would love more training. I think that part would be really helpful."

Future Considerations

A final theme related to the school counselors' perspectives dealt with future considerations of implementing the ReAT approach. Participants discussed ideas for adapting the approach for use with other students and other school-based issues. The participants also shared insights into how they would apply ReAT in the future.

Recommended alternative formats and applications. Several of the school counselors mentioned using the approach with various populations and for other issues. For instance, Leia shared:
   I've actually found myself using it with a lot of the kids who get
   disruptive and kicked out of class. It's been really great for
   them. From that explosive behavior to bring it back to "this is
   what I need to do next" or "now I realize that was not such a great

Diana offered a similar comment: "We could use it with some of our English for Speakers of Other Lanugages (ESOL) students because they can't always have the verbal skills to articulate that or put it into words or writing but they can always draw. They get it." Iris also saw other possible applications of ReAT:
   We have a lot of foster care children who have experienced grief
   and loss. They're going through particular struggles. This may help
   them to understand and formulate what they feel they can control
   and to try to take steps and plans to do something.

Finally, Barbara suggested, "We have some kids with incarcerated parents, so this would be good."

Adherence. The school counselors shared insights regarding the continued use of the approach. Dorothy shared:
   I definitely see myself using it. I have all kinds of students in
   mind that I want to use art therapy for that have a better grasp of
   reality. I love the progression of it and I can see it helping.

Anna echoed this sentiment: "I definitely see myself using it in the future." Barbara discussed using the technique as a means of bridging breaks: "I think I'm going to laminate it and make it a book for her, so she can look at it over the summer and process it for next year." Finally, Diana discussed using the approach broadly in her school counseling program, sharing that she would "make it part of my yearly curriculum for some of our students. I would probably take each piece and then have multiple pieces of it. Like make each one a month and we build on what that looks like."

Student Themes

Students shared insights from experiencing the ReAT sessions. Although the student comments are not numerous, they are meaningful and reflect their experiences. For instance, students' comments shared their views of their condition and how it affected their relationships. Bart said, "Sometimes people are my friends and they're nice. Then other days people will tell mean things about me." Lisa discussed how her condition affects her school attendance: "It's weird because I have to leave class and miss important tests and my mom has to pick me up and I have to miss fun things."

Relationships with the school counselor were an important aspect of the students' stories. For example, Bart said, "She's like my stress reliever. She helps me calm down and she's really nice." This was also the case for Lisa, who said, "It's a safe place to talk about my feelings."

Students also expressed appreciation of the creative approach in their comments. Nelson shared: "I felt like my problems were being fixed, like going through my problems and the one thing I love [art]." Bart said, "I get to be an artist so that I can express my feelings."

Finally, the students shared insights and skills gained from participating in the sessions. For instance, Ralph commented on how the sessions helped him gain insight:
   It helped me straighten up as I move on. It made me feel like I was
   going to do better. I knew what I was doing and why I was doing it
   then I could think about ways I could change it.

Nelson shared what he gained in terms of developing a plan: "It does steps of how I did it. I tried doing those steps and they worked. They helped me not listen to other people when they say something mean to me." He also stated, "[I] learned that anger does not fix problems." Lisa gained valuable knowledge and ideas: "It made me feel better about it and my friends" and "we are going to my third-grade teacher and tell her everything about diabetes." Bart shared that the intervention "teached me how to be more respectful and good. Like not good, but like honest and good and respectful."


The current study explored perceptions of elementary school counselors and their students following the implementation of ReAT with students dealing with chronic conditions. The current study expanded upon existing literature regarding effective counseling interventions for this specific population. Consistent with literature regarding the incidence of chronic conditions and resulting school-based issues for elementary students (Boles, 2017; Gan, Lum, Wakefield, Nandakumar, & Fardell, 2017; Miller et al., 2016), the participating school counselors cited a number of problems related to students' behavior, social and academic interactions, diagnosis, and social/cultural context. According to the school counselors who worked with them, students with chronic conditions experienced decreased attendance, missed assignments, and challenges with their support systems. In particular, school counselors shared the lack of understanding and acceptance of the conditions by other students, shown in ways including teasing and confusion about the chronic disease and its effects. Considering the significant impact of peer influence on school quality for these students (CDC, 2012, 2017; Janin et al., 2018; Merianos et al., 2015; Quach & Barnett, 2014), utilizing interventions that encourage positive peer relationships is imperative.

Many of the participants expressed a desire for increased knowledge of developmentally appropriate and creative strategies for counseling youth with chronic conditions. Although many of the school counselors indicated that they had a variety of counseling interventions currently in place, they all noted a desire to expand their options for working with this population. Both art therapy (Bastemur et al., 2016; Cook et al., 2016; Gonzalez-Dolginko, 2018; Pielech et al., 2013; Randick & Dermer, 2013) and reality therapy (Davis et al., 2015; Mason, 2016; Mason & Dye, 2017) have shown promise as beneficial interventions in school settings; however, the ReAT school counseling interventions for children with chronic conditions is a new addition to the school counseling literature. Although participants had some difficulties implementing ReAT at the elementary school level, the school counselors described numerous benefits with this novel approach that align with reality therapy literature, including enhanced relationship building, improved insights and skills gained by students, and development of problem-solving strategies (Davis & Clark, 2012; Mason, 2016). These findings also coincide with literature noting the importance of such aspects in the quality of school engagement for students with chronic conditions (Bitonte & DeSanto, 2014; Boles, 2017; Gan et al., 2017; Janin et al., 2018; Lum et al., 2017; Merianos et al., 2015; Pedigo et al., 2018).

Findings of the current study are consistent with literature noting the need for additional research regarding the implementation of creative approaches such as art with reality therapy (Davis, 2011; Davis & Clark, 2012; Wubbolding, 2000, 2017). Considering the benefits discussed by the school counselors, ReAT is a viable option for working with elementary school students with chronic conditions and future research is warranted. According to the school counselors, ReAT has potential for adaptation to additional populations (e.g., ESOL) and issues (e.g., grief). Further, the school counselors discussed the flexibility of the approach and adapted the activities to meet the needs of the students based on their unique cultural and developmental situations.

Implications for School Counselors

Both school counselor and student participants discussed the need for increased knowledge and acceptance of chronic condition diagnoses and resulting problems in school. A key finding expressed by both participant groups was a need for increased knowledge and acceptance of the various conditions that students face in the school setting. Considering the importance of collaboration in working with youth with chronic conditions (Emerson et al., 2015; Quach & Barnett, 2014), school counselors can collaborate with appropriate professionals (e.g., school nurses, pediatricians, and other mental health practitioners) to gain access to current information and practices regarding students with chronic conditions. Armed with this knowledge, school counselors can provide classroom lessons and creative informative materials and develop self-awareness activities for students and school personnel to create a more informed and open environment for children with chronic conditions and all stakeholders. As noted in the findings, school counselors can also utilize the student as a means of education and advocacy through the inclusion in this process.

The school counselors noted myriad academic issues experienced by students with chronic conditions (e.g., absences, poor grades, negative social interactions) that align with chronic condition literature (Davis, 2018; Lum et al., 2017; Miller et al., 2016). School counselors can consult with teachers and administration to assist students in making up assignments through a variety of options (e.g., online, extended deadlines). Further, school counselors can develop strengths-based problem-solving approaches that are grounded in a social/cultural context. For example, many school counselors noted cultural and family aspects that exacerbated the school-based chronic condition issues for the students. As an adjunct to the ReAT intervention, school counselors should consider the student's living situation outside of school to identify counseling options, community resources, and types of family support needed. Meeting with caregivers, teachers, and students to gain this knowledge can open up resources for the school counselor to provide more effective and efficient counseling services (Merianos et al., 2015). Finally, in terms of best practices, school counseling interventions like ReAT should be supplemental to current evidence-based practices to treat the students' identified condition (e.g., ADHD) while collecting relevant supporting data such as attendance, self-esteem assessments, and grades and should fit within other responsive services such as IEPs, 504 plans, and ESOL interventions (ASCA, 2016b). For students with more serious mental health problems (e.g., early conduct problems), school counselors work as part of a multidisciplinary team and consult closely with special educators and other mental health-care providers to maintain the highest standard of care (Grothaus, 2013).

Perhaps the most meaningful finding in this study involved the power of the therapeutic relationship established during the ReAT sessions. Strong relationships built on trust and mutual regard allowed both school counselors and students to explore various aspects of students' school experiences related to their conditions and to gain deeper understandings, which resulted in positive strategies to address the presenting issues. As the students noted, engaging in the ReAT sessions also allowed for a positive place to find some much-needed stress relief related to their situations. Employing a relationship-based intervention such as ReAT can be an incredibly effective process for school counselors to engage students in relationship building, stress reduction, and problem-solving to improve their school-based issues (Davis & Clark, 2012; Pedigo et al., 2018; Wubbolding, 2017).

As with the development of any novel counseling approach, practitioners need additional training (Bastemur et al., 2016; Davis et al., 2015). Both school counselors and students desired creative activities, such as art, in the counseling process. School counselors can be proactive in gaining this knowledge by seeking out professional development opportunities through professional conferences, organizations, and materials. They can also advocate to their school administrators and districts for specific training in creativity-focused counseling interventions based in current and relevant research. Seeking additional training and knowledge through continued higher education may also be an option for school counselors. With new approaches such as ReAT, school counselors' collaboration with counselor educators and researchers is vital to remain current on available counseling interventions. With additional training, school counselors can apply ReAT to work with children with chronic condition and adapt the approach to various developmental levels, issues, and populations. For instance, school counselors could change language such as "quality world" to "my school world."

Limitations and Future Research

Addressing this study's limitations would enhance the development and implementation of ReAT. The newness of this approach merits further research with the study population and a wider range of populations and issues. The ReAT counseling intervention is not meant to replace other evidence-based practices for students with specific learning or psychosocial needs. The study was conducted with a small population in a localized area of the Southeastern United States, with the primary researcher conducting the trainings and many of the interviews, and this may have influenced the participants' responses.

Future research could focus on further examination of the ReAT intervention with a larger and more diverse school counselor population, with a diverse student sample, and within a wider geographic area. Research could focus on a different issue rather than chronic condition (e.g., grief, bullying) and with varied populations (e.g., children in foster care, children who speak English as a second language). Researchers could consider adaptations to address difficulties for students who are unable to fully comprehend some of the reality therapy concepts. Finally, trainings could be conducted by professionals familiar with ReAT rather than by the primary researcher. The constructivist qualitative approach revealed perceptions of school counselors and students and is therefore valuable to guide interventions. However, quantitative research designs, mixed-methods studies, and partnerships with school counselors to conduct action research may further validate the effectiveness of the ReAT intervention and its effects on academic, behavioral, and social/emotional outcomes for students (e.g., attendance, grades, self-esteem).


The current qualitative study explored school counselors' experiences implementing ReAT to counsel elementary students with chronic conditions. Although school counselors are highly likely to work with children with chronic conditions, they often lack adequate training in counseling this population. Therefore, we created an art intervention based in reality therapy and implemented it with a small group of school counselors and students. Because ReAT is a new approach, it needs continued development to address this specific population's needs. In the current study, school counselors related the benefits of using the ReAT approach with a student with a chronic condition in their school setting. The current findings contribute to literature related to school counseling interventions for children with chronic conditions; however, further study is needed to advance the research on ReAT as a viable option in working with students with chronic conditions and other school-based issues.

DOI: 10.1177/2156759X19870792

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was supported through a grant provided by the University of South Florida.


Eric Davis [ID]


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Author Biographies

Eric Davis, PhD, is an assistant professor with the Department of Leadership, Counseling, Adult, Career and Higher Education at the University of South Florida in Tampa. Email: esda

Sondra Smith-Adcock, PhD, is an associate professor in counselor education at the University of Florida in Gainesville.

Lindsey Towns is a graduate student in counselor education at the University of South Florida.

Eric Davis [1] [ID], Sondra Smith-Adcock [2], and Lindsey Towns [1]

[1] University of South Florida, Tampa, FL, USA

[2] University of Florida, Gainesville, FL, USA

Corresponding Author:

Eric Davis, PhD, University of South Florida, 4202 E. Fowler Ave., EDU 105, Tampa, FL 33620, USA.

Table 1. Reality Art Therapy Sessions Outline.

Session    Outline

1          Welcome and introduction to sessions/
           research process

           Discuss chronic condition and school issues
           for the student

           Discuss concepts of Basic Needs and Quality

           Complete Basic Needs and Quality World
           drawing activities

           Process the drawings and begin discussion of
           Wants in relations to current situation

           Review session

           Homework: Think about what they Want to see
           in their Quality World based on the current

2          Welcome and review previous session

           Discuss the WDEP process

           Review the Want from the HW

           Complete the Want drawing activity

           Process the Want for reality, immediacy, and

           Discuss what the student is Doing to achieve
           the Want

           Complete the Doing behaviors drawing activity

           Review session

           Homework: Review Doing behaviors and Evaluate
           if they are helping or hurting

3          Welcome and review previous session

           Review the Want and Doing from the HW

           Complete the Evaluation/Results drawing

           Process with the student ideas for new Doing
           behaviors to meet the Want

           Complete the Plan drawing activity

           Review session

           Homework: Review the ideas for new Plans and
           choose the three best

4          Welcome and review previous session

           Review the Plans from the HW and discuss
           which of the three is best option to meet the

           Discuss the best Plan and process the pros,
           cons, implementation, and commitment

           Complete the best Plan drawing activity

           Review session

           Homework: Put the Plan in place and draw the

5          Welcome and review previous session

           Review and process the results of Plan

           Reevaluate the Plan for meeting the Want

           Complete the Plan drawing activity

           Review session and remind of final session

           Homework: Put the Plan in place and draw the

6          Welcome and review previous session

           Review and process the results of Plan

           Reevaluate the Plan for meeting the Want

           Process the next steps and alternative Plans
           for meeting the Want

           Review the concepts of Basic Needs, Quality
           World, and WDEP process for future use

           Questions, thank you, and reminder of
           interview with researcher

Note. WDEP = wants, doing, evaluation, and planning.
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Title Annotation:Featured Research
Author:Davis, Eric; Smith-Adcock, Sondra; Towns, Lindsey
Publication:Professional School Counseling
Date:Sep 1, 2018
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