A four-drawing art therapy trauma and resiliency protocol study

Accepted Manuscript Title: A Four-Drawing Art Therapy Trauma and Resiliency Protocol Study Authors: Noah Hass-Cohen, Rebecca Bokoch, Joanna Clyde Findlay, Alyssa Banford Witting PII: DOI: Reference:

S0197-4556(17)30149-1 https://doi.org/10.1016/j.aip.2018.02.003 AIP 1505

To appear in:

The Arts in Psychotherapy

Received date: Revised date: Accepted date:

19-7-2017 24-1-2018 9-2-2018

Please cite this article as: Hass-Cohen, Noah., Bokoch, Rebecca., Findlay, Joanna Clyde., & Witting, Alyssa Banford., A Four-Drawing Art Therapy Trauma and Resiliency Protocol Study.The Arts in Psychotherapy https://doi.org/10.1016/j.aip.2018.02.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

A Four-Drawing Art Therapy Trauma and Resiliency Protocol Study A Four-Drawing Art Therapy Trauma and Resiliency Protocol Study

U

M D

TE

Clyde Findlay, Joanna M.A., ATR San Rafael, CA Psychotherapist Wellspring Psychotherapy Center 30 N. San Pedro Rd. Suite 290 San Rafael, CA 94903

A

N

Bokoch, Rebecca, Psy.D., Adjunct Faculty Alliant International University 1000 S Fremont Ave, Unit 5, Alhambra CA 91803 Anchor Children and Family Counseling 280 S Los Robles Ave, Unit B, Pasadena, CA 91101 Tel: (323) 301-3984 Email: [email protected]; [email protected]

SC RI PT

Hass-Cohen, Noah, Psy.D., Corresponding Author Associate Professor Couples Family Therapy Masters and Doctoral Programs California School of Professional Psychology 1000 S Fremont Ave, Unit 5 Alhambra CA 91803 [email protected] [email protected] (323) 717-6546

A

CC

EP

Banford Witting, Alyssa, Ph.D. Associate Professor Alliant International University California School of Professional Psychology 10455 Pomerado Road, DH-206E San Diego, CA, 92131 T. 858.635.4889, F. 858.635.4585 [email protected]; [email protected]

+ 1

A Four-Drawing Art Therapy Resiliency Protocol Study The results of an art therapy experimental study of the four-drawing trauma and resiliency protocol showed: 

a decrease in overall effects of the traumatic event, negative affect, pain endorsement and possibly pain intensity. an increase in the number of endorsed resources.



the drawings had a positive impact on participants’ understanding and meaning-making of the traumatic

SC RI PT



event.

Abstract

U

Resiliency, as fostered by creativity, imagination, and the arts therapies, is a critical factor in managing the

N

impact of adversity. This pilot study investigated the potential effectiveness of a four-drawing art therapy

A

trauma and resiliency protocol for coping with adverse life events. The protocol is designed according to

M

memory reconsolidation research and based in art therapy relational neuroscience (ATR-N) principles and

D

trauma models. The hypotheses were that participation in the four-drawing protocol would result in: decreases

TE

in overall effect of the traumatic event (hypothesis one), decreases in negative affect endorsement and rating as expressed by sadness, grief, depression and anxiety (hypothesis two and three), reductions in pain endorsement

EP

and rating (hypothesis four and five), increases in resiliency-based resources (hypothesis six), positively rated impact on participants’ understanding of the problem and resources (hypothesis seven), increases in

CC

posttraumatic growth cognitions (hypothesis eight), and increases in relational security (hypothesis nine). The

A

positive effects of the four-drawing protocol components, including the drawings, questionnaires, and inquiry were examined. Main findings included significant decreases in the rating of the effect of the traumatic event (hypothesis one), self-reported endorsement and ratings of negative affect (hypothesis two and three), trends in pain reduction ratings (hypothesis five), significant increases in endorsed resiliency resources (hypothesis six), and positive ratings of the impact of the drawing activity (hypothesis seven), but no significant changes in 2

endorsement of pain (hypothesis four), posttraumatic growth cognitions (hypothesis eight), or relational security (hypothesis nine). Additional results revealed that decreased endorsement and ratings of negative affect continued to be maintained at follow-up, and that the inquiry had a self-reported positive impact on participants’ understanding and meaning-making of the traumatic event. It is possible that memory reconsolidation processes may account for the positive changes.

SC RI PT

Introduction

Trauma has been associated with a spectrum of behavioral, emotional, cognitive, and intra- and interpersonal impacts, including: chronic negative affect, social isolation, and relational problems, which sometimes qualify for a post-traumatic stress disorder (PTSD) diagnosis (American Psychiatric Association,

U

2013). Trauma types include: relational versus non-relational trauma, and single incident versus chronic-

N

complex trauma. The impact of trauma was shown to depend on perceived degree of threat to self and others,

A

resiliency, and environmental factors (Agaibi & Wilson, 2005), including: relational insecurity and loneliness

M

(Meredith, Ownsworth, & Strong, 2008), negative self-views (Sutherland & Bryant, 2005), and chronic pain (Liedl, O'Donnell, Creamer, Silove, McFarlane, & Knaevelsrud, 2010).

D

A current traumatology focus is resilience, which has been defined as the ability to cognitively anticipate

TE

and cope in the face of stress, threats, and challenges (Agaibi & Wilson, 2005). Critical individual abilities were identified, including: mastery of resources (Gil & Weinberg, 2015), capacity for positive emotions (Kok &

EP

Fredrickson, 2013), an internal locus of control (Agaibi & Wilson, 2005), and availability of social support and

CC

interpersonal security (Meredith et al., 2008). Personality traits were found to contribute to the cognitive and emotional flexibility needed to disclose, explain, and process trauma in therapy and return to baseline levels of

A

life satisfaction (Peterson, Park, & Seligman, 2004). Optimism, flexibility, insight, self-confidence, aptitude for meaning-making, self-care, and identification as a survivor rather than a victim, were some examples (Maddi, 2006). Other characteristics that contributed to resiliency include the capacity for creativity (Gallagher & Lopez, 2007), imagination (Kalmanowitz & Ho, 2016; Lahad & Leykin, 2013), and the appreciation of beauty (Peterson et al., 2004). Strength-based treatment approaches that have also been suggested as contributors to 3

resiliency include: short term group psychotherapy and single sessions, which are based on findings that that most therapeutic change occurred in the first couple of sessions (Başoglu, Salcioglu, & Livanou, 2007; Slive & Bobele, 2012; Talmon, 1993). Art Therapy, Trauma, and Resiliency Research Art therapy practices stimulate integrated and creative cognitive-emotional responses to trauma. Such

SC RI PT

practices supported safe, positive emotional experiences, mastery, coping, and social-communication

(AlAjarma, 2010; Collie, Backos, Malchiodi, & Spiegel, 2006; Johnson, Lahad, & Gray, 2010; Kalmanowitz, 2016; Worrall & Jerry, 2007). Moreover, art therapy was acceptable for a diversity of populations impacted by trauma, such as: refugees (Baker, 2006; Drozˇdek, Bolwerk, Tol, & Kleber, 2012), incarcerated women (Hongo,

U

Katz, & Valenti, 2015), older African American women (Moxley, Washington, & Feen-Calligan, 2012), and the

N

military (Nanda, Gaydos, Hathorn, & Watkins, 2010). Research with active military service members has also

A

demonstrated the potential of expressive arts for integrated medical arts approaches to the treatment of

M

traumatic brain injury (Jones, Walker, Masino Drass, & Kaimal, 2017; Walker, Kaimal, Koffman, & DeGraba, 2016), whereas Carr (2008) has used a third hand approach in a palliative care case study.

D

Randomized clinical trials have included a diversity of art therapy methods (Baker, Metcalf, Varker, &

TE

O’Donnell, 2017; Schouten, de Niet, Knipscheer, Kleber, & Hutshcemaekers, 2015). For example, Erickson (2008) provided six weekly art therapy group sessions for incarcerated women, and Curry and Kasser (2005)

EP

evaluated the effectiveness of mandala drawing with undergraduate students. Henderson, Rosen, and Mascaro

CC

(2007) also used mandala drawings three times with undergraduate students who had experienced a diversity of trauma symptoms. More recently, Zimmermann et al. (2015) used painting, crafts, and relaxation for three

A

weeks with German soldiers, and Wang et al. (2015) studied an eight-week creative writing and drawing for motor vehicle accident survivors to prevent post-traumatic stress disorder. Integrated art therapy and psychotherapy research demonstrated significant decreases in trauma symptom severity (Schouten et al., 2015). Examples include Volker (1999), who provided female sexual assault survivors with a combined CBT and art therapy, and Stok (2007), who combined art and trauma-focused verbal 4

therapy for three sessions. Lahad, Farhi, Leykin, and Kaplansky (2010) compared re-imagining traumatic memory using selected cards as part of art making, to EMDR treatment; whereas, Campbell, Decker, Kruk, and Deaver (2016) compared an eight-week art therapy group with Cognitive Processing Therapy for veterans. Art Therapy, Pain, and Trauma Trauma and pain experiences have been described as correlated and bi-directional (Camic, 1999;

SC RI PT

Siqveland, Ruud, & Hauff, 2017). Art therapy provided a fitting treatment, as the prevalence of strong

distressing imagery was very high for people with pain (Philips, 2011). Meaning-making, a common art therapy practice, seemed to provide the only connection between painful bodily imagery, sensations, and emotionalpsychological functioning (Trauger-Querry & Haghighi, 1999). Art therapy cancer research found statistically

U

significant reductions in pain, fatigue, breathlessness, insomnia, lack of appetite, and anxiety (Nainis et al.,

N

2006). Qualitative pain research also showed support for an integrated art-based cognitive approach

A

(Czamanski-Cohen, Sarid, Huss, Ifergane, Niego, & Cwikel, 2014). Moreover, it is likely that art-making

M

offered increased insight, pleasure, self-management of pain, sense of control, and quality of life (Ennis, Kirshbaum, & Waheed, 2017; Hass-Cohen & Clyde Findlay, 2009; Puetz, Morley, & Herring, 2013).

D

Models and Protocols

TE

Research called for art therapy models and protocols that sequenced interventions according to stages (Gerge & Pedersen, 2017). One such influential art therapy protocol is the Instinctual Trauma Response (ITR)

EP

neuroscientific model, which was developed for diverse types of severe trauma. It emphasized drawing a

CC

graphic narrative and then having the therapist re-present the story back to the survivor (Gantt & Tinnin, 2009). For combat-related PTSD, Collie et al. (2006) recommended a three-stage art therapy model, which

A

involved: (a) reducing arousal and increasing social bonding, (b) processing memories, and (c) attaining insight. For the same population, Naff (2014), suggested: (a) containment and security, (b) narration and exposure allowance, (c) integration, and (d) maintenance. Meekums (1999), proposed an internal-trauma processing model, consisting of: (a) striving, (b) incubation, (c) new perspective, and, (d) reevaluation, whereas Rankin & Taucher (2003) called for a six-task oriented approach: safety planning, self-management, telling the trauma 5

story, grieving losses, self-concept and worldview revision, and self-relational-development. The Expressive Therapies Continuum, a neuroscience approach, was used to treat trauma and highlights levels of processing (Hinz, 2009). Lastly, Lahad (1993) suggested the BASIC PH model for survivors of the ongoing threat of war, which emphasized the importance of specific categories of coping resources, and consisted of: beliefs, affect, social, imagination, cognitions and physical care.

SC RI PT

Therapeutic Change Agents

Memory reconsolidation (MR) was described as a likely therapeutic change agent for art therapy trauma treatment (Hass-Cohen, 2016; Hass-Cohen & Clyde Findlay, 2018). For example, an ATR-N study evaluated how a drawing protocol, which involved changing art-based presentations, and positively affected the arousal of

U

a 9-11 survivor (Hass-Cohen, Clyde Findlay, Carr, & Vanderlan, 2014). Hardt, Einarsson, and Nader (2010)

N

described MR as occurring each time a memory is revisited; during MR, proteins destabilize and then

A

resynthesize in the memory and fear centers of the brain, forming an updated memory within a four-to-six-hour

M

window of opportunity (Nader, Schafe & LeDoux, 2000). Schwabe, Nader, and Pruessner (2014) reported that for MR to occur, a brief reminder is required, which protects from hyperarousal and the triggering of extinction.

D

MR is likely a safer change process than extinction, as survivors experience exposure as frightening. Unless it is

TE

integrated with MR, extinction is also vulnerable to spontaneous recovery, as the conditioned or unconditioned stimuli may be unexpectedly activated (Monfils, Cowansage, Klann, & LeDoux, 2009; Phelps, Delgado,

EP

Nearing, & LeDoux, 2004; Schiller, Raio, & Phelps, 2012).

CC

Creativity has been described as a protective catalyst for memory reconsolidation, as it transforms the past negative experience into something new, providing a sense of control, and distance from the event (Hass-

A

Cohen, 2015). For example, art-making promoted a novel sense of purposefulness, mastery, planning, and resourcefulness, which germinated the discovery of resiliency (Worrall & Jerry, 2007). Hass-Cohen and Clyde Findlay (2018) emphasized that the artwork may aid the art therapist in finding personal clues that strengthen reciprocity between the client’s different resiliency abilities. ATR-N approaches have suggested that safely accessing non-verbal memories (Hass-Cohen & Clyde Findlay, 2018), making implicit memories explicit (Gantt 6

& Tinnin, 2009), and positive effects of sensory and bi-lateral stimulation (Talwar, 2007; Tripp, 2007), likely contributed to MR. The ATR-N Secure Remembrance Model and the Four-Drawing Protocol Hass-Cohen and Clyde Findlay (2015) described the ATR-N secure remembrance components as: safety, relationships, remembrance, reconnection, and resiliency (SR-5). SR-5 does not have fixed stages, as

SC RI PT

establishing safety and building relationships are ongoing tasks in trauma recovery (Hass-Cohen, 2016). SR-5 follows the Tri Phasic model (Herman, 1995), which has been adapted by the International Society for Trauma Stress Studies. Similar to ITR (Gantt & Tinnin, 2009), and in accordance with ATR-N principles and MR theory, SR-5 accentuates the activation of resources and integrative self-functions, as described by Avrahami

U

(2006) and by Gerge and Pedersen (2017). The four-drawing protocol emerged from this framework. Clinical

N

studies have demonstrated the four-drawing protocol’s potential to alleviate pain and trauma (Achterberg,

A

Dossey, & Kolkmeier, 1994; Bridgham & Hass-Cohen, 2008; Clyde Findlay, 2008; Hass-Cohen & Clyde

M

Findlay, 2009; 2018).

The four-drawing protocol was piloted for a diverse range of aversive life experiences, with no

D

documented diagnosis of PTSD. It was designed as a single individual session of 90 to 120 minutes. Retention

TE

and premature dropout were identified as common concerns for trauma treatment, as well as delayed diagnosis (Doran, Pietrzak, Hoff, & Harpaz-Rotem, 2017; Schottenbauer, Glass, Arnkoff, Tendick, & Hafter Gray, 2008).

EP

Thus, the four-drawing protocol was designed to address these gaps, as most models reviewed above provided

CC

service for homogenous populations and utilized short-term groups that ranged from full day workshops to 10week treatments for diagnosed clients. The trauma pictorial narrative is promoted by four directives: (1) “Draw

A

a picture of the problem,” (2) “Draw a picture of yourself,” (3) “Draw the internal and external resources that helped you with the problem,” and (4) “Draw yourself, as you see yourself now.” Methods Sample Demographics

7

Participants were recruited from graduate students in a couple and family therapy program, in accordance with the University IRB approval. Students were offered extra credit for participation in a research study. Students who were not interested in participation were offered an alternative extra credit assignment. There were no other incentives offered. Participants were matched with interviewers from another university campus with whom they had no relationship. The majority identified as female (n = 27/31; 87%) and others as male.

SC RI PT

The mean age was about 30 years old (M = 29.68, SD = 8.32), with an equal number of White and

Hispanic/Latino participants (n = 13/31; 42%, for each), and Black/African American and Asian/Pacific Islander respondents (n = 2/31; 7%). The majority reported satisfactory health ratings (n = 29/31; 94%), being spiritual (n = 24/31; 77.4%), and a third reported being religious (n = 11/31; 35.5%). Average age at the time of

U

the trauma was 25 years (M = 24.94, SD = 10.06), and the traumatic event occurred, on average, about four

N

years ago (M = 4.29, SD = 3.89), (Table 1).

A

Table 1

M

Univariate Statistics for Sample Demographics (N=31) Measures

D

Measures included the Relationship Rating Scale (RR), Negative Affect and Pain Endorsement and

TE

Rating Questionnaire (NAPER), Pre-and Post-Trauma Effect (TE) items, Posttraumatic Growth Cognitions Inventory (PTCI) (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999), and Resource Endorsement Checklist (REC).

EP

The RR (adapted from Bartholomew & Horowitz, 1991) required ratings of six perceived relational security

CC

items with two items for each type of attachment style, including: secure, insecure-avoidant, and insecuredismissive relational styles. Except for the PTCI, all rating measures were on a scale of one to seven (1 “not at

A

all” and 7 “very much so”). The NAPER self-report items required endorsement and then rating of sadness, grief, depression, anxiety, and persisting pain. The Pre/Post-TE items asked participants to rate the effect of the traumatic event on their lives in the last year. The PTCI, a standardized measure, rated self-reliance, initiative, growth, acceptance (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999). The REC required endorsement of resources

8

from six areas: beliefs, emotions and feelings, social and cultural, imagination and interests, thinking and cognitions, and self-care (adapted from Lahad & Leykin, 2013), (Figure 1). Figure 1. Resource Endorsement Check List Hypotheses The first hypothesis postulated that as a result of participating in the four-drawing protocol, ratings of

SC RI PT

overall effect of the trauma on participants’ lives, as measured by TE, would decrease from time of study entry (Time 1) to follow-up (Time 3). As a result of participating in the four-drawing protocol, the second and third hypotheses anticipated that endorsements and ratings of negative affect, as measured by the NAPER, would decrease from Time 1 to 3. Similarly, the fourth and fifth hypotheses anticipated a decrease in pain endorsement

U

and ratings from Time 1 to Time 2a, 2b, and 3 (NAPER). The sixth hypothesis projected that participation in the

N

four-drawing protocol would contribute to an increase from Time 1 to 2b in endorsement of personal resources

A

(REC). The seventh hypothesis specifically postulated that a significant number of participants would report

M

positive impacts of the drawing activity on their understanding of the problem and their resources (Time 2b, post-drawing inquiry), as a result in their participation in the four-drawing protocol. Similarly, the eighth and

TE

relational security (RR), (Table 2).

CC

Procedures

EP

Table 2 Hypotheses

D

ninth hypotheses estimated an increase from Time 1 to 2b in posttraumatic growth cognition (PTCI) and

At study entry (Time 1), participants completed pre-measures: RR, REC, and NAPER. They also chose

A

a traumatic life event that had happened at least one year and not more than five years ago, and rated: a) the PreTE, b) how they felt at the time of their reported trauma, and c) how they perceived their coping (Figure 2). Figure 2. Protocol Sequence and Measures Participation took 90 to 120 minutes and included: pre-protocol measures (Time 1), the four-drawing activity, inquiry after the third drawing, inquiry after completing all four drawings, an endorsement and rating 9

of pain at post four-drawing completion (Time 2a), post-protocol measures (Time 2b and 2c), and follow-up measures (Time 3). As a precaution, interviewers checked in with participants for any pain experiences after completing all four drawings, to ensure that participants were not in pain due to the motor activities associated with drawing. Post-protocol measures included the RR, REC, NAPER, and PTCI. One week after completing the protocol, participants were reminded of the interview and reflected on their experience by listening to a

SC RI PT

recording of the inquiry (Time 2c). The study concluded with follow-up measures, which occurred five to six weeks after entry to the study (Time 1), or two weeks after the reminder reflection at Time 2c (Figure 2). Four-Drawing Protocol

Drawing intervention. For all four drawings, participants chose from a selection of colorful and white

U

paper, and pastels or markers. After each drawing, they wrote a title and short story about the drawing. The first

N

four-drawing protocol directive asked the participants to represent the problem, thus assisting in identifying

A

aspects of the traumatic event that needed processing. The second directive asked for a self-portrait; thus,

M

eliciting the representation of the participant’s mental self-image in the context of the adverse event. Then, an optional break, including a guided relaxation breathing exercise of three to five minutes, was offered. The third

D

directive called for a depiction of internal and external resources that had helped with the problem (Hass-Cohen

TE

& Clyde Findlay, 2009). The trauma memory, which was processed in the context of the resources included prompts: “Which resources are external? Which ones are internal? Which one of out of all the internal and

EP

external resources is the most important to you?” To thicken the resource story, participants were then asked to

CC

prioritize and discuss each resource, as well as identify the order in which they drew the resources. The fourth and final directive, another self-portrait, was drawn after exploring the resources with the participant (Bridgham

A

& Hass-Cohen, 2008) and emphasizes the present tense by stating: “draw yourself as you see yourself now,” (Figure 3).

Figure 3. Four-Drawing Protocol Example Post-drawing inquiry. After participants completed the drawing, they completed a brief questionnaire about pain (Time 2a). Then, participants examined their four drawings, shared titles and narratives, and 10

compared the two self-drawings (drawings 2 and 4). Then, they were asked if the protocol sequence was meaningful and what about the sequence was meaningful to them. They also rated the following statements: “Has your understanding of the problem changed?” (scale of 1-7), “If so what type of change was it?” (positive, neutral, or negative), and “What contributed to this change?” After completing the drawing activity and the related inquiry, participants completed post-measures (Time 2b), (Figure 2).

SC RI PT

Reflection. Participants listened to a recording of their four-drawing protocol inquiry and transcribed their responses to the questions above (Time 2c).

Follow-up. Participants responded to and rated the following: 1) “This event negatively affects my life now” (scale of 1-7), 2) “The (a) art activity, (b) discussion, and (c) questionnaires positively affected my access

U

to my resources” (scale of 1-7), 3) “Which of the above (a-c) was most impactful for you?”, 4) “In the time

N

since participating in the protocol did you notice any changes about your experience of the art-based activity?”,

A

and 5) “In the two weeks since the art activity, have you noticed any changes about your experience of the

M

event?” Participants also completed follow-up questionnaires (Time 3). Data Analysis

D

Non-parametric Wilcoxon’s signed rank tests compared means for event rating, pain, and negative affect

TE

(Time 1 to 3), and for posttraumatic growth cognitions, attachment, affect, pain, and resources (Time 1 to 2b). Paired samples t-tests compared affect subscales: sadness, depression, grief, and anxiety (Time 1 to 3).

EP

Cochran’s Q tests compared the frequency of endorsement of pain and affect from all time measurements. Pain

CC

data was measured and analyzed for all four times. Pain results were interpreted with caution, as at Time 1 participants were asked if they were experiencing or had “ever” experienced persisting pain; therefore, a

A

separate analysis without Time 1 data on pain was also conducted for Time 2a, 2b, and 3, where participants were asked if they were experiencing any pain “now.” Results from the qualitative interpretation of the drawings will be reported in a separate publication. Results Participants 11

Participants presented with a profile of resiliency, consisting of a strong trauma impact of pain and negative emotions, combined with a high level of perceived coping. There were more large traumas than small traumas in this sample (n = 21/31; 67%, versus, 6/31; 19%). Large traumas were identified as involving death, near death, or a severe threat to self or a close other, and examples included: sudden unexpected death, sexual assault, and life-threatening illness (n = 4/31; 12%). Examples of small trauma experiences included: divorce,

SC RI PT

surgery, and family relationship issues. Most of the diverse types of traumas occurred during young adulthood (n = 28/31; 90%), and were single incident traumas (n = 19/31; 61%). A third were identified as chronic traumas (n = 12/31; 28%), out of which, a small percentage were childhood traumas (n = 3/31; 10%).

A large majority of the participants rated their feelings of intense helplessness, fear, or horror at the time

U

of the event as very high (n = 19/31; 74%; ratings 6-7, with 7 being the highest rating possible), about a third of

N

the participants rated their feelings as somewhat high (n = 10/31; 32%; ratings 3-5), and about a fifth of the

A

participants rated their feelings as low (n = 6/31; 19%; ratings 1-2). Two thirds of the participants rated that they

M

had coped with the event very well, (n =21/31; 68%; ratings 5-7), about a third of the participants felt they had somewhat coped with the event (n = 10/31; 32%, rating 3-5), and a minority reported not coping with the event

D

(n = 2/31; 1%; ratings 1-2). More than half of the participants rated the trauma effect on their life as somewhat

TE

high (n = 17/31; 55%; ratings 3-5), more than a third rated the trauma effect as very high (n = 12/31; 39%; ratings 6-7), and a minority rated the trauma effect as very low or not at all (n = 2/31; 6%; ratings 1-2). A

EP

majority also endorsed experiencing overall negative affect (n = 28/31; 90%), including an almost equal

CC

endorsement of sadness (n = 31/31; 100%), grief (n = 25/31; 81%), depression (n = 27/31; 87%), and anxiety (n = 29/31; 94%). No significant correlations were found between the rating of the effect of the traumatic event or

A

the level of coping and the type of trauma. Most participants reported persisting pain at time of entry into the study (n =19/31, 61%), and frequent

pain experiences (n = 12/19; 63%), every hour (n = 2/19; 11%), every day (n = 5/19; 26%), or every week (n = 5/19; 26%). About half of the participants reported that they had been experiencing pain for more than a year (n

12

= 10/19; 53%); whereas, the rest of the participants reported experiencing pain for one to 11 months (n = 8/19; 42%), (Table 3). Table 3 Trauma Related Sample Characteristics (N=31) Trauma Effect (Hypothesis One)

SC RI PT

Participants’ rating of the negative effects of the trauma experience on their life, showed a statistically significant decrease (Z = -2.45, p = .014, p < .016) from Time 1 (M = 4.74, SD = 1.51) to Time 3 (M = 4.03, SD = 1.66), (Table 4). Table 4

U

Means and Wilcoxon Signed-Rank Comparisons for Study Variables

N

Negative Affect (Hypothesis Two and Three)

A

Affect endorsement. The number of participants endorsing negative affect from Time 1 to 2b to 3

M

decreased significantly (Q = 18.78, df = 2, p = .000, p < .001). The number of participants endorsing negative affect at Time 1 to 2b significantly decreased (Q = 8, df = 1, p = .005, p < .001). The number of participants

D

endorsing negative affect at Time 1 was also significantly lower at Time 3 (Q = 15, df = 1, p = .000, p < .001).

TE

There was no significant decrease or increase in participants’ endorsement of negative affect from Time 2b to 3, (Q = 3.77, df = 1, p = .052, p < .001), suggesting that gains were maintained (Table 5).

EP

Table 5

CC

Cochran’s Q-Test Endorsement Comparisons for Negative Affect and Pain Affect rating. Ratings of negative affect significantly decreased (Z= -3.13, p = .002, p <. 016), from

A

Time 1 (M = 5.26, SD = 1.12) to Time 3 (M = 2.62, SD = 1.08), (hypothesis three), (Table 4). Ratings of negative affect also significantly decreased (Z = -3.87, p = .000, p < .01), from Time 1 (M = 5.27, SD = 1.12) to Time 2b (M = 2.67, SD = .94). There was no significant difference found for negative affect ratings (Z = -.358, p = .72, p < .025) from Time 2b (M = 2.67, SD = .94) to Time 3 (M = 2.61, SD = 1.08). However, when comparing negative affect subscales, there was a statistically significant and similar decrease from Time 1 to 3 13

for all subscales, including: sadness (t (6) = 4.75, p = .003), grief (t (4) = 5.01, p = .007), depression (t (4) = 3.54, p = .024), and anxiety (t (7) = 7.00, p = .000), (Figure 4).

SC RI PT

Figure 4. Negative Affect: Averages of Raw Data Note. Endorsements: Time 1: Sadness (n = 31), Grief (n = 25), Depression (n = 27), Anxiety (n = 29), Time 2b: Sadness (n = 14), Grief (n = 14), Depression (n = 5), Anxiety (n = 14), Time 3: Sadness (n = 24), Grief (n = 25), Depression (n = 26), Anxiety (n = 22). Ratings: Time 1: Sadness (M = 5.51, SD = 1.46), Grief (M = 5.44, SD = 1.50), Depression (M = 4.78, SD = 1.72), Anxiety (M = 5.34, SD = 1.42), Time 2b: Sadness (M = 2.50, SD = 1.16), Grief (M = 2.29, SD = .91), Depression (M = 3.00, SD = 1.41), Anxiety (M = 3.00, SD = 1.47), Time 3: Sadness (M = 2.00, SD = 1.00), Grief (M = 2.17, SD = .98), Depression (M = 2.60, SD = 1.52), Anxiety (M = 3.56, SD = 1.01) Pain (Hypothesis Four and Five)

Pain endorsement. There was no significance for pain endorsement from Time 2a to 2b to 3, (Q = 4.2, df = 2, p = .122, p < .001), Time 2a to 2b (Q = 2.67, df = 1, p = .102, p < .001), Time 2a to 3 (Q = 3.571, df = 1,

U

p = .059, p < .001), or Time 2b to 3 (Q = .143, df = 1, p = .705, p < .001), (hypothesis four), (Table 5).

N

Most of the participants that endorsed pain at Time 1 reported experiencing chronic and frequent pain (n

A

= 19/31, 61%); therefore, for discussion purposes, further analysis assessed for significance in the difference in

M

the number of participants endorsing pain between Time 1 and Times 2a, 2b and 3 (hypothesis four). Results

D

showed a significant decrease in the endorsement of pain across all times (Q = 28.41, df = 3, p = .000, p < .001)

TE

(Table 5), (Figure 3). Pain endorsement also significantly decreased from Time 1 to 2a (Q = 17, df = 1, p = .000, p < .001), and from Time 1 to 2b, (Q = 11.267, df = 1, p = .001, p < .001). There was no significant change

EP

between Time 2a and 2b (Q = 2.67, df = 1, p = .102, specified p < .001). While there was a large reduction in the raw number of participants that endorsed pain from Time 1 to 3 (n = 7/31 vs. n = 19/31), this frequency was

CC

not significant (Q = 9, df = 1, p = .003, p < .001), (Table 5), (Figure 5).

A

Figure 5. Pain Endorsement & Rating Note. Time 1 (n = 19), Time 2a (n = 2) Time 2b (n = 6), Time 3 (n = 7). Pain ratings: Time 1 (M = 4.58), Time 2a (M = 2) Time 2b (M = 2.83), Time 3 (M = 3.14). Pain rating. Analysis of ratings for participants who endorsed pain at Time 1 (n = 19) and continued to

endorse pain at Time 3 (n = 5/19) did not significantly decrease (Z = -2.04, p = .041. p < .016) from Time 1 (M = 4.58, SD = 1.78) to Time 3 (M = 3.14, SD = 1.57), (hypothesis five). For participants that continued to endorse pain (n = 6/19) from Time 1 (M = 4.58, SD = 1.77) to Time 2b (M = 2.83, SD = 1.60), ratings showed 14

no significant difference (Z = -1.89, p = .059, p < .01). Finally, for Time 2b (n = 6/19) to Time 3 (n = 7/19) there was not a statistically significant decrease in pain rating for those that continued to endorse pain (n = 6, Z = -1.00, p = .317, p < .01), (Table 4), (Figure 3). Relationship between affect and pain. There were no significant correlations between affect and pain ratings or endorsements (Figure 6).

SC RI PT

Figure 6. Negative Affect and Pain. Note. Time 1 (N = 31), Time 2b (n = 23), Time 3 (n =16). Pain Endorsement: Time 1 (n = 19), Time 2a (n = 2) Time 2b (n = 6), Time 3 (n = 7). Negative Affect Ratings: Time 1 (M = 5.26), Time 2b (M = 2.67), Time 3 (M = 2.62). Pain ratings: Time 1 (M = 4.58), Time 2a (M = 2) Time 2b (M = 2.83), Time 3 (M = 3.14). For purposes of illustration Time 1 endorsement was included. Resources (Hypothesis Six)

U

Participation in the protocol significantly increased the frequency of endorsed resources (Z = -4.06, p =

N

.000, p < .01), from Time 1 (M = 39.81, SD = 8.11) to Time 2b (M = 46.87, SD = 7.24), (Table 5). The types of

A

resources endorsed pre- or post-intervention did not significantly differ.

M

Responses to Drawing (Hypothesis Seven)

On average, participants rated that the drawing activity specifically, greatly changed their understanding

D

of the trauma, their resources, and the self (M = 4.71), (scale of 1-7). The average direction of change for the

TE

participants’ change in understanding of the trauma, resources, and self was positive (M = 1.31), (scale of 1 being positive, 2 being neutral, and 3 being negative), (Figure 7).

CC

EP

Figure 7. Responses to Drawing Note. Increased understanding of problem (DR1, M = 4.06), Self 1 (DR2, M = 5.10), Resources (DR3, M = 4.52), Self 2 (DR4, M = 5.16) Participants agreed that the full protocol, including the drawing activity, questionnaires, and inquiry,

A

positively affected their access to their own resources (M = 5.3), (scale of 1-7). A majority rated the drawing activity as the most positive contributor to their ability to access resources (67%), a quarter of the participants rated discussion as the most positive contributor (25%), and a small number rated the questionnaires as the most positive contributor (8%), (Figure 8). Figure 8. Protocol Components 15

Posttraumatic Growth Cognitions (Hypothesis Eight) There was no significant difference in posttraumatic growth cognitions ratings (Z = -.382, p = .702, p < .01) from Time 1 (M = 3.263, SD = .798) to Time 2b (M = 3.333, SD = .968), (Table 4). Relational Security (Hypothesis Nine) There was no significant difference in attachment security ratings (Z = -.730, p = .465, p < .01) from

SC RI PT

Time 1 (M = 5.069, SD = 1.125) to Time 2b (M = 5.195, SD = 1.007), (Table 4). Summary

There were significant decreases in the trauma effect rating and negative affect endorsements and ratings from time of entry to follow-up at five weeks later. Decreases in negative affect occurred immediately

U

following the drawing activity and were maintained at follow-up, possibly accounting for the trauma effect

N

rating change. Comparisons of pain measurement should be interpreted with caution due to the small sample

A

and methodological issues. At time of entry, 19 participants endorsed pain, whereas, at follow-up, only six

M

participants endorsed pain. The trend was changes in pain endorsement and ratings after the drawing activity and after the full protocol completion, which were maintained at follow-up. It also seems that as pain

D

experiences decreased, so did negative affect. No significant differences in the posttraumatic growth cognitions

TE

or relational security were noted. Interestingly, there is some evidence to indicate that high levels of resilience, such as those associated with a graduate student population, could be associated with low PTCI scores (Levine,

EP

Laufer, Stein, Hamama-Raz, & Solomon, 2009). The number of endorsed resources from time of entry to after

CC

the drawing activity increased significantly. When compared to the questionnaires and inquiry, the drawing activity was rated as the most positive contributor to change.

A

Discussion

The protocol’s fours drawing sequencing which included the revisiting of resource lists, the

contemplation of two self-portraits, and, the inquiry were designed to meet MR critical conditions: The reactivating of old memories and engagement in novel and positive emotive experiences (Lane, Ryan, Nadel, & Greenberg, 2015); Hardt et al., 2010). For the first drawing there was no assumption that the distressing event 16

was the problem and thus, it functioned to redefine the problem while minimizing exposure to the trauma. The second directive invited a view of selfhood in the context of the problem reminder. The trauma reminder and its impact on the person’s reaction and selfhood formed the foundation for MR to occur. The updating of memory was stimulated by the third resource-focused drawing and inquiry. Thus, the adversely impacted autobiographical narrative was sequentially updated with resiliency factors. The fourth drawing and subsequent

SC RI PT

comparison of the two self-portraits provided an opportunity for self-observation and for re-scripting the trauma narrative, while at the same time emphasized an updated view of the self. The implicit and explicit request was to actively integrate what had been learned in order to activate a novel reanimation of the person’s past, present, and future (Hass-Cohen & Clyde Findlay, 2009). Throughout the protocol, implicit art-making played a critical

U

role, as MR implicit and explicit memories were equally activated (Hass-Cohen & Clyde Findlay, 2017). It is

N

possible that this is the reason that participants’ implicit pain experiences were modified. During the protocol,

A

the emotive, cognitive, and somatic externalization of problems were likely mediated by aesthetic distancing

M

(Lahad et al., 2010), and contextualization and mismatching of information (Hass-Cohen, 2016). Distancing provided an opportunity to reflect rather than ruminate, promoted contextualization, and set the stage for new

D

information to be accepted. Contextualization provided coherent temporal dimensions to fragmented

TE

autobiographical narratives; whereas, mismatched information provided compelling evidence that contradicted negative biases and beliefs. Such prediction errors triggered an interaction between the old and new memory

EP

(Pedreira, Pérez-Cuesta, & Maldonado, 2004), which were thought to promote flexible interactions between

CC

physical, emotional, and cognitive perceptions (Sarid & Huss, 2010). Visual memory processing has been strongly correlated with overall cognitive ability (Luck & Vogel,

A

2014). Furthermore, it is likely that the visual memory processing involved in the planning and making of artwork contributed to attention and motivation, despite possible emotional distress. Since memory storage has been described as modality-dependent (Fougnie & Marois, 2011), visual processing most likely increased the capacity for change. Similarly, the sequencing of the art-making likely bypassed the propensity of explicitverbal negative biases to interfere with MR updates. Hypothetically, engaging with the arts during MR 17

mitigated the influences of previous, proactive knowledge or retroactive interference, which may have accounted for results at follow-up (Hass-Cohen, 2016). Finally, our participants presented with a high trauma effect and high perceived coping profile, perhaps suggesting the importance of these two factors for a traumatized population and a role for the four-drawing protocol with potentially resilient individuals. Limitations

SC RI PT

A main study limitation was the initial pain measurement, as it was not clear if participants endorsed pain in general or only at time of study entry. However, results showed that less than half of those that initially endorsed pain, endorsed pain experiences post-protocol participation and at follow-up. While an argument could be made that graduate students prior knowledge positively skewed the results, we suggest that the non-

U

verbal art-making expression, which is implicit and less subject to cognitive functioning, robustly mediated this

N

bias. We anticipate that a future qualitative analysis of the drawings will provide additional information on

A

which type of resources and resiliency traits the participants deemed most important and how the art-making

M

specifically had a meaningful impact. Another main limitation was that the participants were almost all female; thus, the results should not be generalized to other genders. In summary, the current study piloted a single

D

session, strength-based, arts, trauma, and resiliency protocol, and suggested its potential efficacy for alleviating

TE

psychological and physical pain reactions to adversity. It was uniquely designed to provide an opportunity for redrawing and re-narrating selfhood in the context of recalled, perceived, and imagined resources rather than

A

CC

EP

trauma. Future four-drawing protocol research efforts will be focused on randomized controlled clinical studies.

18

References Achterberg, J., Dossey, B., & Kolkmeier, L. (1994). Rituals of healing: Using imagery for health and wellness. New York, NY: Bantam Books. Agaibi, C. E., & Wilson, J. P. (2005). Trauma, PTSD, and resilience: A review of the literature. Trauma, Violence and Abuse, 6(3), 195–216. doi:10.1177/1524838005277438

SC RI PT

AlAjarma, Y. (2010). The role of the arts toward healing trauma and building resilience in the Palestinian community. (Doctoral Dissertation). Retrieved online:

https://digitalcommons.lesley.edu/cgi/viewcontent.cgi?article=1033&context=expressive_dissertations American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

U

Washington, DC: Author.

N

Avrahami, D. (2006). Visual art therapy’s unique contribution in the treatment of post-traumatic stress

A

disorders. Journal of Trauma and Dissociation, 6(4), 5–38. doi:10.1300/J229v06n0402

M

Baker, B. A. (2006). Art speaks in healing survivors of war: The use of art therapy in treating trauma survivors. Journal of Aggression, Maltreatment and Trauma, 12, 183–198. doi:10.1300/J146v12n01_10

D

Baker, F. A., Metcalf, O., Varker, T., & O'Donnell, M. (2017). A systematic review of the efficacy of creative

TE

arts therapies in the treatment of adults with PTSD. Psychological Trauma: Theory, Research, Practice and Policy. doi:10.1037/tra0000353.

EP

Başoglu, M., Salcioglu, E., Livanou, M. (2007). A randomized controlled study of single-session behavioral

CC

treatment of earthquake-related post-traumatic stress disorder using an earthquake simulator. Psychological Medicine, 37(2), 203-13. doi:10.1017/S0033291706009123

A

Bridgham, T., & Hass-Cohen, N. (2008). Art therapy and acquired immune deficiency syndrome (AIDS): A relational neuroscience case conceptualization. In N. Hass-Cohen & R. Carr (Eds.), Art therapy and clinical neuroscience (pp. 270–281). London, England: Jessica Kingsley. Camic, P. M. (1999). Expanding chronic pain treatments through expressive arts. In C. Malchiodi (Ed.), Medical art therapy with adults (pp. 43–46). Philadelphia, PA: Jessica Kingsley. 19

Campbell, M., Decker, K. P., Kruk, K., & Deaver, S. P. (2016). Art therapy and cognitive processing therapy for combat-related PTSD: A randomized controlled trial. Art Therapy: Journal of the American Art Therapy Association, 33, 169 –177. doi:10.1080/07421656.2016.1226643 Carr, S. M. D. (2014). Revisioning self-identity: The role of portraits, neuroscience and the art therapist’s ‘third hand.’ International Journal of Art Therapy, 19(2), 54–70. doi:10.1080/17454832.2014.906476

SC RI PT

Clyde Findlay, J. (2008). Immunity at risk and art therapy. In N. Hass-Cohen & R. Carr (Eds.), Art therapy and clinical neuroscience (pp. 207–220). London, England: Jessica Kingsley.

Collie, K., Backos, A., Malchiodi, C., & Spiegel, D. (2006). Art therapy for combat-related PTSD:

Recommendations for research and practice. Art Therapy: Journal of the American Art Therapy

U

Association, 23, 157–164. doi:10.1080/07421656.2006.10129335

N

Curry, N. A., & Kasser, T. (2005). Can coloring mandalas reduce anxiety? Art Therapy: Journal of the

A

American Art Therapy Association, 22, 81–85. doi:10.1080/07421656.2005.10129441

M

Czamanski-Cohen, J., Sarid, O., Huss, E., Ifergane, A., Niego, L., & Cwikel, J. (2014). CB-ART—The use of a hybrid cognitive behavioral and art based protocol for treating pain and symptoms accompanying coping

D

with chronic illness. The Arts in Psychotherapy, 41(4), 320-328. doi:10.1016/j.aip.2014.05.002

TE

Doran, J., Pietrzak, R. H., Hoff, R., & Harpaz-Rotem, I. (2017). Psychotherapy utilization and retention in a national sample of veterans with PTSD. Journal of Clinical Psychology 73(10), 1259–1279.

EP

doi:10.1002/jclp.22445

CC

Ennis, G., Kirshbaum, M., & Waheed, N. (2017). The beneficial attributes of visual art-making in cancer care: An integrative review. European Journal of Cancer Care. doi:10.1111/ecc.12663

A

Erickson, B. J. (2008). Art therapy treatment with incarcerated women (Unpublished dissertation). Dissertation Abstracts International Section A: Humanities and Social Sciences, 70(1-A), 100.

Foa, E. B., Ehlers, P., Clark, D. M., Tolin, D. F., & Orsillo, S. M. (1999). The posttraumatic cognitions inventory (PTCI): Development and validation. Psychological Assessment, 11(3), 303–314.

20

Fougnie D., & Marois R. (2011). What limits working memory capacity? Evidence for modality-specific sources to the simultaneous storage of visual and auditory arrays. Journal of Experimental Psychology, Learning Memory and Cognition, 37(6), 1329-41. doi:10.1037/a0024834. Gallagher, M. W., & Lopez, S. J. (2007). Curiosity and well-being. The Journal of Positive Psychology, 2(4), 236–248. doi:10.1080/17439760701552345

SC RI PT

Gantt, L., & Tinnin, L. W. (2009). Support for a neurobiological view of trauma with implications for art therapy. The Arts in Psychotherapy, 36, 148–153. doi:10.1016/j.aip.2008.12.005

Gerge, A., & Pedersen, I. N. (2017). Analyzing pictorial artifacts from psychotherapy and art therapy when overcoming stress and trauma. The Arts in Psychotherapy, 54, 56–68. doi:10.1016/j.aip.2017.02.001

U

Gil, S., & Weinberg, M. (2015). Coping strategies and internal resources of dispositional optimism and mastery

A

Trauma, 7(4), 405–411. doi:10.1037/tra0000032.

N

as predictors of traumatic exposure and of PTSD symptoms: A prospective study. Journal of Psychological

M

Hardt, O., Einarsson, E. Ö., & Nader, K. (2010). A bridge over troubled water: Reconsolidation as a link between cognitive and neuroscientific memory research traditions. Annual Review of Psychology, 61, 141–

D

167. doi:10.1146/annurev.psych.093008.100455

TE

Hass-Cohen, N. (2008). CREATE: Art therapy relational neuroscience principles (ATR-N). In N. Hass-Cohen & R. Carr (Eds.), Art therapy and clinical neuroscience (pp. 283–309). London, England: Jessica Kingsley.

EP

Hass-Cohen, N. (2016). Secure resiliency: Art therapy relational neuroscience trauma treatment principals and

CC

guidelines. In J. King. Art therapy, trauma and neuroscience: Theoretical and practical perspectives (pp. 100–138). London, England: Routledge Publishers.

A

Hass-Cohen, N., & Clyde Findlay, J. (2009). Pain, attachment, and meaning making: Report on an art therapy relational neuroscience assessment protocol (A case study). The Arts in Psychotherapy, 36(4), 175–184. doi:10.1016/j.aip.2009.02.003

21

Hass-Cohen, N., & Clyde Findlay, J. (2015). Adaptive responding: Secure remembrance. In Art therapy & the neuroscience of relationships, creativity, and resiliency: The interpersonal neurobiology series (pp. 258– 300). New York, NY: W.W. Norton Publishers. Hass-Cohen, N., & Clyde Findlay, J. (2018). Recovery from grief and pain: Results from an art therapy relational neuroscience four-drawing art therapy trauma and resiliency protocol. In D. Abuhoff-Gaydos &

SC RI PT

M. Gliniak, Medical arts therapy. In press. London, England: Routledge Publishers.

Hass-Cohen, N., Clyde Findlay, J., Carr, R., & Vanderlan, J. (2014). Check, change, and/or keep what you need”: An art therapy relational neurobiological (ATR-N) trauma intervention. Art Therapy: Journal of the American Art Therapy Association, 31(2) 69–78. doi:10.1080/07421656.2014.903825

U

Henderson, P., Rosen, D., & Mascaro, N. (2007). Empirical study on the healing nature of mandalas.

N

Psychology of Aesthetics, Creativity, and the Arts, 1, 148–154. doi:10.1037/1931-3896.1.3.148

A

Herman, J. L. (2015). Trauma and recovery: The aftermath of violence--From domestic abuse to political

M

terror. New York, NY: Basic Books.

Hinz, L. (2009). Expressive therapies continuum: A framework for using art in therapy. New York, NY:

D

Routledge.

TE

Hongo, A., Katz, A., & Valenti, K. (2015). Art: Trauma to therapy for aging female prisoners. Traumatology, 21(3), 201-207. doi:10.1037/trm0000042

EP

Jones, J. P., Walker, M., S., Masino Drass, J., & Kaimal, G. (2017). Art therapy interventions for active duty

CC

military service members with post-traumatic stress disorder and traumatic brain injury. International Journal of Art Therapy, (online). doi.org/10.1080/17454832.2017.1388263

A

Johnson, D. R., Lahad, M., & Gray (2009). Creative therapies for adults. In E. B. Foa, T. M. Keane, & M. J. Friedman (Eds.), Effective treatments for PTSD: Practice guidelines from the international society for traumatic stress studies (pp. 600–602) (2nd edition). New York, NY: Guilford. Kalmanowitz, D. (2016). Inhabited studio: Art therapy and mindfulness, resilience, adversity and refugees. International Journal of Art Therapy: Inscape, 21(2), 75-84. doi:10.1080/17454832.2016.1170053 22

Kalmanowitz, D., & Ho, R. T. (2016). Out of our mind. Art therapy and mindfulness with refugees, political violence and trauma. The Arts in Psychotherapy, 49, 57-65. doi:10.1016/j.aip.2016.05.012 Kok, B. E., & Fredrickson, B. L. (2013). Positive emotion: How positive emotions broaden and build. In J. J. Froh, A. C. Parks, J. J. Froh, A. C. Parks (Eds.), Activities for teaching positive psychology: A guide for instructors (pp. 61–63). Washington, DC: American Psychological Association. doi:10.1037/14042-010

SC RI PT

Lahad, M. (2017). From victim to victor: The development of the BASIC PH model of coping and resiliency. Traumatology, 23(1), 27–34.

Lahad, M., & Leykin, D. (2013). Introduction: The integrative model of resiliency – The BASIC Ph model, or What do we know about survival? In M. Lahad, M. Shacham, & O. Ayalon (Eds.), The "BASIC Ph" model

U

of coping and resiliency: Theory, research and cross-cultural application (pp. 9–30). London, England:

N

Jessica Kingsley.

A

Lahad, M., Farhi, M., Leykin, D., & Kaplansky, N. (2010). Preliminary study of a new integrative approach in

M

treating post-traumatic stress disorder: SEE FAR CBT. The Arts in Psychotherapy 37, 391-399. doi:10.1016/j.aip.2010.07.003

D

Lane, R. D., Ryan, L., Nadel, L., & Greenberg, L. (2015). Memory reconsolidation, emotional arousal, and the

TE

process of change in psychotherapy: New insights from brain science. Behavioral and Brain Sciences, 38(1). doi:10.1017/S0140525X14000041

EP

Levine, S. Z., Laufer, A., Stein, E., Hamama-Raz, Y., & Solomon, Z. (2009). Examining the relationship

CC

between resilience and posttraumatic growth. Journal of Traumatic Stress, 22, 282–286. doi:10.1002/jts.20409

A

Liedl, A., O'Donnell, M., Creamer, M., Silove, D., McFarlane, A., & Knaevelsrud, C. (2010). Support for the mutual maintenance of pain and post-traumatic stress disorder symptoms. Psychological Medicine, 40(7), 1215–1223. doi:10.1017/S0033291709991310 Luck, S. J., & Vogel, E. K. (2013). Visual working memory capacity: From psychophysics and neurobiology to individual differences. Trends Cognitive Science, 17(8), 391–400. doi: 10.1016/j.tics.2013.06.006 23

Maddi, S. R. (2006). Hardiness: The courage to grow from stresses. Journal of Positive Psychology, 1(3), 160–168. doi:10.1080/17439760600619609 Meekums, B. (1999). A creative model for recovery from child sexual abuse trauma. The Arts in Psychotherapy, 26(4), 247–259. doi:10.1016/S0197-4556(98)00076-8 Meredith, P., Ownsworth, T., & Strong, J. (2008). A review of the evidence linking adult attachment theory and

SC RI PT

chronic pain: Presenting a conceptual model. Clinical Psychology Review, 28, 407–429. doi:10.1016/j.cpr.2007.07.009

Monfils, M., Cowansage, K. K., Klann, E., & LeDoux, J. E. (2009). Extinction-reconsolidation boundaries: Key to persistent attenuation of fear memories. Science, 324(5929), 951-955. doi:10.1126/science.1167975

U

Moxley, D., Washington, O., & Feen-Calligan, H. (2012). Narrative insight into risk, vulnerability and

N

resilience among older homeless African American women. Arts in Psychotherapy, 39(5), 150–157.

A

doi:10.1016/j.aip.2012.08.002

M

Naff, K. (2014). A framework for treating cumulative trauma with art therapy. Art Therapy: Journal of the American Art Therapy Association, 31(2), 79–86. doi:10.1080/07421656.2014.903824

D

Nainis, N., Paice, J. A., Ratner, J., Wirth, J. H., Lai, J., & Shott, S. (2006). Relieving symptoms in cancer:

TE

Innovative use of art therapy. Journal of Pain and Symptom Management, 31(2), 162–169. doi:10.1016/j.jpainsymman.2005.07.006

EP

Nanda, U, Gaydos, L., Hathorn, K., & Watkins, N. (2010). Art and posttraumatic stress: A review of the

CC

empirical literature on the therapeutic implications of artwork for war veterans with posttraumatic stress disorder. Environment and Behavior, 42, 376. doi:10.1177/0013916510361874

A

Pedreira, M. E., Pérez-Cuesta, L. M., & Maldonado, H. (2004). Mismatch between what is expected and what actually occurs triggers memory reconsolidation or extinction. Learning and Memory, 11(5), 579-585. doi:10.1101/lm.76904 Peterson, C., Park, N., & Seligman, M. E. P. (2004). Strengths of character and well–being. Journal of Social and Clinical Psychology, 23(5), 603–619. doi:10.1521/jscp.23.5.603.50748 24

Philips, H. C. (2011). Imagery and pain: the prevalence, characteristics, and potency of imagery associated with pain. Behavioral and Cognitive Psychotherapy, 5, 523–40. doi:10.1017/S1352465811000282 Puetz, T. W., Morley, C. A., & Herring, M. P. (2013). Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer. Journal of the American Medical Association, 173(11), 960–969. doi:10.1001/jamainternmed.2013.836

SC RI PT

Rankin, A. B., & Taucher, L. C. (2003). A task-oriented approach to art therapy in trauma treatment. Art Therapy: Journal of the American Art Therapy Association, 20(3), 138–147. doi:10.1080/07421656.2003.10129570

Sarid, O., & Huss, E. (2010). Trauma and acute stress disorder: A comparison between cognitive behavioral

U

intervention and art therapy. The Arts in Psychotherapy, 37(1), 8–12. doi:10.1016/j.aip.2009.11.004

N

Schouten, K. A., de Niet, G. J., Knipscheer, J. W., Kleber, R. J., & Hutschemaekers, G. M. (2015). The

A

effectiveness of art therapy in the treatment of traumatized adults: A systematic review on art therapy and

M

trauma. Trauma, Violence, and Abuse, 16(2), 220–228. doi:10.1177/1524838014555032 Schwabe, L., Nader, K., & Pruessner, J. C. (2014). Reconsolidation of human memory: Brain mechanisms and

D

clinical relevance. Biological Psychiatry, 76(4), 274–280. doi:10.1016/j.biopsych.2014.03.008

TE

Schottenbauer, M. A., Glass, C. R., Arnkoff, D. B., Tendick, V., & Hafter Gray, S. (2008). Nonresponse and dropout rates in outcome studies on PTSD: Review and methodological considerations. Psychiatry:

EP

Interpersonal and Biological Processes, 71(2), 134–168. doi.org/10.1521/psyc.2008.71.2.134

CC

Siqveland, J., Ruud, T., & Hauff, E. (2017). Post-traumatic stress disorder moderates the relationship between trauma exposure and chronic pain. European Journal of Psychotraumatology, 8(1).

A

doi:10.1080/20008198.2017.1375337 Slive, A., & Bobele, M. (2012). Walk-in counseling services: Making the most of one hour. Australian and New Zealand Journal of Family Therapy, 33(1), 27–38. doi:10.1017/aft.2012.4 Stok, M. (2007). Eenmalige exposure in beeldende therapie. Onderzoek naar het in beeld brengen van traumatische ervaringen optraumagerelateerde klachten. Tijdschrift voor Vaktherapie, 3, 3–10. 25

Sutherland, K., & Bryant, R. A. (2005). Self-defining memories in post-traumatic stress disorder. British Journal of Clinical Psychology, 44(4), 591–598. doi:10.1348/014466505X64081 Talmon, M. (1993). Single-session solutions: A guide to practical, effective, and affordable therapy. Reading, MA: Addison-Wesley Publishing Company Talwar, S. (2007). Accessing traumatic memory through art making: An art therapy trauma protocol (ATTP).

SC RI PT

The Arts in Psychotherapy, 34(1), 22–35. doi:10.1016/j.aip.2006.09.001

Trauger-Querry, B., & Haghighi, K. R. (1999). Balancing the focus: Art and music therapy for pain control and symptom management in hospice care. Hospice Journal,14(1), 25-38.

Tripp, T. (2007). A short-term therapy approach to processing trauma: Art therapy and bilateral stimulation. Art

U

Therapy: Journal of the American Art Therapy Association, 24(4), 176–183.

N

doi:10.1080/07421656.2007.10129476

A

Volker, C. A. (1999). Treatment of sexual assault survivors utilizing cognitive therapy and art therapy

M

(Unpublished Dissertation). Dissertation Abstracts International: Section B. 60(5B), 2374. Walker, M. S., Kaimal, G., Koffman, R., & DeGraba, T. J. (2016). Art therapy for PTSD and TBI: A senior

D

active duty military service member’s therapeutic journey. The Arts in Psychotherapy, 49, 10-18. doi:

TE

https://doi.org/10.1016/j.aip.2016.05.015

Wang, X., Lan, C., Chen, J., Wang, W., Zhang, H., & Li, L. (2015). Creative arts program as an intervention for

EP

PTSD: A randomized clinical trial with motor vehicle accident survivors. International Journal of Clinical

CC

and Experimental Medicine, 8, 13585–13591. Worrall, L., & Jerry, P. (2007). Resiliency and its relationship to art therapy. Canadian Art Therapy Association

A

Journal, 20(2), 35–53. doi:10.1080/08322473.2007.11434772 Zimmermann, P., Firnkes, S., Kowalski, J., Backus, J., Alliger-Horn, C., Willmund, G., Hellenthal, A., Bauer, A., Petermann, F., & Maercker, A. (2015). Mental disorders in German soldiers after deployment - Impact of personal values and resilience. Psychiatrische Praxis, 42(8), 436-442. doi: 10.1055/s-0034-1370242

26

D

TE

EP

CC

A

Fig 1

27

SC RI PT

U

N

A

M

D

TE

EP

CC

A

Fig 2

28

SC RI PT

U

N

A

M

Fig 3

29

D

TE

EP

CC

A

SC RI PT

U

N

A

M

D

TE

EP

CC

A

SC RI PT

U

N

A

M

Fig 4

Fig 5

30

D

TE

EP

CC

A

SC RI PT

U

N

A

M

Fig 6

Fig 7

31

SC RI PT U N A M D TE CC

Table 1

EP

Fig 8

A

Univariate Statistics for Sample Demographics (N=31)

Gender Female Male Age Race White Hispanic/Latino

N 31 27 4 31 31 13 13

% M - 1.87 87 13 - 29.68 - 1.97 42 42 -

SD .34 8.32 1.28 -

Median 2 26 1 32

2 2 1 31 31 31 2 2 7 14 8 31 24 7 31 20 11

7 7 3 - 24.94 10.06 - 4.29 3.89 - 3.90 .87 7 7 23 45 26 .77 .43 77 23 .35 .49 65 36 -

22 3 4 1 0 -

N

U

Table 2

SC RI PT

African American/Black Asian/Pacific Islander Other Age when the event occurred Years since the event occurred Physical health rating 1= Poor 2= Unsatisfactory 3= Satisfactory 4= Good 5= Very Good Spirituality Yes No Religion No Yes

TE

D

M

A

Hypotheses Participation in the four-drawing protocol would result in: 1. decreases in overall effect of the traumatic event 2. decreases in negative affect endorsement (sadness, grief, depression, anxiety) 3. decreases in negative affect rating (sadness, grief, depression, anxiety) 4. reductions in pain endorsement 5. reductions in pain rating 6. increases in resiliency-based resources 7. positive impact of the participants’ understanding of the problem and resources 8. increases in posttraumatic growth cognitions 9. increases in relational security

A

CC

EP

Table 3 Trauma Related Sample Characteristics (N=31) N % M SD Median Horror 31 - 5.55 1.57 7 1= not at all 1 3 2 1 3 3 0 0 4= somewhat 6 19 5 4 13 6 8 26 7= very much so 11 36 Coping 31 - 5.26 1.15 4 1= not at all 0 0 2 0 0 3 1 3 33

M

D

EP

SC RI PT U

N

CC

Table 4

6 5.33 5 3 6 -

A

9 29 7 23 9 29 5 16 31 - 4.74 1.51 1 3 1 3 6 19 3 10 8 26 10 32 2 7 31 - 5.27 1.12 31 100 25 81 27 87 29 94 31 - 4.58 1.77 19 61 12 39 19 - 3.22 1.44 3 17 2 11 5 26 5 26 2 11 1 6 19 - 4.67 1.65 0 0 3 17 2 11 3 17 0 0 10 53 -

TE

4= somewhat 5 6 7= very much so Trauma effect 1= not at all 2 3 4= somewhat 5 6 7= very much so Negative affect Sadness Grief Depression Anxiety Pain Yes No Frequency of Pain 1= one to three times a year 2= one to two times a month 3= every week 4= every day 5= every hour 6= other (please describe) Duration of Pain 1= two weeks 2= one month 3= two months 4= three months or more 5= six months or more 6= a year or more

A

Means and Wilcoxon Signed-Rank Comparisons for Study Variables Time

Time 1Entry to Time 3Follow up

Measures TE: Rating of trauma’s negative effect on participant’s life NAPER: Rating of negative affect

N 31

Pre Pre Mean SD 4.74 1.51

Post Mean 4.03

Post SD 1.66

-2.45*

palpha value level .014 .016

16

5.26

2.62

1.08

-3.13*

.002

1.12

Z/t

.016 34

1.27 1.52 1.23 1.20 1.78

2 2.20 2.60 3.75 3.14

1 1.10 1.52 .89 1.57

4.75 5.01 3.54 7.00 -2.04

.003 .007 .024 .000 .041

.01 .01 .01 .01 .016

3.26

.80

3.33

.97

-.38

.702

.01

5.07

1.13

5.19

1.01

-.73

.465

.01

5.27

1.12

2.67

.94

-3.87*

.000

.01

4.58

1.77

2.83

1.60

-1.89

.059

.01

7.24

-4.06*

.00

.01

1.57

-1.00

.317

.025

1.08

-.358

.72

.025

46.87

2.83

1.60

3.14

2.67

.94

2.61

N

U

39.81 8.11

SC RI PT

5.57 5.60 5.00 5.50 4.58

M

A

- Sadness 7 - Grief 5 - Depression 5 - Anxiety 8 NAPER: Rating of 5 persistent physical pain PTCI: Post31 Traumatic Growth Cognitions RR: Rating of 31 Time 1 relationship items Entry to NAPER: Rating of 19 Time 2b negative affect Protocol NAPER: Rating of 6 Completion physical pain REC: Average 31 endorsement of resources NAPER: Rating of 6 Time 2bIntervention physical pain to Time 3 NAPER: Rating of 7 Follow up negative affect Note. Significant Z’s are denoted with a *.

Table 5

Measures Endorsement of negative affect Endorsement of pain Time 1 to Endorsement Time 3 of negative (Pre and 5 affect week Endorsement Conclusion) of pain Time 1 to Endorsement Time 2a of pain Time 1 to Endorsement Time 2b of negative Pre and affect Post Endorsement Protocol of pain

N

TE

Time Across Time

31

Q

df

p-value

alpha level

18.78*

2

.000

.001

30

28.41*

3

.000

.001

31

15*

1

.000

.001

31

9

1

.003

.001

31

17*

1

.000

.001

31

8

1

.005

.001

30

11.267

1

.001

.001

EP

CC

A

D

Cochran’s Q-Test Endorsement Comparisons for Negative Affect and Pain

35

A

CC

EP

TE

D

M

A

N

U

SC RI PT

Interview Time 2a to Endorsement 30 2.67 1 .102 .001 2b of pain Time 2b to Endorsement Time 3 of negative 31 3.769 1 .052 .001 Post affect Protocol to Endorsement 30 .143 1 .705 .001 Conclusion of pain Note. The * represents significance. A Bonferroni adjustment for familywise error determined alpha level for pvalue analysis.

36