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Trauma and acute stress disorder: A comparison between cognitive behavioral intervention and art therapy
The Arts in Psychotherapy 37 (2010) 8–12
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The Arts in Psychotherapy
Trauma and acute stress disorder: A comparison between cognitive behavioral intervention and art therapy Orly Sarid, PhD ∗ , Ephrat Huss, PhD Social Work Department, Faculty of Humanities & Social Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Keywords: Acute stress disorder Cognitive behavioral intervention Art therapy
a b s t r a c t The aim of this paper is to initiate a comparative and theoretical study between the mechanisms of cognitive behavioral intervention (CBI) versus art therapy, in relation to the acute stress disorder (ASD) stage of trauma. The literature on CBI, art therapy, and ASD will be briefly reviewed. Similarities between these two theoretically disparate interventions will be outlined, pointing to the relevance of CBI and art therapy to alter maladaptive and traumatic sensory processing, affect excitatory reactions, modulate and challenge explicit traumatic memories and stimulate a subsequent cognitive process. Implications for mental health professionals intervening in the relatively flexible ASD period are discussed. © 2009 Elsevier Inc. All rights reserved.
Introduction This paper seeks to compare the principles of two clinical interventions, cognitive behavioral intervention (CBI) and art therapy, in acute stress disorder (ASD). While both interventions stem from very different theories, we will present their similarities in practice, and point to their specific characteristics of integrating an intervention on traumatic memory formation utilizing physical, emotional, and cognitive aspects simultaneously. The objectives of this paper are first, to briefly review the literature on trauma and ASD, secondly, to shortly examine the literature on ASD in relation to CBI, and in relation to art therapy, and thirdly, to discuss the similarities and differences of CBI and art therapy in the treatment of ASD. Literature on trauma and ASD A traumatic event can be described as an event that involves actual or threatened death, serious injury, or a threat to physical integrity of self or other, to which the individual’s response involves intense fear, helplessness, or horror. A traumatic event exacts a toll on body as well as mind as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000). Trauma is experienced as a psychophysical experience, even when the traumatic event causes no direct bodily harm. The symp-
∗ Corresponding author at: Social Work Department, Faculty of Humanities & Social Sciences, Ben-Gurion University of the Negev, POB 653, Beer-Sheva 84105, Israel. Tel.: +972 8 6472337; fax: +972 8 6472933. E-mail address: [email protected] (O. Sarid). 0197-4556/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.aip.2009.11.004
toms of acute stress disorder include a combination of one or more dissociative and anxiety related symptoms, as well as avoidance of reminders of the traumatic event. Examples of dissociative symptoms are emotional detachment, temporary loss of memory, depersonalization, and de-realization (Isserlin, Zerach, & Solomon, 2008). ASD categorization regards traumatized people in the time span of two to four weeks from the occurrence of the trauma (Bryant & Harvey, 1997). Previous studies regard this time span as an especially significant period of intervention in order to prevent long-term post-traumatic stress disorder (PTSD) (Elzinga & Bremner, 2002; Yehuda, McFarlane, & Shalev, 1998). Prospective studies indicated that 80% of people with ASD suffer PTSD six months post-trauma (Bryant & Harvey, 1998; Harvey & Bryant, 1998). Between 63% and 80% suffer PTSD two years posttrauma if not treated in the ASD period, close to the traumatic event (Bryant, Moulds, & Nixon, 2003; Harvey & Bryant, 1999, 2000). Thus, an early intervention in ASD may play a critical role for the prevention and treatment of future PTSD. Several researchers have purposed that the detrimental effects of stress on brain systems can be reversed or blocked in the immediate aftermath of trauma before memories become stabilized through a time-dependent process (Alberini, Milekic, & Tronel, 2006; Bremner, 2006). Memories become stabilized through a time-dependent process that requires gene expression and protein synthesis and is commonly known as consolidation (Alberini et al., 2006). Albeit this time span is not fully understood and therefore defined; within it memories are labile and can be disrupted by a number of interfering events among them learning process or the effect of drugs (Alberini et al., 2006). Once consolidated, memories are insensitive to these disruptions. However, they can again become fragile if recalled or reactivated. Reactivation creates another time-dependent process, known as
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reconsolidation, during which the memory can be re-stabilized (Alberini et al., 2006; Tronel, Milekic, & Alberini, 2005). Ordinary memories have a clear structure, are easy to remember, and tend to be voluntary and conscious. Unlike memories for traumatic experiences, they do not interfere with the person’s normal functioning, and they can be associated with both painful and joyful feelings (Sotgiu & Mormont, 2008; van der Kolk & Fisler, 1995). Several researchers describe traumatic memories as a special kind of memory that is experienced in the form of vivid fragments of images, sounds, smells, and bodily sensations (Ogden, Minton, & Pain, 2006; Sotgiu & Mormont, 2008; van der Kolk, Hopper, & Osterman, 2001; Whitfield, 1995). Furthermore, McCleery and Harvey (2004) suggested that the physiological over-excitation of the senses enhance the reprocessing of traumatic memories. Memory distortions caused by trauma can prevent a sense of control and lack of coherent narrative of the traumatic event (McNally, 2003, 2006; van der Kolk et al., 2001). Few studies reported that traumatic recollections are less vivid and clear than are non-traumatic emotional memories (Tromp, Koss, Figueredo, & Tharan, 1995; van der Kolk & Fisler, 1995). Conversely, other findings indicated that traumatic memories might be more vivid relative to positive memories (Berntsen, Willert, & Rubin, 2003; Peace & Porter, 2004; Porter & Peace, 2007; Rubin, Boals, & Berntsen, 2008). Findings from empirical studies are inconsistent. Although some researchers have found that traumatic memories are retrieved differently than are emotional memories, others have demonstrated that the phenomenological characteristics of these memory types are highly similar (Sotgiu & Mormont, 2008; van der Kolk & Fisler, 1995). The underlying principle for the immediacy of intervention in the ASD period lies in the possibility to modulate the above described traumatic memories so that retrieved memories will be experienced less intensively mentally and physiologically and will cause a lesser degree of symptoms. Recent experimental pharmacological intervention that was conducted with animals exemplify that cortisol treatment before stress exposure have blunted the hypothalamus–pituitary–adrenal (HPA) response to stress and thus prevented traumatic memory formation (Cohen et al., 2006). Another study showed that in patients with PTSD, low-dose cortisol treatment for one month reduced symptoms of traumatic memories. The researchers claimed that the persistent retrieval and reconsolidation of traumatic memories is a process that keeps these memories vivid and thereby the disorder alive. By inhibiting memory retrieval, cortisol may weaken the traumatic memory trace, and thus reduce symptoms (de Quervain & Margraf, 2008). However, while promising, this pharmacological intervention is not always applicable, and is still in experimental stages. We see from the above that the clinical relevance of how people code and recall the various components of their traumatic experiences (i.e., cognitive, physiological, behavioral) points to the importance of an early intervention at the ASD time period. This paper will describe, and discuss, two clinical interventions, CBI and art therapy, that aim to treat ASD by providing an integrative intervention bringing together physical, emotional, and mental aspects of traumatic memory.
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nificantly reduces the risk of developing PTSD (Bryant et al., 2003, 2006). CBI integrates a cluster of interventions that can be employed together or alone in a therapeutic meeting, according to the patient’s most disturbing symptoms. A common order includes physical relaxation through breathing exercises and/or progressive muscle training that aims to modify psycho-physiological reactions in the body and aims to reduce the excitatory effect of implicit traumatic memories. An additional component focuses on cognitive elements, providing information about possible reactions to trauma, learning rational self-talk to manage anxiety-producing situations, and using cognitive restructuring techniques to intervene on the interpretation and thus autobiographical memories of the traumatic events. To elaborate, the cognitive restructuring of fear-related beliefs includes the identification and modification of automatic thoughts in order to gain a more balanced perspective of events (Bisson & Andrew, 2008; Bryant et al., 2003). The following case study can illustrate the above techniques: a 23 year old man was referred to a community medical clinic after being physically assaulted and robed in the gas station where he worked a night shift. He was injured in the event and was bruised. The intervention took place in the ASD period a week after the incident. His main complaints and reason for referral were hand shaking, palpitations and breathing difficulties. The therapist firstly taught him deep and slows breathing techniques and progressive muscle relaxation. The relaxation was practiced a few times. The therapist then identified the most disturbing repetitive thought which was “this world is a dangerous place and I am in constant danger”. This thought was contextualized as a typical and normal reaction to such a situation through providing information about reaction to trauma and he was reminded that these feelings are a reaction to trauma and not necessarily the reality. The therapist encouraged the man to practice comforting self-talk to manage his anxiety such as: “I handled the situation well and I can now trust my abilities to deal with danger.” An additional component of CBI is imaginal exposure which consists of therapist guided imagery of the traumatic event. The individual is asked to imagine and re-experience as vividly as possible the target event while being guided by techniques that include modifying shapes, colures, textures and distancing images (Bryant et al., 2008; Vrielynck & Philippot, 2008). The young man most disturbing memory was seeing himself hunched over next to the gas pumps protecting his head from being hit by the attackers and the attackers shouting at him. The client identified the screams as the most disturbing part of this image. The therapist with the client adjusted this memory by modifying the screams on the auditory level, and also distanced the image of the attackers making them smaller. The therapist prompted him to create a memory of a safe place that he could go when overwhelmed. By shifting between these different techniques, CBI integrates both sensory and cognitive elements as it focuses on traumatic memories providing modulation and a restructuring of the negative memory into a less intense and more integrated memory (Bryant et al., 2003; van Emmerik, Kamphuis, & Emmelkamp, 2008).
CBI art therapy and ASD CBI and ASD
Art therapy and ASD
As stated above, the traumatic event is characterized by excessive anxiety and physiological excitation. CBI is one of the most commonly used interventions in ASD and PTSD. Previous studies indicate that CBI conducted with ASD patients to prevent PTSD sig-
Art therapy, also suggested in the literature to treat trauma effects, contains three levels of intervention in treating clients with ASD (Hass-Cohen & Carr, 2008; Klingman, Koenigsfield, & Markman, 1987; Mallay, 2002). Firstly, it engages the senses and
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the body, through observing, touching, and manipulating art materials. Secondly, it engages autobiographical traumatic memories through the personal symbolic meanings that the client attributes to shapes, textures and colors. The art process and product becomes the symbolic container of traumatic memories. Thirdly, the cognitive reflective component becomes dominant and the art work is contemplated and re-explained. The client and therapist together through elaboration, repetition, and reframing of the art product integrate a coherent and enabling narrative of the traumatic memories (Hass-Cohen & Carr, 2008; Perry, Pollard, Blakely, Baker, & Vigilante, 1995). A twenty four years old female student arrived at a community medical clinic after a bike accident. She collided with a massive object on the path, was thrown off her bike and broke her shin bone. She had a cast and walked with crutches. Her main complains were repeated self blame and intense anger at both the object and at herself that disturbed her concentration on her studies. The intervention took place in the ASD period a week after the incident over four meetings which are summed up below. Within art therapy sessions, the client chose a large sheet of paper and drew a black rectangle in the middle of the road, using large back and forth movements with black oil pastel. She then added next to the black rectangle a black colored figure. She stated “why didn’t I see it, usually I am so careful, how stupid I am.” The therapist suggested she add colors to her black figure representing the many characteristics that she has as a person defining each color as a distinct characteristics. She stated the role of each color and noticed that even with the black color the overall effect of her figure is bright and colorful. In her own words: “The black highlights my other colors.” She stated that she now experiences her anger as just a part of herself that has found the right size and place again. We see in the above case study that firstly, the physical agitation of the client was modulated through the manipulation of different art materials (the use of the black crayon). Secondly, the experience of self anger was reframed through contextualizing it in a larger self concept. Emotions were thus given control through symbolization on the page and reframing of their impact. In art therapy these three stages are also utilized together, or in a cyclical manner, with the third stage often leading back to the first stage of tactile stimulation and art making, in which new memories can be re-integrated into the sensory and emotional as well as cognitive levels (Hass-Cohen & Carr, 2008; Talwar, 2007). This ongoing activity and shifting between the stages helps the client rearrange the sensory over-excitation of the traumatic memories and creates a sense of control (Rankin & Taucher, 2003) and thus optimism (Appleton, 2001). Nainis et al. (2006) describe this process as the base for his findings that art therapy helped to relieve general anxiety and global distress in cancer patients. In other words, the flexible shifts between these three stages encourage physical, as well as mental, control and relaxation (Hass-Cohen & Carr, 2008; Kozlowska & Hanney, 2001). This may be particularly effective in integrating the fragmented components of traumatic memory and especially relevant at the ASD period, where traumatic memory is still relatively flexible, and not yet finally encoded. Chapman, Morabito, Ladakakos, Schreier, and Knudson (2001) demonstrated that while there was no significant difference between the art therapy group and the control group for sufferers of PTSD, the effectiveness of art therapy on pediatric patients diagnoses with ASD, was significant. Pifalo (2002) found a significant reduction in trauma symptoms in sexually abused children after art therapy. However, it is important to note that currently there is little evidence-based research on art therapy in general, and on art therapy as an effective treatment for acute stress disorder (Bisson, 2007; Hass-Cohen, 2003).
Discussion The above description of CBI and of art therapy, in terms of their implications for the ASD symptoms, have highlighted the possible structural commonalities of two seemingly different theoretical and clinical methods and thus point to a central process in intervening with ASD. We saw that both interventions can alter the maladaptive and traumatic sensory processing and affect excitatory reactions by shifting excessive arousal to regulatory processes (Schore, 2002). CBI and art therapy utilize sensory triggers such as smells, sounds, sights, textures, and situations as part of the therapeutic techniques of imaginal exposure and of art making. In other words, a characteristic common to both interventions is the integration of sensory stimulants, using art materials, or imaginal exposure. Both, art materials and imaginal exposure modify emotional–physiological responses which assist in desensitizing physiological reaction. Differences in alteration of the psychophysiological excitation could be that CBI focuses on modifying excitatory reactions by shifting excessive arousal to regulatory processes as can be achieved by breathing exercises and autogenic training (Norris & Fahrion, 1993). Art therapy, on the other hand, creates actual sensory experiences based on the visual and tactile characteristics of art materials. This enables control through the physical elements of the art making Such as different types of sensory experience, muscle pressure and motor control. In other words, art therapy involves the actual manipulation of art material while CBI utilizes imaginal exposure (Harmon-Jones & Winkielman, 2007; Hass-Cohen, 2003). Thus, even when the senses are utilized in CBI, they are mostly experienced in the mind. Imaginal exposure provides an opportunity to visualize, hear, and sense traumatic events but under the control of cognitive process. CBI can thus be conceptualized as working from “top-down” as compared to art therapy that works from “bottom-up” (Riva, 2005; Safran & Greenberg, 1991). The modulation of explicit memory is another common feature. This is achieved dissociatively through awareness and through the restructuring of disturbing cognitions so as to bridge fragmented memories (Schore, 2002; Bryant et al., 2008; Bryant, Sackville, Dang, Moulds, and Guthrie, 1999). Both CBI and art therapy seem to modulate and challenge explicit traumatic autobiographical memories through stimulating a subsequent cognitive process. Differences between the two interventions are that CBI modifies disturbing memories by adjusting their elements such as shifting the relative size, composition and content of the image within the imagination. This modulates recalled images and challenges explicit traumatic autobiographical memories and automatic patterns of thinking through stimulating a subsequent cognitive process. Reframing is thus conducted concurrently or back to back with recalling and adjusting disturbing images. Conversely, in art therapy, image modulation is conducted more sequentially. Firstly, an art product is created. Secondly, an enabling interpretation can be verbalized around the art product or process. Thirdly, the art product can be physically adjusted to the new meaning and so on. Above we saw that CBI and art therapies are made up of different modules and different “directions” of intervention. However, despite these differences their most relevant contribution to ASD treatment can be defined as the common characteristic of their interactive combination of their different modules within each intervention. This has the potential of creating new connections and pathways between the physical, emotional, and cognitive components of traumatic memory. A possible cautious explanation of the efficiency of this integrative process can be conceptualized through a neuro-scientific perspective. Current neuro-scientific studies suggest that inhibitory processes are allocated in the brain within the medial pre frontal cortex (mPFC). This area governs executive cognitive functions such as reallocation of attention and thus inhibitory
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control over physical stress responses. It could be that the similarities between CBI and art therapy are that they both initiate regulatory process that decrease anxiety and negative emotional responses by inhibiting hypothalamic release of cortisol (Mohlman & Gorman, 2005; Radley, Gosselink, & Sawchenko, 2009). Conclusions Although CBI and art therapy stem from different theoretical orientations, they both utilize a multi-faceted intervention that creates flexible pathways between the physical, emotional, and cognitive aspects of the traumatic experience. This is especially important at the ASD period when traumatic memories are still pliable (Gantt & Tinnin, 2009; Rankin & Taucher, 2003). When analyzing both CBI and art therapy through the prism of physical–emotional stress reduction, and through memory restructuring, they seem to aim at similar outcomes, both utilizing a holistic approach to trauma memories that helps to re-integrate the overwhelming and fragmenting experience of trauma. These pathways help to modify the stress levels so as to enable the restructuring of more positive memories. This process implicates the therapist role as more of a guide rather than as a lead. The therapist enables the above integration through shifting the client’s attention to different elements of the traumatic experience. A limitation of this paper is that it did not exemplify or evaluate the above clinical implications, and this is suggested for further research. Future empirical studies could compare CBI and art therapy and provide better understanding of the role of this type of multi-faceted intervention. However, this theoretical model does have implications on the level of theory and of practice of both CB practitioners and art therapists dealing with the symptoms of trauma, in the ASD period. References Alberini, C. M., Milekic, M. H., & Tronel, S. (2006). Mechanisms of memory stabilization and de-stabilization. Cellular and Molecular Life Sciences, 63(9), 999–1008. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (DSM-IV-TR). Washington, DC: Author. Appleton, V. (2001). Avenues of hope: Art therapy and the resolution of trauma. Art Therapy, 18(1), 6–13. Berntsen, D., Willert, M., & Rubin, D. C. (2003). Splintered memories or vivid landmarks? Qualities and organization of traumatic memories with and without PTSD. Applied Cognitive Psychology, 17, 675–693. Bisson, J. I. (2007). Post-traumatic stress disorder. BMJ, 334, 789–793. Bisson, J., & Andrew, M. (2008). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, 4. doi:10.1002/14651858.CD003388.pub3. Bremner, J. D. (2006). Stress and brain atrophy. CNS & Neurological Disorders – Drug Targets, 5(5), 503–512. Bryant, R. A., & Harvey, A. G. (1997). Acute stress disorder: A critical review of diagnostic issues. Clinical Psychology Review, 17, 757–773. Bryant, R. A., & Harvey, A. G. (1998). Relationship of acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury. American Journal of Psychiatry, 155, 625–629. Bryant, R. A., Moulds, M. L., Guthrie, R. M., Dang, S. T., Mastrodomenico, J., Nixon, R. D., et al. (2008). A randomized controlled trial of exposure therapy and cognitive restructuring for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 76(4), 695–703. Bryant, R. A., Moulds, M. L., & Nixon, R. V. (2003). Cognitive behavior therapy of acute stress disorder: A four-year follow-up. Behavior Research & Therapy, 41(4), 489–494. Bryant, R. A., Moulds, M. L., Nixon, R. D., Mastrodomenico, J., Felmingham, K., & Hopwood, S. (2006). Hypnotherapy and cognitive behavior therapy of acute stress disorder: A 3-year follow-up. Behavior Research & Therapy, 44(9), 1331–1335. Bryant, R. A., Sackville, T., Dang, S. T., Moulds, M., & Guthrie, R. (1999). Treating acute stress disorder: An evaluation of cognitive behavior therapy and supportive counseling techniques. American Journal of Psychiatry, 156, 1780–1786. Chapman, L. M., Morabito, D., Ladakakos, C., Schreier, H., & Knudson, M. (2001). The effectiveness of art therapy interventions in reducing post traumatic stress disorder (PTSD) symptoms in pediatric trauma patients. Art Therapy, 18(2), 100–104. Cohen, H., Zohar, J., Gidron, Y., Matar, M. A., Belkind, D., Loewenthal, U., et al. (2006). Blunted HPA axis response to stress influences susceptibility to posttraumatic stress response in rats. Biological Psychiatry, 59(12), 1208–1218.
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Contents lists available at ScienceDirect
The Arts in Psychotherapy
Trauma and acute stress disorder: A comparison between cognitive behavioral intervention and art therapy Orly Sarid, PhD ∗ , Ephrat Huss, PhD Social Work Department, Faculty of Humanities & Social Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
a r t i c l e
i n f o
Keywords: Acute stress disorder Cognitive behavioral intervention Art therapy
a b s t r a c t The aim of this paper is to initiate a comparative and theoretical study between the mechanisms of cognitive behavioral intervention (CBI) versus art therapy, in relation to the acute stress disorder (ASD) stage of trauma. The literature on CBI, art therapy, and ASD will be briefly reviewed. Similarities between these two theoretically disparate interventions will be outlined, pointing to the relevance of CBI and art therapy to alter maladaptive and traumatic sensory processing, affect excitatory reactions, modulate and challenge explicit traumatic memories and stimulate a subsequent cognitive process. Implications for mental health professionals intervening in the relatively flexible ASD period are discussed. © 2009 Elsevier Inc. All rights reserved.
Introduction This paper seeks to compare the principles of two clinical interventions, cognitive behavioral intervention (CBI) and art therapy, in acute stress disorder (ASD). While both interventions stem from very different theories, we will present their similarities in practice, and point to their specific characteristics of integrating an intervention on traumatic memory formation utilizing physical, emotional, and cognitive aspects simultaneously. The objectives of this paper are first, to briefly review the literature on trauma and ASD, secondly, to shortly examine the literature on ASD in relation to CBI, and in relation to art therapy, and thirdly, to discuss the similarities and differences of CBI and art therapy in the treatment of ASD. Literature on trauma and ASD A traumatic event can be described as an event that involves actual or threatened death, serious injury, or a threat to physical integrity of self or other, to which the individual’s response involves intense fear, helplessness, or horror. A traumatic event exacts a toll on body as well as mind as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000). Trauma is experienced as a psychophysical experience, even when the traumatic event causes no direct bodily harm. The symp-
∗ Corresponding author at: Social Work Department, Faculty of Humanities & Social Sciences, Ben-Gurion University of the Negev, POB 653, Beer-Sheva 84105, Israel. Tel.: +972 8 6472337; fax: +972 8 6472933. E-mail address: [email protected] (O. Sarid). 0197-4556/$ – see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.aip.2009.11.004
toms of acute stress disorder include a combination of one or more dissociative and anxiety related symptoms, as well as avoidance of reminders of the traumatic event. Examples of dissociative symptoms are emotional detachment, temporary loss of memory, depersonalization, and de-realization (Isserlin, Zerach, & Solomon, 2008). ASD categorization regards traumatized people in the time span of two to four weeks from the occurrence of the trauma (Bryant & Harvey, 1997). Previous studies regard this time span as an especially significant period of intervention in order to prevent long-term post-traumatic stress disorder (PTSD) (Elzinga & Bremner, 2002; Yehuda, McFarlane, & Shalev, 1998). Prospective studies indicated that 80% of people with ASD suffer PTSD six months post-trauma (Bryant & Harvey, 1998; Harvey & Bryant, 1998). Between 63% and 80% suffer PTSD two years posttrauma if not treated in the ASD period, close to the traumatic event (Bryant, Moulds, & Nixon, 2003; Harvey & Bryant, 1999, 2000). Thus, an early intervention in ASD may play a critical role for the prevention and treatment of future PTSD. Several researchers have purposed that the detrimental effects of stress on brain systems can be reversed or blocked in the immediate aftermath of trauma before memories become stabilized through a time-dependent process (Alberini, Milekic, & Tronel, 2006; Bremner, 2006). Memories become stabilized through a time-dependent process that requires gene expression and protein synthesis and is commonly known as consolidation (Alberini et al., 2006). Albeit this time span is not fully understood and therefore defined; within it memories are labile and can be disrupted by a number of interfering events among them learning process or the effect of drugs (Alberini et al., 2006). Once consolidated, memories are insensitive to these disruptions. However, they can again become fragile if recalled or reactivated. Reactivation creates another time-dependent process, known as
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reconsolidation, during which the memory can be re-stabilized (Alberini et al., 2006; Tronel, Milekic, & Alberini, 2005). Ordinary memories have a clear structure, are easy to remember, and tend to be voluntary and conscious. Unlike memories for traumatic experiences, they do not interfere with the person’s normal functioning, and they can be associated with both painful and joyful feelings (Sotgiu & Mormont, 2008; van der Kolk & Fisler, 1995). Several researchers describe traumatic memories as a special kind of memory that is experienced in the form of vivid fragments of images, sounds, smells, and bodily sensations (Ogden, Minton, & Pain, 2006; Sotgiu & Mormont, 2008; van der Kolk, Hopper, & Osterman, 2001; Whitfield, 1995). Furthermore, McCleery and Harvey (2004) suggested that the physiological over-excitation of the senses enhance the reprocessing of traumatic memories. Memory distortions caused by trauma can prevent a sense of control and lack of coherent narrative of the traumatic event (McNally, 2003, 2006; van der Kolk et al., 2001). Few studies reported that traumatic recollections are less vivid and clear than are non-traumatic emotional memories (Tromp, Koss, Figueredo, & Tharan, 1995; van der Kolk & Fisler, 1995). Conversely, other findings indicated that traumatic memories might be more vivid relative to positive memories (Berntsen, Willert, & Rubin, 2003; Peace & Porter, 2004; Porter & Peace, 2007; Rubin, Boals, & Berntsen, 2008). Findings from empirical studies are inconsistent. Although some researchers have found that traumatic memories are retrieved differently than are emotional memories, others have demonstrated that the phenomenological characteristics of these memory types are highly similar (Sotgiu & Mormont, 2008; van der Kolk & Fisler, 1995). The underlying principle for the immediacy of intervention in the ASD period lies in the possibility to modulate the above described traumatic memories so that retrieved memories will be experienced less intensively mentally and physiologically and will cause a lesser degree of symptoms. Recent experimental pharmacological intervention that was conducted with animals exemplify that cortisol treatment before stress exposure have blunted the hypothalamus–pituitary–adrenal (HPA) response to stress and thus prevented traumatic memory formation (Cohen et al., 2006). Another study showed that in patients with PTSD, low-dose cortisol treatment for one month reduced symptoms of traumatic memories. The researchers claimed that the persistent retrieval and reconsolidation of traumatic memories is a process that keeps these memories vivid and thereby the disorder alive. By inhibiting memory retrieval, cortisol may weaken the traumatic memory trace, and thus reduce symptoms (de Quervain & Margraf, 2008). However, while promising, this pharmacological intervention is not always applicable, and is still in experimental stages. We see from the above that the clinical relevance of how people code and recall the various components of their traumatic experiences (i.e., cognitive, physiological, behavioral) points to the importance of an early intervention at the ASD time period. This paper will describe, and discuss, two clinical interventions, CBI and art therapy, that aim to treat ASD by providing an integrative intervention bringing together physical, emotional, and mental aspects of traumatic memory.
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nificantly reduces the risk of developing PTSD (Bryant et al., 2003, 2006). CBI integrates a cluster of interventions that can be employed together or alone in a therapeutic meeting, according to the patient’s most disturbing symptoms. A common order includes physical relaxation through breathing exercises and/or progressive muscle training that aims to modify psycho-physiological reactions in the body and aims to reduce the excitatory effect of implicit traumatic memories. An additional component focuses on cognitive elements, providing information about possible reactions to trauma, learning rational self-talk to manage anxiety-producing situations, and using cognitive restructuring techniques to intervene on the interpretation and thus autobiographical memories of the traumatic events. To elaborate, the cognitive restructuring of fear-related beliefs includes the identification and modification of automatic thoughts in order to gain a more balanced perspective of events (Bisson & Andrew, 2008; Bryant et al., 2003). The following case study can illustrate the above techniques: a 23 year old man was referred to a community medical clinic after being physically assaulted and robed in the gas station where he worked a night shift. He was injured in the event and was bruised. The intervention took place in the ASD period a week after the incident. His main complaints and reason for referral were hand shaking, palpitations and breathing difficulties. The therapist firstly taught him deep and slows breathing techniques and progressive muscle relaxation. The relaxation was practiced a few times. The therapist then identified the most disturbing repetitive thought which was “this world is a dangerous place and I am in constant danger”. This thought was contextualized as a typical and normal reaction to such a situation through providing information about reaction to trauma and he was reminded that these feelings are a reaction to trauma and not necessarily the reality. The therapist encouraged the man to practice comforting self-talk to manage his anxiety such as: “I handled the situation well and I can now trust my abilities to deal with danger.” An additional component of CBI is imaginal exposure which consists of therapist guided imagery of the traumatic event. The individual is asked to imagine and re-experience as vividly as possible the target event while being guided by techniques that include modifying shapes, colures, textures and distancing images (Bryant et al., 2008; Vrielynck & Philippot, 2008). The young man most disturbing memory was seeing himself hunched over next to the gas pumps protecting his head from being hit by the attackers and the attackers shouting at him. The client identified the screams as the most disturbing part of this image. The therapist with the client adjusted this memory by modifying the screams on the auditory level, and also distanced the image of the attackers making them smaller. The therapist prompted him to create a memory of a safe place that he could go when overwhelmed. By shifting between these different techniques, CBI integrates both sensory and cognitive elements as it focuses on traumatic memories providing modulation and a restructuring of the negative memory into a less intense and more integrated memory (Bryant et al., 2003; van Emmerik, Kamphuis, & Emmelkamp, 2008).
CBI art therapy and ASD CBI and ASD
Art therapy and ASD
As stated above, the traumatic event is characterized by excessive anxiety and physiological excitation. CBI is one of the most commonly used interventions in ASD and PTSD. Previous studies indicate that CBI conducted with ASD patients to prevent PTSD sig-
Art therapy, also suggested in the literature to treat trauma effects, contains three levels of intervention in treating clients with ASD (Hass-Cohen & Carr, 2008; Klingman, Koenigsfield, & Markman, 1987; Mallay, 2002). Firstly, it engages the senses and
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the body, through observing, touching, and manipulating art materials. Secondly, it engages autobiographical traumatic memories through the personal symbolic meanings that the client attributes to shapes, textures and colors. The art process and product becomes the symbolic container of traumatic memories. Thirdly, the cognitive reflective component becomes dominant and the art work is contemplated and re-explained. The client and therapist together through elaboration, repetition, and reframing of the art product integrate a coherent and enabling narrative of the traumatic memories (Hass-Cohen & Carr, 2008; Perry, Pollard, Blakely, Baker, & Vigilante, 1995). A twenty four years old female student arrived at a community medical clinic after a bike accident. She collided with a massive object on the path, was thrown off her bike and broke her shin bone. She had a cast and walked with crutches. Her main complains were repeated self blame and intense anger at both the object and at herself that disturbed her concentration on her studies. The intervention took place in the ASD period a week after the incident over four meetings which are summed up below. Within art therapy sessions, the client chose a large sheet of paper and drew a black rectangle in the middle of the road, using large back and forth movements with black oil pastel. She then added next to the black rectangle a black colored figure. She stated “why didn’t I see it, usually I am so careful, how stupid I am.” The therapist suggested she add colors to her black figure representing the many characteristics that she has as a person defining each color as a distinct characteristics. She stated the role of each color and noticed that even with the black color the overall effect of her figure is bright and colorful. In her own words: “The black highlights my other colors.” She stated that she now experiences her anger as just a part of herself that has found the right size and place again. We see in the above case study that firstly, the physical agitation of the client was modulated through the manipulation of different art materials (the use of the black crayon). Secondly, the experience of self anger was reframed through contextualizing it in a larger self concept. Emotions were thus given control through symbolization on the page and reframing of their impact. In art therapy these three stages are also utilized together, or in a cyclical manner, with the third stage often leading back to the first stage of tactile stimulation and art making, in which new memories can be re-integrated into the sensory and emotional as well as cognitive levels (Hass-Cohen & Carr, 2008; Talwar, 2007). This ongoing activity and shifting between the stages helps the client rearrange the sensory over-excitation of the traumatic memories and creates a sense of control (Rankin & Taucher, 2003) and thus optimism (Appleton, 2001). Nainis et al. (2006) describe this process as the base for his findings that art therapy helped to relieve general anxiety and global distress in cancer patients. In other words, the flexible shifts between these three stages encourage physical, as well as mental, control and relaxation (Hass-Cohen & Carr, 2008; Kozlowska & Hanney, 2001). This may be particularly effective in integrating the fragmented components of traumatic memory and especially relevant at the ASD period, where traumatic memory is still relatively flexible, and not yet finally encoded. Chapman, Morabito, Ladakakos, Schreier, and Knudson (2001) demonstrated that while there was no significant difference between the art therapy group and the control group for sufferers of PTSD, the effectiveness of art therapy on pediatric patients diagnoses with ASD, was significant. Pifalo (2002) found a significant reduction in trauma symptoms in sexually abused children after art therapy. However, it is important to note that currently there is little evidence-based research on art therapy in general, and on art therapy as an effective treatment for acute stress disorder (Bisson, 2007; Hass-Cohen, 2003).
Discussion The above description of CBI and of art therapy, in terms of their implications for the ASD symptoms, have highlighted the possible structural commonalities of two seemingly different theoretical and clinical methods and thus point to a central process in intervening with ASD. We saw that both interventions can alter the maladaptive and traumatic sensory processing and affect excitatory reactions by shifting excessive arousal to regulatory processes (Schore, 2002). CBI and art therapy utilize sensory triggers such as smells, sounds, sights, textures, and situations as part of the therapeutic techniques of imaginal exposure and of art making. In other words, a characteristic common to both interventions is the integration of sensory stimulants, using art materials, or imaginal exposure. Both, art materials and imaginal exposure modify emotional–physiological responses which assist in desensitizing physiological reaction. Differences in alteration of the psychophysiological excitation could be that CBI focuses on modifying excitatory reactions by shifting excessive arousal to regulatory processes as can be achieved by breathing exercises and autogenic training (Norris & Fahrion, 1993). Art therapy, on the other hand, creates actual sensory experiences based on the visual and tactile characteristics of art materials. This enables control through the physical elements of the art making Such as different types of sensory experience, muscle pressure and motor control. In other words, art therapy involves the actual manipulation of art material while CBI utilizes imaginal exposure (Harmon-Jones & Winkielman, 2007; Hass-Cohen, 2003). Thus, even when the senses are utilized in CBI, they are mostly experienced in the mind. Imaginal exposure provides an opportunity to visualize, hear, and sense traumatic events but under the control of cognitive process. CBI can thus be conceptualized as working from “top-down” as compared to art therapy that works from “bottom-up” (Riva, 2005; Safran & Greenberg, 1991). The modulation of explicit memory is another common feature. This is achieved dissociatively through awareness and through the restructuring of disturbing cognitions so as to bridge fragmented memories (Schore, 2002; Bryant et al., 2008; Bryant, Sackville, Dang, Moulds, and Guthrie, 1999). Both CBI and art therapy seem to modulate and challenge explicit traumatic autobiographical memories through stimulating a subsequent cognitive process. Differences between the two interventions are that CBI modifies disturbing memories by adjusting their elements such as shifting the relative size, composition and content of the image within the imagination. This modulates recalled images and challenges explicit traumatic autobiographical memories and automatic patterns of thinking through stimulating a subsequent cognitive process. Reframing is thus conducted concurrently or back to back with recalling and adjusting disturbing images. Conversely, in art therapy, image modulation is conducted more sequentially. Firstly, an art product is created. Secondly, an enabling interpretation can be verbalized around the art product or process. Thirdly, the art product can be physically adjusted to the new meaning and so on. Above we saw that CBI and art therapies are made up of different modules and different “directions” of intervention. However, despite these differences their most relevant contribution to ASD treatment can be defined as the common characteristic of their interactive combination of their different modules within each intervention. This has the potential of creating new connections and pathways between the physical, emotional, and cognitive components of traumatic memory. A possible cautious explanation of the efficiency of this integrative process can be conceptualized through a neuro-scientific perspective. Current neuro-scientific studies suggest that inhibitory processes are allocated in the brain within the medial pre frontal cortex (mPFC). This area governs executive cognitive functions such as reallocation of attention and thus inhibitory
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control over physical stress responses. It could be that the similarities between CBI and art therapy are that they both initiate regulatory process that decrease anxiety and negative emotional responses by inhibiting hypothalamic release of cortisol (Mohlman & Gorman, 2005; Radley, Gosselink, & Sawchenko, 2009). Conclusions Although CBI and art therapy stem from different theoretical orientations, they both utilize a multi-faceted intervention that creates flexible pathways between the physical, emotional, and cognitive aspects of the traumatic experience. This is especially important at the ASD period when traumatic memories are still pliable (Gantt & Tinnin, 2009; Rankin & Taucher, 2003). When analyzing both CBI and art therapy through the prism of physical–emotional stress reduction, and through memory restructuring, they seem to aim at similar outcomes, both utilizing a holistic approach to trauma memories that helps to re-integrate the overwhelming and fragmenting experience of trauma. These pathways help to modify the stress levels so as to enable the restructuring of more positive memories. This process implicates the therapist role as more of a guide rather than as a lead. The therapist enables the above integration through shifting the client’s attention to different elements of the traumatic experience. A limitation of this paper is that it did not exemplify or evaluate the above clinical implications, and this is suggested for further research. Future empirical studies could compare CBI and art therapy and provide better understanding of the role of this type of multi-faceted intervention. However, this theoretical model does have implications on the level of theory and of practice of both CB practitioners and art therapists dealing with the symptoms of trauma, in the ASD period. References Alberini, C. M., Milekic, M. H., & Tronel, S. (2006). Mechanisms of memory stabilization and de-stabilization. Cellular and Molecular Life Sciences, 63(9), 999–1008. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (DSM-IV-TR). Washington, DC: Author. Appleton, V. (2001). Avenues of hope: Art therapy and the resolution of trauma. Art Therapy, 18(1), 6–13. Berntsen, D., Willert, M., & Rubin, D. C. (2003). Splintered memories or vivid landmarks? Qualities and organization of traumatic memories with and without PTSD. Applied Cognitive Psychology, 17, 675–693. Bisson, J. I. (2007). Post-traumatic stress disorder. BMJ, 334, 789–793. Bisson, J., & Andrew, M. (2008). Psychological treatment of post-traumatic stress disorder (PTSD). Cochrane Database of Systematic Reviews, 4. doi:10.1002/14651858.CD003388.pub3. Bremner, J. D. (2006). Stress and brain atrophy. CNS & Neurological Disorders – Drug Targets, 5(5), 503–512. Bryant, R. A., & Harvey, A. G. (1997). Acute stress disorder: A critical review of diagnostic issues. Clinical Psychology Review, 17, 757–773. Bryant, R. A., & Harvey, A. G. (1998). Relationship of acute stress disorder and posttraumatic stress disorder following mild traumatic brain injury. American Journal of Psychiatry, 155, 625–629. Bryant, R. A., Moulds, M. L., Guthrie, R. M., Dang, S. T., Mastrodomenico, J., Nixon, R. D., et al. (2008). A randomized controlled trial of exposure therapy and cognitive restructuring for posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 76(4), 695–703. Bryant, R. A., Moulds, M. L., & Nixon, R. V. (2003). Cognitive behavior therapy of acute stress disorder: A four-year follow-up. Behavior Research & Therapy, 41(4), 489–494. Bryant, R. A., Moulds, M. L., Nixon, R. D., Mastrodomenico, J., Felmingham, K., & Hopwood, S. (2006). Hypnotherapy and cognitive behavior therapy of acute stress disorder: A 3-year follow-up. Behavior Research & Therapy, 44(9), 1331–1335. Bryant, R. A., Sackville, T., Dang, S. T., Moulds, M., & Guthrie, R. (1999). Treating acute stress disorder: An evaluation of cognitive behavior therapy and supportive counseling techniques. American Journal of Psychiatry, 156, 1780–1786. Chapman, L. M., Morabito, D., Ladakakos, C., Schreier, H., & Knudson, M. (2001). The effectiveness of art therapy interventions in reducing post traumatic stress disorder (PTSD) symptoms in pediatric trauma patients. Art Therapy, 18(2), 100–104. Cohen, H., Zohar, J., Gidron, Y., Matar, M. A., Belkind, D., Loewenthal, U., et al. (2006). Blunted HPA axis response to stress influences susceptibility to posttraumatic stress response in rats. Biological Psychiatry, 59(12), 1208–1218.
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