COGNITIVE-BEHAVIORAL ART THERAPY

Cognitive-Behavioral Art Therapy explores the intersection of art therapy practices and principles within cognitive-behavioral therapy (CBT) theories and models. This timely new resource examines CBT theory as it relates to art therapy, and offers an argument for the inclusion of CBT within art therapy-based treatments. An analysis of the historical roots of both CBT and cognitive-behavioral art therapy (CBAT) is presented along with current practices and a proposed model of implementation. Also included are case studies to enhance this in-depth exploration of a largely unexamined perspective within the arts therapies.

Marcia L. Rosal, PhD, ATR-BC, HLM is a Past-Chair of the Art Education Department and Past Director of the Art Therapy Program at Florida State University. She received a master’s degree in art therapy from the University of Louisville, and a doctorate in educational psychology from the University of Queensland. In 1999, she joined the faculty at Florida State University as a Professor in the Art Therapy Program after teaching for 14 years at the University of Louisville where she received the 1998 University Distinguished Teaching Award. She has been a practicing art therapist for 40 years, received her ATR in 1979, and was board certifi ed in 1995. She specialized in teaching art therapy research, group art therapy, and art therapy with children. She has published numerous articles and chapters in edited texts, and co-edited The Wiley Handbook of Art Therapy (2016). She has lectured widely across the USA as well as Australia, New Zealand, the UK, Taiwan, and South Korea. She is a Fulbright Scholar (Taiwan, 2008) and a Fulbright Specialist (Latvia, 2014). Dr. Rosal is an Honorary Life Member and a Past President of the American Art Therapy Association. She serves on the Editorial Boards of Art Therapy , The Arts in Psychotherapy, Clinical Art Therapy , and the Journal of Art for Life. She was recently honored with the title of professor emerita from Florida State University.

COGNITIVE-BEHAVIORAL ART THERAPY

From Behaviorism to the Third Wave

Marcia L. Rosal First published 2018 by Routledge 711 Third Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2018 Taylor & Francis The right of Marcia L. Rosal to be identifi ed as author of this work has been asserted by her in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilized in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice : Product or corporate names may be trademarks or registered trademarks, and are used only for identifi cation and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Names: Rosal, Marcia L., editor. Title: Cognitive-behavioral art therapy : from behaviorism to the third wave / edited by Marcia L. Rosal. Description: New York, NY : Routledge, 2018. Identifi ers: LCCN 2017057240 (print) | LCCN 2017059063 (ebook) | ISBN 9781315459257 (ebk) | ISBN 9781138208421 (hbk) | ISBN 9781138208438 (pbk) Subjects: LCSH: Art therapy. | Cognitive therapy. Classifi cation: LCC RC489.A7 (ebook) | LCC RC489.A7 C638 2018 (print) | DDC 616.89/1656—dc23 LC record available at https://lccn.loc.gov/2017057240 ISBN: 978-1-138-20842-1 (hbk) ISBN: 978-1-138-20843-8 (pbk) ISBN: 978-1-315-45925-7 (ebk) Typeset in Bembo by Apex CoVantage, LLC CONTENTS

List of Figures x List of Tables xii Preface xiii Acknowledgments xvi

1 The Uneasy Connection Between Cognitive-Behavioral Therapy and Art Therapy 1 Some Background on Art Therapy 2 The Need for a Theoretical Foundation 4 Art Therapists Adhere to Theoretical Perspectives 4 CBT and CBAT 5 Obstacles to Adopting CBAT 5 An Argument for CBAT 6 Cognitive Skills Improved by Art Therapy 7 A Problem Focus 8 Externalizing the Problem 8 Problem-Solving 8 Perspective Expansion 9 Reframing Problems 9 Decision-Making 10 Reinforcements and Prompts 10 Creating Order out of Chaos 11 Improving Executive Function 11 Summary 12 vi Contents

Constructivist Theory, Cognition, and CBAT 12 Organization of the Book 13 Notes 15

2 Creative, Imaginal, and Emotional Aspects of Cognitive-Behavioral Therapy 16 Mental Imagery 17 Historical Roots of Imagery in Psychotherapy 17 Imagery Research 18 Imagery and Neuroscience 21 Assessing Imagery in Clinical Settings 22 Summary 23 History of Imagery in CBT 23 Early Imagery Approaches in Behavior Therapy 24 Dreams and Daydreams in CBT 25 Imagery and Self-Effi cacy 27 Summary 28 Current Uses of Imagery in CBT 29 Reducing the Frequency of Intrusive Imagery 30 Changing the Meaning of Negative Imagery and Image Rescripting 30 Fostering Positive Imagery 31 Summary 32 Emotions as Cognitions 33 Early Thinking about the Emotion–Cognition Link 33 Emotions Related to Appraisal 35 Emotion Interventions Used in CBT 36 Summary 37 Conclusion 38 Notes 38

3 Art-Making as a Cognitive-Constructivist Process 39 Cognitive-Constructivism 40 Piaget 40 Vygotsky 47 Bruner 50 Comparative Analysis 52 Art-Making as a Cognitive-Constructivist Process 53 Cognitive Qualities of Art-Making 54 Art as Building and Expanding Cognition 57 Art and Meaning-Making 58 Summary 58 Contents vii

Final Thoughts 59 Notes 60

4 The History of CBT 61 The Cognitive Revolution 61 The First Wave: Behavior Therapy 63 Behavioral Therapy Treatments 63 The Second Wave: Cognitive Behavior Therapy 67 Early CBT Treatment Models 68 Personal Construct Theory 71 From Assessment to PCT Treatment 77 Summary 78 Conclusion 78 Notes 79

5 The Historic Roots of CBAT 80 Pioneer CBAT Art Therapists 80 First-Wave CBAT: Reality Shaping 81 Second-Wave CBAT: Personal Construct Theory and Art Therapy 83 Carnes 83 Rhyne 84 Summary 87 Solidifying CBAT as a Legitimate Approach to Art Therapy 87 Developing a CBAT Program 88 Key Elements of CBAT 89 Integrating Personal Construct Psychology in CBAT 89 Summary 96 Other Second-Wave Examples of CBAT 96 CBAT with Children 96 CBAT with Adults 99 Summary 100 Conclusion 100

6 Current CBAT Practices 102 Understanding Constructs and Thoughts 103 Cognitions as Constructions 103 Identifi cation and Assessment of Thoughts 105 Cognitive Restructuring 107 Feelings and Emotions 109 Assessment of Feelings 110 Making Meaning of Emotions 112 viii Contents

Emotions as Functional and Transformative 115 Dealing with Feelings In Vivo 117 Altering the Self-Schema 121 Identifying Self-Schemas 122 Identifi cation of Strengths and Resources 122 Creating a Cohesive Sense of Self 125 Self-Effi cacy Development 126 Using Mental Imagery 127 Guided Imagery 128 Imaginal Exposure 131 Imagery Rescripting 132 Problem-Solving 134 With Children 135 With Adults 135 Coping 137 Adaptation and Resiliency 139 Conclusion 141

7 The Mindfulness Evolution of CBT 143 Initial Inquiries into Third-Wave CBT Practices 144 Setting the Stage: Buddhist Psychology 145 Suffering and Mental Health 147 Defi nition of Mindfulness 149 Basic Tenets of Buddhism for CBT Practitioners 149 Cognition Through the Lens of Buddhism 151 Metacognition 152 Concentration and Attention 154 Mental Imagery 154 Descriptive Purpose 155 Prescriptive Purpose 156 Summary 159 Notes 160

8 Third-Generation Variants of CBT and CBAT 161 Dialectical Behavioral Therapy 161 CBAT and DBT 164 Summary 169 Mindfulness-Based Stress Reduction 169 The MBSR Program 169 Evaluation of MBSR Programs 170 Integrating Art Therapy with MBSR 171 Contents ix

Summary 175 Mindfulness-Based Cognitive Therapy 175 Rethinking Depression Relapse 176 MBCT Today 177 Art Therapy and MBCT 178 Summary 179 Acceptance and Commitment Therapy 179 Philosophical Underpinnings 179 Treatment Constructs 180 ACT and Art Therapy 181 Summary 183 Conclusion 183 Notes 185

9 Unravelling CBAT for Practitioners 186 Summary of Signifi cant Principles 186 Cognitive Development 186 Focus on Emotions 187 The Philosophy of Constructivism 188 Mental Imagery 188 Cognitive Aspects of Art-Making 189 The Shift from Behaviorism to the Second Wave of CBT and CBAT 189 The Transition to Third-Wave CBT and CBAT 190 Summary 191 CBAT Practice Strategies 192 PTSD 192 Anxiety 198 Depression 199 Major Mental Illnesses 200 Behavior and Emotional Disorders 201 Stress Reduction 202 Cancer and Chronic Medical Conditions 203 Synthesis 203 Conclusion 204

Appendix A: Kelly’s Repertory Grid and Figure List Sheet 207 Appendix B: Rhyne’s Personal Construct Drawing Template and Repertory Grid 209 References 211 Index 228 FIGURES

4.1 CBT in relation to two previous theories of behavior change 68 4.2 Healthy personal construct system 73 4.3 Loose construct system 73 4.4 Constricted construct system 74 4.5 Portrait gallery and self-description grid 76 5.1 Susan’s set of mind-state drawings 85 5.2 Susan’s similarity cluster 86 5.3 Susan’s contrast cluster 86 5.4 Scott’s personal construct drawing of someone studying at school 91 5.5 Scott’s PCP analysis grid 92 5.6 Scott’s drawing of feeling sad 93 5.7 Scott’s drawing of feeling angry 94 5.8 Scott’s angry mask with fl ames shooting out of its head and a third eye 94 5.9 Scott’s drawing of feeling happy at the end of group art therapy 95 6.1 Scott’s painting of his home from a bird’s-eye perspective and in a layout design 104 6.2 Scott’s personal construct drawing of someone being bad at school 106 6.3 Collage of feeling like the elephant in the room 107 6.4 Scott’s self-image as a stronger person 108 6.5 Painting depicting others as only thinking about themselves 109 6.6 Emma’s emotion expression collage 112 6.7 Karen’s drawing of the feeling of depression 113 6.8 Karen’s drawing of being anxious 113 6.9 Drawing of reporting bullying to the teacher 114 6.10 Karen’s depiction of anxiety on her lifeline and as the primary feeling leading to depression, hopelessness, and feeling threatened 115 Figures xi

6.11 Karen’s drawing of the feeling of hopelessness 117 6.12 Karen’s drawing of feeling hopeful 118 6.13 Karen’s drawing of being serene 118 6.14 Susie’s drawing of the black hole of shame and regret for yelling at her mother 119 6.15 Susie’s drawing of positive emotions squishing down the black hole 119 6.16 A warrior mask created by a combat veteran from an intrusive memory 120 6.17 Box as a container for the warrior mask and for the fears and anxieties associated with the mask 121 6.18 John’s drawing of being bored 123 6.19 John’s drawing of being wild and weird, with tongue sticking out and enlarged ear 123 6.20 April’s drawing of both positive and diffi cult self-attributes 124 6.21 Helen’s raven mask illustrating her true self 125 6.22 Maggie’s power bear in its habitat 126 6.23 Group member’s clay anxiety monster 127 6.24 Scott’s painting of being prepared to go into the cave from a guided imagery intervention, with a sword held high and a backpack 129 6.25 From a guided imagery journey: Scott’s painting of slaying the dragon guarding the treasure 130 6.26 From a guided imagery journey: Scott’s painting of fi nding the treasure inside the cave 130 6.27 Example of six drawings related to a combat trauma event. 134 6.28 Self-symbol paper sculpture by a prison inmate demonstrating his problem-solving skills 136 6.29 Paper sculpture incorporating ideas from all group members to increase problem-solving skills 136 6.30 John as a warrior battling his impulsive behavior 138 6.31 Scott’s drawing of what he learned about someone else in his therapy group. He learned that he could make friends 141 8.1 Illustration of a body scan 173 8.2 Illustration of a mindful doodle 174 TABLES

5.1 CBAT techniques and goals for children 97 5.2 CBAT techniques and goals for adults 99 9.1 CBAT interventions for various diagnostic groups 193 PREFACE

As an art therapy student, many years ago, practicing behavioral or cognitive- behavioral art therapy was an approach I never thought about using in my prac- tice. I understood the psychodynamic roots of the profession and was interested in developmental approaches as espoused by Donald Uhlin and other art thera- pists, especially since my client interest area was working with children and teens. Gestalt art therapy as examined by Janie Rhyne also held my curiosity. I practiced all these approaches as part of my earliest clinical positions, fi rst in psychiatric set- tings, and then in school settings. I valued working in both these settings. Based on my years in psychiatry, as I often told my students, if you really want to learn about psychopathology and psychotherapy, get a job in a psychiatric setting. It is the best learning laboratory that I know of for honing therapy skills. School set- tings were fascinating because it was clear from the start that when you conduct therapy with a child, you are also working with the entire family system and with the dynamics and culture of the classroom and the entire school. So the reason I decided to embark on a doctoral degree was not because I did not appreciate and cherish clinical practice—it was curiosity about what I didn’t know that drove me to pursue further education. For doctoral applications, I was asked to write an essay about my research interests, and I discussed my interest in the concept of locus of control (LOC) and how many of the patients and students with whom I worked seemed to have their behavior dictated by others—parents, teachers, peers, and institutions. When asked how they would want to behave or think, they looked bewildered. When asked how they would change their circumstances, answers eluded them. LOC is orga- nized along a continuum ranging from internal to external reward or reinforce- ment expectation orientations. Individuals with an internal orientation possess a sense that reinforcements originate from their own actions, and not necessarily xiv Preface from others or the environment. Individuals at the external end of the continuum expect that reinforcements will be from others—parents, teacher, peers, and oth- ers in the environment. At the time I did not fully comprehend the personality construct of LOC, but I was willing to learn. All I grasped at the time was that the construct had a profound effect on the students experiencing problem behaviors whom I worked with and wanted to study. One of the aspects of LOC that I was unaware of was that it developed from cognitive psychology theory. As requested by my doctoral advisor, the fi rst step in my doctoral research was to study LOC and to become well versed in its historical and theoretical founda- tions as well as the therapeutic implications of having a LOC that was either too external or too internal. This was followed by conducting a meta-analysis of the LOC attributes of children and students with behavior disorders. It was not sur- prising to fi nd that students with behavior disorders, including those with ADHD, possessed a LOC orientation that was signifi cantly more external than that of their peers without a diagnosis of behavior problems. Next, I conducted another meta-analysis on the therapeutic interventions that were most effi cacious for helping children and teens to become more internal in their LOC orientations. Cognitive-behavioral therapy (CBT) was at the top of the list of interventions that were most effective. This fi nding started me on a lifelong quest to incorporate CBT into art therapy processes. It has taken a long time for cognitive-behavioral art therapy (CBAT) to be accepted by the art therapy community. From my perspective, it has taken at least 30 years. Today, many art therapists are engaged in CBT, especially third-wave CBT. In fact, when third-wave CBT came into vogue about 10 years or so ago, I was surprised by how many art therapists embraced this evolutionary step in CBT theory and therapy. Then I realized that it was not CBT that the art therapists were drawn to, but the mindfulness and meditative aspects of third-wave CBTs that caught their attention. What remained was a lack of understanding of CBT and CBAT. So therein lies the continuing problem of the acceptance of CBT and CBAT. Thus the need to write a book that spanned the evolution of CBT from its early days of behavioral therapy through the injection of cognitive science and psychology into behaviorism (which is now called CBT, or the second wave), and fi nally onto the infusion of mindfulness into CBT (or what is often called the third wave of CBT), seemed imperative. As the author of this book, I also wanted to dispel some myths about CBT that have continually plagued its reputation. I was going to begin the process of offering alternative perspectives about CBT, which are common and that often prevent therapists—yes, even art therapists—from incorporating CBT into their work. As I was working on dispelling these common misconceptions, Margarita Tartakovsky wrote about these “myths” in her blog, listing them as follows: (1) CBT is a rigid, one-size-fi ts-all approach, (2) CBT is simply shifting negative thoughts to positive ones, (3) CBT does not believe in an unconscious, (4) CBT Preface xv ignores emotions, and (5) CBT is not concerned with a client’s past or their child- hood (Tartakovsky, 2017). These fi ve “myths” not only keep art therapists at arm’s length from CBT, but also verbal psychotherapists are very often put off by these erroneous beliefs about CBT. Tartakovsky was even concerned about therapists who use CBT regularly yet have never realized that it is a creative and interactive approach that is con- ceived according to each client and his or her specifi c needs. As I complete this book, I hope that I can do justice to an attempt to dispel the myths of CBT and to conduct a thorough overview and investigation of CBT, which includes an integration of CBT and CBAT for the art therapist and for other therapists who are interested in imagery and creativity as part of CBT work. Marcia L. Rosal ACKNOWLEDGMENTS

Although this is a single-author book, I could not have completed it without the assistance of several supportive friends, intelligent mentors, and generous colleagues. There are many people to thank for their encouragement and belief in my ideas. First, I would like to thank the four individuals who offered to read and pro- vide feedback on various chapters. Dr. Deborah Elkis-Abuhoff reviewed two chapters exploring early concepts of cognitive-behavior therapy (CBT) and cog- nitive-behavioral art therapy (CBAT). With her keen eye, her incisive feedback, and her insistence not only that CBAT exists, but also that it is an important and valued approach to art therapy, she urged me to continue working on this book. Dr. David Gussak took on the task of slogging through two chapters exploring philosophical and theoretical tenets of CBT and CBAT. I thought these chapters were necessary to provide a fundamental background for the ideas behind CBT and CBAT. He agreed and offered much needed insight into how to frame the two chapters for art therapists. Based on her vast clinical background, Dr. Patricia Isis generously read through two chapters exploring mindfulness and third-wave CBT and CBAT. Her insight greatly improved these two chapters. Dr. Alexandria Zettler read the fi rst chapter and let me know that it needed some “oomph” and more of my own voice. She also provided case vignettes to illustrate various CBAT interventions described in Chapter Six. In addition, Dr. Amy Backos per- mitted me use information of the Powerpoint she presented at the 2016 Annual Conference of the American Art Therapy Association, and Dr. Patricia Isis and Dr. Kathleen Decker offered examples of art work from personal collections. There are others I wish to thank for their years of professional mentorship and support. My academic career began at the University of Louisville Expressive Therapies Program. For most of my 14 years there, I was fortunate to have a sup- portive and brilliant colleague in Dr. Vija Lusebrink, who had unwavering faith in Acknowledgments xvii me and my ideas. Even though her work on the expressive therapies continuum is not the topic of this book, the essence of her infl uence is on each and every page. Another infl uential mentor, Dr. Frances Anderson, was one of the fi rst art therapy professionals to reach out to me to write. I was honored to submit a chapter for her book, Art for All the Children (second edition). When she asked me to write a chapter, I wrote a tome. She expressed regret about having to cut many pages from my submission, but to make up for her “slash-and-burn” policy, she later published the entire chapter as a monograph and had it translated into Spanish and Chinese (Mandarin). Dr. Judith Rubin did the same, and invited me to write a chapter for the second and third editions of her Approaches to Art Therapy: Theory and Technique . Before my career as an art educator began, in the early 1980s, I embarked on a doctoral program at the University of Queensland in Australia. My research interest was art therapy with children and teens with behavior disorders, and I was fortunate to have two exceptional supervisors. Dr. John Elkins, a researcher in special education, and Dr. Martin Ritchie, a professor of counseling psychology, both taught me the importance of having an empirical mindset and not proclaim- ing anything to be effi cacious unless there was research-based evidence for this. As I set out to fi nd the best therapeutic approach for the treatment of behavior disorders, I would never have anticipated that behavioral and CBT approaches would have been the most effective by far. It was this fi nding that led me on a career-long path to integrate art therapy and CBT. I shall end by thanking Florida State University for giving me the opportunity to teach at a Research I public institution and to develop the graduate art therapy program there. Every day I was reminded that academic rigor and exceptional teaching were expected. For 18 years I have had the opportunity to benefi t from both colleagues and students challenging and honing my thinking. My work is all the richer for their enthusiasm and input.

1 THE UNEASY CONNECTION BETWEEN COGNITIVE-BEHAVIORAL THERAPY AND ART THERAPY

“Genuine art work requires organization which involves many and perhaps all of the cognitive operations known from theoretical thinking.” (R. Arnheim, 1969, p. 263)

The time has come for art therapists to embrace one of the most researched and most effective approaches to art therapy today. Cognitive-behavioral ther- apy (CBT) is not only a meticulous treatment modality, but also an effective and viable approach to art therapy. The longevity of CBT is due to the com- mitment to research each CBT technique. Any strategies that do not result in positive therapeutic changes are eliminated from CBT protocols. According to Herbert and Forman (2011b), “Hundreds of studies have evaluated various cog- nitive behavioral theories of psychopathology, and hundreds more have assessed the effi cacy of CBT interventions. This scientifi c literature has placed CBT in a unique position to dominate the fi eld of psychotherapy” (p. 3). The same is true for cognitive-behavioral art therapy (CBAT). A number of art therapy research studies have investigated the success of CBAT, and accord- ing to Anderson (2001) “the evidence supporting it [CBAT] is very strong” (p. 254). Even with positive outcome research and signifi cant effi cacy, art ther- apists are still wary of embracing CBAT. Therefore the mission of this book is to provide a comprehensive examination of CBAT for art therapists and other mental health professionals who want to investigate the power of art therapy as part and parcel of CBT. This will be accomplished by presenting philosophi- cal and theoretical information throughout the evolutionary phases of CBT and CBAT. 2 The Connection between CBT and Art Therapy

There are three distinct stages or waves in the progression of CBT and CBAT practice. 1 Throughout the book, each wave will be examined and deconstructed for practitioners; specifi c art therapy practices will be illustrated through the use of case vignettes. The foundation of CBT and CBAT begins with the onset of behaviorism or what is now regarded as the fi rst wave of CBT. Behavior theory and behavior therapy were the foundation of this fi rst wave of CBT when behav- ior therapy was the rule. Problematic behavior was hypothesized to be learned and maintained by the environment. Albert Ellis (1962) and other staunch behav- iorists such as Skinner (1953, 1971) and Watson (1913, 1924) used the philoso- phy of stoicism to undergird their ideas. Stoicism, which emerged in the third century ad , regarded emotions as phenomena that needed to be tamed. In sto- icism, emotions are not ignored, but rather the Stoics crafted principles of living that would mitigate purely emotional responses to diffi cult situations (Russell, 1945). Behaviorists embraced this principle of stoicism and developed interven- tions to help clients to fi nd a less reactive and more adaptive and rational course of action when dysfunctional behaviors manifested. The second wave of CBT and CBAT began with the emergence of the new science of cognition and the integration of cognitive science into behaviorism, or what is now termed the second wave of CBT. This new phase of behaviorism began with Albert Bandura (1969) and the development of social learning theory, which proffered that the regulation of human behavior is determined through one’s cognitive processes rather than being regulated by the environment. Beck (1976), Meichenbaum (1974), and other psychologists used this new-found understanding of cognition to develop the early therapeutic mechanisms of CBT. The integration of Buddhist psychology, mindfulness, and meditative prac- tices into CBT practice is referred to as the third wave or third generation in the evolution of CBT. This evolutionary advancement of CBT began with Kabat- Zinn (1982), who created a successful mindful meditation program for individu- als with chronic pain. The purpose of this program was not only to reduce the amount and strength of pain medications required to manage pain, but also to help patients to regain their former lifestyle. Soon thereafter Kabat-Zinn’s ideas were studied by cognitive-behavioral psychologists and were transferred to the treatment of relapsing depression, borderline personality disorders, and other self- harm diagnostic groups. The third wave set of CBT approaches has energized art therapists more so than the fi rst two evolutions of CBT. Today, art therapists are embracing mindfulness and meditative practices as integrated into art-making.

Some Background on Art Therapy Art therapy is one of several experiential modes of treatment, including the cre- ative arts therapies (e.g., art, bibliotherapy, dance, drama, music, poetry, psy- chodrama) as well as recreation therapies, which include equine interventions. Experiential treatments engage the client in participating in a creative activity that The Connection between CBT and Art Therapy 3 embodies therapeutic value. When art therapy is employed, clients are encour- aged to interact with an assortment of art materials through touching, smelling, and manipulating art media. The therapeutic value of using art materials has been explored by numerous art therapists, and there are many books and journal articles that advance the use of art therapy with a multitude of diagnostic groups. Under- standing the therapeutic application of the many art materials available to art ther- apists is explored through the expressive therapies continuum (Kagin & Lusebrink, 1978; Lusebrink, 1990, 2016; Hinz, 2009, 2016) as well as investigations of both traditional and contemporary media by C. Moon (2010). The manipulation of art materials was initially discussed by Kramer (1971), who found that forming a product out of raw art materials can be empowering and ego-building. Manipulating art materials can assist in advancing self and environmental awareness. According to Lorenzo de la Peña (2016), “Individuals naturally turn toward their environment when translating the emotive experience into concrete form” (p. 146). Body awareness is one of the areas that can be improved through interacting with art materials (L. Wilson, 1977; Anderson, 1992). Understanding where the body is in space is one possible outcome of art therapy. Spatial awareness is another (Packard, 1977). And, as proposed by Uhlin (1972) and Silver (1987), improvement in developmental and cognitive abilities is also possible through interacting with art materials. Most recently, there is evidence that art therapy can address neurological issues and can enhance brain functions (Chapman, 2014; King, 2016). The work of the art therapist includes encouraging the client to engage with art materials as a means of self-exploration and self-expression, and most impor- tantly, utilizing art materials to move the client towards healing. For the non- art therapist, it might seem, from an objective perspective, that conducting art therapy is simple—just supply an array of art materials to a client and arrange some time and space for them to engage with these materials. Although engaging in art-making has many benefi ts, the practice of art therapy involves more than just providing materials, space, and time. In addition to a thorough understanding of the therapeutic properties of art media, art therapists are also versed in aspects of creativity and the power inherent in the creative environment and the creative process (Lusebrink, 1990). For example, several art therapists have found that being engaged in a creative act can have both transcendent and therapeutic effects (Garai, 1987; McNiff, 1998; Rubin, 1984). In addition, the creative product is one that exudes meaning not only for the client, but also for the viewer of the art. The experiential and creative aspects of art therapy require art therapists to provide an environment where choice of media and a welcoming setting are of utmost importance. A place of nonjudgmental acceptance is vital to the success of art therapy treatment. This type of climate was fi rst proposed by both C. Rogers (1951) and N. Rogers (2001), and regardless of the theoretical perspective embraced by an art therapist, this type of acceptance has been integral to the art therapeutic process. Art therapists carefully think through each encounter with a 4 The Connection between CBT and Art Therapy client with an understanding of the issues faced by that person, framing goals and objectives for what needs to be accomplished in each session, and formulating outcomes. The endeavor is not and should not be atheoretical.

The Need for a Theoretical Foundation Judith Rubin wrote about the need for a theoretical perspective for the practice of art therapy in the Introduction to the fi rst edition of her book, Approaches to Art Therapy, in which she stated that “At fi rst, I worked with people on a largely intuitive basis. Later, I looked for ways to understand what was going on and ideas about how best to proceed” (Rubin, 1987, p. xv). What Rubin sought was a theory that would not only enable her to understand her work with children, but also provide a framework for developing her approach to art therapy with children. Theory is fundamental to art therapy because of its importance in planning and implementing art therapy, explaining and justifying one’s work to other art therapists, and demystifying the work of art therapy for other mental health professionals. The profession has evolved over the decades and now includes numerous theoretical perspectives. As espoused by Rubin, theories provide a scaffolding for the art therapist’s thinking and allow him or her to envision how to proceed with any given client. Theoretical perspec- tives not only offer principles of behavior change, but also assist the clinician in conceptualizing strategies for applying these principles for the betterment of the client.

Art Therapists Adhere to Theoretical Perspectives Theoretical approaches to art therapy have been examined and utilized over the years. Art therapists borrow theory and therapeutic models from several educa- tional and psychological sources, and have applied these borrowed concepts to art therapy practice. Early practitioners of art therapy used psychoanalytic techniques, models, and principles (Kramer, 1971; Naumburg, 1966/1987; Rubin, 2016; Wilson, 2016). Art therapists have also used Jungian principles (Abbenante & Wix, 2016; Bonny & Kellogg, 1976; M. Edwards, 1987; Wallace, 1987; Wittels, 1978), Adlerian theory (Lewis, 1979), phenomenological approaches (Betensky, 1977), humanistic philosophies (Garai, 1987), Gestalt principles (Rhyne, 1974, 1987; Ciornai, 2016), existential tenets (B. Moon, 1990), and eclectic approaches (Vogt & Vogt, 1983; Wadeson, 1987, 2016). Behavioral approaches emerged in the art therapy literature in the 1970s, and cognitive-behavior art therapy fi rst appeared in the art therapy literature during the late 1970s, when two important think- ers wrote about their work. Ellen Roth (1978, 1987) discussed the idea of using behavior therapy techniques and “reality shaping” as a means of conceptualizing art therapy for children with both developmental and psychiatric disorders. Janie Rhyne (1979a, 1979b) explored personal construct theory (Kelly, 1955) as a The Connection between CBT and Art Therapy 5 basis for helping individuals to explore emotional states. Thus CBAT has only been around for about 25 years, or about half as long as CBT. Neither Roth nor Rhyne realized just how pivotal their work would become to the fi eld of art therapy.

CBT and CBAT The belief that CBT interventions do not have a place in the practice of art ther- apy still exists today. Yet there is common ground between CBT and CBAT, and it is an aim of this book to fi nd and illuminate these intersections. In fact, CBT should hold a signifi cant place among the many major theoretical approaches to art therapy because it is a research-based practice. However, many art therapists have been cautious about regarding the two perspectives as compatible. One of the main concerns is the opposition of an experiential treatment such as art therapy to the perceived prescriptive nature of CBT. For example, Sobol (1985) wrote about the feelings of alarm and distaste that many art therapists have about the trends in behavioral psychology. Reynolds (1999) was curious as to why “cognitive behavioral approaches appear almost entirely missing from the creative therapies literature” (p. 165). More recently, Roghanchi et al. (2013) noted that even though both CBT and art therapy have long histories, the integration of the two is not widely adopted. Fortunately, today there are CBAT ideas scattered throughout the art therapy literature.

Obstacles to Adopting CBAT The obstacles to adoption of CBAT are many, and need to be addressed. Here the arguments against the use of CBAT will be challenged. There are at least fi ve signifi cant obstacles to the use of CBT in the practice of art therapy. The fi rst is a concern about the sense that CBT is a “cookbook approach” to the practice of therapy. It is true that there are numerous CBT workbooks regularly used by CBT mental health practitioners. Often step-by-step manuals are perceived as rigid, not allowing for the individuality of the client to inform the therapist of where and how to go next in treatment. Although there is a kernel of truth to this concern, most CBT therapists are signifi cantly infl uenced by the immedi- ate needs of a client, and do not allow a workbook to hinder them from veer- ing away from a specifi c intervention in order to address a client’s troublesome worries. The second concern was outlined by Sarid and Huss (2010), and is related to the fi rst obstacle. They pointed out that CBT is often identifi ed as a top-down therapeutic process. By this they mean that the shape of the treatment is devel- oped by the therapist and then provided to the client. Yet art therapy is recog- nized as a bottom-up treatment modality, in which the client shapes the course of treatment. Although there is some evidence that this is accurate, CBT does not 6 The Connection between CBT and Art Therapy always circumvent the client’s input. In fact, one of the strengths of CBAT is that the art itself brings to the fore the trajectory of the treatment process. The third perceived problem is that CBT and CBAT do not address the emo- tional content of client issues. Again this is inaccurate. Feelings and emotions are considered to be cognitive processes, which are therefore important to examine and address as part of treatment. According to Hofmann, Asmundson, and Beck (2013), both cognitive therapy and CBT address the interplay of cognition and emotion. In current CBT and CBAT practice, there are specifi c interventions for tackling the emotional intensity and affective content of anxiety, PTSD, and other diagnostic groups, such as depression and chronic pain. 2 Assisting a client in making sense or making meaning out of diffi culties has been a vital part of the practice of art therapy. Therefore the fourth reason why art therapists may shun CBAT is because there has been a lack of discourse on how it helps a client to make sense of their dilemmas. Meaning-making is a key compo- nent of CBAT. In fact, the incorporation of art-making into CBT increases the probability that fi nding the signifi cance of life events will be possible. Meaning can be constructed through art-making and can be understood through the lens of constructivist theory. 3 Fifth, the perception that CBT is about the power of positive thinking is unfounded. Rather CBT is about helping someone to think and act more ratio- nally, and this is the root of CBT and CBAT. Rational thinking, as fi rst intro- duced by Albert Ellis, is crucial to adaptation and to adjusting more effectively to problematic situations. In CBT and CBAT, rational thought patterns mitigate or modify maladaptive ones and lead to adaptive behaviors. Both CBT and CBAT therapists believe that rational thinking may help clients to construct a life with less upheaval and distress.

An Argument for CBAT CBT, which encompasses a constellation of treatment variants, has been around for over 50 years. According to some psychologists, it is still regarded as a rela- tively new theoretical approach to therapy when compared with psychodynamic approaches (Davey, 2013). Based on numerous studies, including randomized controlled studies, CBT is a highly effective and useful therapeutic approach for anxiety disorders (including PTSD), depression, eating disorders, schizophrenia, personality disorders, criminality, substance abuse disorders, etc. In fact, some even tout cognitive therapy as one of the most important advances in medical treatment in the past 50 years (Altman, cited in Hofmann, Asmundson, & Beck, 2013). The foundation of CBT is rooted in social learning theory (Bandura, 1969; Miller & Dollard, 1941; Rotter, 1966). This theory arose at a time when psychologists were exploring theories to accommodate not only how humans behave but also how we think about issues, emotions, events, and ourselves, as well as how we perceive important aspects of being. The Connection between CBT and Art Therapy 7

Therefore one argument for the use of CBT in art therapy is important to note: CBT has signifi cance in the psychology world because of the massive amount of evidence for its effectiveness for treating individuals suffering from numerous concerns, such as anxiety, depression, and PTSD, as well as behav- ioral problems such as addictions, compulsions, and eating disorders. Also, art therapy, although often perceived as an experiential type of therapeutic treat- ment, has cognitive components that are inherent to the artistic process and to the practice of art therapy. In addition, CBT has creative and imaginal aspects as well as intervenes with diffi cult emotional content. The practice of art therapy is complex and intricate. Using art as a means of addressing the behavioral, emotional, and mental concerns of clients requires thought and experience as well as that all-important scaffolding known as a theoret- ical orientation. Before making the decision to embrace a specifi c theory, it is essen- tial to have a thorough understanding of the philosophical and theoretical constructs upon which the approach was built. Thus a second aim of this book is to provide that foundational evidence needed to underscore the power of CBT and CBAT. With the mounting evidence for the effi cacy of CBT, the purpose of this chapter is to lay the groundwork for the argument that CBAT is a vital, impor- tant, and effi cacious approach to art therapy. Included will be information that I hope will counter the notion that CBT and art therapy are incompatible. Based on the experience of several art therapy authors, a survey of how engaging in art therapy offers a client improved cognitive skills will be outlined.

Cognitive Skills Improved by Art Therapy CBT and CBAT have the following common elements: (1) developing healthy and fl exible adaptation strategies in order to enhance the chances of survival and improve life, (2) understanding cognitions, including inner speech and mental imagery, as antecedents to behavior, and (3) promoting pragmatic solution gen- eration for helping individuals under duress and as an effi cient way to relieve stress and enhance coping. In addition, uncovering mental images and emotion states, as part of the cognitive framework, is an important component of CBAT. As stated previously, CBAT began with Roth and Rhyne. Other art thera- pists experimented with incorporating CBT into their work. Some CBT principles that are useful to art therapists include problem-solving (Packard, 1977), modeling (Roth, 1987; Rozum, 2001), relaxation techniques and mental imagery (Lusebrink, 1990; Rosal, 1985, 1993, 2001), stress reduction (Lusebrink, 1990), and systematic desensitization and/or fl ooding (De Francisco, 1983; Gerber, 1994; Matto, 1997; Reynolds, 1999). These CBAT principles will be discussed in this book using examples from both historic and current writers. Although the amount of literature on art therapy using a cognitive-behavioral perspective is limited, those who did write about this theoretical approach discussed the cognitive skills enhanced by art therapy. Arnheim (1969) found that art-making was a robust cognitive activity, and 8 The Connection between CBT and Art Therapy

Rosal (2001) theorized that “When engaged in art making, we use a full range of cognitive processes” (p. 222). This idea was echoed by Roghanchi et al. (2013), who avowed that art therapy was particularly suited for CBT because art-making is inherently a cognitive activity. To provide an initial understanding of CBAT, the various art-making skills that engage cognitive functioning and improve thinking and problem-solving are discussed below.

A Problem Focus One of the strongest reasons for incorporating CBT into art therapy is the emphasis on developing a problem-focused mindset. After supporting the client’s willingness to engage in treatment, the next step is to uncover the problem or the set of problems that brought the client to art therapy. Art therapists who use CBT techniques have understood the power of zoning in on a problem or the set of problems that a client brings to therapy. Rosal (2001) found that “swiftly getting to the heart of the problem can provide immediate relief” (p. 223). Reynolds (1999) discussed the need for carefully analyzing the problem with a client she named Anne. When Anne entered therapy, she stated that she had come to work on depression and marital problems. By the third session, after careful questioning and thoughtful discourse, Anne admitted that she felt shame about her irrational fear of looking at family photos. Reynolds realized that this would be the prob- lem focus of the treatment. From there, Reynolds had Anne engaged in creating a tapestry incorporating the troubling photos.

Externalizing the Problem Matto, Corcoran, and Fassler (2003) discussed the value of externalizing the problem focus of treatment. In CBT, the problems that are identifi ed by a client can be reconfi gured and restructured. When using CBAT, a problem is created on paper and it frees the client “from the belief that the problem is a fi xed and inherent quality. . . . It introduces fl uidity into problems that may have become rigid and seemingly fi xed” (Matto et al., 2003, p. 266). These authors found that when externalized in a visual image, once the problem is in visual form, it is easier and safer for a client to explore. The external image of the problem is malleable, can be altered, and can also be a bridge to fi nding solutions. Problems may be externalized by creating several images in the form of stages of behavioral action (Rosal, 2001). Examples are drawing the cycle of offending behaviors or drawing “before,” “during,” and “after” sketches of fi ghts or arguments. 4

Problem-Solving According to Arnheim (1969), “visual perception is visual thinking and art- making is a kind of visual problem-solving.” Curl (2008) echoed these remarks The Connection between CBT and Art Therapy 9 and found that art-making, in and of itself, is a form of problem-solving. Epp (2008) used art therapy for individuals with autism to solve problems visually. Through art-making, “Rapid and solid solutions can help an individual to gain self-control” (Rosal, 2001, p. 223). In CBT, mental imagery is often used as a tool to activate solution generation, to organize one’s thinking, and to problem-solve. Rosal (2001) understood that “Since the mental image is [therapeutically] effec- tive, the drawn image is a compelling addition to the already effective array of CBT techniques” (p. 223). Matto et al. (2003) initiated a brief art therapy program that was solution-focused and problem-focused, and proposed that the art experi- ence exposed a fuller picture of the problem as well as the solution. Curl (2008) incorporated the concept that art-making is essentially about fi nding solutions to problems into a photo-collage program for young girls, where the act of creating collages aided problem-solving and confl ict resolution. Matto et al. (2003) found that using the images created by a client could lead to fi nding new possibilities and solutions to thorny problems. In summary, with regard to the problem-solving capacity of art-making, and as affi rmed by the words of Parsons (1998), “The artist is therefore a problem-solver” (p. 81).

Perspective Expansion Often clients have a fi xed perspective on an issue or concern. Altering an ingrained point of view can be the impetus for increasing fl exibility in their thinking. Matto et al. (2003) used CBAT to broaden the client’s perspective on a problem. Once an image had been completed, they asked the client to create “a second picture, magnifi ed on a larger piece of paper, to exaggerate the prob- lematic aspect” (p. 269). This process allowed the client to explore the problem and its bothersome aspects from a different perspective. This can also be done by asking the client to hone in on the most diffi cult part of an image and enlarge it on a larger piece of paper. Alternatively, the client may be asked to take a prob- lematic image and reproduce it on a smaller piece of paper, thereby minimizing the problematic image.

Reframing Problems In a similar manner to altering the perspective on a problem, CBAT art thera- pists also help clients to reframe their diffi culties. Reframing is a technique used in CBT to help the client to view diffi cult events, situations, and thoughts in a more positive light. Matto et al. (2003) cited examples of reframing with a group of adolescents with substance abuse disorders and discovered that refram- ing problems leads to uncovering strengths. The group was fi rst asked to draw a problematic behavior related to their addiction behaviors. Next, they were asked to identify a skill required for that delinquent behavior and, in a second drawing, to create an image of how those skills might be translated into a positive behavior. 10 The Connection between CBT and Art Therapy

The purpose of this intervention was to allow the teens to uncover the positive aspect of the skills they possessed, and to reframe and reimagine how these same skills might be put to good use.

Decision-Making Art-making is replete with opportunities to make decisions. Even the decision to pick up an utensil to begin a piece of art embodies an important decision. For many clients, this fi rst step is diffi cult and requires determination and will—two key components of cognition. Once a client has begun, there are a multitude of decisions that ensue. Factors such as the type of media, size of the paper, which color(s) to use, where to place certain aspects of the drawing, and when to stop drawing all have an impact on the outcome of the art piece. According to Matto (1997), art therapy with a client with an eating disorder “provid[ed] her with a means of actively participating in decision-making” (p. 350). In CBAT, clients “choose art materials, choose how to approach a drawing, and choose how and what to discuss about created pieces” (Rosal, 2001, p. 223).

Reinforcements and Prompts Two traditional behavior techniques used in CBT are reinforcements and prompting to shape and develop new behavior or eliminate problematic behav- ior. Even among art therapists who do not adhere to behavioral and CBT practices, use of these two techniques occurs as a matter of course. Even a com- ment as simple as “it is time to sit down and begin to make art” is a behavioral prompt. Reinforcing pro-art-making behavior is also common in art therapy practice (e.g., “Today you worked very hard on that sculpture and it looks almost fi nished”). Roth (1978, 1987) explored how most psychotherapists, including art therapists, use reinforcements such as verbal praise when a client can stay on track or when he or she reports making progress in dealing with problematic social encounters. According to Rosal (2001), “Whether drawing or sculpting, creating art involves instant feedback systems and the ongoing reinforcement of satisfying behaviors. Each brush stroke that appears on the paper can suggest or promote further action (feedback) as well as delight (rein- force) the artist” (p. 217). Two examples of the use of prompts and reinforcement stand out. Roth (1987) used a series of prompts to help children to develop clear visual constructs. In her work, which she called reality shaping, she had children work and rework spe- cifi c visual schemas to create concepts that were related to dysfunctional behav- ior. 5 Mellberg (1998) worked with adolescents with developmental disabilities and created a watercolor protocol that relied on positive reinforcements to help the teens to gain control over watercolors. The protocol led the clients in a step- by-step process that ensured success and mastery over the medium. Making art The Connection between CBT and Art Therapy 11 has some inherent reinforcement qualities. Each mark that is made in a drawing visually reinforces the effort made by the artist. Experimenting with materials can have a reinforcement quality because completing a picture can embody rein- forcement value in and of itself.

Creating Order out of Chaos In discussing the problem-solving aspects of children’s art, Arnheim (1969) stated that “Image-making serves to make sense of the world” (p. 257), and he theo- rized that at “higher levels of mental development the compositional patterns [in children’s art] become more complex” (p. 259). Certainly art therapists accept the notion that developmental milestones can be observed in the art of children as they mature. Advances in composition, which correspond to developmental maturity, are clues that a child is bringing order to their world. In addition, Matto (1997) found that through creating art works, which includes problem-solving and decision-making, order can be created out of chaos. Messy efforts can release energy and subsequently can be reconfi gured or re-formed. Many theoretical approaches to art therapy underscore the use of art- making to bring order out of chaos. However, Rosal (2001) asserted that:

Cognitive-behavioral art therapy accelerates the acquisition of control through combining the inherent internal control building aspects of art therapy with additional techniques such as 1) discovering, promoting, enhancing, and reconfi guring mental images; 2) comparing and contrasting drawings; 3) carefully choosing ad portraying problem-specifi c situations and events; and 4) creating pictorial metaphors of feelings and mind states. (p. 223)

When clients gain control of art processes in order to complete a piece of art, they feel accomplished, empowered, and in control. Pifalo (2007) found that helping abused children fi nd some order amidst the turmoil of an abusive situation was an important goal of treatment. One form of art therapy that Pifalo used to help to bring order was to have children create road maps of their young lives. This signifi cant concept was echoed by Reynolds (1999), who found that art processes lead to the structuring of chaotic feelings, which in turn leads to a change in per- spective and ultimately to empowerment.

Improving Executive Function Developing mastery over art materials leads to behavioral and emotional control. Rosal (2001) confi rmed that “The overriding goal of CBT is for the client to gain self-control” (p. 218). For both children and adults, self-control is essential for maturation and a move towards improved mental health. Managing one’s own 12 The Connection between CBT and Art Therapy behavior allows for greater freedom and personal choice. Self-control is a crucial executive function located in the prefrontal cortex of the brain. According to Sarid and Huss (2010), both CBT and CBAT are interactive modalities which access various modes of cognitive processing. These authors established that CBT and CBAT increase the executive function of the brain through “initiat[ing] regulatory processes that decrease anxiety and negative emotional responses by inhibiting hypothalamic release of cortisol” (p. 11). Thus control over chaos through art-making is a step towards behavioral self-control. Tolerating ambigu- ity and disappointment when art products do not manifest as imagined not only improves self-control, but also improves executive functioning.

Summary Selecting a theoretical orientation is critical to the practice of art therapy. As Rubin (1987) advocated, a theory informs the art therapist about how to formu- late a treatment perspective and build a scaffold on which goals and objectives as well as the development of specifi c interventions can be envisioned and imple- mented. Over the decades, art therapists have adopted numerous psychological approaches. Yet CBT is one theory that art therapists still debate as an appropri- ate model for their work. Several obstacles remain that hinder the inclusion of CBAT among the favored theories of art therapy. These obstacles, which include the concern that CBAT does not include attending to the emotional needs of the client, are unfounded. It is because of this debate that I chose to undertake the writing of this book. My aim is to put to rest the concern that CBT does not align with an experiential treatment such as art therapy. The power of CBAT is that it is a problem-focused and practical approach to art therapy. Art-making involves numerous cognitive skills that are targeted and expanded through CBAT. CBAT therapists use the intrinsic cognitive proper- ties of art-making and imagery in treatment. They also apply CBT principles to uncover problematic cognitive processes that interfere with positive adap- tation, and develop art-making strategies to challenge these cognitions and to form new perspectives and behaviors. Even when one is armed with a thorough understanding of the power of CBT, it may continue to be a diffi cult theory to embrace. A few of the cognitive skills needed for art-making have been outlined above, and others will be discussed in subsequent chapters, as outlined later in this chapter.

Constructivist Theory, Cognition, and CBAT Behind each theoretical approach is an epistemological stance. I am propos- ing that CBAT is steeped in the philosophy of constructivism. Simply stated, this philosophy is a perspective on how humans build knowledge and create meaning. Art therapists have embraced this epistemological stance. For example, The Connection between CBT and Art Therapy 13

Matto et al. (2003) built her art therapy program on constructivism, and stated that this philosophical perspective is knowledge about how reality is constructed in concert with social interactions. As an art therapy educator, I embraced this philosophy for the education of art therapists. The basic tenet is to provide as much theoretical information about the fi eld and as many practical experiences as possible, and to trust students to discover what matters to them most as a means of building a conception of the profession. At the center of this philosophy, in educational terms, is the assumption that students have what is termed human agency , whereby learners serve as active agents and determine their views on art therapy practice (von Glasersfeld, 1995). As proposed by Larochelle and Bednarz (1998), for students the epistemology of constructivism “should help them refl ect on the processes, referents, and scope of their constructions and aid them in becoming acclimatized to the singular nature of the elements and activities from which other constructions—including those of a scholarly variety—are gener- ated” (p. 8). In addition, the principles of constructivist learning also include a teacher who consistently and carefully questions and challenges, rather than one who is just a lecturer. Constructivist ideas are based on the theories of cognitive psychology and cognitive science. Many credit the work of Piaget as introducing psychological constructivist ideas (Fosnot & Perry, 2005), and he infl uenced thinkers such as Lev Vygotsky (1964), Jerome Bruner (1990), and George Kelly (1955), to cite just a few. Constructivist philosophy deepens our understanding of CBT and CBAT as proposed by Carnes (1979), Rhyne (1979a, 1979b), Matto et al. (2003), and Fenner (2016). These ideas will be explored in the following chapters. Begin- ning with the research and ideas put forward by Piaget, constructivism is the idea that each person creates their own understanding of the world around them; how the world works and how people behave and interact pervades the ideas embedded in constructivism and CBAT. Constructivism is crucial to art therapy because it also informs the way in which a person constructs a drawing, painting, or sculpture (Fenner, 2016). Art-making is the construction, deconstruction, and reconstruction of personal stories. The constructivist model explores the origin of mental imagery, metaphor, and narrative, and identifi es the cognitive operations that make these tasks possible. These cognitive functions are vital to the practice of art therapy.

Organization of the Book Chapter One has introduced the book and provided a general foundation for the argument in favor of CBAT. In addition, summaries of the chapters that fol- low will be provided. Chapter Two presents an exploration of the creative and imaginal aspects of cognition and cognitive-behavioral theory. This information is vital to understanding the link between CBT and CBAT. Specifi cally, two important topics will be covered: (1) theories of mental imagery and their use in 14 The Connection between CBT and Art Therapy

CBT, and (2) theories on the links between emotion and cognition. The con- nection between imagery and perception and how imagery is used in behavior therapy and CBT is covered. In Chapter Three a deeper analysis of the cognitive aspects of art-making will be presented. The chapter begins by delving into constructivist theory thinkers. Specifi cally, the constructivist-developmental theories of Piaget, Vygotsky, and Bruner will be explored. This discussion sets the stage for exploring cognitive- constructivist aspects of art-making. The work of Eisner (2002) and Efl and (2002) will focus on how thinking and cognition are integral to art-making. Chapters Four and Five are historical examinations. In Chapter Four, the progression of CBT will be explored, beginning with the inception of behavior- ist theories (sometimes referred to as the fi rst wave of CBT) and the behavioral therapy interventions that were based on these ideas. Next, the way in which the emergence of cognitive science and understanding of higher cognitive processes in humans led to the second wave or cognitive-behavioral theories in therapy will be investigated. Historical accounts of CBAT will be covered in Chapter Five. The way in which early art therapists merged CBT and art therapy will be examined. Again, art therapists who employed behavior techniques fi rst and then those who embraced the new cognitive science or the second wave of CBT will be discussed. Key elements of CBAT will be examined. Chapter Six provides a thorough overview of contemporary CBT and CBAT techniques. Examples of case material will enhance the reader’s understanding of each technique. Current and contemporary literature will be used to supplement the discussions. Chapter Seven begins the exploration of the third wave of CBT. In this chap- ter, the origins of mindfulness as part of CBT will be discussed. The cognitive elements of Buddhist psychology, mindfulness, and meditation will provide the context for how and why CBT theorists and therapists have embraced aspects of Eastern philosophies, particularly Buddhism, as part of their practice. Chapter Eight is an overview of CBAT in concert with third-wave theories of cognition and cognitive processes. The main third-generation theories explored in this chapter are dialectical behavior therapy, mindfulness-based stress reduc- tion, mindfulness-based cognitive therapy, and acceptance and commitment therapy. Both third-wave CBT and CBAT will be examined for each of these new iterations. The art therapists who now include these mindfulness techniques will be discussed. In Chapter Nine, the complex theory of CBAT is distilled into a summary of best practices for various diagnostic groups. The compilation of CBAT prac- tices will provide students and practitioners with a clear picture of how to work within the CBAT model. I conclude this fi nal chapter with a decisive argument for CBAT as an important and timely approach to art therapy. The Connection between CBT and Art Therapy 15

Notes 1 The fi rst two waves will be discussed in Chapters Two, Three, Four, Five, and Six. In Chapter Seven, the third wave, based on Buddhist psychology, mindfulness, and medi- tation, will be investigated through a cognitive lens. In Chapter Eight, both third-wave CBT and CBAT approaches will be explored. 2 See Chapter Six for CBT techniques such as making meaning out of emotions, deal- ing with emotions in vivo , and imagery rescripting to mitigate disturbing and anxiety- producing mental images. 3 See below as well as Chapter Three, in which this theory will be explored in depth. 4 In Chapter Six, further discussion of externalizing the problem is explored for intrusive thoughts. 5 See Chapter Five for more information on Roth’s work. 2 CREATIVE, IMAGINAL, AND EMOTIONAL ASPECTS OF COGNITIVE-BEHAVIORAL THERAPY

“When you concentrate on a mental picture, it begins to stir, the image becomes enriched with details, it moves and develops.” (C.G. Jung, 1935, p. 19)

“Imagination is the act or power of forming mental images of what is not actually present to senses or what has not actually been experienced. It is also the act or power of creating new ideas or images through the combination and reorganization of previ- ous experiences.” (A.D. Efl and, 2002, p. 133)

There is a misconception that cognitive-behavioral therapy (CBT) treatments are solely symptom-focused or skills-based. This fallacy is understandable due to the proliferation of CBT workbooks and skills training texts in the practice literature. Although valuable, these books often do not explore the subtleties of CBT practice. While CBT therapists are focused on identifying and ameliorating specifi c problem areas, these practitioners also understand that the mind is com- plex and several mental processes occur simultaneously. In cognitive-behavioral art therapy (CBAT), the power of mental imagery and emotional processing is combined with cognitive-behavioral therapeutic techniques to increase internal locus of control, self-effi cacy, and self-control, as well as to improve adaptive behavior. Thus a deeper understanding of mental imagery, its origins, its uses, and its connections to other cognitive processes is needed. Emotions are also part and parcel of the practice of art therapy. In addition, the role of emotion in meaning- making, appraisal, and behavior change is integral to CBT. In this chapter, the focus will be on exploring two aspects of CBT that require creativity and nuance, namely imagery and emotions. CBT: Creative and Imaginal Aspects 17

Mental Imagery In 2011, Hackmann, Bennett-Levy, and Holmes stated that “Imagery is one of the new, exciting frontiers in cognitive therapy” (p. xxvii). Yet there is a long history of using imagery in CBT. As early as the 1960s, cognitive psychologists and cognitive-behavioral therapists discovered that mental imagery is as pow- erful as or more so than internal verbalizations or self-talk. This is particularly pertinent when a client experiences distress or is re-experiencing traumatic events. Early CBT treatments used imagery as part of systematic desensitization and covert modeling. Today, using what is called image restructuring, mental imag- ery is now part and parcel of CBT. So how did imagery come to be such an important aspect of CBT? An attempt at answering this question will be pre- sented in this chapter.

Historical Roots of Imagery in Psychotherapy Imagery has always been a part of human heritage derived from magic, religion, philosophy, and literature (Waller, Schweitzer, Brunton, & Knudson, 2012). And it has been a part of the discussion in many philosophical and psychotherapeutic traditions. For example, although not directly addressed, psychoanalytic theory is replete with references to mental imagery as part of the unconscious. McKellar (1986) noted that concepts such as repression, free association, and transference are fraught with the “past doings of the imaged self” (p. 49). Freud was interested in imagery, too, and wrote The Interpretation of Dreams (1913), which even today is an important work on not one, but two, types of mental imagery—dreams and hypnogogic states. Imagery was addressed more directly in other in-depth psy- chology traditions. Dream interpretation and the use of active imagination were two techniques used by Jung in his work (Jung, 1965). Active imagination is the process of having a client pay close attention to all aspects of the dream imagery and then report these to the therapist, who watches for changes in the dreams- cape. According to Jung, the dream reports uncovered clues to the individual’s unconscious. Jung also hypothesized that archetypal imagery forms part of our understanding of the collective unconscious (McKellar, 1986). For over a century, psychologists have been researching the role that mental images play in helping clients to gain self-control (Janet, 1889; Perky, 1910; Piaget & Inhelder, 1969; Watson, 1913; Wolpe, 1958; Paivio, 1971; Kazdin, 1978; Meichenbaum, 1977, 1978). D. Edwards (2007) traced the use of imagery in psychotherapy back to the hypnotherapist Pierre Janet in the 1880s, who used what he called imagery substitution in his clinical work. In this treatment, he had the clients imagine diffi cult scenarios and subsequently alter the images to be more adaptive as one means of increasing coping. As a complicated phenomenon, mental imagery has perplexed philosophers and psychological researchers over the decades. Although a complete philosophical 18 CBT: Creative and Imaginal Aspects timeline on the nature of mental images is not possible here, it is important to touch on important aspects of the philosophies that drove psychological research in this area. For example, Berkeley (as cited in Kaufmann, 1986) espoused an imagist theory where mental images are considered a primary symbolic system as part of classical empiricism. Based on this philosophy, secondary symbols such as language are derivative; Berkeley considered language to be the most important aspect of secondary symbols. In his thinking, words derive their meaning through images, and words are substitutes for images. According to Berkeley, “thinking occurs mainly in the medium of words, but . . . thinking is only meaningful when the words are convertible, either directly or indirectly, into the relevant images” (Kaufmann, 1986, p. 172). 1 From Berkeley’s philosophy, structural psychologists such as Wundt and Titchener used imagist theory and classical empiricism as a paradigm for researching mental imagery (Kaufmann, 1986). They attempted to uncover whether thought could occur without imagery through empirical research meth- odologies (Waller et al., 2012). Titchener (as cited in Singer, 1974) theorized that introspection is a central tool in thinking, and thus brought imagery to a position of great importance in his paradigm. For Tichener, imagery had a prominent role because it did not need a stimulus to occur, and he considered imagery to be a basic cognitive function. The diffi culties of Tichener’s theory were exposed by psychologists at the Wurzberg School in Germany, where numerous studies indicated that various modes of thinking “did not require imagery in order to infl uence thinking or perception” (Singer, 1974, p. 25).

Imagery Research Most early research on imagery focused on its perceptual properties and the link between these two mental processes. Research conducted by Perky in 1910 sealed the important connection between imagery and perception (Waller et al., 2012). Perky conducted a series of experiments with barely perceptible colors that resulted in her participants reporting that what they saw was from their own imaginations. Perky concluded that perception and imagery shared common mental systems. Even very recently, Waller et al. have found perception to be an integral aspect in defi ning imagery. For example, Wragg and Kosslyn (as cited in Waller et al., 2012) defi ned an image as “an internal representation that produces the experience of perception in the absence of the appropriate sensory input” (p. 293). When psychologists were steeped in strict behaviorism, the investigations of mental imagery were placed on the sidelines. According to Waller et al. (2012), the gap in imagery research between Perky’s work in 1910 and research in the 1960s sits squarely on the shoulders of Watson and the rise of behaviorism. Watson’s 1913 article, Psychology as the Behaviorist Views It , set forth his view of psychology as based solely on observable behavioral phenomena. This pronouncement put a hiatus on imagery research because it was considered introspective rather than as CBT: Creative and Imaginal Aspects 19 possessing observable qualities. Watson and his colleagues focused on what could be seen rather than on such mentalist concepts as imagery. According to Singer (1974), Watson deemed thought to be behavior and all thinking to be subvocal speech. Yet according to Marks (1986), even Watson and other strict behaviorists began to rethink the signifi cance of imagery when the cognitive revolution and the science of the mind emerged. Renewed interest in how humans think and process information emerged with the onset of cognitive psychology and with contemporary understanding of the mediating effects of cognitive processes on behavior. The convergence of behaviorism with the emergence of cognitive psychology was the reason for this paradigm shift (Marks, 1986). Once cognitive science legitimized the study of mentalist phenomena, the role of imagery in psychology rebounded and imagery research commenced anew. The use of imagery was almost immediately adopted in certain forms of behavior therapy techniques, such as systematic desensitization and covert conditioning . Thus this paradigm shift reintroduced the importance of imagery and affect as vital aspects of psychological treatment. As a result, research on imagery increased in the late 1960s and early 1970s. Bugelski (1971) attempted to help psychologists to understand the nature of mental imagery in his chapter, The Defi nition of the Image, which presented a review of the research conducted in the late 20th century. To defi ne imagery, Bugelski cited a number of imagery researchers and theorists (e.g., Richardson, Leuba, Mowrer, Paivio). He found fl aws in the many ideas of the time, but could pinpoint some aspects of imagery that held merit based on careful study and research. For example, he found that mental images are involuntary and occur naturally as people journey through their day. Although images can be explic- itly solicited, it is often diffi cult for a particular mental image to be called forth. Nonetheless, there is evidence that some individuals are more adept at inviting mental images to come to the fore. According to Bugelski there was one researcher, Paivio, whose studies help therapists to understand some of the many aspects of imagery. Paivio (1971) found that imagery can and does occur as an associative reaction to words, and that it plays a role in our memory for (and comprehension of) language. Paivio also learned that imagery cannot be understood in isolation, but only in comparison to other constructs such as verbalizations and perceptions. Thus linguistic competence and performance may be initially dependent upon imag- ery. Paivio theorized “that imagery can be profi tably viewed as an aspect of meaning, or at least as an implicit reaction to verbal stimuli, which mediates such psycholinguistic phenomena as comprehension, retention, and the pro- duction of connected discourse” (1971, p. 28). The concept that images carry meaning, which may lead to increased comprehension, supports the current CBT use of image restructuring . If mental images hold meaning, then it is impor- tant to uncover them as part of inner speech and other cognitions that mediate behavior. 20 CBT: Creative and Imaginal Aspects

Based on his imagery research, Naruse (1986) found four aspects of men- tal imagery that may be useful to the therapist. First, imaging activities during the waking state become easier with practice or experience; in other words, the uncovering of mental imagery can be learned. Second, the construction of mental images relies on past experience as well as the present moment. In other words, what Naruse calls the original image may or may not be altered when it is recalled. Alterations are based on the current internal and external circumstances of the individual. Third, imaginings are best utilized under the following condi- tions: “mental relaxation, passive concentration, dissociation from the perceptual world, meditative concentration, acceptance of imaginal experience, positive adjustment to the imaginal world, absorption into imaginal experience, staying in a state of meditative or altered consciousness and so on” (Naruse, 1986, p. 97). Finally, mental imaginings take a back seat to the outer, perceptual activity, yet can enrich cognitive activity. Bugelski (1971) also recognized that mental images occur more frequently and vividly when the body is relaxed and at rest, and that they “happen[s] to us when we are relatively quiet, not talking, or unable to talk, and not trying to have images” (p. 57). This fi nding is important as it provides a basis for understand- ing dreams, and for the use of guided imagery in therapy. In the guided imagery method, the client is asked to relax prior to being asked to imagine various activi- ties or travels (Lusebrink, 1990). Of course, images occur whether we are asleep or awake. Bugelski understood that images have qualities that are more akin to processes rather than fi xed entities, and that they are neural activities in the brain in a real person or body. Mental images are not static pictures, but rather they are progressions where one image may lead to another. There is a dynamic quality to imagery. Therefore Bugelski proposed that we think of imagery as an active process and not an idea in the sense of an object, and that we consider it as a verb rather than a noun. The connection between imagery and emotion is another key area of research. Holmes and Matthews (2010) found that emotions are more read- ily accessed when in image form as compared with language-based informa- tion. Memory also plays a role in the connection between mental imagery and emotion. Conway (2001), a major researcher in this area, distinguishes autobio- graphical memory, which is directly related to the individual, from memories that contain general events. Conway proposed that autobiographical memory is directly linked to imagery that is emotion-laden. In comparison, language- based event memories are not linked to imagery, nor are they emotion-laden. He hypothesized that imagery is the main conduit for recalling highly affective experiences and events. In other words, imagery holds emotional power because of its direct access to memories of related emotional events which are held in autobiographical memory. In this paradigm, “imagery-based memories can be retrieved directly (rather than deliberately built up), and when they spring into mind unbidden they CBT: Creative and Imaginal Aspects 21

‘hijack’ our attention” (Hackmann et al., 2011, pp. 35–36). In fact, individuals may experience troubling imagery as if it were reality, happening in real time. Thus intrusive imagery has powerful and distressing consequences, especially for those experiencing PTSD. It is hypothesized that imagery may be linked directly with fear and other emotional responses based on our evolutionary history where sensitivity to perceptual stimuli was a necessity. Based on this area of research, key imagery-based CBT interventions such as image restructuring and system- atic desensitization are useful for decreasing the emotional impact of problematic memories and their correlate imagery.

Imagery and Neuroscience Over the past two decades, neuroscience research has provided evidence that the areas of the brain which produce mental images are like those which aid in perception. These fi ndings support the research on mental imagery and percep- tion conducted over 100 years ago by Perky. Waller et al. (2012) explored the concept of double dissociation between imagery and perception uncovered in indi- viduals with brain lesions. An individual with a brain lesion may have inhibited abilities to produce imagery, but their perceptual abilities remain intact, and vice versa. Yet after a thorough review of the neuroscience research, Waller et al. (2012) concluded that their prevailing understanding of imagery and perception is that imagery

engages many of the psychological structure and processes used in percep- tion; however, imagery is thought to instigate these processes through top- down instead of bottom-up pathways. . . . In this view because imagery uses the self-same psychological process as perception, the two functions are intimately related. However, because the instigation of these processes derives from internal sources in imagery and external sources in perception, the two phenomena are dissociable. (p. 295)

Pearson et al. (2013) reviewed research on three important components of mental imagery: (1) imagery generation, (2) image maintenance, and (3) image inspec- tion. Their review revealed that mental imagery can be created via two routes, namely from immediate perceptual information, and from memory. Several studies have indicated that there are differences between images recovered from short-term versus long-term memory, and there is now evidence that images can be called forth intentionally or involuntarily. In clinical psychology, intrusive images have a high research priority because they are often found in such dis- orders as anxiety, phobias, and PTSD, and this research is needed for treatment purposes, whereas purposefully bidden imagery is the purview of experimen- tal psychologists. Pearson also reported that there are documented defi cits in 22 CBT: Creative and Imaginal Aspects imagery generation in various disorders, such as representational neglect, depres- sion, attention defi cit hyperactivity disorders, and congenital blindness. Based on the research of Kosslyn (as cited in Pearson et al., 2013), mental images easily decay once they are generated. The root of this brevity might be its shared neural system with perception such as the occipital cortex and other neural substrates, and it may be that images fade quickly so as not to interfere with normal perceptual activities. Image decay may also be linked to the depletion of attentional resources needed to hold the image. Finally, Pearson et al. found that research supports the idea that once an image is maintained, it can be inspected and used in cognitive processing. Kosslyn (as cited in Pearson et al., 2013) found that the neural processes used for image inspection are distinct from those utilized in image generation, transformation, and maintenance. This research suggests that using mental images in treatment encourages involvement of several parts of the brain and may lead to neural plasticity. Brain imaging research on both imagery and perception processes revealed that the occipital, temporal, and parietal cortical areas of the brain are active in both. Brain imaging techniques were also used by Kosslyn, Ganis, & Thompson (2001) to uncover the neural processes of both imagery and perception. In one experiment, they used brain scanning to determine which area of the brain was used when a research participant was asked to imagine a type of line. They dis- covered that the same region of the brain was used when a person used their eyes to perceive the same item in the environment. Thus they discovered that imagery engages the same neural structures that are employed in perception, and that those neural structures can in turn affect sensory events in the body itself. Based on their fi ndings, they proposed a theory of functional equivalence between imagery and perception. This conclusion provides support for the use of imagery in CBT practice as well. For example, when clients are asked where they experi- ence a feeling or emotion in their body, they pull forth mental images as well as physical perceptions and sensations. Therapists use the information given by clients to intercede with what their perceptions mean. This research also supports the work of Kabat-Zinn (1982), who used mindful meditation as a treatment for chronic pain. The image of pain and where it lies in the body is a starting point in this type of treatment.

Assessing Imagery in Clinical Settings There are numerous assessments for imagery. Pearson et al. (2013) reviewed many tasks to assess imagery abilities for clinical as well as experimental use, and organized them into four categories corresponding to the four cognitive aspects of mental imagery: (1) image generation, (2) image maintenance, (3) image inspection, and (4) image transformation and manipulation. The authors also examined 25 measures of imagery in the following categories: (1) imagery use CBT: Creative and Imaginal Aspects 23 and experience, (2) imagery re-experiencing phenomenon and intrusive imagery, (3) assessment of prospective imagery, and (4) assessment of bias in imagery. 2 These measures may be useful when making clinical decisions about the use of imagery in treatment. When using imagery in any psychotherapy tradition, the authors suggested assessing mental image in several domains, not just one. For example, in work with individuals with depression, it has been demonstrated that these individuals are not impaired in image duration or maintenance, but are defi cient in sensory and motor processing of mental pictures; thus there is support for using imagery rescripting in CBT treatment to help clients with depression to apprehend and manage these images. To understand the importance of imagery in the treatment of the other diagnostic groups, Pearson et al. encouraged more research using multiple existing measures to provide evidence and guidance to CBT therapists on how to use imagery in treatment.

Summary Mental imaging has been an aspect of human life for centuries. Yet a complete understanding of imagery remains somewhat elusive. Nonetheless, there is now a measure of documentation informing psychologists about this important cogni- tive process. Based on a century of research, it is clear that imagery is a power- ful aspect of cognition, and may even be as vital as perception and language in understanding how humans think and learn. Some ideas on how to assist clients with bringing forth mental pictures have been uncovered. There is also evidence that using imagery in psychotherapy can be an agent of change. Most psycho- therapeutic traditions incorporate imagery as part of the principles of treatment. Based on recent research, we now possess an understanding of the power of imagery in memory, especially when associated with personal or autobiographi- cal events. Numerous clinical tools are available for use by clinicians to assess and under- stand the imaging processing of clients. Recent research is now focused on the neuroscience of imagery. To date it has been documented that imagery is situ- ated in several parts of the brain and occupies the same neurology as perception. Furthermore, generation of imagery uses a different part of the brain to imagery inspection. Understanding that mental imagery is vital to the practice of CBT may help the art therapist to embrace cognitive-behavioral principles in art ther- apy. It is important to discuss the uses of mental imagery in CBT here as a prelude to understanding both of these therapeutic traditions.

History of Imagery in CBT Since its inception, cognitive therapy has emphasized the role of mental imag- ery (Holmes, Arntz, & Smucker, 2007). Mental activity can involve words and phrases (verbal) or images (visual cognitions; Beck, 1976). Affective distress can 24 CBT: Creative and Imaginal Aspects be linked to visual cognitions as well as to verbal ones, and modifi cation of dis- tressing visual cognitions can lead to signifi cant cognitive and emotional shifts (Beck, as cited in Holmes et al., 2007). Since imagery is an important psycho- logical percept in CBT, an examination of the historic roots of imagery in this therapeutic tradition is needed. An understanding of some of its theoretical and therapeutic precursors will richly inform this practice. According to D. Edwards (2007), imagery as part of CBT was informed by several psychotherapeutic traditions familiar to the art therapist, including those espoused by Anna Freud, Piaget, Moreno, and Perls. For example, D. Edwards (2011) found that Moreno’s psychodrama had several commonalities with the use of imagery in treatment. In psychodrama, the patient acts out scenes to expose specifi c details of diffi cult experiences. The scenes begin with memories and the mental images associated with problematic situations, and are then played out in front of the psychodrama group. In the early 1980s, key CBT thinkers found that Gestalt techniques might be used in their work (D. Edwards, 2007). Beck (1970) hypothesized that distorted assumptions might arise from schemas from childhood, which is reminiscent of Piagetian as well as Gestalt principles. D. Edwards (2007) recognized that Gestalt principles were some of the strongest infl uences for current imagery practices in CBT. Perls (as cited in D. Edwards, 2011) theorized that schemas which carry an emotional charge may be diffi cult to uncover, and found that if they were left unprocessed, these schemas would lead to unfi nished business that might affect behavior. One method for uncovering unfi nished business was the use of the hot seat. The use of intensive imagery was a vital component of the hot seat exercise, where the client would express emotions to reveal the core of troubling experiences (D. Edwards, 2011). In addition, Perls would often begin sessions by asking the client to close their eyes and bring to mind dream imag- ery or other spontaneous mental images; these would serve as starting points for the session. Perls also understood that careful attention to the here and now and moment to moment focusing , as well as self-observation, was important to treat- ment. Careful examination of the here and now opened up the possibility that these tenets of Gestalt work are part of CBT as well as mindfulness approaches to treatment. 3

Early Imagery Approaches in Behavior Therapy Initial cognitive approaches to behavior therapy were based on the idea that schemas with a strong emotional charge could be altered and mental imagery was a signifi cant aspect of the techniques to mitigate powerful schemas. Two such techniques, namely systematic desensitization and covert rehearsal, utilize mental images to situate one’s self in a stressful scene. Systematic desensitization, which was developed by Wolpe (1958), used imagery to assist clients in managing phobias. Within systematic desensitization, the client would identify a diffi cult CBT: Creative and Imaginal Aspects 25 or fearful object or situation. The treatment was relatively simple, as it involved asking the client to list, in hierarchical form, the situations that were most fright- ening. These situations formed the basis for developing visual images. Relaxation is also a key component of systematic desensitization. First, clients are led through relaxation exercises, and once a signal is given that they are relaxed, the therapist asks the clients to imagine the least stressful situation. During the treatment, the clients make their way up the hierarchy of stressful events using mental images of each situation. The aim is to decrease general anxiety responses to each event in the hierarchy. Lazarus, as a student of Wolpe, “employed imagery not only to desensitize anxiety but also for rehearsing new habits of assertiveness, mastering problem- atic situations, coping with anticipated challenges, and ameliorating stress-related conditions such as hypertension, spastic colon, and dermatitis” (D. Edwards, 2011, p. xl). This led to another important early behavior therapy technique that had imagery at its core, namely covert rehearsal. In covert rehearsal, the client is asked to imagine or rehearse how they might act under duress through imagin- ings in the mind’s eye rather than in situ or in real life. Once the client achieves mastery in the imagined scenarios, they may be motivated to deal with phobias and fears in the natural environment. There is a continuing debate as to whether the imagined scenarios are as effective as in-situ exercises. Nonetheless, imagery exercises prepare the client to cope with real-life situations. These historic behavior techniques used mental imagery to alter arousal reac- tions to diffi cult issues, yet the emotional charge of these images was largely left unattended in the treatment in favor of mitigating the fear response itself. Beck theorized that early uses of these two techniques were too restrictive, and preferred the work of Lazarus (1971), who had depressed clients imagine posi- tive images of the future (Holmes et al., 2007). Today, Beck would encourage understanding the meaning of the stressful object or event as part of current CBT approaches, and would counsel therapists to address the affective component as part of CBT treatment (Hackmann et al., 2011). 4

Dreams and Daydreams in CBT Early in the development of CBT, dream and daydream imagery was considered a vital link between psychoanalysis and the cognitive process. Beck (as cited in Rosner, 2002) began to uncover the role of cognition in psychotherapy in the late 1950s. Part of his early work included a desire to bridge psychoanalytic thought and behavior therapy methods. This led him to conduct research on dreams as part of his work on treating depression. Because Beck considered empirical research methods to be the gold standard of psychological research, he focused on what was found in the data versus adherence to a specifi c theory. Thus his research on dreams (Beck, 1971) did not support several tenets of psy- choanalysis, including dreams as wish fulfi llments, so he determined that dream 26 CBT: Creative and Imaginal Aspects research should focus on the manifest content of dreams and “staying on the level of the patient’s experiences [rather] than to infer some underlying process” (p. 171). He discovered that the dream content of depressed individuals was “analogous to the kind of suffering a depressed patient experienced in his wak- ing life” (p. 208). He also realized that dream material revealed how individuals saw themselves, the world, and the future, and he labeled these three spheres the cognitive triad . Singer (1975) studied the world of daydreaming at great length and found that it was a natural process used by numerous people and was not pathological. Through various studies he found that a large percentage of people’s daydreams are future-oriented and practical. Using an information-processing paradigm, Singer postulated that daydreaming is a positive phenomenon. Singer’s research group found that adolescents daydream more frequently than young adults and older people. Most of these daydreams have an anticipatory component, and there is evidence to support the hypothesis that daydreaming in the teen years is preparation for the future. Singer also reviewed the research literature which suggests that adolescents who have a rich daydreaming life are more likely to grasp and mull over a mul- titude of circumstances that might involve behaviors that would be risky. They also exhibit greater creativity and productivity. According to Singer, there is research which indicates that delinquent teens do not have the capacity to think about the past or imagine the future as well as their nondelinquent peers. This may indicate that helping teens with behavior problems to imagine and daydream may be useful in developing pro-social behaviors. Of course, working with dreams and daydreams also means working with imagery. Early CBT therapists understood that a disturbing dream or image was often directly related to depression or anxiety, and that a calm image can reduce arousal (Freeman & White, 2002). According to these authors, CBT therapists should be ready to assist a client with dreams if they are brought up in the ses- sion. They offered a dream log (DL) approach as well as 15 guidelines on how to approach dreams in the CBT tradition. The DL was used to record dreams. Once the dream had been recorded, the client was encouraged to keep a record of the dream analysis, which the authors labeled the dream analysis record or DAR. The DAR was a record of the date of the dream, a synopsis of the dream, a rating of the emotional content of the dream, the restructuring of a dream image, and a re-rating of the emotional impact post restructuring. This record was brought to sessions and was part of the CBT treatment. Freeman and White’s 15 guidelines for using dreams in CBT are as follows:

1 The dream needs to be understood in thematic rather than symbolic terms. 2 The thematic content of the dream is idiosyncratic to the dreamer and must be viewed within the context of the dreamer’s life. 3 The specifi c language and imagery of the dream are important to the meaning. CBT: Creative and Imaginal Aspects 27

4 The affective responses to the dreams can be seen as similar to the dreamer’s affective responses in waking situations. 5 The particular length of the dream is of lesser import than the content. 6 The dream is a product of, and the responsibility of, the dreamer. 7 Dream content and images are amenable to the same cognitive restructuring as are automatic thoughts. 8 Dreams can be used when the patient appears “stuck” in therapy. 9 The dream material and images will refl ect the patient’s schema. 10 Dreams need to be dealt with as part of the session agenda setting. 11 A system and regimen for the collection and logging of the dream material should be encouraged. 12 The patient should develop skill at restructuring negative or maladaptive dream images into more functional and adaptive images. 13 The patient should try to capsulize and to draw a “moral” from the dream. 14 The dream images, as appropriate, can be used as a shorthand in therapy. 15 The collection and analysis of the dream content should be employed as a standard homework task. (Freeman & White, 2002, pp. 45–48)

The use of dreams and dream imagery in CBT was thought to break through symptoms and help the client to proceed with healing. With the help of the ther- apists, clients are encouraged to begin to restructure the dream imagery on their own. The rating and re-rating of the emotional content gauges how effectively the restructuring technique worked for the client.

Imagery and Self-Effi cacy While Beck found that dreams and imagery refl ected the cognitive distortions of his clients, other psychologists were considering additional aspects of mental imagery. For example, Bandura (1977) found that CBT approaches to treatment suggest that mental imagery contributes to self-effi cacy. According to Singer (1974), Bandura provided a model of imagery that was suited to a cognitive approach and to learning theory. Bandura’s thinking on imagery was related to symbolic modeling (as opposed to behavioral modeling). While his strict behav- iorist colleagues used modeling to change behavior, he theorized that imita- tion is also developed internally through symbolic form. He opened the door to understanding that internal representations lead to learning. In fact, Bandura theorized that the most effective learning included interactions between internal symbolic representations, in visual form, with verbal coding of these representa- tions. Through various research studies, Bandura (1977) and colleagues found that symbolic modeling can lead to the development of internal control and self-regulation. Other imagery interventions can also lead to expectations of self-effi cacy. For example, systematic desensitization and covert modeling “often reduce the 28 CBT: Creative and Imaginal Aspects negative affect associated with the imagined situations and provide the person with an additional sense that they do have the coping skills to confront such situ- ations” (Singer, 2006, p. 109). Singer and Pope (1978) proposed that imagery could be used constructively for adaptive escapism, self-awareness, self-regulation and biofeedback, and for creativity and aesthetics experiences. They stated:

Self-effi cacy cognitions in the form of imagery, fantasies, or self- communications in some form determine whether we will initiate certain types of behavior and, once engaged in them, how long we will persist or how much effort we will expend. The private image that one can cope will help one stick it out in situations that are believed to be dangerous, embarrassing, or otherwise aversive. (pp. 26–27)

Meichenbaum (1978) summarized three important processes for the use of imagery in CBT for the development of self-control and effi cacy: (1) clients gain control when they are able to monitor and rehearse mental images, which leads to control over emotions and behaviors, (2) imagery plays an important role in helping clients to reconceptualize a problem, which in turn alters the meaning of the problem and subsequently will mitigate instances of the problem behavior, and (3) imagery aids in mental rehearsal of alternative behaviors that lead to the development of coping skills. Singer also theorized that imagery is useful for improving expectations of self-effi cacy. Based on the work of Beck, Bandura, Meichenbaum, and Singer, numerous imagery techniques are now used in CBT.

Summary The history of using images in treatment begins with Janet in the 1880s, and the history of using imagery in CBT treatment goes back almost as far. Although it was not widely described as such, imagery played a vital role both in systematic desensitization and in covert modeling. Yet there were criticisms of these tech- niques due to the lack of attention to the emotional content and fi nding the meaning behind the issues that required these therapeutic interventions. Beck was one of the fi rst to make this claim, and thought that understanding dreams and other forms of imagery would add to the overall effi cacy of CBT treatments. His work with individuals suffering from depression and anxiety is most widely known. His studies of the dream imagery of clients with depression led to his hypothesis that the content of dreams was analogous to the concerns that these individuals had in their waking life. He also worked with people deal- ing with anxiety. Beck identifi ed several imagery techniques (imagined scenes) in his book on CBT with anxiety (Beck & Emery, 1985), and he wrote about the cognitive aspects of dream imagery as well (Beck, 1971; Rosner, 2002). CBT: Creative and Imaginal Aspects 29

According to Hackmann et al., (2011), CBT therapists have researched imagery for various disorders and “have also examined connections between intrusive imagery and memory in psychopathology, the relationship between imagery and emotion, and the effects of targeting imagery, directly or indirectly, on efforts to change cognitions and affect” (p. 6).

Current Uses of Imagery in CBT Pearson et al. (2013) reviewed the use of contemporary imagery techniques with several diagnostic groups, including PTSD, social anxiety, schizophrenia, and bipolar illness. Through their study, they could pinpoint specifi c therapeutic interventions and found justifi cation for the various imagery techniques used for each diagnostic group. According to Holmes, Arntz, and Smucker (2007), “imagery techniques in CBT are based on the premise that imagery has a pow- erful impact on emotion, and that mental imagery in a clinical setting can be a powerful psychotherapeutic tool for alleviating emotional distress” (p. 298). Vari- ous imagery techniques have been incorporated into CBT for several diagnostic groups, including PTSD, social phobia, and personality disorders. The purpose of imagery interventions in CBT is to reduce and/or transform disturbing emotions that interfere with daily life, and regular behaviors can go on without further disturbances. Hackmann et al. (2011) noted three common properties fundamental to CBT interventions for intrusive imagery:

1 The establishment of a refl ective metacognitive stance, in which the client is able and willing to refl ect on aspects of their imagery (or lack of it), and to hold these aspects in awareness, providing an opportunity for the establish- ment of a wider perspective. 2 Evocation of disturbing imagery, and accompanying meanings and affect, and/or acknowledgement of the lack of healthy imagery. This provides opportunities for refl ection, and for cognitive and metacognitive change. 3 Deliberate introduction of old or new incompatible information to change negative imagery and/or its meanings, or to create positive images and carry out imaginal rehearsal of new possibilities. (p. 47)

It is important to note that there are CBT interventions that address negative imagery and those which promote positive imagery (Hackmann et al., 2011). Finally, there are what Hackmann et al. call direct CBT interventions, which address imagery problems in a straightforward way, including exposure therapy and manipulation of imagery. Indirect imagery techniques, which are part of third- wave CBT or mindfulness, work with mental images from a compassionate point of view. 5 In this section, an overview of three direct imagery techniques used in CBT will be explored. 30 CBT: Creative and Imaginal Aspects

Reducing the Frequency of Intrusive Imagery Smucker (1997) noted that most of the cognitive-affective disturbance in PTSD comes from intrusive trauma-related memories embedded in traumatic images. Directly challenging and modifying traumatic imagery becomes a powerful if not preferred means of processing the traumatic material. Re-experiencing har- rowing events is a key component of trauma-related disorders such as PTSD and other anxiety-related disorders. Hackmann and Holmes (2004) outlined two key components of intrusive images: (1) they are meaningful to the context of the trauma, and (2) they lack context such as time and place. The authors added that intrusive images appear unintentionally, hold meaning that is threatening, and contain threats to self. Ehlers and Clark (2000) suggested that intrusive images should be examined in detail, both verbally and using all the senses. This type of exposure therapy may be the key to reducing the involuntary nature of the trauma image. Although this type of intervention is distressing, it is one key to reducing the intensity of these intrusions, especially if the client can link the image to other autobiographical memories. By doing this, the client conceptualizes that the intrusive image is one of many memories that make up the past of the person. Focusing on the hotspots of the traumatic memory is another CBT approach (Holmes, Grey, & Young, 2005). Rather than attempting to deal with the entire traumatic scenario, the client is asked to identify the most diffi cult aspects of a trauma image. The hotspots, where affect is greatest, are targeted and the client is asked to describe in detail these problematic aspects of the trauma. The negative impact of these images on the self is uncovered, and fi nally the alteration of the meaning can be created. Another CBT technique is the disruption of the image, developed by Bad- deley and Andrade (2000). This means that the traumatic image is disrupted by offering the client an alternative imagery task. Other CBT interventions, namely image rescripting and the use of positive imagery, are described below.

Changing the Meaning of Negative Imagery and Image Rescripting A better understanding of the role of imagery in memory and cognition has led CBT practitioners to fi nd ways to alter the negative emotional responses to mental imagery. According to Holmes, Arntz, and Smucker (2007), the fi rst person to use this technique was Janet in 1919, and he labeled his work imag- ery substitution (replacing one mental image with another). To understand the underlying theory for the use of image rescripting (IR), it is necessary to go back to Paivio. As examined by Paivio (1971), mental images carry meaning and contribute to the comprehension of events. Negative intrusive affect-laden CBT: Creative and Imaginal Aspects 31 images, thoughts, and memories carry meaning that is often detrimental to the well-being of a client, and are at the root of a multitude of psychological prob- lems (Holmes et al., 2007). Based on Paivio’s research, CBT now includes imagery techniques to reshape the meaning of a traumatic image. This is a par- ticularly important technique for CBT approaches to PTSD and other anxiety and depressive disorders. The aim of IR is to update diffi cult or traumatic imagery (Wild & Clark, 2011). IR is used to modify the meanings of negative or traumatic memories, and to transform traumatic imagery into adaptive imagery (Arntz & Weertman, 1999). Cognitive restructuring, which involves identifying, challenging, and altering maladaptive cognitions, is often used in conjunction with IR. There is evidence that cognitive restructuring without IR is not as effective because it does not address the distressing mental imagery that gives a distorted cognition its affective power. Generally, there are three stages in IR (Hackmann et al., 2011; Smucker, Dancu, Foa, & Neideree, 1995). The fi rst stage is a reliving of the traumatic scene or imaginal exposure as seen from the perspective of the child (or younger adult). The second stage involves the client entering the traumatic scene as an adult today and viewing the incident with adult eyes. Finally, the client is asked to go back into the scene to soothe and nurture the child and to envision asking what else the child needs from an adult. Although this is similar to other CBT techniques, IR “goes beyond mere extinction not only by modifying recurrent images of the traumatic event, but also by creating more adaptive schematic representations” (Smucker et al., as cited in Wheatly et al., 2007, p. 372). There are two types of IR. In type A, the negative imagery is “transformed into a more benign image” (p. 298). In type B, positive images are constructed to counteract the negative consequences of an image (Holmes et al., 2007). The use of IR is now widespread, and includes work not only with individuals experiencing PTSD (Grunert, Weis, Smucker, & Christianson, 2007), the effects of childhood sexual abuse (Arntz & Weertman, 1999; Smucker et al., 1995), depression (Wheatly et al., 2007), or suicidality (Holmes et al., 2007), but also with those with social anxiety (Wild & Clark, 2011), bulimia (Somerville, Cooper, & Hackmann, 2007), obsessive-compulsive disorders (Speckens, Hackmann, Ehlers, & Cuthbert, 2007), and personality disorders (Arntz, 2011).

Fostering Positive Imagery Holmes et al. (2007) proposed that “imagery has a more powerful impact on positive emotion than verbal processing, and therefore cognitive behavioural techniques used to promote positive change should also employ imagery” (p. 300). According to Singer (2006), positive imagery can be employed in vari- ous therapeutic situations. Termed emotive imagery by Lazarus (1971), it is the 32 CBT: Creative and Imaginal Aspects use of pleasing and soothing images to counteract anxiety-producing and nega- tive ones. Pleasurable nature scenes are predominantly used alongside anxiety- inducing images to decrease the arousal response to diffi cult situations. Images of positive life experiences are also used to decrease arousal states. Positive images can aid the systematic desensitization process during the treat- ment of numerous phobias, especially when relaxation techniques are not pro- ductive. Relaxation processes can be enhanced by positive imagery in several CBT techniques, including covert reinforcement (Singer, 1974). Covert model- ing can also be enhanced when using positive imagery as a reinforcement to see one’s self doing well in otherwise stressful situations (Singer, 2006). Hackmann et al. (2011) found that positive imagery can promote the formulation of both therapy goals and new skills in coping, as well as imagining new ways of being. Positive imagery can also be applied to counteract anxiety during illnesses or painful medical procedures.

Summary The history of using images in treatment begins with Janet in the 1880s, and the history of using imagery in CBT treatment goes back almost as far. Although it was not widely described as such, imagery played a vital role both in systematic desensitization and in covert modeling. Yet there were criticisms of these tech- niques due to the lack of attention to the emotional content and fi nding the meaning behind the issues that required these therapeutic interventions. Once the therapeutic value of imagery came to the fore, it was discovered that the imagery could enhance these two early CBT techniques and address more of the emotional content needed for dealing with problematic issues. Beck was one of the fi rst to make this claim that early interventions lacked understanding of the emotional content, and he thought that understanding dreams and other forms of imagery would add to the overall effi cacy of CBT treatments. His work with individuals suffering from depression and anxiety is most widely known. His studies of the dream imagery of clients with depression led to his hypothesis that the content of dreams was analogous to the concerns these individuals had in their waking life. He also worked with people dealing with anxiety. Beck identifi ed various imagery techniques (imagined scenes) in his book on CBT with anxiety, and he also wrote about the cognitive aspects of dream imagery (Beck, 1971, 2002). Three areas in which imagery has made great inroads are decreasing intrusive imagery, altering negative imagery, and fostering positive imagery. The integra- tion of imagery into CBT for dealing with these three major issues is important and vital for today’s CBT practice. Finally, the recent CBT intervention of IR has been found to be important in the treatment of anxiety and PTSD as well as depression and other disorders. IR helps clients to change the meaning of intru- sive thoughts and traumatic images. CBT: Creative and Imaginal Aspects 33

Emotions as Cognitions It does not follow . . . that emotion as such is uniformly hostile to cognitive endeavors, nor may we properly conclude that cognition is, in general, free of emotional engagement. Indeed, emotion without cognition is blind, and, as I shall hope particularly to show in the sequel, cognition without emotion is vacuous. (I. Scheffl er, 1991, p. 3)

D. Edwards (as cited in Greenberg and Safran, 1984) challenged the idea that cognition could be separated from emotion, and stated that there is “no affect without cognition and no cognition without affect” (p. 569). CBT theorists and practitioners embrace this notion. Even though CBT is about addressing behav- ioral responses infl uenced by cognitions and perceptions of the environment, Hofmann and Asmundson (2008) asserted that CBT is not solely based on cogni- tion modifi cation. They found that CBT also addressed all aspects of a psycho- logical disorder, including emotional experiences. The investigation of emotions is complex and detailed, and now includes neu- roscience as part of the study of these intricate entities. There is also a long his- tory of understanding emotions. Due to the multifaceted study of emotions, the overview in this chapter will be limited to the cognitive underpinnings of emotion and the emotion–cognition links. The strongest link between these two constructs is that emotions have an adaptive function. Emotions not only alert a person to dangers and fears or to pleasurable phenomena, but may also lead to action. Due to our status as higher beings, we also cognitively appraise what is happening in our environment, and if threats are perceived, an emotional response may ensue.

Early Thinking about the Emotion–Cognition Link According to Samoilov and Goldfried (2000), early behavioral theorists and thera- pists had a similar view of emotions to the Stoic philosophers in that emotions “interfered with rational thinking and behavior” (p. 374). For example, Samoilov and Goldfried cited both Watson in 1924 and Skinner in 1953 being dismissive of emotions in behavioral theory. Watson thought that emotions were inherited and disruptive, and that learning could mitigate the unsettling power of emotions. Skinner, like Watson, considered emotions to be disruptive and a by-product of one’s environment. These ideas stemmed from the philosophy of stoicism. The Stoics, some of the earliest philosophers to address emotions (from the third century ad ), hypothesized that emotions served no adaptive purpose. In the philosophy of stoicism, emotions were deemed to be detrimental to a rational existence, and teachings were fostered to minimize the effects of passion and other emotions in order to live a tranquil life (Russell, 1945). Stoics postulated that emotions were automatic responses not under our control, and therefore they 34 CBT: Creative and Imaginal Aspects focused on what could be controlled. To do this, the Stoics espoused the devel- opment of self-control to alleviate the power of destructive emotional responses. This view of emotions was compatible with the early behaviorist theorists such as Ellis (1962), whose treatment model counseled clients to think more rationally about their experiences. The understanding of emotions as harmful prevailed with the rationalists such as Dewey (1895). Darwin in his evolutionary research studied human emotional responses as early as 1872, and concluded that they were vestiges of the responses of other mammals to adaptations to or threats in the environment. Other noted theorists, such as Freud and Strachey (1930/1961), Watson (1924), and Skinner (1953), agreed that the functionality of emotions included traces of our evolution- ary past and were disruptive. They used Darwin’s line of thinking to advocate the harnessing of emotions as a mean of working towards mental health (Keltner & Gross, 1999). However, Darwin’s understanding that organisms respond to their envi- ronment as a means of adaptation led to another line of thinking. His theo- ries informed psychologists and philosophers that under most circumstances an organism’s response was natural and automatic. Yet, according to Ellsworth and Smith (1988), higher beings do not just respond, but also interpret what is hap- pening in the environment. These interpretations, especially those that have an impact on needs, lead to emotions. Emotions motivate action, but instead of being automatic or instinctive as they are in less complex organisms, in humans they are adaptive and fl exible. Now most psychologists who study emotions fi nd that they are functionally important in our lives, and most agree that the function is related to the cogni- tive appraisal of and adaptability to the environment (Gross, 1998; Keltner & Gross, 1999). This view of emotions allows researchers to study the causes and concomitant effects of emotions within a person’s environment, and to research the effects on social and physical survival. Lazarus and Smith (1988) thought it was crucial to clarify the difference between two types of cognitive information in the development of emotional responses for CBT research and practice, namely knowledge and appraisal. They stated that knowledge constitutes the facts accumulated about an event, “whereas appraisal defi nes the signifi cance of an encounter for well-being” (p. 281). It is how one assesses a situation that leads to an emotional response and adaptation. They proposed that there are two types of knowledge—general and contex- tual. General knowledge is readily understood as the facts of a situation, but also includes the facts of who we are, our attitudes, beliefs, and generally how we see ourselves. Contextual knowledge is perceptual to the specifi c event or situation. The authors pointed out that both general and contextual knowledge can be accurate or inaccurate, and that both types of knowledge are integral to react- ing to a situation or event. They posited that it is not knowledge that leads to emotion, but rather it is the appraisal of a situation that leads to an evaluation of whether it might affect well-being. They stated: CBT: Creative and Imaginal Aspects 35

Whereas knowledge, although necessary, is not by itself suffi cient to pro- duce an emotion, the appraisal of the personal signifi cance of the encoun- ter, based on this knowledge, is both necessary and suffi cient. Each positive emotion refl ects a kind of appraised benefi t, and each negative emotion refl ects a kind of appraised harm. (p. 283)

An appraisal of an event may lead to adaptive emotions and actions (e.g., appraising that one is in a dangerous situation, experiencing the fear that is asso- ciated with danger, and fi nally taking steps to elude or mitigate the danger). However, an appraisal may not be accurate or based on past dangers or situations, and may lead to maladaptive emotions and actions (e.g., a combat veteran might interpret an auto engine backfi re noise as meaning that he is back in a war zone, use this as a stimulus for arousal, and then hit the ground to protect himself ). With the clarifi cation that appraisals are an important component of emotional responses, CBT therapists began to work on strategies to uncover how clients appraise situations.

Emotions Related to Appraisal The appraisal model of emotion elicitation is only one of numerous theories of emotion in humans. Yet it has claimed center stage in the understanding of emotions. According to Coppin and Sander (2013), the appraisal model had two approaches. The fi rst approach conceptualized appraisal using an information- processing model, and the second approach used an evaluative cognitive- processing model. It is the second type that has formulated the CBT model and will be the focus of the discussion here. The appraisal theory of emotion elicitation was fi rst described in depth by Lazarus as outlined above, but has its basis in earlier thinking. For example, Kreitler and Kreitler (1972), when trying to fi gure out the evolution of per- sonal meaning, found that the development of meaning had two parts—what does it mean in general and what does it mean to me . The what does it mean to me component was a rather new but signifi cant construct in the search to deter- mine how people make meaning, and was signifi cant to the development of the concept of appraisal. Arnold (as cited in Coppin and Sander, 2013) was also a pioneer of the appraisal model. She proposed that each evaluation structure leads to different types of emotions. There is now research evidence to support her hypothesis. Lazarus (1968) postulated that there were three aspects to the process of appraisal. The fi rst, labeled primary appraisal, occurs when a stimulus is recog- nized in the environment and an individual evaluates its signifi cance to their well-being. Secondary appraisal concerns the analysis of the resources available to the individual to cope with the stimulus. Finally, re-appraisal occurs as the 36 CBT: Creative and Imaginal Aspects person is dealing with the situation and adapts accordingly. Lazarus and Smith (1988) found knowledge to be cold, but the primary appraisal of the situation “provides the heat in a transaction, based on personal relevance, which is what makes knowledge potentially emotional” (p. 284). Lazarus hypothesized that there was considerable variability in interpretations of the environment, which would lead to a wide range of emotions. Coppin and Sander (2013) stated that the ideas advanced by Lazarus are still widely accepted today. His hypothesis, that emotions are continuous processes, also has contem- porary relevance.

Emotion Interventions Used in CBT As can be inferred from the information presented so far, the history of CBT often neglected emotions or found emotions to be an experience to be mini- mized by interventions. Recently, CBT theorists and practitioners have realized the importance of emotions as part of cognition. Hofmann, Asmundson, and Beck (2013) stated that the “relationship between emotions and cognition is bidirectional because changes in emotions can also lead to changes in cognitions” (p. 200). They also found that perceptions and events in the environment causally affect emotions, and theorized that how a person thinks about a situation infl u- ences how they feel and act. Thus they recommended that regulating emotional distress should be a part of cognitive therapy interventions. According to Samoilov and Goldfried (2000), there has been a shift in the focus of CBT from addressing emotions and emotional disorders as part of cognition as a means of containing emotions to treating clients through re-experiencing emo- tions and emotion activation in sessions. The purpose of this shift is to help clients to understand the personal meaning of emotions as proposed by Kreitler and Kreitler (1972). Some of the new developments incorporating emotions in CBT include addressing the emotional aspects of cognitive schemas, and using in-session arousal to access and challenge emotional structures (Samoilov & Goldfried, 2000). Cognitive schemas are separate from emotional schemas, which are at the root of personal meaning, and are important to address in therapy. According to Greenberg and Safran (1984), there is a link between emotional schemas and memories as well as expectations. 6 In a CBT session, emotional expression can be used to restructure old meanings and develop newer, more adaptive meanings. This process is called cognitive restructuring. Even though there are new CBT interventions to address emotional schemas, emotion processing was at the root of the treatment for a few historical interven- tions. An example of this is the in vivo and imaginal work of exposure interven- tions. Emotional arousal is at the nexus of this treatment, and targets high-level cognitive structures at the same time as it targets emotional experiences. Accord- ing to Samoilov and Goldfried (2000), therapeutic change occurs through the emotional activation and processing in this type of CBT intervention. Lang CBT: Creative and Imaginal Aspects 37

(1979) concurred, and found that if emotional activation is insuffi cient, thera- peutic change will suffer. Another example of the use of emotions in CBT was developed by Barlow (1988) for the treatment of anxiety disorders. He found that if the client’s anxious emotional contexts (i.e., helplessness, worry, losing control) were not addressed within the session, the treatment would not be complete. A combination of relaxation techniques and humor are implemented to increase a sense of control over the emotional contexts of anxiety. This emotional shift occurs because these interventions provide an alternative to the behavioral consequences of anxiety, such as smiling and other changes in physiology. CBT treatment for clients with PTSD includes exposure of the emotional content of traumatic events and memories. Exposure to the emotional content of memories is a prelude to cognitive restructuring. There is a similar process for bereavement work. CBT practitioners recommend addressing the emotional aspects of grief before moving on to helping the client fi nd the meaning of the loss (Fleming & Robinson, 2001). Exploration of emotions is needed to deal with bereavement and to reconstruct meaning. Hofmann et al. (2013) also recommended cognitive restructuring techniques and in vivo techniques to mitigate distressing emotions. The goal of these inter- ventions is to “modify maladaptive thoughts and cognitive distortions . . . to increase[d] perceived ability of coping, reduce[s] perception of personal vulner- ability, and reduce[s] emotional distress” (p. 200). In addition, they proposed two types of treatment for emotion-laden cognitions. Antecedent-focused emotion regulation interventions include cognitive reappraisal. Response-focused emo- tion regulation techniques involve modifying the exhibition of emotion, which includes increasing adaptive models of expression. They suggested that other techniques, such as acceptance and mindfulness, hold promise for addressing dif- fi cult emotions. 7 Goldfried and Davidson (1976) proposed using cognitive–affective associa- tions in CBT. To do this, they employed several interventions to target emotion- laden structures, including a two-chair technique. Reminiscent of some of Perls’ techniques based on Gestalt principles, the chair disrupts reticence and mobilizes emotional states. This intervention requires the clients to identify and have a dis- cussion between their realistic and unrealistic meanings of events and emotions. Cognitive restructuring is then implemented to enhance changes in emotions and personal meaning. Finally, guided imagery can be employed in CBT to mobilize emotional arousal and, as noted above, to augment modeling and desensitization interventions (D. Edwards, 1990).

Summary Emotions have been found to have an adaptive function in the CBT paradigm. They alert individuals that action might be necessary. Although largely ignored in 38 CBT: Creative and Imaginal Aspects the early years of CBT, emotions have become integral to its practice. The reasons for this are numerous and include greater understanding of emotions in general and uncovering of the link between emotions and cognitions. And, according to Lazarus, Beck, and others, CBT interventions that do not address the emo- tional aspect of a cognition miss the opportunity to engage the client to uncover personal meaning. Cognitive appraisal is an important process in understanding emotional responses, and appraisal is a critical antecedent to the emotions. Some CBT techniques target the antecedent appraisal link to mitigate distressing emo- tions. Interacting with both cognitive schemas and emotional schemas completes CBT work. Emotional schemas provide the heat or power as an impetus for change. According to CBT practitioners, helping an individual with emotional arousal in-session helps the client to uncover the personal meaning associated with troublesome behaviors and disorders. This is particularly important for work with PTSD and anxiety.

Conclusion Mental imagery and emotions are two key aspects of CBT practice. This may be a surprise to many art therapists who might perceive CBT as a “cookbook approach” to therapy. These two experiential aspects of CBT are based on thor- ough empirical research as well as current understanding of neuroscience. Both constructs have cognitive components, and CBT practitioners have found that addressing these constructs in their therapeutic model has enhanced the effi cacy of their work. Art-making engages both of these important cognitive structures and provides rich material for art therapists to consider in treatment. An under- standing of the CBT interventions that employ these important concepts may provide a wider context for how working with imagery and emotions may assist a client using art therapy through a cognitive-behavioral lens.

Notes 1 See Ahsen (1986) or Pearson et al. (2013) for comprehensive coverage of the philo- sophical history of imagery. 2 A comprehensive list of imagery assessment tools is available in Pearson et al. (2013). 3 See Chapter Seven for more information on the link between CBT and mindfulness. 4 See the section on emotions as cognitions below. 5 Compassion and other third-wave CBT techniques are explored in Chapter Seven. 6 See the section above on research on imagery for more information on the connection between autobiographical memories and emotions. 7 See Chapter Eight for a discussion of acceptance and mindfulness techniques. 3 ART-MAKING AS A COGNITIVE- CONSTRUCTIVIST PROCESS

“Thinking calls for images, and images contain thought. Therefore, the visual arts are a homeground of visual thinking.” (Arnheim, 1969, p. 254)

Art-making is an exploratory activity where involvement in the process takes an art-maker to places that may not have been conceivable otherwise. When immersed in art-making, people can lose time or can be focused solely on the here and now. Art engages the senses, and often the entire body is used during the experience of art-making. Art therapists are fully aware of the aspects of art- making that make it an experiential-emotive therapy. By contrast, others may not be as knowledgeable about the cognitive corollaries of art-making. Problem- solving, discrimination, and decision-making skills as well as many other cogni- tive processes are employed when a person is engaged in art-making. The purpose of this chapter is to explore some of the cognitive aspects of art- making. An exploration of cognitive-constructivism will lay the philosophical foundation for art as cognition. Therefore the fi rst part of this chapter outlines the aspects of constructivist philosophy that infl uenced cognitive psychology and the cognitive development theories of Piaget, Vygotsky, and Bruner. The link of cognitive development and constructivism with cognitive-behavioral therapy (CBT) and cognitive-behavioral art therapy (CBAT) is explored as a means of anchoring art-making in this cognitive realm. The second section of the chapter will focus specifi cally on the cognitive-constructivist aspects of art-making. This second part of the chapter will explore the specifi c cognitive features of art and art-making that are essential for understanding CBAT. 40 Art-Making as Cognitive-Constructivism

Cognitive-Constructivism Constructivist philosophical ideas are based on the theories of cognitive psychol- ogy and cognitive science. Many credit the work of Piaget for introducing psy- chological constructivist ideas (Fosnot & Perry, 2005), and he infl uenced thinkers such as Lev Vygotsky (1965), Jerome Bruner (1990), and George Kelly (1955), to cite just a few. Constructivist philosophy deepens our understanding of CBT and CBAT. Constructivism is a way of understanding how humans acquire knowledge and make meaning of the world around them. Although others before him suggested that humans construct their vision of the world, Piaget was the fi rst to initiate the study of knowledge building from a developmental perspective (von Glasersfeld, 1995). Also, Piaget was the fi rst to use the term constructivist epistemology , in 1967. Accord- ing to von Glasersfeld, the constructivist perspective is a radical one because, prior to Piaget, philosophers studied knowledge and its acquisition from a universalist perspective in which knowledge was a true representation of reality. Questioning the position that there is one true representation of reality, Piaget decided to take a pragmatic approach to knowledge building, and used the following question to inform his research agenda: how does a child learn and gain knowledge? Piaget drew upon Darwin’s theory of biological adaptation and natural selection, and hypothe- sized that knowledge acquisition has similar adaptive qualities to those found in the biological world. Based on his extensive understanding of philosophy, and with the assistance of Piaget’s research, von Glasersfeld (1995) identifi ed two guiding principles of constructivism:

• Knowledge is not passively received either through the senses or by way of communication; knowledge is actively built up by the cognizing subject. • The function of cognition is adaptive, in the biological sense of the term, tending towards fi t or viability; cognition serves the subject’s organization of the experimental world, not the discovery of an objective ontological reality. (p. 51)

Building a foundation for understanding cognitive development, knowledge acquisition, and meaning-making begins with Piaget’s theories. Other theorists will be discussed in relation to Piaget, and include Vygotsky and Bruner. Based on the frameworks of these authors, a justifi cation for tapping into the cognitive qualities of art-making for therapeutic use will be explored.

Piaget Piaget’s work is a model for understanding cognitive-constructivist perspectives on human development and knowledge acquisition and, as I am advocating, on Art-Making as Cognitive-Constructivism 41 art therapy. As acknowledged by von Glasersfeld (1995, p. 54), “Piaget was the pioneer of the constructivist approach to cognition” as he sought to generate a coherent model of human cognition and its development. His importance to understanding cognitive development cannot be overstated. Piaget (1967) held the view that the acquisition of knowledge is an adaptive function in the cognitive- conceptual realm. Adaptation, according to Piaget, is key to human functioning. In contrast to biological adaptation, he conceptualized knowledge acquisition as cognitive equilibrium (Piaget, 1967). The concept of equilibrium is fundamental to building of knowledge, and von Glasersfeld (1995) agreed that “Cognitive devel- opment is characterized by expanding equilibrium” (p. 67). For Piaget (1967), acquisition of knowledge is based on action, either physical or mental, and he suggested that “all knowledge is tied to action, and knowing an object or an event is to use it by assimilating it to an action scheme” (pp. 14–15). Action schemes are the basis for Piaget’s ideas of constructing consciousness about the world. He hypothesized that knowledge, rather than a static picture of reality, is continually evolving. Because cognitive structures are tied to action and to use, they are not random and do not randomly change. According to von Glasersfeld (1995), Piaget conceptualized how the mind organizes itself and hypothesized that the cognitive action schemas help to systematize experiences and thus trans- form these experiences into a structured world. New experiences are continually added to the prior accumulation of structures. Because he focused on the structure of intelligence and not the volume, Piaget (1967) was opposed to the notion of measuring intelligence. He viewed cogni- tive development not as a static endeavor, but rather as a result of action, not so much of the body after young childhood, but of the mind or mental operations. Since acquisition of knowledge takes place in the context of action schemes, it is not a stimulus–response process, but rather it is goal-directed. Like a feedback loop, schemas are self-regulating due to the functions of assimilation and accom- modation (these processes are discussed below). Conceptual structures are modi- fi ed when confronted with a problem in the environment and when a schema is no longer functional. The failure of a conceptual structure may occur due to a problem with the schema or when there is a need to expand the model of a schema. In summary, according to Piaget (1967), a person’s knowledge of the world is one that is created and constructed, and most importantly, is based on individual experiences. To understand the complexity of Piaget’s theory, some defi nitions are needed. Efl and (2002) found that explanations of Piaget’s four basic concepts of intel- lectual development are required to understand his theory: schema, assimilation, accommodation, and equilibrium. 1 In addition to the four defi nitions deemed important by Efl and, four additional aspects of Piaget’s theory deserve expla- nation here: achieving maturity, social learning, stage theory, and symbolic development. 42 Art-Making as Cognitive-Constructivism

Schema According to Efl and (2002), a schema is a structure in one’s mind based on past experiences that occur regularly and are held in memory as a guide for future encounters with the world. Schemas change and adapt throughout life and through the different developmental stages. Through the learning process, schemas become more differentiated and less dependent on sensory–motor expe- riences (Efl and, 2002). von Glasersfeld (1995) understood that Piaget’s work led to what he termed “schema theory,” of which the schema was one of the fun- damental building blocks. According to von Glasersfeld (1995), Piaget’s schema theory has three capacities:

The ability and, beyond it, the tendency to establish recurrences in the fl ow of experience; this, in turn, entails at least two further capabilities: remem- bering and retrieving (re-presenting) experiences, and the ability to make comparisons and judgements of similarity and difference; and the presup- position that the organism “likes” certain experiences better than others; which is to say, it must have some elementary values. (p. 68)

Thus a schema is not only a cognitive structure but also the basis for Piaget’s understanding of building knowledge. Anderson (1984) agreed with Piaget that the essence of knowledge is structure, the schema being the basic scaffolding of this structure.

Assimilation Two processes are fundamental to the building of intelligence, developmen- tal learning, and adjustment or adaptation: assimilation and accommodation. Efl and’s (2002) understanding of assimilation is that new information is grafted onto previous schemas and assimilates the novel to already constructed structures. One implication of assimilation is that this process takes what fi ts into conceptual structures and disregards the rest. The process of discarding is adaptive in Piaget’s theory, as it lets go of what does not fi t into cognitive structures and aids a person to fi nd equilibrium. Assimilation is the “cognitive process by which the person integrates new perceptual matter into existing schemata or patterns of behavior” (Wadsworth, 1971, p. 14). Assimilation does not change a schema, but does allow it to adapt to the addition of new information. Thus assimilation is a crucial con- structivist principle as it does not imply adapting to the external world, but rather to the person’s inner world improving his or her equilibrium (von Glasersfeld, 1995). As Piaget (1952) stated, “Assimilation is therefore not reduced to a simple identifi cation, but is the construction of structures at the same time as the incor- poration of things to these structures” (p. 416). Art-Making as Cognitive-Constructivism 43

Accommodation Accommodation is the process whereby new experiential input does not readily attach to already existing conceptual structures or schemas, and if accommodation is not reached, the new input is either used to prevent an unproductive event (a block) or it can lead to a new schema distinct from previous ones (Efl and, 2002). Either way, learning takes place. As Wadsworth (1971) stated, “accommodation is defi ned as the creation of new schemata or the modifi cation of old schemata” (p. 16). According to Wadsworth, “Accommodation accounts for development (a qualitative change), and assimilation accounts for growth (a quantitative change); together they account for intellectual adaptation and the development of intellec- tual structures” (p. 16). To clarify, accommodation takes place if new information does not yield an expected result. And accommodation is needed for the child to begin assimilation again. When the individual can assimilate to new experi- ences, the resultant schemas represent a reliable match of the person’s world; to the extent to which these structures match the person’s experiences of the world, these might be an indication of intelligence (von Glasersfeld, 1995).

Equilibrium Equilibrium is another essential component of Piaget’s understanding of knowl- edge acquisition. As perceived by von Glasersfeld (1995), the notion of accom- modation is based on the learning theory of equilibrium; this process eliminates distress through the development of new schemas. According to Efl and (2002), if someone only assimilates and does not accommodate, they would have a few very large schemas that would be diffi cult to detect differences in objects or events, and reality would be an undifferentiated whole. If one accommodates and never assimilates, they would get bogged down in minute differences and would not be able to generalize. Either of these possibilities will disrupt equilibrium and cause a host of problems for the individual. It is easy to extrapolate from Efl and’s understanding of assimilation/accommodation to the burdens and the discom- forts that numerous clients bring to art therapy. Maintaining a balance between the two processes is vital to a state of cognitive balance or equilibrium, and can be framed as a goal in treatment.

Achieving Maturity As conceived by von Glasersfeld (1995), Piaget’s model of cognitive develop- ment is when a schema, instead of producing an expected result, leads to distress, and in turn an accommodation (possibly a new schema) is developed that main- tains or re-establishes equilibrium. Thus maturity and/or mental health are char- acterized by the expansion of equilibrium (i.e., increasing the number of anxieties the person eliminates). This concept is also applicable to therapy. In Piaget’s 44 Art-Making as Cognitive-Constructivism theory, it is not the elimination of anxieties per se that is equilibrium-producing, but rather that the disturbances, which begin the accommodation process, might lead to refl ective abstractions of the problem (von Glasersfeld, 1995). This refl ec- tion may be the impetus for transforming distress into a new schema or a way of re-imagining the problem. This process is at the basis of therapeutic work with traumatic memories. CBT clinicians would label this process imagery re- scripting, and CBAT therapists would encourage the client to re-draw, reframe, or re-present the anxieties that come from traumatic events.

Social Learning Although Piaget is often criticized for lacking a social context, his theory is inter- personal as well as intrapersonal. According to von Glasersfeld (1995), for chil- dren, it is in interactions with others that produce disquieting effects or what he terms perturbations . As stated previously, perturbations then lead to accommoda- tions. Since perturbations occur when interacting with others, Piaget’s theory includes an interpersonal and social-cultural aspect. However, for several theo- rists, Piaget did not explore social-cultural learning thoroughly. Efl and (2002), for example, criticized Piaget on this matter and found the work of Vygotsky to provide a deeper understanding of social-cultural leaning. 2

Developmental Stage Theory Although Piaget is predominantly known as a developmental-stage theo- rist (Piaget’s four stages of cognitive development are sensory–motor, pre- operations, concrete operations, and formal operations), his theory on how humans construct and adapt knowledge should be the focus of his work (von Glasersfeld, 1995). The hierarchical stages were originally envisioned to be a tool for research or as a framework for observing developmental behavior. Piaget’s (1962) conceptualization of the stages is not an exact step-by-step process; he understood that a child could reach formal operations in one set of contexts and still be in pre-operations in others. Therefore learning is relative or context driven. For art therapists, the stages of cognitive development can be assessed through drawings and may provide an approximate gauge of where the child may be on the developmental level, but should not be generalized to all aspects of the child’s abilities. In fact, art therapists may provide useful information to a treatment team about the outcome of an art therapy evaluation of the child’s cognitive abilities. They can also document other developmental clues through the art-making process that may not be readily noted elsewhere.

Symbolic Development Piaget’s (1962) framework includes two types of learning: (1) sensory learn- ing or action schemas that aid in goal achievement and survival equilibrium; Art-Making as Cognitive-Constructivism 45 and (2) refl ective abstraction, which includes operative schemas that help to achieve a coherent conceptual framework of structures that lead to action as well as higher-level thinking. Sensory–motor knowledge manifests itself in both action and refl ective abstraction or conceptual knowledge in symbols (Lusebrink, 1990). There is a distinction between the fi gurative and the opera- tive, and between physical acting and mental operating. Figurative sensations by motion are physical actions and are observable. Abstraction or mental operations are what the child constructs by associating and combining sensorimotor signals. Operations are always of the mind and are not observable, and results are refl ec- tive abstractions. Operations are then said to be not only abstract, but may also be symbolic. Piaget uncovered symbol development through observing the play of children (Piaget, 1962). Through observations he posited that children are either aware of their symbolic play, which he termed primary symbols, or unaware of the symbolic importance of their behavior, or secondary symbols. An example of a primary symbolic moment is when a child sees a parent rocking a newborn baby sibling and subsequently picks up a doll and imitates this action. A secondary symbolic moment is when a child reverts to earlier behaviors such as sucking a thumb when observing a caregiver closely attending to the needs of a new addi- tion to the family. Piaget would say that secondary symbols are unconscious and the child is not aware of his or her behavior. He also hypothesized that second- ary symbolic behaviors often have compensatory qualities. Secondary symbols can be categorized into three groups: “those related to interests with the child’s own body (suction, erection); those related to elementary family feelings (love, jealousy, and aggression); and those related to anxieties centered on the birth of babies” (Piaget, 1962, p. 173). Of course, symbols are developed through the assimilation/accommodation process and are indicative of the development of higher mental processes. Sym- bols related to assimilation are more internal and have affective qualities, whereas symbols related to accommodation, such as those with cognitive qualities, can be more external and conscious. Symbols can also possess properties of both processes. For Piaget (1962), symbols held both cognitive and psychological importance and often revealed the psychic concerns of an individual. This assumption is particularly important when attempting to understand secondary symbols, as they can have liquidation properties or be of a compensatory nature. An example of liq- uidation is when a child in play therapy uses a family of mouse fi gures to act out abuse in the home. A child who is compensating for weaknesses, anxieties, or fears may desire to wear a Superman costume to school every day. These types of play behaviors are also evident in art therapy, where a child may liquidate by vigorously scribbling with thick crayons on several extra-large papers, or com- pensate by creating and recreating superheroes in their art work. These types of symbolic actions also apply to adults when confronted with traumatic stressors, such as those suffering from PTSD. 46 Art-Making as Cognitive-Constructivism

Summary Piaget, in addition to being one of the earliest cognitive-constructivist theorists, offers several concepts upon which to build a case for CBT and CBAT. His theory offers a picture of how individuals acquire knowledge that is in concert with constructionist ideas. In his theory, individuals acquire knowledge through interactive experiences with their environment, and thus people build their own perspective of the world. Piaget’s view of cognitive development is that it is an adaptive function. He hypothesized that people continually absorb new knowl- edge, which helps them to be better equipped to deal with the changes in their world or reach a state of equilibrium. Similarly, the fundamental goal of CBT is to help individuals to adapt to new or problematic situations and reach a state of stability. This is true of CBAT as well. Several of Piaget’s cognitive constructs are useful to the art therapist. First, a schema, as one building block of knowledge, can be recreated or, as von Glasersfeld (1995) discussed, re-presented , and examined. Knowing that schemas are based on a person’s experience, an art therapist may request a drawing of a schema followed by exploration of the schema from multiple perspectives to uncover parts that work and others that may not be useful in adapting to the present environment. 3 Assimilations are important to internal development and equilibrium. If an individual is having trouble assimilating an event fraught with emotion, the art therapist can examine the event and help him or her to re- experience and/or re-present it as a means of understanding and acceptance. The same is true of accommodation. An examination of a diffi cult external event may be the start of developing or creating a new schema that allows for the assimila- tion process to proceed anew. If an individual relies on only one of these two processes exclusively, which Efl and (2002) noted as being problematic, then the art therapist can assist in developing the other. A person stuck in minute details can begin to create con- texts for these details. Conversely, for a person whose knowledge construction is too broad and lacks context, the art therapist can support the client in creating smaller aspects of an environment and uncovering similarities and differences among various settings. 4 The essential point is to assist the person with achieving equilibrium and maturity—both worthy goals for therapy. Even Piaget’s refl ections on the topic of symbol development fi t within the framework of CBT and CBAT. Piaget conceptualized symbols as having both cognitive and affective components and as constructed through interactions with the environment. In addition, he envisioned symbols as cognitions which could be either primary or secondary. It is the secondary symbols that might be of signifi cance to art therapists. These symbols are developed when the process of accommodation is diffi cult and the result is an internal struggle. Thus symbols (often in the form of mental images) are created to refl ect struggles, and they reveal an individual’s thinking and become a part of his or her reality. Art-Making as Cognitive-Constructivism 47

According to Efl and (2002), the perception of art changed with the intro- duction of Piaget’s theories. Prior to understanding constructionism, the arts were differentiated from cognition and were placed exclusively in the affective domain. Piaget revolutionized this by proposing that symbol-development and art-making are cognitive activities that augment intellectual development. This principle underscores the theoretical relevance of CBAT. Most people know Piaget’s theory as a cognitive developmental framework. His stages of cognitive development help us grasp that knowledge acquisition is an ongoing process and that early learning is the basis for more sophisticated and abstract thinking. According to von Glasersfeld (1995), Piaget was criticized for not going far enough in exploring how social and cultural events shape a person’s cognitive development. Yet framing Piaget’s theory within an interactionalist perspective, social learning is a component of his theory. However, Vygotsky took the idea of social learning a step further and proposed that culture was a vital key to the construction of knowledge.

Vygotsky Both Vygotsky and Piaget theorized that knowledge is constructed through inter- actions with the environment. Yet for Vygotsky, culture’s impact on learning was more signifi cant in his theory of human development than in Piaget’s system; the term sociocultural cognition is often used to describe Vygotsky’s cognitive develop- ment principles (Efl and, 2002). Eisner (2002) is one of the many recent thinkers who credited Vygotsky with introducing the importance of social and cultural factors not only into the learning process but also into cognitive development. Since Vygotsky’s model contains this ground-breaking variation of knowledge construction, it is imperative to cover his ideas on the development of cognition as it related to art and art-making.

Interactions Needed for Acquiring Knowledge According to Vygotsky (1978), two categories of interaction are needed to become a fully realized human. First, he established that the acquisition of social signs, derived from social language learning and through the internalization of culture and social relationships, were essential for people to acquire knowledge (Blanck, as cited in Efl and, 2002). Signs are internally-oriented and are used to shape self-regulation of conduct. The social world consists of objects and signs, but behavior is determined not by objects in and of themselves, but by the signs attached to them; people attach meaning to the objects that surround them and act in concert with those meanings. Through the internalization of signs, con- sciousness is structured and restructured. Language in Vygotsky’s (1965) view is one such social sign, and is a crucial tool for the organization of thinking. Using 48 Art-Making as Cognitive-Constructivism

Vygotsky’s theory, Efl and (2002) reiterated that “it is language acquisition that makes conscious mental life possible” (p. 33). Secondly, Vygotsky proposed that there is an interactive process between the use of tools to infl uence the environment and the transformation of the self. He maintained that tools, which he called mediators, were a way to infl uence as well as control the environment. Mediators, he speculated, could also be social signs. In Vygotsky’s thinking, humans acquire knowledge because they utilize instruments and tools to mediate and modify stimuli in the environ- ment. According to Efl and (2002), Vygotsky also suggested that people also use instruments and tools to regulate behavior. The outcome of tool usage is that higher mental processes are engaged and honed. “Tools are externally-oriented and are employed to transform physical and social reality” (Blanck, 1990, cited in Efl and, 2002, p. 33). Like Piaget, Vygotsky thought that play was essential to the child’s develop- ment. The play of young children includes the exploration of social roles and, according to Efl and (2002), provides a forum for rehearsing adult roles. Vygotsky found that through play, children represent their world and, through this ele- mental activity, build an understanding of the meaning of life.

Levels of Development Vygotsky envisioned two levels of development. The fi rst level consists of lower-order mental processes such as attention, perception, and memory. For children, these processes are acquired through interacting with adults, and are methods utilized by children to become socialized. The second stage is when higher mental processes are developed, which occurs using the tools provided by culture (e.g., language, writing, and art). In his theory, behavior change results from the internalization of sign systems. Modifi cations in behavior ulti- mately lead to higher forms of development. The lower-level stage of develop- ment enables humans to acquire the higher level both through cultural leaning and with the help of tools. Thus the process of internalization leads humans to acquire higher levels of cognition. According to Blanck (cited in Efl and, 2002, p. 32), “Tools are oriented outward, toward the transformation of phys- ical and social reality. Signs are oriented inward toward the self-regulation of conduct itself.” Vygotsky identifi ed development as existing on two planes: social and psycho- logical. In his theory, Vygotsky hypothesized that the meaning of being human is determined from culture. Thus higher forms of mental life begin when a child’s cultural infl uences are internalized. Efl and (2002) stated that “For Vygotsky, cul- ture determines both form and content of cognition” and “For Vygotsky, higher forms of mental life begin only when cultural infl uences are internalized!” (p. 33). The internalization of culture is what stimulates meaning-making. Art-Making as Cognitive-Constructivism 49

Creativity and Art-Making as a Sign Vygotsky cited language as one of the primary cultural signs used in cognitive development, but he also studied creativity and the processes children use in imagination, creativity, and art. In a paper titled Imagination and Creativity in Childhood , Vygotsky (2004, English translation by Sharpe from a Russian text, 1967) discussed the nature of human imagination and proposed two levels of imaginative activity. The fi rst, related to memory, he called reproductive imagina- tion . This form of imagination is based on recall of the past, and allows people to play with memories and current experiences. The second type, true imagina- tion, he termed creative or combinatorial behavior . In this type of imagination, the individual recalls past experiences and combines them with other memories to formulate a new idea or behavior. Vygotsky stated that “It is precisely human creative activity that makes the human being a creature oriented toward the future, creating the future and thus altering his own past” (p. 3). He explored writing, acting, and art as creative experiences. The emphasis was on how cre- ating the future is uniquely human and is key to a person crafting a picture of who they are becoming; creative experiences also advance the culture. Vygotsky proposed that when a person is involved in creative acts, they also reconfi gure the past in order to make meaning of experiences. Just as importantly, humans create the future. His ideas on imagination and creativity are vital to understanding cognitive development, constructivism, and the use of art in therapy. Vygotsky realized that art is a primary form of creativity in children. Through art-making (Vygotsky specifi cally studied drawing in children), he believed that children create their memories and current experiences through drawing. As with involvement in play activities, artistic endeavors provide the child with opportunities to explore their experiences and realize the meaning of their world. For Vygotsky, with regard to the importance of art to cognitive development, there is a rationale for using art in treatment. Furthermore, the main principles of CBT include helping clients to envision a better future and simultaneously, through tapping into memory and past diffi cult events, help the client to recreate, reconfi gure, or reimagine the past. Combining these two ideas provides a foundation for CBAT.

Summary People develop through interaction with the environment. For Vygotsky, children learn the importance of culture through these interactions and become encultur- ated. Both social signs, such as language, and the use of instruments and tools, are fundamental to cognitive development and building knowledge. Signs are internal and assist in behavior regulation. Tools make their mark on external, physical envi- ronments. Vygotsky envisioned two levels of cognitive development: lower and higher. The lower level is vital to the acquisition of higher mental processes. For 50 Art-Making as Cognitive-Constructivism

Vygotsky, art is a sign, and in addition to language, is used to build self-knowledge. He purported that creativity is uniquely a human endeavor, and that it is an impor- tant part of conceiving a future orientation. Constructivism, CBT tenets, and the formulation of CBAT are steeped in the ideas of Vygotsky.

Bruner Bruner (1990), a cognitive psychologist and constructivist theorist, believed that individuals construct meaning through personal discovery. Like Piaget, he was interested in how a child acquires knowledge. Bruner believed that children learn through interactions with the social environment, and that knowledge acquisi- tion is built and therefore has levels of learning. Bruner saw language not just as an overlay to the human culture or as an imposed structure for communication purposes; he found that language was culturally bound and that it is an essential tool for use in making meaning.

Language Acquisition Bruner developed his theory through observing the language acquisition process of children, and found three contexts needed for language. First, he proposed that language is acquired through interacting with caregivers and is developed through continued use of what is learned from these interactions. Second, he found that there are communicative functions already in place prior to when the child learns language, and these “include indicating, labeling, requesting and misleading” (Bruner, 1990, p. 71). Third, “the acquisition of a fi rst language is very context-sensitive, by which is meant that it progresses far better when the child already grasps in some prelinguistic way the signifi cance of what is being talked about or of the situation in which the talk is occurring” (p. 71). Based on his understanding of language acquisition, he theorized that children’s learning is signifi ed through three developmental stages: enactive representation, iconic representation, and symbolic representation.

Developmental Stages According to Bruner, the enactive stage occurs in the fi rst year of life. Knowledge is stored and based upon past motor actions. And events are represented through motor responses. A simple example of this concept is what happens when a rattle is taken away from a very young child, who will nevertheless continue to move their hand and arm as if still shaking the rattle. This type of learning is used throughout the lifespan and into the adult years. For example, it is often easier for someone to learn new skills through doing versus explanation. Although this idea is usually thought of as a means for young children to learn, enacting can aid in learning new skills over the lifespan. Art-Making as Cognitive-Constructivism 51

For children in the ionic stage, from ages one to six years, knowledge is stored in mental images . In this stage, children represent events by organizing perceptions and images. The child understands that a picture of an object is a representation of the object; he or she also recognizes that the word designated for an object represents that object: a real fl ower can be represented by the word “fl ower” and/or a picture of a fl ower. There is a marked transition from the iconic to the symbolic stage, and this shift occurs through the development of language. Lan- guage allows children to represent complex ideas with an economy of energy, as language is symbolic. According to Bruner, the better a child uses language, the better he or she can cope with external forces. Two important linguistic concepts are operational in the symbolic stage: remoteness and arbitrariness. The construct of remoteness occurs when a person grasps that a word stands for or represents an object. This allows individuals to speak about objects with others when the object being referred to is not vis- ible. For example, a school-aged child tells a caregiver that they read a book at school that day. The word book is a somewhat remote signifi er for a book that is in front of a person. As a child develops, more diffi cult terms can be understood through remoteness. Other words have increased remoteness, such as the word garden . Most individuals have a concept of a garden, but it is a more remote con- struct compared with a book or a fl ower, because there are many different types of gardens, so the type of garden needs to be explicated. Arbitrariness is more abstract, and allows an individual to think or speak about complex concepts that have innumerable features. The child who referred to a recently read book can discuss the concepts learned from that book, such as ecology, climate change, or freedom. These concepts are arbitrary because of their diverse features, and some people will focus on certain aspects and others will emphasize other features. Embracing specifi c features of an abstract concept not only indicates acquisition of knowledge, but also fashions the construction of meaning. As an individual learns to use language, it becomes a building block for devel- oping further knowledge. Bruner found that successful language usage leads not only to knowledge acquisition, but also to improved coping strategies. These strategies pertain to grappling with both external forces and internal struggles. Increased language usage also allows for a greater capacity for symbol formation and uncovering meaning. Thus Bruner’s conceptualization of symbol formation is one that integrates a great deal of information into a single thought or concept or image that holds multiple layers of meaning.

Cognitive Psychology and Meaning-Making As one of the major theorists in the cognitive revolution of psychology, Bruner (1990) was disheartened by the detours taken in this movement. To his dismay, he saw the construction of meaning-making substituted by information process- ing. He wanted to be clear that his stance on the cognitive psychology revolution 52 Art-Making as Cognitive-Constructivism was about a return to understanding the human mind after behaviorism domi- nated psychological thinking. He stated:

Its aim was to discover and to describe formally the meanings that human beings created out of their encounters with the world, and then to pro- pose hypotheses about what meaning-making processes were implicated. It focused upon symbolic activities that human beings employed in construct- ing and in making sense not only of the world, but of themselves. (p. 2)

When the shift from constructing meaning to information processing occurred, Bruner attributed it to the rise and common use of the computer: information processing was equated with computer processes. His conviction here is impor- tant; although computers do meaning-like operations, they cannot deal with ambiguity or metaphor. Bruner proposed that as people, we are aware of the ambiguous situations and dilemmas that humans face. This awareness is what pushes people towards therapy and meaning-making.

Summary Bruner is a major fi gure in the development of constructivist theory. He pro- posed that language is a central aspect of cognitive development, and developed stages of development by observing how children use language. His three stages of development, which correspond to Piaget’s developmental stages, delineated the phases through noting the sophistication employed in using language through childhood and into adolescence. Frustrated by how many theorists equated con- struction of knowledge to information-processing, he proposed strong statements that resolved this issue. He avowed that meaning-making was the fundamental aim of constructivist principles and cognitive psychology.

Comparative Analysis There are several similarities between Piaget and Vygotsky. Both articulated theories on cognitive development. Whereas Piaget solely used his observa- tions of play in childhood, Vygotsky based his ideas on cultural signs and tools. This allowed him to bring in ideas from language, play, and other imagina- tive activities, such as art-making. Both authors hypothesized that the building of knowledge had both external and inner components. Piaget formulated four main stages of development, and Vygotsky used two levels to explore knowl- edge acquisition. Both proposed that the earlier level was needed to progress to the next. In Piaget’s theory, the process of assimilation fostered the creation of an inner life, and accommodation encouraged understanding of the external. Similarly, Vygotsky hypothesized that social signs promoted self-regulation and Art-Making as Cognitive-Constructivism 53 tools crafted the external. The major difference in their beliefs was that Vygotsky emphasized the importance of culture and the integration of cultural learning as a major aspect of cognition. His ideas put the internalization of culture as the key component of knowledge building, whereas Piaget’s main building block of cognition was interaction with the environment. A comparison of Bruner and Piaget reveals that some similarities and differ- ences exist. Both theorists understood cognitive development and knowledge acquisition as an incremental process through increased interaction with the envi- ronment. However, their ideas came through different observational strategies. Piaget used observations of children at play to inform this theory, whereas Bruner observed children acquiring language at various ages to hone his ideas. Both found that with increased cognitive awareness, individuals have improved ability to adapt (Piaget) and cope (Bruner). Symbols and symbolism are key components of each theory. For Piaget, symbolic thinking is part of the accommodation and assimilation processes, where liquidation and compensation contain both cogni- tive and affective symbolic components. In Bruner’s theory, words and language are symbolic and have components of mental imagery. In his theory, symbols are cognitively constructed and hold meaning. The most signifi cant aspect of their viewpoints is that knowledge is constructed. However, it was Bruner who took knowledge acquisition a step further, and found that meaning was revealed through language acquisition and was the key feature of cognition. The theories of Vygotsky and Bruner also have similarities. They both focused on the acquisition of language as a means of cognitive growth. Both found that language possesses cultural meanings. For Bruner, the ability to make meaning was possible through the ability to use language to present diffi cult, abstract con- cepts. For Vygotsky, the internalization of culture led to self-regulation. Thus both theories promote the ability to cope as an important psychological con- struct. Bruner focused on symbols as part of his model. Vygotsky put emphasis on higher mental processes. Both concepts are needed in the construction of meaning and in the ability to navigate the diffi culties of life. Understanding cognitive development and constructivist ideas is a prerequisite for comprehending the aspects of art that possess these properties. In the next section, theories to elucidate the cognitive nature of art processes will add to the argument that cognitive psychology and art therapy are compatible, and will illuminate art-making as a cognitive and constructivist process.

Art-Making as a Cognitive-Constructivist Process Often art and art-making have been relegated to the affective realm as the expres- sion of and container for emotions. The problem with this perspective is that art became the poor step-sister of cognition and cognitive development. As noted by Eisner (2002), “The arts have long been perceived as being ‘affective’ rather than cognitive, easy not tough, soft not hard, simple not complex” (p. 35). Fortunately, 54 Art-Making as Cognitive-Constructivism this conceptualization is changing, which began with the evolution of cognitive psychology and science. This paradigm shift does not preclude that emotions are not a part of artistic endeavors, but rather emotions are now understood to be a part of, and integral to, perceptual and cognitive development. For example, Piaget (1954) did not fi nd a difference between the cognitive and affective in cognitive development. Today many theorists argue that artistic activities possess cognitive qualities and are a means of building cognition and advancing learning. In this section, an argument for art as a cognitive and constructivist process will be explored. First, the cognitive qualities of art-making will be surveyed through the ideas of Eisner and Efl and. Second, the idea that art is a process of building and expanding cognition will be discussed. Finally, the way in which art advances meaning-making will be examined.

Cognitive Qualities of Art-Making Over the years, various authors have explored how art and art-making add to the quality of the mind. For example, Arnheim (1969) argued that art improves perception, which he maintained was a cognitive process. He added that art helps children to conceptualize ideas and aids in understanding relationships, structure, and ultimately “Image-making serves to make sense of the world” (p. 257). Eisner (2002) theorized that “work in the arts contributes to the development of com- plex and subtle forms of thinking” (p. 35). And Efl and (2002) set out to discover how the arts “develop cognitive abilities in children” (p. 7). Like Piaget, all three of these authors studied young children to uncover how cognition develops in humans. For these authors, the art of children provided clues to the evolution of problem-solving, concept formation, and meaning-making. These three theorists are not the only ones in recent decades to have uncovered the cognitive power of art-making; others include Getzels and Csikszentmihalyi (1976), Wallace and Gruber (1989), and Weisberg (1986). Although it is not possible to cover all the thinkers in this area, I shall attempt to make a cogent argument for art as a cognitive process. In doing so, I shall examine two theorists, Eisner and Efl and, who have provided evidence of the cognitive power of the arts.

Eisner Eisner’s (2002) theory of understanding the cognitive components of the arts encompassed all the processes of awareness and perception of one’s environ- ment, and “includes the most sophisticated forms of problem-solving imaginable through the loftiest fl ights of the imagination” (p. 9). He proposed that art- making involves four important cognitive processes that enhance the imagination and mental image-making. First, the act of creating a representation of an idea, or what he designated an inscription , is a cognitive function. He found that mental Art-Making as Cognitive-Constructivism 55 images are fl eeting and often lost if they are not concretized. Moving an image from a fl uid and elusive entity to a representation on paper, which can then be explored, is a valuable cognitive process. Once an image is in front of the artist, it can be edited; this is the second cog- nitive process cited by Eisner. The editing process is a critical exploration process that allows artists to refi ne their work. The art piece communicates to others about what is going on in the mind, and is the third cognitive process noted by the author. According to Eisner, the third cognitive process of art is related to its communicative features. This aspect is vital not only for the artist to express a point of view, but also to culture-building through enriching of the lives of oth- ers (i.e., the audience). The fourth process is the discovery process that is initiated when creating a representation. The art maker will, at times, be surprised by what has been crafted, and according to Eisner such surprise leads to learning that in turn leads to attempts to solve more complex problems and concepts. Even the decision to follow a surprise event down another path is knowledge-building according to Eisner. He purported that it is challenging and takes courage to pursue the unknown. Eisner (2002) not only cited four cognitive processes used during art-making, but also noted that art has seven cognitive functions (pp. 9–11):

1 Helps people learn to notice the world 2 Engages the imagination to explore new possibilities 3 Increases toleration of ambiguity 4 Stabilizes thoughts and ideas that are ethereal 5 Increases the inspection of ideas more carefully 6 Explores one’s inner landscape 7 Informs us about relationships

Although all of these functions are applicable to the practice of art therapy, four cognitive functions that are directly related to CBAT will be discussed here. First, the cognitive function of engaging the imagination is often the beginning of CBAT. As discussed in the previous chapter, mental imagery and imagining are cognitive functions. Often clients are not aware of their own ability to imag- ine their life beyond the concrete day-to-day roles they inhabit. Art-making can awaken this cognitive function through interactions with art materials. Begin- ning with simple materials, forms and shapes can be brought into focus and these become a fuller representation of a person’s inner world. Improving one’s ability to tolerate ambiguity is an important therapeutic goal. In CBAT, the therapist uses this cognitive function of art to address the client’s anxieties about not being able to control external or inner forces by fi rst experiencing the unpredictability of controlling the media or the outcome of art-making. Connecting these apprehensions with dealing with the day- to-day concerns of the client is pivotal to building coping strategies. Once 56 Art-Making as Cognitive-Constructivism worries are better contained, a client can begin to thoroughly explore ideas and worries; this is another cognitive function of the artistic process. Further examination of ideas is vital for in-depth understanding of the issues that a cli- ent brings to art therapy. Exploration of one’s inner landscape is another cognitive function of art that is vital to the therapeutic purpose of CBAT. Similar to understanding one’s men- tal images, acquiring a map of how one processes information, learning how one thinks, and comprehending how one comes to conclusions is vital to the advancement of therapeutic goals in CBAT. This process is often called metacog- nition or possessing the ability to refl ect on one’s thinking, imagery, and emo- tions. 5 Art-making provides a window into these cognitive operations.

Efl and Efl and (2002) asserted that the purpose of art “throughout human cultural history has been and continues to be the task of ‘reality construction’” (p. 171). Based on his study of Piaget, Vygotsky, and others, Efl and (2002) established that four cognitive features are attained through involvement in the arts, namely cogni- tive fl exibility, integration of knowledge, the imagination, and the aesthetic in learning. Cognitive fl exibility as defi ned by Efl and is “the ability to change strategies as one becomes mindful of the structural demands of each domain, and the ability to activate the appropriate means to secure meaning or understanding” (p. 160). Eisner (2002) certainly agrees with Efl and here, and found that fl exibility “per- tains to the improvisational side of intelligence” (p. 77). Cognitive fl exibility is achieved through involvement in the complexity and the relative lack of structure of art. Because art relies on individual cases versus generalizations, and also relies on individual interpretations, it is often perceived as lacking structure. Yet the complexity and lack of structure are the very aspects of art that lead to knowledge construction. Efl and’s conception of the cognitive value of art, especially the act of interpretation, is based on Bruner’s view that interpretations are based on a person’s own cognitive understanding. Thus interpretations are malleable and dependent on each person’s construction of its meaning, and will differ at vari- ous stages of cognitive development and sophistication. Efl and (2002) stated that “Therefore, one answer to the question of why the arts are cognitively signifi cant is that they provide encounters that foster the capacity to construct interpreta- tions” (p. 161). Integration of knowledge, Efl and’s second cognitive feature, places art at the center of learning where assimilation of multiple areas of understanding is pos- sible. Efl and found that art uncovers places where “different domains of knowl- edge overlap and coalesce as learners construct their understanding of the work” (p. 166). In addition, what Efl and calls lifeworld , or one’s understanding of one’s Art-Making as Cognitive-Constructivism 57 day-to-day knowledge, is enhanced through art-making. In a process that has been likened to Piaget’s construction of cognition, people create art to under- stand and incorporate new information into their lifeworld. Third, the imagination is a vital cognitive feature of art. 6 Efl and cited Lakoff and Johnson as stating that imagination “is one of our most important tools for trying to understand what cannot be fully comprehended: our feelings, aesthetic experiences, moral practices, and spiritual awareness” (Lakoff & Johnson, 1980, p. 193, cited in Efl and, 2002). Imaginative learning is integral to Piaget’s formal operations stage of cognition building when abstraction is possible and under- standing of metaphors is achievable. Efl and claimed that the aesthetic is cognitive. His conceptualization of the aesthetic marks a shift in thinking. Whereas other scholars and philosophers claimed that an aesthetic process may lead to the possibility of new knowledge, Efl and took a stronger stance. Borrowing the idea of cognitive mapping from Jameson (1988, cited in Efl and, 2002), Efl and found that the mapping process begins with the art image as perceived by the individual through the senses. Since perception is a cognitive process, he hypothesized that the aesthetic is cognitive, and emphasized this point by stating, “I am not saying that the aes- thetic is integrated into the cognitive, but that the aesthetic is cognitive from the start” (p. 171).

Art as Building and Expanding Cognition Both Eisner and Efl and held that art processes build and expand cognition. Eisner (2002) believed that the creation “of visual images is characterized by the gradual emergence and refi nement of forms of thinking” (p. 111), and he claimed that art “promotes the child’s ability to develop his or her mind through the experi- ence that the creation or perception of expressive form makes possible” (p. 24). As with Piaget (1954), who concluded that through play, children construct their mind and their cognition, Eisner understood that art fosters “learning how to become the architect of your own experience and therefore learning how to create yourself” (p. 24). He maintained that this outcome of art-making was the principal value of art. Efl and (2002) argued that the signifi cance of art to building cognition is that involvement in art “provide[s] encounters that foster the capacity to con- struct interpretations” (p. 161). According to Efl and, the ability to interpret is imperative for dealing with the ambiguities of life. Coping with the dilemmas of living in the real world is diffi cult, and the ability to grasp what is happen- ing is a skill of interpretation. Interpretation leads to constructing understand- ing. Through encounters in art, a person learns to interpret the meanings of art products. Interpretation leads to understanding, and understanding builds cogni- tion. Just as important is the role of art in building knowledge in a sociocultural 58 Art-Making as Cognitive-Constructivism context. Efl and used Vygotsky’s cognitive developmental theory to underscore this notion. Since art is situated in culture, an important way to expand under- standing of the culture is through engagement with the arts. Both authors provide theoretical arguments for the use of art to build the mind and construct knowledge. This stance underscores the use of art in cognitive- behavioral theory. If the primary goal of CBT is adaptation, and adaptation is built on the construction of knowledge as advanced by Piaget, and if art-making builds knowledge, then art is a source of adapting to one’s own environment. This is a major tenet of CBAT.

Art and Meaning-Making According to Piaget, children construct knowledge and adapt to both environ- mental and inner turmoil by interacting with the environment, fi rst through play and then through more sophisticated means. Bruner was clear that his theoretical stance on cognitive psychology was to investigate how people make meaning of their world experiences, and not just for information-processing. His belief was that the development of language built cognition and con- structed meaning. Both Eisner and Efl and envisioned parallels between the processes of play and language as builders of cognition, and interactions with art and art-making to construct knowledge and create meaning. Eisner found that the arts are integral to personal transformation. Efl and took this idea a step further and was more rigorous in his examination of the purpose of the arts. He expressed a great deal of concern that other theorists did not quite understand the purpose of art, and cited Cobb and Driver as limiting the purpose of art as only a conduit for repre- senting culture and society. Efl and proposed the ground-breaking idea that the purpose of art was to make meaning. If this hypothesis has merit, it indicates that through making art, cognition, knowledge, and meaning are being constructed. Comparing his view with those of others, Efl and declared that “Rather, its [art’s] purpose is to enable individuals to fi nd meaning in the world of art for life in the everyday world” (2002, p. 77).

Summary Art is a complex construct, and art-making is a multifaceted act. Art therapists are aware of this fact. There are thinkers from related disciplines who have helped to bring clarity to this intricate endeavor. Two such thinkers, Eisner and Efl and, bring the cognitively exquisite nature of the arts into focus. Both propose that art-making is a cognitive venture. It helps us to build our understanding of and interpretation of reality, including the internalization of culture, it promotes the construction of an inner life, it provides opportunities to explore our inner land- scape, and it stimulates cognitive fl exibility. Both Eisner and Efl and affi rmed that Art-Making as Cognitive-Constructivism 59 art-making affords individuals the ability to make meaning of their world and of their life. Art-making possesses these attributes, promotes cognition, and builds the mind. Cognitive-behavioral art therapists employ these cognitive-constructivist attributes in treatment.

Final Thoughts An argument for the cognitive components of art is vital prior to further discus- sions of CBAT. In addition, I have proposed that making art is constructing knowledge and is thus a constructivist process. In the previous chapter, an argu- ment for the creative aspects of cognitive-behavior therapy was presented. Before proceeding to the chapters on CBT and CBAT, an overview of the salient points made in Chapters Two and Three will help to consolidate these concepts and set the stage for the rest of the book.

• Imagery has been an essential concept in psychology and used as a technique in therapeutic interventions for over a century. • Philosophers and psychologists alike have researched and attempted to understand the structure and purpose of imagery. • A strong link exists between imagery and perception based on both psycho- logical research and neurological studies. • From its inception, imagery has been a major technique used in behavior therapy. • Currently, imagery is a key component of CBT. • The use of mental imagery links CBT and CBAT. • Imagery is directly linked to emotions and to autobiographical memory. • CBT and CBAT therapists use these links as part of treatment for clients whose mental images hold traumatic memories and distressing thoughts. • To fully treat an individual who is experiencing intrusive imagery, the emo- tions associated with the imagery must be addressed. • CBT and CBAT have roots in cognitive development theories (Piaget and Vygotsky) and constructivist philosophy (von Glasersfeld and Bruner). • Current CBT techniques have roots in cognitive theories, namely re-scripting, re-presenting, and re-imaging, which are also used by CBAT therapists. • Art and art-making, although fi rst perceived as solely in the affective realm of learning, are now fi rmly situated in the cognitive realm and possess numer- ous cognitive functions and features. • Symbol processing and sociocultural connections are important cognitive constructs in CBAT. • Important outcomes of art-making and CBAT include the construction of the self and involve cognitive fl exibility, improved adaptation skills, and increased coping abilities. 60 Art-Making as Cognitive-Constructivism

• CBT and CBAT therapists guide the client to be oriented towards the future rather than to ruminate about the past, and encourage the client to reconfi g- ure the past to move forward. • The ultimate goals of CBT and CBAT are to assist the client to adapt to life’s obstacles and to guide them in making meaning of their own life.

Notes 1 The terms schema and scheme are used interchangeably. 2 See the section on Vygotsky below. 3 Gantt and Tinnin (2007) used the concept of re-presenting in their art therapy interven- tions for individuals with PTSD. 4 See the account of the work by Rhyne (1979a, 1979b) in Chapter Five. 5 Hackmann et al. (2011) found that metacognition is a key component of imagery change techniques (see Chapter Two). It is also a signifi cant aspect of mindfulness and meditation, as discussed in Chapter Seven. 6 As outlined in Chapter Two, mental imagery and imagination are key cognitive-building entities. 4 THE HISTORY OF CBT

“Throughout its history, CBT has been committed to a scientifi c perspective to the study of psychopathology and its treatment…This scientifi c literature has placed CBT in a unique position to dominate the fi eld of psychotherapy.” (Herbert & Forman, 2011b, p. 3)

Visiting the historical roots of CBT theory provides context for ongoing devel- opment and contemporary use of CBT in therapy and treatment. In this chapter, the fi rst two generations of CBT will be discussed: the fi rst wave, behavior therapy and treatment, and the second wave , which incorporates aspects of cognition and cognitive psychology with behavior therapy. The third wave , which added new information about attention and mindfulness concepts as well as knowledge from Buddhist psychology and CBT, will be discussed in Chapters Seven and Eight.

The Cognitive Revolution Cognitive-behavioral therapy (CBT) is the use of higher mental or cognitive processes to uncover, identify, and access patterns and modes of thinking and per- ceiving. Once these processes are uncovered, a therapist can help clients to shed light on the detrimental aspects of these patterns. Equipped with an understand- ing of cognitive patterns, clients are exposed to a series of techniques designed to change processes that are detrimental to mental, emotional, or physical health. CBT, which encompasses a constellation of treatment variants, has been around for over 50 years. According to some psychologists, it is still regarded as a relatively new theoretical approach to treatment (when compared with psychodynamic approaches; Davey, 2013). Based on numerous research 62 The History of CBT

fi ndings, including randomized controlled studies, CBT is identifi ed as being a highly effective and useful therapeutic approach for anxiety disorders, includ- ing post-traumatic stress disorder, as well as for depression, eating disorders, schizophrenia, personality disorders, criminality, substance abuse disorders, etc. In fact, some psychologists even tout cognitive therapy as one of the most important advances in medical treatment in the past 50 years, and state that it “is one of the biggest success stories in contemporary psychology” (Hofmann et al., p. 199). The cognitive revolution in psychology took place in the 1970s, but its roots are older than this (Baars, 1986). During the early part of the 20th century, behaviorism was dominant. In this model, behaviors could be either learned or eliminated using reinforcements. If a new behavior was the goal, reinforcement was used to encourage this behavior and, typically, the reward was from an exter- nal source. If decreasing a specifi c behavior was the target, reinforcement was withheld when the behavior was exhibited. These treatment approaches are what is known as behavioral therapies or the fi rst wave in the continuum of cognitive- behavioral treatments. A second evolutionary step in CBT theory and practice developed when a deep understanding of how human beings used cognition and higher mental processes in their thinking was discovered. The inclusion of cognition to understand human behavior represents the sec- ond wave of CBT. With new research on cognition, which began in the second half of the 20th century, several behavioral theorists began to incorporate the notion of how one thinks into behavior therapy models. According to G. Wilson (1978), it was the landmark book, Principles of Behavior Modifi cation, by Bandura (1969) which infl uenced others to consider the ways in which a person’s cogni- tive processes mediate and regulate behavior. In the cognitive model, Bandura found that conditioned responses are not automatic or refl exive, but rather “are seen as self-activated on the basis of learned expectations” (G. Wilson, 1978). At the other end of behavioral learning, external reinforcements may shape behav- ior, but may also be used as a source of information that may or may not regulate future behavior. Based on the work of Bandura and other important theorists, such as Lazarus (1971) and Meichenbaum (1975, 1977), the second wave of CBT was launched. The addition of contemporary therapy tools such as mindfulness and medita- tion to assist clients to pay attention to their cognitive processes represents the third wave of CBT. The teaching of mindful meditation to cope with a variety of physical and emotional disorders was fi rst introduced by Kabat-Zinn (1994) when he began to research mindfulness to help patients to deal with chronic pain. His ideas infl uenced Segal, Williams, and Teasdale (2002) to consider the cogni- tive aspects of mindfulness practice to assist individuals with relapsing depression. Treatments in the third wave or third generation include dialectical behavior therapy, mindfulness-based cognitive therapy, and acceptance and commitment therapy. The History of CBT 63

In this chapter, an exploration of the evolution of cognitive behavior therapies is presented from the fi rst iterations of behavior therapy through the second wave of CBT. This will set the stage for how CBT and CBAT are currently practiced.

The First Wave: Behavior Therapy Behavioral therapy, the fi rst wave of the cognitive behavioral revolution in psy- chotherapy, was a break from traditional psychoanalytic modes of understanding human behavior. Psychologists working early in the 20th century were troubled by the lack of objective data supporting widely held psychological principles of psychoanalysis. For example, Monte (1980) considered problems in behavior (or neurosis) to be the consequence of confl icts between unconscious desires and external reality. According to this theory, external reality is the antagonist with which the ego must cope; thus the ego is the lone mediator of the id and super- ego. Along with defense mechanisms, the ego manages these forces that mainly operate at the unconscious level, and thus problems are also solved from the unconscious as well. Although this is a skeletal outline of the psychoanalytic system, the purpose of its presentation here is to serve as a model for the therapeutic goals of psycho- dynamic therapists, and for comparison with behavioral theory and therapy. The aim of psychodynamic therapy is to change an individual’s personality, includ- ing unconscious processes. The problems or neurotic behaviors that the person brings to therapy are not targeted specifi cally for change. Rather, by changing the individual’s personality structure, a change in a specifi c behavior is sought. Therefore behavior alterations were not directly viewed as the goals of treatment. In contrast, a behavioral approach to the therapeutic process focuses on the treat- ment and modifi cation of specifi c, overt behaviors.

Behavioral Therapy Treatments From about 1913 to around 1960, many social scientists researched overt, observ- able behavioral phenomena. For example, Pavlov (1927) introduced the prin- ciple of classical conditioning where an unconditioned stimulus was continuously paired with a neutral stimulus; eventually the neutral stimulus elicited the uncon- ditioned response even when the original stimulus was absent. His experiments were conducted on dogs and the unconditioned stimulus was food. Research undertaken by Skinner (1953) evolved into what we now know as behavior modifi cation, and began with the principle of operant conditioning. According to Skinner, behaviors can be either eliminated or encouraged by the events that follow the exhibition of those behaviors. The research that followed the devel- opment of these two main principles led to the theory that maladaptive behav- ior is learned. The treatment interventions based on these principles of learning became known as behavior therapy. 64 The History of CBT

During this period, behaviorism—understanding how behaviors are learned and eliminated—was hailed as the meta-theoretical base of psychology and under- standing human behavior (Baars, 1986). According to G. Wilson (1978), behavior therapy was not a single treatment method, but rather a diverse set of therapeu- tic interventions. To grasp this diversity, he categorized four major emphases within behavior therapy: (1) applied behavior analysis (ABA), (2) stimulus– response (S–R) treatment models, (3) social learning theory, and (4) cognitive (behavior) therapy.

Applied Behavior Analysis (ABA) This was defi ned by G. Wilson as “applications of the experimental analysis of behavior problems of social importance” (1978, p. 8). This therapy is based on the principles set forth by Skinner and others whereby overt behavior is not only the lone factor in behavioral research, but also the tool by which to measure behavior change. Three important constructs underlie ABA: (1) repeated mea- sures of behavior on a single subject in a controlled environment is the general rule, (2) reinforcement and punishment are key elements of the learning strategy, and (3) this treatment is mostly, but not always, utilized for individuals with some form of cognitive impairment, such as young children, people with intellectual disabilities, and hospitalized patients with psychotic disorders (G. Wilson, 1978). ABA is still practiced today in order to understand the pathological behavior of children, usually in school or at home, and in other institutional-type settings. This style of behavior therapy is both an assessment tool and a tool for assessing reinforcement and punishment (withholding) types of interventions.

Stimulus–Response Models G. Wilson (1978) labeled the second type of behavior therapy the Neobehavior- istic Mediational Stimulus–Response Model, which uses the principles of con- ditioning and counterconditioning to mitigate abnormal behavior (i.e., usually fears and anxieties). S–R treatments were based on learning theories such as those conceived by Pavlov (1927) and others familiar to art therapists. Included in this type of behavior therapy are the techniques associated with systematic desen- sitization and fl ooding, the goal of which is to decrease or extinguish the fears and anxieties relating to phobias. Clients are instructed to imagine the frightful situation or object, identify their response, and fi nally, visualize the consequences of engaging with the problematic condition. Imaginal or symbolic representa- tions produce an arousal response not unlike exposure to the real object or in situ conditions. The introduction of mental imagery, a higher cognitive process, is a step towards hypothesizing that cognitive mediators, as part of behavior therapy (or what G. Wilson labeled “neobehavioristic” methods), are useful in treatment (p. 10). What follows in this form of behavior therapy, through incremental The History of CBT 65 exposures in a hierarchical manner to the feared event, is that an individual learns to effectively cope with their anxieties. Today, systematic desensitization is still used, but often in conjunction with anti-anxiety medications, cognitive-behav- ioral therapy, and/or relaxation treatments.

Social Learning Theory This third behavior therapy is more comprehensive in its approach to treating the individual. Trying to grasp how human behavior differs from that of the rest of the animal world, psychologists realized that our capacity to think, pon- der, and use language and mental images greatly affected the learning process. Indeed, reinforcement itself was theorized to be an internal cognitive process. Early cognitive psychologists were exploring alternative theories to accommo- date not only how humans behave but also how we think about issues, emo- tions, and events, and how we perceive ourselves. Bandura (1969) stated the problem succinctly:

Unlike humans who continually engage in self-evaluative and self- reinforcing behavior, rats or chimpanzees are disinclined to pat themselves on the back for commendable performances, or to berate themselves for getting lost in culs-de-sac. By contrast, people typically set themselves cer- tain standards of behavior and self-administer rewarding or punishing con- sequences depending on whether their performances fall short of, match, or exceed their self-prescribed demands. (p. 32)

Bandura (according to G. Wilson, 1978) theorized that three discrete systems regulate behavior: (1) external stimulus events, (2) external reinforcement, and (3) cognitive mediation processes. Thus, one key component of social learning theory is that cognitive processes are a major component of social learning and mediate the acquisition and regulation of behavior (G. Wilson, 1978). Another aspect of social learning theory is the “reciprocal interaction between a person’s behavior and the environment” (G. Wilson, 1978, p. 11). Or as stated by Ban- dura (as cited in G. Wilson, 1978, p. 12), “to the oft repeated dictum ‘change contingencies and you change behavior’” should be added the reciprocal side, “‘change behavior and you change the contingencies.’” A third component of social learning theory is self-control; humans have the capacity to be self-directed in changing their behavior, and can shape their future behavior. Finally, G. Wil- son identifi ed a fourth component of social learning therapy, namely self-effi cacy, whereby individuals are found “to determine the activation and maintenance of behavior strategies for coping with anxiety-eliciting situations” (1978, p. 12). Self-effi cacy was another pivotal concept put forward by Bandura (1977), who wrote an infl uential article on this topic. 66 The History of CBT

According to Mahoney and Thoresen (1974), the introduction of cognitive mediators as a primary determinant of behavior is a hallmark of social learning theory. Thus self-effi cacy expectations became the major aspect of mediating behaviors. The cognitive connection in general, and the concept of self-effi cacy as a mediating variable in behavior change, is the main concept in cognitive behavior therapy (CBT). Another social learning theorist, Julian B. Rotter, pointed out that behavior is not only determined by the importance of goals or reinforcements, but “also by the person’s anticipation or expectancy that these goals will occur” (Rotter, 1954, p. 102). In Rotter’s conceptualization of social learning theory, reinforcement increases an individual’s expectancy that a specifi c behavior or event will be fol- lowed by that reinforcement in the future. One of Rotter’s main hypotheses was that reinforcement, if seen as contingent upon an individual’s specifi c behavior, will increase expectancy that a future behavior will be reinforced. When rein- forcements are not viewed as contingent upon a specifi c behavior, expectancy will not increase. Everyone has a unique background with distinct patterns of reinforcements; therefore, people differ in the degree to which they attribute rein- forcement to their own behaviors. If reinforcements are contingent upon personal actions then a generalized expectancy will develop that purports individuals are in control of their reinforcements. The converse is also true. Rotter referred to this concept of generalized expectancy of reinforcement as locus of control. A locus of control continuum is formed, with rewards being externally depen- dent at one end and internally determined at the other. People who view rein- forcements as based outside their own actions are said to have a belief in external locus of control. Individuals who perceive their own actions as the basis for reward or reinforcement are said to have a belief in internal locus of control. Understanding and using the locus of control construct as a function of adap- tive behavior is supported and complemented by various theoretical constructs, including self-effi cacy (Bandura, 1971) and self-control (Rotter, 1966). Rotter (1996, p. 6) also developed a defi nition of self-control and framed it as a person’s ability to deal with reality. Adding to the defi nition of self-control, Rotter stated that this construct contains a component of confi dence. Therefore the self-control construct implies that an individual with self-control is not only able to act, but also possesses the confi dence that they can perform and that their expectations will be effective. Lefcourt (1976), in his review of the locus of con- trol construct, stated that individuals who realize that they have the ability to act or perform have a perceived sense of self-control. He continued by postulating that having a sense that one can be in control lessens the effects of negative situa- tions. In social learning theory, self-control is a variable or characteristic that can be learned (Bandura, 1971; Kanfer, 1970). From social learning theory, the emphasis on how humans view their abil- ity to infl uence the environment and themselves, and how they self-evaluate, The History of CBT 67 serves as the basis of both cognitive psychology and cognitive-behavioral thera- pies. Understanding the mediating effects of cognitive processes and the aware- ness that building self-effi cacy, internal locus of control, and self-control serve as possible outcomes of treatment form the basis for cognitive-behavioral therapy strategies and techniques.

The Second Wave: Cognitive-Behavior Therapy Although cognitive (behavioral) therapy (CBT) 1 was labeled as the fourth cate- gory of behavior therapy identifi ed by G. Wilson (1978), the foundation of CBT, now known as the second wave, is rooted in social learning theory (Bandura, 1969; Miller & Dollard, 1941; Rotter, 1966). The fi rst attempt to integrate higher mental or cognitive processes, wishes, and desires into a behavioral framework was conceptualized by Miller and Dollard (1941). In their work, Social Learning and Imitation, two levels of learned behavior were explored. The fi rst-level behaviors, labeled as simple stimulus–response types of behaviors, included auto- matic habits. This level constituted behaviors that were a direct response to both environmental cues and internal drives. The second-level behaviors, such as lan- guage, imagery, thinking, and affect, were also used for problem-solving. These cognitive operations mediated and facilitated the generation of solutions to a wide variety of problems that faced individuals daily. Miller and Dollard acknowl- edged that many actions were a complex blend of both types of behaviors, and that humans have a huge capacity for the second type, namely “higher mental processes” (1941, p. 48). The work by Miller and Dollard (1941) laid the foundation for social learn- ing theory as developed by Bandura (1969). However, Bandura criticized Miller and Dollard’s work as being too closely linked with psychoanalytic traditions. Miller and Dollard continued to assume that disturbed behaviors were caused by hidden sources of confl ict. In contrast, Bandura initiated a social learning approach in which inferences about the person’s internal state may be made, but behavior change was devised on the basis of manipulable and observable behaviors. Whereas Miller and Dollard agreed with psychodynamic theorists that neu- rotic confl ict had unconscious determinants, Bandura (1969) conceptualized neurotic symptoms as products of past learning that were continually maintained by ongoing environmental rewards. As stated above, social learning theory is about the effects of the environment on behavior, and the effects of behavior on the environment. It also attempts to bridge the gap between the inner mental processes of psychodynamic theories and the overt behavior of learning theories (see Figure 4.1). Bandura stated that we are “continually engage[d] in self-evaluative and self- reinforcing behavior” (1969, p. 32). Although Miller and Dollard felt that social 68 The History of CBT

psychoanalytic CBT behaviorism

FIGURE 4.1 CBT in relation to two previous theories of behavior change.

learning theory confi rmed some psychoanalytic principles, Bandura saw clear differences between the two theoretical models:

. . . social learning theory approaches treat internal processes that are manipulable and measurable. These mediating principles are extensively controlled by external stimulus events and they regulate overt responsive- ness. By contrast, psychodynamic theories tend to regard internal events as relatively autonomous. These hypothetical causal agents generally bear only a tenuous relationship to external stimuli, or even to the symptoms that they supposedly produce. (1969, pp. 10–11)

Meichenbaum (1977) hailed Miller and Dollard as initiating the “conceptualiza- tion of cognition” (p. 109), and bringing cognitive process back into serious con- sideration as a tool for behavior change. And Bandura (1986) labeled this model social cognitive theory . Both Meichenbaum and Bandura infl uenced CBT treatment methodology as well: for example, modeling is a cognitive therapy tool borrowed directly from social learning theory. In summary, social learning theory integrates the effects of the environment on a person’s behavior and the effects of their behavior on the environment. In addition, social learning theory attempts to bridge the gap between the inner mental processes from psychodynamic theories and the overt behavior of the behavioral and learning theorists (see Figure 4.1). The theory that evolved to explain the profound impact of internal messages on human behavior is now called cognitive psychology . Cognitive psychology is a descendent of social learning theory and is also a foundational theory of CBT.

Early CBT Treatment Models Mahoney and Arnkoff (1978) understood that there were numerous variations of CBT. Through careful research on the plethora of CBT treatment models, they found that cognitive therapies exhibit three core underlying constructs:

1 Humans develop adaptive and maladaptive behavior and affective patterns through cognitive processes. The History of CBT 69

2 Cognitive processes are functionally activated by procedures that are gener- ally isomorphic with those of the human learning laboratory (although there may be other procedures which activate the cognitive processes as well). 3 The resultant task for the therapist is that of a diagnostician-educator who assesses maladaptive cognitive processes and subsequently arranges learning experiences that will alter cognitions and the behavior and affect patterns with which they correlate. (p. 692)

The effectiveness of several cognitive-behavioral therapy techniques has been studied widely. 2 For adults, cognitive techniques are effective in treating depres- sion (Beck, Rush, Shaw, & Emery, 1979), schizophrenia (Meichenbaum & Cameron, 1973), and phobic reactions (Meichenbaum, 1977). CBT techniques are useful for children who are impulsive (Meichenbaum & Goodman, 1971) and have behavior disorders (DiGiuseppe, 1981; Kanfer & Zich, 1974; Spivack & Shure, 1974). There are several treatment models that fall under the CBT umbrella, and these variants have certain commonalities. Hofmann, Admundson, and Beck (2013) found that having numerous types of CBT interventions is a strength rather than a problem, as it speaks to the adaptability of the CBT theoretical base. At the root of CBT is that cognitive processes mediate behavior. Early in the history of CBT, Mahoney and Arnkoff (1978) identifi ed three major forms of CBT: (1) cognitive restructuring therapies, (2) coping skills therapies, and (3) problem-solving therapies.

Cognitive Restructuring Therapies The primary example of these therapies is Albert Ellis’ rational-emotive therapy (RET; Ellis, 1962). In his mode of treatment, Ellis challenged false beliefs and faulty thinking. He composed a dozen irrational beliefs that he determined were at the root of most emotional disorders. RET is predicated on challenging the irrational beliefs and helping the client to identify when these arise. Problematic beliefs are then replaced with ideas that have greater rationality and are more constructive to the life of the individual. Another restructuring therapy, developed by Meichenbaum (1975), focused on self-instruction training (SIT), which combined RET and Luria’s develop- ment of inner speech (Luria, 1961). This treatment was geared towards both and children with impulsive disorders (Meichenbaum & Goodman, 1971). To replace maladaptive thinking, children used self-statements to complete work on tasks, or to bolster the ability to do well, or to self-reinforce. For individuals with major mental illnesses, Meichenbaum and Cameron (1973) used SIT to encour- age daily self-care skills and attendance at various therapies. Beck (1976) conceived a cognitive therapy approach with the goal of helping depressed clients to identify faulty cognitions, such as those that lead to helplessness 70 The History of CBT and hopelessness, in order to develop rational, adaptive thought patterns. After clients become aware of their inner thought processes, they learn to identify faulty cognitions on their own, and fi nally replace these with thoughts that are more accurate and less toxic. All three of these therapies consider what clients say to themselves as being defective, using techniques such as distancing and decentering as part of CBT. According to G. Wilson (1978), distancing is the art of regarding thoughts in an objective manner, and decentering is the process by which a client begins to sepa- rate his or her self from external events. Therefore cognitive restructuring alters inner speech and cognitions, and in turn overt behavior also changes.

Coping Skills Therapies These therapies help to expand and teach an array of coping strategies to indi- viduals for better adaptation to stressful situations. Self-effi cacy is an outcome of both social learning theory and CBT. Learning new coping strategies improves self-effi cacy and is at the root of coping skills therapies. The treatments under this category have much in common with treatments in the other two categories, but have the distinction of enabling the client to acquire new coping techniques. Wolpe (1958) was an early adopter of coping strategies and developed the sys- tematic desensitization technique, which is still an important technique today. In this method, the client imagines a stress-provoking stimulus (e.g., fear of snakes) and then focuses on relaxing until they gradually become desensitized to the images they fear. Another example of a coping skills treatment is stress inoculation (Meichenbaum, 1975), in which the client identifi es an emotion or stress reaction to an external event. Meichenbaum had the client practice coping self-statements and relaxation skills during the session. The test involved putting the client in the stressful situation and assessing how well the new coping strate- gies worked. Another coping skills treatment is covert modeling (Kazdin, 1974). In a treatment situation, the client imagines someone (i.e., a model) performing the behavior that is desired. This type of treatment is effective both for decreasing anxiety and for developing new coping responses in stressful situations. Both anxiety-management training (Suinn & Richardson, 1971) and modifi ed system- atic desensitization (Goldfried, 1971) are categorized as coping treatments. As a result of these therapies, clients experience a greater sense of control over the stressful experiences or adverse events in their lives.

Problem-Solving Therapies The treatment models within this category are diverse in nature. Problem behav- ior was defi ned by D’Zurilla and Goldfried (1971) as “ineffective behavior and its consequences, in which the individual is unable to resolve certain situational The History of CBT 71 problems” (p. 107). The philosophical core of problem-solving therapies is prag- matism and humanism (Mahoney & Arnkoff, 1978). Problem-solving therapists fi nd the most effi cient avenue to help a person in confl ict. Some problems that have been targeted with CBT include anxiety, time management, and social skills.

Personal Construct Theory The other foundational theory of CBT relevant to art therapists is personal con- struct theory, which was developed by George Kelly (1955/1991). According to Singer (2006), Kelly’s work is an important forerunner of current cognitive psychology. Thus Kelly is considered by some to be one of the important theo- rists who contributed to the cognitive movement in psychology (Fransella & Neimeyer, 2005), and Clarkson and Pokorny (1994) stated that Kelly “laid the foundation stone of cognitive therapy” (p. 151). Like other cognitive psycholo- gists, Kelly found that people are active and constructive in developing an inter- nal view of the world, and he created cognitive models to explain human activity (Taylor, cited in Diamond, 1982). Kelly’s place as one of the founders of cognitive psychotherapy is based on his premise that humans behave according to their expectations. These expectations are anticipatory and based on past experiences and events. “Kel- ly’s view of human action assumes that we operate through expectation and mental plans that almost always involve some fl eeting imagery using past event memories to set up possible futures” (Singer, 2006, p. 106). His model for understanding an individual’s perceptions or hypotheses of how the world works was labeled personal construct theory (PCT). The overarching concept of PCT is that individuals are natural scientists seeking to comprehend their environment and uncovering how they react to that environment: “Kelly believed that we strive to make sense out of our universe, out of ourselves, out of the particular situations we encounter” (Fransella & Bannister, 1977, p. 4). As scientists, people form assumptions or hypotheses about how the world is organized and how people behave. He called these hypotheses personal constructs . According to Fransella and Bannister, a personal construct is not just a verbal label, but also a person’s perspective of the world and the person’s view of him- or herself. It is important to discuss the cognitive basis of Kelly’s theory because it served as the cornerstone for the cognitive-based work of two art therapists, namely Rhyne (1979b) and Carnes (1979). Both proposed a cognition-based understand- ing of art therapy as an examination of mental image-based or concrete-visual image-based processes as informed by PCT and as personal constructs. Singer (2006) proposed that people’s anticipatory expectations or personal constructs have an imagery component. Rhyne and Carnes understood this, and suggested that these personal constructs could be created in art therapy. Each was dedicated 72 The History of CBT to helping individuals to understand emotions and affect-charged situations and events, and to examining these cognitive-based constructs. 3

Basic Tenets Before we can understand how art therapists used Kelly’s work, it is important to explore the basic tenets of the personal constructs psychology (Kelly 1955/1991). At the core of PCT is the assumption that an individual’s perceptions of their world are based on interactions with their environment; based on their percep- tions, individuals form hypotheses about how the world works and how they perceive themselves within that world. These hypotheses are called personal con- structs . The person’s conglomeration of personal constructs forms their personal construct system. An examination of an individual’s personal construct system helps him or her to uncover constructs that may be inaccurate or faulty. Once problem constructs are identifi ed, an investigation of how the problem developed may result in revising the personal construct or making changes to the entire system. Kelly proposed that the nature of personal constructs is inherently bipolar. A person may not realize the bipolarity of a hypothesis or construct. Often it is this lack of cognizance that is the source of discomfort for a person. For example, if a client hypothesizes that all people are inherently good and then experiences an assault or personal robbery, a disequilibrium might occur in their personal construct system. Through examination of the faulty, unipolar construct (that all people are good), the client can reformulate the construct to something like most people are good, but some are not. By understanding the bipolar nature of personal constructs, he or she can recognize that there is the possibility of opposing ideas or values in one’s system.

Various Construct Systems Personal constructs are individually conceived based on one’s perceptions of experiences. These perceptions may or may not be in concert with what exists in the real world. According to Kelly, all perceptions or constructs are taken at face value; however, they may be confused, distorted, or complex and lucid (Rhyne, 1979b). A healthy construct system allows for new information to enter the system and for the revision of constructs to occur (see Figure 4.2). For example, as a person observes interactions with work colleagues, they learn how best to approach their peers. Perhaps after some missteps, they learn that interacting with super- visors may require different tactics and attitudes to interactions with peers; as a result of this self-knowledge, they may now add to or reconfi gure hypotheses or constructs regarding how to thrive with supervisors in professional settings. Con- versely, there are people who possess construct systems that may cause some dif- fi culties. For example, a person may allow most or all new information to invade The History of CBT 73 the system. There is little editorial will within this system; the consequence is that the person may become overwhelmed by their environment or may be confused about their belief system (see Figure 4.3). Alternatively, a system may be so locked or tight that it is diffi cult for an indi- vidual to accept new data or be able to integrate new information or experiences. The result is a person who is rigid or constricted in their thinking processes, or who fi nds change diffi cult (see Figure 4.4).

FIGURE 4.2 Healthy personal construct system.

FIGURE 4.3 Loose construct system. 74 The History of CBT

FIGURE 4.4 Constricted construct system.

Kelly’s Repertory Grid Test Kelly began treatment by helping the client to uncover their personal construct system. He developed a process for interviewing new clients that he termed the “Repertory Test” or “Repertory Grid,” which he explained was a system for studying relationships between personal constructs (Kelly 1955, p. 219). 4 After fi rst identifying the most important people in the client’s life (e.g., a mother fi g- ure, a favorite teacher, their closest friend, etc.), he asked the client to compare and contrast the qualities of these individuals. He requested that clients identify 22 individuals for the assessment interview, which Kelly labeled elements . The repertory grid or the triadic method of construct elicitation required a person to compare and contrast groups of three people or triads identifi ed in the grid (see Appendix A). He would then ask the client the following question: Which two of the three people are alike, and how are they alike ? If the person replied that these two are warm and nurturing, this descriptor would be considered to be the construct . Kelly would then ask how is the third person in this triad different? The answer to this question represents the opposite pole or the contrast . The bipolar personal construct for this individual would then be that some people are nurturing and some people are aloof. The interview process asks the client to compare and contrast 22 triads leading to 22 valuable bipolar personal constructs, thus creating a snapshot of the client’s personal construct system. Kelly would use the construct system information obtained in this way to help the client to pinpoint problem thinking and behavior and subsequently allow him or her to revise the system as needed. The History of CBT 75

According to Fransella and Bannister (1977) the grid had several uses, but most importantly “Kelly devised repertory grid techniques as a method for exploring personal construct systems. It is an attempt to stand in others’ shoes, to see the world as they see it, to understand their situation, their concerns” (p. 5). The repertory grid that Kelly developed resulted in numerical data and in the form of a mathematical structure; as he stated, “we may have a math- ematical basis for expressing and measuring the perceptual relationships between the events which are uniquely interwoven in any person’s psychological space” (Kelly, 1955, p. 302).

Variations in Grid Techniques The repertory grid as designed by Kelly was found to be diffi cult to administer to some age groups and populations. Over the years, personal construct psycholo- gists and other therapists have adapted the repertory grid technique. One easy adaptation is to rank order constructs rather than eliciting them through the triadic method. An example of this is to make a list of elements for clients and then have them rank order these elements when given a prompt (e.g., identify the element or situation in which you would be most likely to feel confi dent ). Because the ele- ments are numbered, numerical data can still be collected. Another less complex technique for eliciting constructs is a rating grid (Fransella & Bannister, 1977). In this method, instead of ranking the elements based on the constructs, the elements are rated on a linear scale with contrasting poles or bipolar constructs (e.g., between rationality and irrationality) (p. 40). These adaptations have allowed researchers and therapists to assess construct systems for a variety of clients with regard to a wide array of personality and sociological issues.

Shift from Language- to Image-Based Grids Kelly used words and language to ascertain an individual’s personal construct sys- tem through the repertory grid system, yet subsequent therapists and researchers incorporated photographs or drawn images of people and situations as prompts to assist in the triadic compare/contrast or rank order interview. Wooster (1970) used a personal construct activity in a study of the self-concepts of intellectually disabled children which utilized photographs of children. He had the participants rank order the photos according to eight personality attributes, such as which boy is most kind . Salmon (1976), in researching ideal self-concept of children, used pre- drawn children of a similar age as the elements and then supplied the constructs. When constructs were provided (e.g., who probably does as he’s told or who probably gets into trouble with grown-ups ), the child selects the drawn image of the child that he or she thinks corresponds to the construct. It was a short leap from providing photographs and pre-drawn images to assist in the construct elicitation to having clients create or draw the elements for personal constructs elicitation. 76 The History of CBT

For example, Ravenette (2005) used what he termed a portrait gallery and self-description grid when working with a 12-year-old boy with bullying behav- iors (see Figure 4.5). After getting to know the child, he asked him to list four terms that he would use to describe himself: doesn’t care , intelligent , naughty , and polite . The therapist offered three more qualities based on his knowledge of the child: world against him, kind , and I want it now. The child was asked to draw and number these seven faces, which form the x axis on the grid. He was also asked to list important people in his life (mother, father, brother, sister, teachers, boys, and self). These individuals form the y axis on the grid. In response to questions by the therapist, the child would select a face (e.g., he selected 1 or intelligent in response to the question If I were to ask your mother, which of these would she say was most like you, and he selected 7 or don’t care for least like you). This questioning continued until all the faces were selected for the questions If I were to ask your mother which of these would she say was most like you and least like you. This continued for each of the individuals along the y axis. Kelly (1955/1991) devised mathematical analyses to represent how each per- son’s responses are compiled to gain an overall picture of how the person “sees the world.” Therefore the grid test has not only been used to test the psycho- logical space of individuals, but also has uses in psychological research. There are computer programs designed to analyze the data gathered from all these grid techniques (Fransella & Bannister, 1977). These programs develop a graphic pic- ture of an individual’s personal construct system or can be used to provide a

FIGURE 4.5 Portrait gallery and self-description grid. Drawings from left to right: don’t care, intelligent, naughty, polite, world against him, kind, and I want it now . Source : From “Constructive Intervention with Children When Presented as Problems,” (p. 139), by T. Ravenette, in The Essential Practitioner’s Handbook of Personal Construct Psychology, by F. Fransella (ed.), 2005, Chichester, UK: John Wiley & Sons. Reprinted with permission. The History of CBT 77 composite picture of a small group of individuals. For the child with whom Rav- enette worked, the analysis of the grid revealed that this child identifi es with how adults see him, which was polite and intelligent. Yet at the same time he identifi es with his peer group, where “he creates for himself, in their eyes, the antithesis of that adult view” (p. 140). This divided self-perception became the root of future therapeutic interventions.

From Assessment to PCT Treatment According to Epting, Gemignani, and Cross (2005), Kelly (1955/1991) out- lined four aspects of PCT treatment. Kelly started treatment with a focus on the immediate concerns of the client. In what he labeled controlled elaboration, clients identify problems along a timeline, which helps them to view issues as temporary rather than fi xed. In addition, Kelly urged therapists to help the client to fi nd that problems can be reconstrued . Problem identifi cation can be aided through several means, including the use of the repertory grid. However, Kelly most often used the grid in the second stage of PCT treatment. Kelly used the term transitive diagnosis for the second stage, in which the thera- pist plans the path of treatment. In this phase, the therapist helps the client to elaborate on the issues brought to treatment. There was a strongly held belief that the focus of treatment should be on the problem and how to move forward with resolutions, rather than on a fl aw in the client. It is during this stage that Kelly might use the repertory grid as a way for clients to paint a picture of themselves. Through the grid and other assessment procedures, the individual’s personal con- struct system is revealed and clients are challenged to think about their life role . According to Kelly, envisioning a life role helps clients with the development of a future orientation—something to work towards and something to anticipate. The third stage is where the therapist challenges the client to loosen and tighten personal constructs in their system. Kelly found this aspect of treatment to be creative and exciting. According to Epting et al. (2005), Kelly defi ned “cre- ativity as a cycle involving the weaving back and forth between loose and tight constructs” (p. 118). During this stage, the therapist encourages the reporting of dreams, as “Dreams are the most loosened constructions that can be verbalized” (p. 118). As part of the examination of loose and tight personal constructs, clients are encouraged to experiment with new behaviors. Thus “the central technique used for constructive revision is experimentation” (p. 119). Fixed role therapy is the fi nal step in personal construct therapy. In this stage, role plays as part of the therapy begin. The client fi rst writes a short narrative or sketch describing him- or herself. Using the new constructs that were uncovered in the third stage, the client is persuaded fi rst to enact new roles in the session, and then to carry out new roles in their world. There is a great deal more information available regarding the stages and techniques devised by Kelly and his predecessors. In this short overview, the 78 The History of CBT following PCT techniques are highlighted: focus on the problem, examination and re-examination of the personal construct system, and practicing new roles in the session and in vivo . Even from this quick overview, art therapists can imagine a plethora of ways in which art therapy can be integrated into Kelly’s work.

Summary It may not be immediately evident that personal construct theory is related to either social learning theory or cognitive therapy. However, there are similari- ties which tie all three models together. One commonality running through all paradigms is the use of higher cognitive processes. In personal construct theory, the personal constructs or assumptions affect a person’s behavior in social interac- tions. The development of personal constructs is a higher cognitive function on which Kelly focuses in his work. In personal construct therapy, modeling and role changing aid in reassessing a person’s construct system, cognitive ideations, and overt behaviors. Modeling is also a key technique in social learning theory and in cognitive therapy. All three perspectives view humans as interacting with the environment through cognitive mediators. Each paradigm supports the impor- tance of changing problematic cognitive processes in altering problem behavior.

Conclusion Historical accounts of CBT were discussed in this chapter. It is valuable for the art therapist to grasp the historic and theoretical roots of CBT. Understanding how CBT was formulated provides a picture of where CBT fi ts into the pantheon of other theories of behavior and personality change. It also offers a scaffold for the goals and therapeutic techniques of CBT practice. There is no one map for the conceptualization and prominence of CBT in the psychological world. The theoretical underpinnings are multifaceted and com- plex. From its roots in behavior therapy to the rethinking of the mediating effects of cognition in the social learning process, and fi nally to the emergence of the cognitive revolution, CBT consists of dozens of therapeutic variations; in addi- tion to the sheer number of variants, there is also complexity within each type of CBT. What is presented here is a broad overview of four historic origins of CBT: behavior therapy, social learning theory, cognitive behavior therapy, and per- sonal construct theory. This collection of theories and concepts will set the stage for understanding how art therapists began to conceptualize a CBT approach to art therapy, and will be examined in the following chapter. Remember that this is a historical overview of CBT. In Chapter Six, a full range of current CBT and CBAT practices will be discussed. More recently, the number of CBTs has expanded to include (although not limited to) the fol- lowing new variations of this theoretical approach: dialectical behavioral therapy (DBT), mindfulness-based stress reduction (MBSR), mindfulness-based cognitive The History of CBT 79 therapies (MBCT), and acceptance and commitment therapies (ACT). These third-wave variations will be explored in Chapters Seven and Eight.

Notes 1 In this book, the terms cognitive therapy and cognitive-behavioral therapy will be used interchangeably. 2 Sometimes the behavior is deleted, leaving only cognitive therapy. 3 See Chapter Five for more information on Carnes and Rhyne. 4 Although many call it a test, it is really a method of gathering information about how one views the world.

5 THE HISTORIC ROOTS OF CBAT

“. . . an art therapist who encourages a blocked or inhibited patient to make a scribble in order to involve the patient with media, and then praises the individual for his/ her participation, is using a behavioral approach.” (E. Roth, 1987, p. 216)

Visiting the historical roots and current iterations of CBT theory in Chapter Four provided context for the ongoing development and contemporary uses of CBT in therapy and treatment. The same applies to cognitive-behavioral art therapy (CBAT). Early thinking and practices in behavior therapy developed out of increased understanding of human behavior, which led to the development of reality shaping in the practice of the fi rst wave of CBAT. The introduction of social learning theory and the beginnings of cognitive psychology and CBT led to the development of specifi c therapeutic practices designed to help clients to adapt and thrive. Art therapists found these practices to be important, and their work formed the second wave of CBAT. In this chapter, a historical study of how the fi rst two waves of CBT were employed to create CBAT is presented.

Pioneer CBAT Art Therapists Psychotherapists have been discovering that private or mental images are a pow- erful tool for enabling clients to gain self-control as conceptualized by social learning theorists. Bandura’s (1977) approaches suggested that private imagery contributes to self-effi cacy. Singer and Pope (1978) proposed that imagery could be used constructively for adaptive escapism, self-awareness, self-regulation, and biofeedback, and for creativity and aesthetic experiences, and stated:

Self-effi cacy cognitions in the form of imagery, fantasies, or self- communications in some form determine whether we will initiate certain The Historic Roots of CBAT 81

types of behavior and, once engaged in them, how long we will persist or how much effort we will expend. The private image that one can cope will help one stick it out in situations that are believed to be dangerous, embar- rassing, or otherwise aversive. (pp. 26–27)

Bandura (1977) hypothesized that private images are self-reinforcing. In art therapy, the reinforcement value of images may take three forms: (1) through the act of imaging itself, (2) through reproducing the image in artistic form, and (3) through discussion of the mind or mental image and the artistic image. There- fore, if images are linked with the acquisition of self-control, perhaps art therapy is also a modality that can foster self-effi cacy. CBAT fi rst appeared in the art therapy literature during the late 1970s, when three art therapists began to theorize about the cognitive aspects of art therapy. Ellen Roth (1978) discussed the idea of using behavior therapy techniques and reality shaping as a means of conceptualizing art therapy for children with both developmental and psychiatric disorders. Janice Carnes (1979) as well as Janie Rhyne (1979a, 1979b) explored personal construct theory (Kelly, 1955/1991) as a basis for helping individuals to explore cognitive and emotional states. Thus CBAT has been around for about 35 years. Neither Roth nor Rhyne and Carnes realized just how pivotal their work would become. All three of these art therapists based their work on the assumption that drawn images and mental images mediate or shape behavior. Roth used art therapy in the fi rst wave of CBAT or behavior therapy. Carnes and Rhyne can be considered to be part of the second wave of CBAT. In this chapter, the work of Roth, Carnes, and Rhyne and their early CBAT work will be discussed. As a result of their initial progress, other early adopters of CBAT treatment techniques will be explored in this chapter as well.

First-Wave CBAT: Reality Shaping Roth (1987, 2001) used “the application of behavior modifi cation techniques (operant conditioning and modeling procedures) to the practice of art therapy (with emotionally disturbed, mentally retarded children)” (1987, p. 216). This was a type of behavioral art therapy that falls within the fi rst wave of the behavioral- cognitive treatments. Roth based her treatment on the operant conditioning tech- nique of shaping or bringing a person closer to a “desired behavior by reinforcing small steps that gradually lead to the terminal behavior” (1987, p. 214). In addi- tion, chaining , another operant conditioning technique, helps a client to learn a sequence of positive behaviors. Both shaping and chaining are enhanced by rein- forcements and prompts—techniques used by many therapists, including psycho- dynamically trained practitioners. Roth referred to her combined approach of behavioral therapy and art ther- apy as reality shaping. This process involves identifying a concept that eludes the 82 The Historic Roots of CBAT understanding of the client. First the art therapist helps the client to bring rep- resentational form to the problematic concept by creating a shape. Second, the child constructs and reconstructs these structures using art materials; this can be a repetitive process. Also the child is encouraged to use increasingly more complex materials to explore the form by using both two-dimensional (2D) and three- dimensional (3D) materials. The goal of reality shaping is based on the principle that developing and constructing a schema (through both mental and graphic images) for complex, psychologically sensitive issues is a means of organizing confused, dysfunctional thinking, and can be useful for helping a client to gain control of destructive urges. The result is the creation of a fully formed schema, which is formed in the here and now, and is reality based. Roth hypothesized that the well-formed schema enhanced understanding of the object and ultimately allowed the art therapist and the child to appraise both the value of the schema and the ramifi ca- tions that might ensue if that creation were to be destroyed. As an example, Roth used reality shaping with Larry, a child with low intel- lectual abilities and destructive behavior, who set fi re to the family home. Using craft sticks, Roth formed a fl at model of a house, which Larry used as a tem- plate to re-create houses; after several sessions of forming 2D houses, Larry was ready to build 3D houses. He treated the houses he drew and constructed with care, which coincided with a shift in seeing his family home as something that should be protected and not destroyed. The caveat to this approach is that real- ity shaping does not “assess[ing] internal psychological variables” (Roth, 2001, p. 208). However, once the child’s behavior has been controlled through these new learning experiences, the prospect of disturbing information being revealed is possible and can be subsequently explored. Roth reminded art therapists that they use behavioral tenets in their work as a matter of course. For example, reinforcement, a common classical condi- tioning behavioral tenet, is an important component of working with children with behavior problems. Reinforcement also encourages those who have trouble engaging in the art process, and helps other patients to continue to work on a problem even when it is diffi cult to do so. Prompting is a second behavioral technique widely used by art therapists (Mellberg, 1998; Roth, 2001). Examples of simple prompts are now it is time to work on your art project , or although you say your drawing is complete, there is a great deal of empty space over here, perhaps you would like to add something there . Roth found value in using behavioral techniques as part of the art-therapy process for the population with whom she worked. She combined the experien- tial techniques of painting and building with the behavioral techniques of model- ling, reinforcement, and systematic learning. As a person who brought behavioral techniques into art therapy, she is credited with opening the door to combining cognitive-behavioral therapy and art therapy. The Historic Roots of CBAT 83

Second-Wave CBAT: Personal Construct Theory and Art Therapy It is no coincidence that two art therapy theorists, Janice Carnes and Janie Rhyne, used the work of George Kelly (1955/1991) to conceptualize a cognitive approach to art therapy. As stated earlier in this chapter, Kelly’s personal con- structs (or perceptions or hypotheses about one’s world view) are easily translated from verbal to drawn constructs.

Carnes In the late 1970s, Carnes (1978, 1979) was concerned that too little emphasis had been placed on understanding the cognitive aspects of art therapy. She proposed that through understanding cognitive therapies, art therapists could expand their understanding of the therapeutic value of art therapy. She noted that imagery, visual thinking, and creativity, all of which are aspects of art therapy, are also fea- tures of cognition, and she suggested that art therapists might want to incorporate the importance of cognition into their work:

Cognitive therapy stresses the human capacity to symbolize, to think, and to think about thinking. It emphasizes the self: the self who experiences, and the self who stands back, observes, and thinks about the experience. This dual-faceted self is manifested in art therapy and fi ne art activity. It is the subjective, experiencing self who makes the art work, and the objective observing self who thinks about the meaning of what he or she has done. (p. 69)

In particular, she posited that Kelly and his model of personal constructs psy- chology (PCP) could be a fi tting basis for discussing a cognitive approach to art therapy. She hypothesized that personal constructs could be nonverbal as well as verbal, and that making art provides an opportunity to express nonverbal ideas, which may be situated within the core of an individual’s construct system. Carnes also suggested that creating art may expand and enrich one’s personal construct system. With a stronger personal construct system, the range of solutions to per- sonal problems would be increased. She even postulated that engaging with the art created in treatment would be a quick and effective way to experiment with the creation of new constructions or alternative solutions to problems. An exam- ple of this approach would be to have an individual create a troubling situation in art. Viewing the drawing of this construct would then elicit reframing of the drawing to be less troublesome or “provide[s] the viewer . . . with a depiction of possible events” (p. 74). Additions to or subtractions from the art could change the construct so as to be less problematic. Carnes found that “New thoughts or 84 The Historic Roots of CBAT constructs are not viewed as insights by Kelly, but are rather seen as hypotheses to be tested and accepted if useful” (p. 73). Carnes expanded Kelly’s ideas regarding loose and tight construct systems in terms of creativity. According to Carnes, creativity usually begins with a loose construct, which is indistinct, and after exploration of the construct, “terminates in a tightened and validated construct” (p. 73). As discussed in the section on Kelly in the previous chapter, if a system is too tight, very little creative thinking can occur. Conversely, if a person’s system is too loose, it may be diffi cult to be creative until some tightening occurs. As cited by Carnes, Kelly was clear that it was the work of the therapist to release as well as “harness” the imagination of the client, otherwise “there may be an endless repetition of old complaints and conventionalized insights” (p. 73).

Rhyne Rhyne also used Kelly’s work as one of several theoretical bases for her doc- toral research (Rhyne, 1979b). Like Carnes, she hypothesized that drawings and other works of art in treatment are expressions of personal constructs. She theorized that both cognitive and emotional components of experiences uncov- ered in treatment are interwoven, and both need attention. She stressed the link between thoughts and feelings to her clients. By having each participant in her dissertation research study create a set of personal construct “mind states” draw- ings, she encouraged them to come to a broader understanding of themselves and their individual belief systems. Rhyne found that when participants under- stood the bipolar nature of their drawn constructs, their meaning was enriched and elaborated. Using the personal construct model, she found that the cogni- tive and emotional components of experiences were inextricably connected. Based on Kelly’s work, Rhyne researched personal construct drawings to uncover common visual elements assigned to various emotions. She proposed that 15 common feeling or mind states might reveal a picture of how individuals deal with emotions (Rhyne, 1979b). She encouraged 50 participants to create small black-and-white drawings of each mind state or personal construct of emotions (see Appendix B for Rhyne’s template for creating personal construct drawings). Through the process of fi nding commonalities and differences among the drawn personal constructs, individuals (1) uncovered how the emotionally charged situ- ations in their life became out of control, (2) used the mind-state drawings to understand which feeling states preceded uncomfortable periods in their life, and (3) learned how to use mind states to regulate their emotional well-being. The mind states were drawn with three thicknesses of black markers on white 5" × 5" squares. This uniformity lent itself to a process of comparing and con- trasting the mind-state drawings for each participant and for the entire group of those involved in the research. Rhyne revised the repertory grid created by Kelly to gather data about constructs of emotional or mind states. The elements The Historic Roots of CBAT 85 in Rhyne’s grid were the 15 mind states she proposed as being representative of a full range of emotions. The constructs were hypotheses she derived from a theory of visual literacy; these hypotheses were about the visual elements of the draw- ings. She also used the triadic method as proposed by Kelly (see Appendix B for Rhyne’s grid) to gather the quantitative data needed to analyze the experiences of the research participants. A statistical program was utilized to assess the degree of relationship among the drawings. The task of the participant was to compare and contrast the mind-state drawings to ascertain common visual elements for each of the emotions. In her dissertation, Rhyne fi rst analyzed the group data and then elected to analyze the sets of mind-state drawings of fi ve participants as case studies. One of the case-study participants, Susan, quickly grasped the task of comparing and contrasting her mind-state drawings (see Figure 5.1 for a complete set of Susan’s 15 mind-state drawings). Rhyne selected Susan as one of the case studies, as she was in treatment because of her diffi culty in making important decisions. Rhyne found that Susan’s decisions about the drawings were quickly and judiciously made, in contrast to her poor decision-making in real life. Rhyne discussed one of Susan’s similarity clusters ( threatened and going crazy ) and a contrast cluster ( hoping and threatened ). Susan told Rhyne that going crazy was an “awkward and contracting drawing and that it represented an ‘overwhelming’

FIGURE 5.1 Susan’s set of mind-state drawings. From left to right, top to bottom: fearful, depressed, excited, passive, aggressive; serene, anxious, hoping, threatened, hostile; curious, guilty, innocent, going crazy, being sane. Source : From Drawings as Personal Constructs: A Study in Visual Dynamics (p. 179), by J. Rhyne, 1979. (Unpublished doctoral dissertation). University of California Santa Cruz, Santa Cruz, CA. 86 The Historic Roots of CBAT experience” (Rhyne, 1979b, p. 178). Susan used similar descriptors for both drawings, including diagonal, angular, static, orderly, and heavy (see Figure 5.2). Susan selected hoping to contrast with threatened (see Figure 5.3). Rhyne reported that for the threatened drawing, Susan used numerous emotion-laden

FIGURE 5.2 Susan’s similarity cluster. Source : From Drawings as Personal Constructs: A Study in Visual Dynamics (p. 180), by J. Rhyne, 1979. (Unpublished doctoral dissertation). University of California Santa Cruz, Santa Cruz, CA.

FIGURE 5.3 Susan’s contrast cluster. Source : From Drawings as Personal Constructs: A Study in Visual Dynamics (p. 181), by J. Rhyne, 1979. (Unpublished doctoral dissertation). University of California Santa Cruz, Santa Cruz, CA. The Historic Roots of CBAT 87 descriptors, including static, oppressive, hemmed in, and pressed in. She used the following terms for the hoping drawing: light, ethereal, delicate, frail, and fl ow- ing. Rhyne surmised that Susan had an “intense awareness of the differences of her experiences of being threatened and being hopeful ” (Rhyne, 1979b, p. 182). During their discussions, Rhyne found that Susan was overwhelmed when “outside forces ‘pressed in’ on her” (Rhyne, 1979b, p. 183). Susan also admitted that she was afraid to hope. Rhyne found that using the mind-state drawings or personal constructs assisted Susan in not only understanding her visual language, but also clarifying her understanding of diffi cult emotions. This parallels the fi rst step in personal construct theory (PCT) treatment as described in Chapter Four. Kelly called this step controlled elaboration, and where Susan might identify her concerns along a timeline, so they are not fi xed and perceived as temporary. Similar to the second phase in PCT therapy, called the transitive diagnosis, the next step is for the art therapist to further explore these issues by formulating a plan for treatment. Both Carnes and Rhyne found common ground with cognitive theory and art therapy. Using a second-wave cognitive theory, each was able to lay the ground- work for CBAT. They found that by understanding thoughts and ideas, clients could better grasp how they interpreted the world around them. This under- standing was fortifi ed by drawing problems, issues, and feeling states. Hence CBAT was born.

Summary Through the work of these three theorists, a cognitive-behavioral basis of art therapy was launched. They cautiously and courageously dipped their toes into the cognitive realm. This was a radical act in art therapy during the 1970s and 1980s. As Carnes (1978) stated, “In much of the art therapy literature, affective elements are emphasized without due consideration for the cogni- tive aspects” (p. 91). Even Roth (2001) admitted that “At fi rst, the idea of a behavioral approach of art therapy may appear antithetical” to the process orientation of art therapy (p. 197). Yet these beginnings helped many art therapists to reframe the types of approaches and interventions used in their work. In the next section, a few techniques used in the early years of CBAT will be reviewed.

Solidifying CBAT as a Legitimate Approach to Art Therapy In the 1980s, I had the opportunity to embark on a research project to discover how best to treat children and teens with emotional and behavior disorders, with the aim of developing an art therapy program that would address behavior issues (Rosal, 1985). I was interested in fi nding out if these types of children had an external locus of control (LOC) as had been hypothesized by Rotter (1954), 88 The Historic Roots of CBAT and then researching whether an external LOC was treatable. To begin with, I conducted two meta-analyses—fi rst, to uncover whether children with behavior problems did indeed have an external LOC as compared with children without behavior issues, and second, to research what type(s) of therapeutic interventions provide the most effi cacious ways to treat children. It was not surprising to learn that children with behavior diffi culties have a stronger external LOC orientation when compared with children without these problems. However, it was a revelation that the most effi cacious type of inter- vention for helping children with an external LOC was CBT. This outcome led me to study CBT approaches and to struggle to fi nd the common ground between CBT and art therapy.

Developing a CBAT Program To do this, I utilized nine CBT techniques that had been found useful in the meta-analysis of therapeutic effects on LOC. The CBT strategies found in the studies were incorporated into an art-therapy program for behavior change:

1 Behavior contingencies (Rose, 1980; Spivack & Shure, 1974; Wodarski, Feldman, & Flax, 1974) 2 Imagery (Barry, 1982; Stanton, 1982) 3 Modeling (Kazdin, 1974) 4 Modifi ed desensitization (Goldfried, 1971) 5 Problem-solving (D’Zurilla & Goldfried, 1971) 6 Relaxation (Barry, 1982; Stanton, 1982) 7 Stress inoculation (Meichenbaum, 1975) 8 Verbal self-instruction (Barry, 1982; Meichenbaum & Cameron, 1973) 9 Personal construct activities (Kelly, 1955/1991; Monte, 1980; Rhyne, 1979a, 1979b).

The CBAT program was developed with the information based on the out- come of the two meta-analyses and spanned 20 sessions. Each session was pre- pared prior to the beginning of the intervention, and included a theme, detailed objectives, specifi c media choices to enhance the objectives, delineated verbal instructions, and discussion topics. Each session was built upon the previous ses- sion in a development sequence. The basic structure of each session included the following: (1) a relaxation period in which behavior contingencies aided children’s participation, (2) an imagery activity in which the children were asked to imagine certain situations, (3) directions for art-making and media usage, (4) time to interact with the art materials, (5) clean-up, and (6) discussion and closure. During the last three sec- tions of the session, the children were encouraged to interact with each other The Historic Roots of CBAT 89 while the art therapist asked questions, clarifi ed issues, pointed out group dynam- ics, and aided participants who were experiencing diffi culty with the media.

Key Elements of CBAT One key element of the CBAT program that was used to bridge the CBT focus with the experiential nature of art therapy was the use of internal or mental imagery. Imagery has been found to have a profound impact on the individual, and can be used therapeutically to change perspectives, constructs, and behav- ior. Bandura (1977) hypothesized that mental imagery was one of the types of cognitive processes that might underscore and reinforce behavior. I used this psychological construct as the beginning aspect of each session. Relaxation was combined with imagery, as mental imagery is facilitated and enhanced when an individual is in a relaxed state (Lusebrink, 1990). Other aspects of the CBAT model include the emphasis on the human capac- ity to utilize higher mental processes such as imagery, categorization, problem- solving, and thinking, as well as self-instruction and self-evaluation. In CBAT, the therapist is active and directive. Verbal instructions aided the involvement in uncovering both mental and visual imagery-making. Education about art media is another important task of the art therapist. The art therapist also reinforces and rewards positive and prosocial behaviors. In summary, the CBAT approach uses delineated techniques, specifi cally applied imagery and media techniques, and a structured approach to aid in altering an external LOC and maladaptive behaviors. Using mental imagery as a means to enable clients to become more internal thinkers is an important aspect of CBAT. In the CBAT program for behavior disorders, children were taught how to access and use mental imagery throughout the entire treatment protocol. After very short relaxation exercises, they imagined what it was like to travel to school and to remember key aspects of this journey. Other short journeys were more imaginary and included obstacles to overcome, such as climbing a mountain to get to the summit, or going into a cave to slay a dragon and fi nd the treasure. The problem-solving aspects of these mental-image journeys were not only exciting for the children but also encouraged them to think and problem-solve about how they would handle hurdles (see Figures 6.24, 6.25, and 6.26). Other imagery was more static, such as imagining their classroom and visualizing where and how they navigated that room.

Integrating Personal Construct Psychology in CBAT Personal construct psychology (PCP) and activities are also vital to a beginning conceptualization of CBAT. As stated earlier, both Carnes and Rhyne found this cognitive psychology theory to be vital to a deeper understanding of the value 90 The Historic Roots of CBAT of art therapy. PCP has two roles in CBAT, namely for assessment purposes and for therapeutic value.

PCP in CBAT Assessments Based on the ground-breaking work of Kelly and the revisions of other PCP therapists, such as Wooster (1970), Salmon (1976), Ravenette (2005), and Rhyne (1979a, 1979b), the uncovering of personal constructs can help clients and thera- pist to identify areas of their life that are troublesome and need therapeutic atten- tion. The use of a repertory grid is a cognitive-process aid for the elicitation of these constructs. As was pointed out in Chapter Four, Kelly (1955/1991) used key people such as friends and relatives (the elements) in a client’s life to elicit constructs (remember that constructs or hypotheses are how individuals view their world). He asked the client to compare and contrast three elements at a time. He would ask the client which two elements are alike and verbalize how they are similar, followed by how and why the third is different (these elicita- tions are called the constructs). The comparison of the two that are alike con- trasted with the one that is different, representing the bipolarity of a personal construct (e.g., these two people are considerate, and the third person can be harsh). Wooster and Salmon understood that, for children, Kelly’s original grid was too abstract, and they began to use photographs of children to aid in this type of assessment; the photographs were the elements. Ravenette and Rhyne took this a step further and had clients draw the elements (instead of using the names of key people) to begin the process of identifying constructs. Art therapists can develop their own PCP assessment. In the study mentioned above, I had the participants draw eight pictures of children (i.e., the elements) engaged in various activities (see Figure 5.4 for a sample of drawn elements), as follows:

1 Someone studying at school. 2 Someone being bad at school. 3 Someone daydreaming . 4 Someone studying at home. 5 Someone breaking the law. 6 Someone being helpful to others. 7 Someone fi ghting with others . 8 Someone playing with others.

You will note that the elements pertain directly to the experiences of chil- dren, and have either an external or an internal LOC orientation. To under- stand how each child viewed their world, bipolar constructs were used. The constructs utilized were derived from common group experiences of chil- dren. Salmon (1976) found that using common group experiences lessens the The Historic Roots of CBAT 91

FIGURE 5.4 Scott’s personal construct drawing of someone studying at school. possibility of semantic problems when working with children. The following eight constructs were used:

1 Who likes school the best/who likes school the least? 2 Who is happiest/who is most unhappy? 3 Who is most like you/who is least like you? 4 Who would make other kids most pleased/most angry? 5 Who is learning the most/learning the least? 6 Who would make teachers the most pleased/most angry? 7 Who feels most grown up/least grown up? 8 Who would you most want to be like/least want to be like?

The questions are used to prompt children to select a drawing that corre- sponds to their answer. For example, a participant might select drawing 1 in response to the fi rst question, who likes school the most and might select drawing 2 for who likes school the least. Question 1 is repeated until all the drawings are selected in a rank-order fashion. Since the drawings are numbered from 1 to 8, once a drawing is selected in response to the question, data are generated, and with the use of FOCUS and SOCIOGRIDS programs, it is possible to develop a profi le of the child that can illustrate how they see themselves in their environ- ment (Shaw, 1980). An example of a PCP grid, shown in Figure 5.5, is that of Scott, a child who had serious behavioral issues. A close look at the grid revealed that three ele- ments and clusters were matched: who likes school the best/the least, who is learning the most/the least , and who would make teachers most pleased/most angry. The second 92 The Historic Roots of CBAT

FIGURE 5.5 Scott’s PCP analysis grid. level match paired who is happiest/most unhappy and who would make other kids most pleased/most angry. The three constructs least matched were who would you most want to be like/least want to be like , w ho is most like you/least like you, and who is most grown up/least grown up. The distance between these three constructs might indicate that Scott’s sense of self is unstable and that there is a discrepancy between how he sees himself and how he would like to be. For example, he chose the drawing someone being bad at school as his top choice to the question who is most like you , and someone studying at home as his fi rst choice to the question who is least like you . This information was used to inform a few of the objectives of art-therapy treatment. The Historic Roots of CBAT 93

Using PCP in CBAT Treatment The idea of comparing and contrasting personal issues is a vital aspect of CBAT. This is a concept that was integral to Kelly’s work. Again, both Carnes and Rhyne found this cognitive process useful to art therapy. Some examples of this type of art therapy include having individuals compare and contrast feeling states as espoused by Rhyne. Rhyne’s work included 15 mind/mood states, but for children this can be distilled into four—mad, sad, glad, and scared. These mood states or emotions are familiar to children, and most have experienced one or all of these as part of interacting with the environment and with others. The four mind-state drawings can be compared and contrasted in a similar way to Kelly’s and Rhyne’s process. For example, Scott’s four mind-state drawings were easy for the members of his group to decipher. In his case, the drawings of angry and sad were similar, but his group members pointed out that the sad drawing seemed to be angry, and the angry drawing seemed to be sad (see Figures 5.6 and 5.7). After this was pointed out to Scott, he was able to refl ect more realistically about his moods and came to the realization that when he is sad, it makes him angry and then he lashes out. To solidify his understanding of these two emotions, he created an angry mask (see Figure 5.8). Elements of the angry mask illustrated his improved understanding

FIGURE 5.6 Scott’s drawing of feeling sad. FIGURE 5.7 Scott’s drawing of feeling angry.

FIGURE 5.8 Scott’s angry mask with fl ames shooting out of its head and a third eye. The Historic Roots of CBAT 95 of anger as distinct from being sad. Although the angry mask has some playful elements, there is fi re coming from the top of the head. The mask also has a third eye, which might be related to his new found understanding of emotional states. Another CBAT technique based on PCP involves having participants create drawings designed to help with refl ection on the self and experiences. Examples of this type of intervention might include thinking about life stages: me younger, me now, and me in a few years’ time. Also, creating two drawings comparing aspects of school that are liked and one aspect that is not appreciated is produc- tive for children having school-based problems to fi rst identify specifi c issues and then allow the art therapist to use this information to assist them in solving this problem. For refl ecting on changes made during art therapy, participants can be asked to complete two drawings: (1) what you were like at the beginning of treatment and (2) what you are like today. Scott’s group was asked to create these two draw- ings during the fi nal session of CBAT. In Figure 5.9, Scott’s drawing depicted himself as a happy person. He admitted he never understood what being happy was like and now this is what he is like.

FIGURE 5.9 Scott’s drawing of feeling happy at the end of group art therapy. Source: From “Approaches to Art Therapy with Children” (p. 178), by M.L. Rosal, in Art for All the Children, by F.E. Anderson (ed.), 1992, Charles C. Thomas. Reprinted with permission; and with permission from Approaches to Art Therapy with Children (p. 64), by M.L. Rosal, 1996, Burlingame, CA. Reprinted with permission from Abbeygate Press. 96 The Historic Roots of CBAT

Summary CBAT was developed using the theories and techniques from behavior therapy, cognitive psychology, cognitive-behavioral theory and therapy, and personal construct psychology, as well as theories from the art-therapy professionals. The ideas put forth by Roth, Carnes, and Rhyne made it possible to con- ceptualize and advance CBAT. Integration of this information into a CBAT program was carefully crafted into a therapy protocol for children with behav- ioral diffi culties. The program selected the most effi cacious treatment concepts from the information garnered from two meta-analyses. The integration of art therapy with CBT proved to be valuable for children and teens with various behavior disorders.

Other Second-Wave Examples of CBAT In a chapter written in 2001 (Rosal, 2001), I found that numerous art therapists used CBAT in their work during the 1970s, 1980s, and 1990s. Much of the early behavioral therapy as well as the CBT work began with children, which is not surprising because behavior management is often needed with troubled young people. Art therapists working with adults were fewer in number in the early years of CBAT, but still provide a sense of the early CBAT work. Examples of art therapy with both age groups will be covered here.

CBAT with Children In addition to the reality-shaping work by Roth (1987, 2001), art therapists also used the following techniques: cognitive mapping, problem-solving therapy, modeling, systematic desensitization, relaxation techniques, personal constructs, mental messages, implosion and stress inoculation, reinforcement, and prompts (see Table 5.1). For example, Packard (1977) used a technique she called cog- nitive mapping for the acquisition of new concepts for children with learning disabilities (LD), for whom new ideas or concepts can get lost or tangled in disorganized pathways. Using drawn or visual images, Packard found that new information can be reorganized, or as she termed it repaved , and cleaned up. These reconfi gured mental layouts can lead to increased abilities to make novel connections and innovative learning. Similar to Roth’s reality shaping, several art therapists had children create dif- fi cult personal and social situations to increase problem-solving. The depiction of complex events is then followed by the generation of alternative solutions, in graphic form, which increases choices. De Francisco (1983), Gerber (1994), and Rosal (1985, 1992) advocated four CBT techniques in art therapy, namely relax- ation, systematic desensitization, implosion, and stress inoculation. Stress relief and lowered states of anxiety are the goals of these techniques. The basic idea behind these techniques is the induction of relaxed states. Once the participants TABLE 5.1 CBAT techniques and goals for children.

CBAT Technique CBAT Goal(s) Art-Therapy Author(s) and Date Adaptation

Cognitive To decrease faulty Draw problematic Packard (1977) mapping thinking patterns situations and events Problem-solving To increase solution Draw various Packard (1977); generation and solutions to a Rosal (1985, behavior choices problem 1992, 1993, 1996) Modeling To practice and Reality shaping Roth (1987) learn new behaviors Relaxation To decrease stress Use of soothing Rosal (1985, 1992, techniques and acting out; to media to 1993, 1996) increase mental enhance imagery relaxation Systematic To decrease stress Use images (mental De Francisco (1983); desensitization and phobias or drawn) for Gerber (1994) slow exposure to feared object or situation Implosion To increase ability Use images (mental De Francisco (1983); and stress to cope with stress or drawn) to Rosal (1985, inoculation fl ood or induce 1992) emotional responses Personal To assess and treat Draw constructs Rosal (1985, 1992, constructs cognitive aspects from child’s 1993, 1996) of a child’s life life to compare and contrast cognitions Mental messages To decrease negative Write or draw De Francisco (1983); inner speech and messages and Rosal (1985, increase self- revise to decrease 1992, 1993, 1996) control irrationality Mental imagery To link inner world Induce relaxation Rosal (1985, 1992, with external and mental 1993, 1996) behavior; for images; draw covert modeling and revise these or rehearsal of images behaviors Externalizing Uncover mental Draw cycle of Gerber (1994); internal processes leading offense acts: Gentry & Rosal processes to offense; before, during, (1998); Roth restructure and after; draw (1987); Stanley & dysfunctional inside/outside Miller (1993) thought patterns self; masks (Continued) 98 The Historic Roots of CBAT

TABLE 5.1 (Continued)

CBAT Technique CBAT Goal(s) Art-Therapy Author(s) and Date Adaptation

Assessing feeling To increase control Draw feeling states Gerber (1994) states over negative from least to feelings: to most complex; increase empathy categorize feeling-state drawings Reinforcements To increase positive, Reality shaping; Roth (1987); and prompts prosocial, and structured art Mellberg (1998) adaptive behavior experiences

Source: Adapted from “Cognitive-Behavioral Art Therapy” (p. 216), by M.L. Rosal, in Approaches to Art Therapy: Theory and Technique, (2nd ed.), by J.A. Rubin (ed.), 2001, New York, NY: Brunner- Routledge. Reprinted with permission. are relaxed, several other behavioral techniques can be introduced to mitigate diffi cult behavioral responses. For example, both De Francisco (1983) and Gerber (1994) used images for slowly exposing children to challenging events, or systematic desensitization to a feared object or situation. Implosion and stress inoculation were used to increase the coping abilities of children. Mental and drawn images were used to fl ood their affective experience (De Francisco, 1983), which led to stress resistance, or served to inoculate the child as a means of mitigating the effects of stress, and increase coping (Rosal, 1985, 1992). Other uses of mental imagery can include the rearrangement of diffi cult mem- ories, adding or eliminating aspects of the drawn image to make it less onerous or threatening. Creating images of tough events step-by-step can expose areas where the child can make changes to a cycle of aggression or offending behavior. For example, drawings of “before,” “during,” and “after” an argument can be enlightening (Rosal, 1985). Changes in self-control or LOC were important in the work of early adopt- ers of CBAT. Gerber (1994) used art therapy to help children to gain control over challenging feeling states in order to improve their empathy skills. Work- ing from the least complex feeling states to the most demanding emotions, she facilitated cognitive understanding of the ways in which these moods affect how teens feel and act. Rosal (1985, 1992) found that art about both problematic mental images and challenging feeling states helped children to gain a more internal sense of LOC. Creating pictures of both inner and outer self-images helps children to compare and contrast how they see themselves versus how others see them. This is called externalizing inner processes (Gerber, 1994; Gentry & Rosal, 1998; Stanley & The Historic Roots of CBAT 99

Miller, 1993). The use of personal construct drawings helps to open the inner world of children and to externalize the internal (Rosal, 1985). Based on the techniques of Kelly (1955) and Rhyne (1979a, 1979b), children created pictures of major life events. These drawings were used by the children to explore how they perceived their world and identify areas where they felt comfortable or out of place.

CBAT with Adults The forerunners of CBAT with adults include Reynolds (1999), who lamented that “cognitive behavioral approaches appear almost entirely missing from the creative therapies literature” (p. 165). I found a few references to CBAT with adults in 2001 (see Table 5.2). Many of the art therapists worked with people with major mental illnesses or extreme behavior disorders. Two art therapists worked with people with eating disorders. Gentile (1997) wanted to increase both internal LOC and self-control in this population. She cited studies which indicated that anorexic patients have an external LOC

TABLE 5.2 CBAT techniques and goals for adults.

Cognitive-Behavioral Cognitive-Behavioral Art-Therapy Author(s) and Date Goal(s) Techniques Adaptation

To increase locus Guided imagery Crayon drawings Bowen & Rosal of control of sensory and collages of (1989) experiences imagery To identify and In-vivo techniques Creating social Rosal, Ackerman- label triggers and uncovering milieus such Haswell, & cognitive as villages and Johnson (1994) distortions carnivals To increase locus Increased self- Using art to Gentile (1997) of control control externalize internal feelings To decrease In vivo and Drawing feeling Matto (1997) anxiety in systematic states from least dealing with desensitization to most anxiety emotions provoking To decrease Systematic Re-creating photos Reynolds (1999) avoidance desensitization with high and fl ooding emotional value into tapestry

Source: Adapted from “Cognitive-Behavioral Art Therapy” (p. 214), by M.L. Rosal, in Approaches to Art Therapy: Theory and Technique, (2nd ed.), by J.A. Rubin (ed.), 2001, New York, NY: Brunner- Routledge. Reprinted with permission. 100 The Historic Roots of CBAT orientation, and found that art therapy produces “tangible, concrete and kines- thetic quality that words lack” (p. 196). Thus externalization of inner feelings was hypothesized to increase LOC. Likewise, Matto (1997) used a systematic desensi- tization technique that involved women drawing feeling states from least to most anxiety-provoking. Through this process, the clients were able to gain control and accept each emotional state before moving onto the next one. Reynolds (1999) also used a systematic desensitization protocol to help women who were experiencing unresolved grief. By recreating photographs of the person whom they had lost, bereaved clients reworked the photos into tapestries. When working with sex offenders, Rosal, Ackerman-Haswell, and Johnson (1994) had patients draw triggers which led to offending behaviors. The art- therapy program also included the creation of social milieus that might lead to offenses, and learning how to deal with their triggers in these situations. The aim of this CBAT treatment was to increase self-control. Improving a sense of control was also the goal of CBAT with an adult woman with an intellectual disability (Bowen & Rosal, 1989). Problem behavior plagued this person’s performance at a sheltered workshop. Stress was one component of the client’s troublesome behavioral issues, and she was taught relaxation techniques to help with self- soothing and reducing stress. This helped her cope with the stressors of the work- shop and assisted with her ability to stay on task.

Summary Moving from theory to practice, art therapists began to experiment with using CBT techniques in their practice. For children who were experiencing critical behavioral and learning diffi culties, CBAT was useful for creating an arena in which to change behavior and understand tricky feelings, as well as to mitigate the effects of diffi cult feelings. The use of CBAT with adults was focused on the use of systematic desensitization to externalize awkward feelings or challenging thoughts and triggers. The focus of CBAT for both age groups was to increase coping, self-control, and internal LOC in order to mitigate the effects of stress and problematical situations.

Conclusion Using aspects of the work of Miller and Dollard, Bandura, Rotter, and Kelly, Roth, Carnes, and Rhyne laid the groundwork for how the CBAT approach to art therapy was established. Early adopters of CBAT experimented with the tech- niques fi rst outlined by Ellis, Meichenbaum, Beck, and Spivack and Shure. Using cognitive mapping, systematic desensitization, mental images, personal construct drawings, stress inoculation, relaxation, and bringing the inner into the external, art therapists have been successful in applying CBAT to both child and adult clients in practice. The Historic Roots of CBAT 101

I used treatment techniques from CBT therapists and the work of Roth, Carnes, and Rhyne to meld together a CBAT protocol for children with behav- ior disorders. The program included the therapeutic power of imagery and relax- ation, as well as the technique of comparing and contrasting issues that concern children. Using the work on Kelly, Carnes, and Rhyne, personal construct psy- chology and the assessment protocol from Kelly and Rhyne yielded a unique way to assess the children and teens in the program. Advances in CBAT theory over the years and the way in which these changes have infl uenced the practice of CBAT will be explored in the following chap- ter. Today, the number of art therapists using CBAT techniques continues to expand. The work is exciting and timely. A thorough exploration is presented in Chapter Six.

6 CURRENT CBAT PRACTICES

“Tapping into the inherently cognitive essence of making art is at the heart of cognitive- behavioral art therapy.” (M. L. Rosal, 2001, p. 222)

CBAT, like CBT, is equated with the identifi cation and alteration of erroneous thinking. When the new science of cognition and cognitive psychology was introduced into behavior therapy, attention shifted from modifying problem- atic behavior to altering distorted cognitions and uncovering how problematic reasoning led to dysfunctional behavior. Thinking was not the only cognitive process examined at that time, CBT therapists began to attend to all aspects of cognition: thinking, affect and feeling states, perceptions, imagery, and behavior (Hofmann & Asmundson, 2008). In the 1980s, CBT theorists began to unravel the importance of emotions as part of the cognitive change process (Samoilov & Goldfried, 2000). CBAT therapists agreed, and engaged all aspects of cognition, including emotions, in their work. CBAT is also a problem-focused treatment. Helping the client to identify the problem(s) that brought them to therapy occurs at the onset of treatment. Nonetheless, just as with other approaches to art therapy, it is vital for CBAT therapists to fi rst develop a therapeutic alliance with the client. Developing a positive relationship will set the stage for the other steps in the therapeutic process, which begins with understanding the problem. Once the problem has been identifi ed, the work of identifying, challenging, testing, and invalidating erroneous thought processes begins. When clients understand that some of their thoughts are fl awed or some of their emotional responses are irrational, the next step is to alter or reconstruct cognitions to be more adaptive and effective (Hofmann & Asmundson, 2008). Current CBAT Practices 103

The effectiveness of CBT and CBAT practices is critical to this theoretical approach. If something does not work, it is not unusual for it to be eliminated. Each new practice is researched for its effi cacy. Once a practice has been thor- oughly examined, it undergoes continual scrutiny to ensure that it can be con- sidered an effective treatment. CBT has been widely researched, and there is copious evidence that it is effi cacious (i.e., that outcomes are positive); there is even ample evidence about the various populations who respond to numerous approaches to CBT treatment. However, still under scrutiny are the mechanisms of change of CBT and CBAT; this refers to the processes whereby therapeutic change occurs and “why it works” (Hayes, Hope, & Hayes, 2007; Kazdin & Nock, 2003). In art therapy, mechanisms of change refer to the characteristics of art-therapy processes and client–therapist relationships that mediate therapeutic change in CBAT. In this chapter, various current CBT and CBAT techniques will be explored, and the processes of change within the CBAT model will also be examined. Six broad categories of CBAT interventions will be examined through case vignettes: (1) understanding constructs and thoughts, (2) dealing with feelings and emo- tions, (3) altering the self-schema, (4) using mental imagery, (5) improving problem-solving and coping skills, and (6) cultivating adaptation and self- regulation. Each category includes a subset of specifi c goals or interventions, which will be examined.

Understanding Constructs and Thoughts To begin an exploration of current CBAT processes, I shall fi rst focus on how art therapy can unlock how a person’s cognitions were constructed. Once there is an understanding of how the client developed their thinking styles and major constructs, a clearer picture of their issues is revealed. Next, the use of CBAT to uncover and assess problematic thinking will be discussed. Cognitive restructur- ing or methods of reframing diffi cult thought processes will follow.

Cognitions as Constructions It is important to begin this section with a short review of how thoughts are formed as an introduction to how CBAT therapists understand cognition. Based on the information in Chapter Two, we know that people create or construct their ideas or schemas about the world around them through their interactions both with the environment and with others. Cognitions are uniquely con- structed by each individual and are based on that person’s experiences (Piaget, 1954, 1962). Matto (1997) clarifi ed that although CBT focuses on erroneous thought patterns, understanding Kelly’s work on personal constructs (as outlined in Chapter Four) helps art therapists to understand how an individual’s cogni- tions are developed. Carnes (1979) and Rhyne (1979a, 1979b) also proposed the 104 Current CBAT Practices constructivist approach to understanding the development of thought processes. Carnes, Rhyne, and Matto espoused approaching CBAT with a constructivist conceptualization of cognitive development. In addition, CBAT therapists take time to uncover a client’s thinking on mat- ters affecting problematic behavior. As stated above, focusing on thoughts is a fundamental underlying principle of CBT. Cognitions causally infl uence prob- lematic behavioral and emotional issues. Therefore CBAT therapists focus fi rst and foremost on understanding the cognitive style and thinking processes of the client (Hofmann et al., 2013). In CBAT, clients are offered the opportunity to explore their cognitions and schemas and how they evolved through art. This is done by providing clients with simple art materials (small pieces of paper and easy-to-use art materials) and time to illustrate various constructs relevant to the client’s therapeutic pur- pose. Once an art piece has been completed, the client is given opportunities to describe the art piece and explore how the thinking about the content of the piece evolved.

Case Vignette Scott, a 12-year-old student with multiple behavior problems, painted the picture of his home shown in Figure 6.1. The house is painted from a bird’s-eye view and depicts the interior as a blueprint. His house had few barriers between rooms, and he could not identify his bedroom or any personal space in the home. He clarifi ed that the house was small and that, in addition to his immediate family, members of a relative’s family often stayed there. Because his younger cousins

FIGURE 6.1 Scott’s painting of his home from a bird’s-eye perspective and in a layout design. Current CBAT Practices 105 needed a room to sleep in, he was relegated to sleeping on the couch or in a corner with blankets, never knowing from day to day where he would lay his head. After questions and comments from group members, Scott agreed that his home life was chaotic, and that it fostered a sense of not belonging and of being a person of no importance. His conceptualization that his environment was chaotic, and his self-schema, which indicated that he did not believe he was a person of value, were both transferred to the school and classroom environment. These concepts were con- structed through the history of his home-life experiences. He thought of school as an extension of the chaos that was his home life, and as a place where he did not matter; these negative self-cognitions were the basis for his problematic behavior at school. Thus the drawing of his house was the conduit that Scott needed to reveal a few of his thought patterns and how these schemas and cogni- tions had evolved.

Identifi cation and Assessment of Thoughts In addition to helping clients to grasp how cognitions are developed, CBAT therapists have clients identify and assess problematic thoughts. An assessment provides opportunities for identifying erroneous thoughts as well as for recogniz- ing healthy ones. Kelly (1955/1991) would theorize that an examination of one’s thoughts or constructs might be just the intervention a person needs to solve a problem, and may result in the individual not needing further therapeutic atten- tion. He used a personal construct grid assessment to elicit a person’s hypotheses about their thoughts and perceptions of their world. Rhyne (1979b) adapted Kelly’s grid for assessing people’s perceptions of their emotions. I used a similar method to uncover how school-age children understand their thinking about school (see Chapter 5). Assessing client thinking in CBAT does not have to be as formal as using a personal construct method. Art therapists have multiple methods at their disposal to assess the thinking processes of their clients. There are various formal assessments that have been developed by art therapists, such as the one used to assist Scott, and numerous informal ones as well, as used by Morris (2014).

Case Vignettes Scott, the client mentioned earlier, completed a personal construct drawing assess- ment, which uncovered his anger issues. He created the drawing in Figure 6.2 when asked to draw someone being bad at school. When describing the drawing, Scott stated that “the boy was sitting on the other one so he can’t move . . . he will probably hit him.” When asked if he ever had thoughts of hurting others, he said that he does when other boys make fun of him. In response to a question about being bullied, Scott said that he usually gets so mad that he wants to hit others, but he just yells at the kids, runs away, and cries instead. Since the drawing 106 Current CBAT Practices

FIGURE 6.2 Scott’s personal construct drawing of someone being bad at school . Source: Reprinted with permission from “Approaches to Art Therapy with Children” (p. 175), by M.L. Rosal, in Art for All the Children by F.E. Anderson (ed.), 1992, Springfi eld, IL: Charles C. Thomas. Reprinted with permission; and with permission from Approaches to Art Therapy with Children (p. 64), by M.L. Rosal, 1996, Burlingame, CA. Reprinted with permission from Abbeygate Press. depicted a violent act, he was asked if there was someone in particular that he wanted to hurt, and he said no. Through the drawing, it was assessed that Scott is easily angered and that this anger arises when he is bullied and, because of the bullying, his sense of self is attacked. This evaluation of the sequence of events that negatively affected Scott revealed his thinking about his self-schema and became a focus of art-therapy treatment. Morris (2014) had clients with anxiety disorders use simple collage materials to explore the thinking that precipitated anxiety attacks. Basic materials were chosen as they are familiar and easy to use for inexperienced art-makers. One of Morris’s clients used simple drawings and words in addition to cut-out images to explore cognitions related to her problem of anxiety. The collage helped one client to ascertain her thinking that led to anxious moments. Her collage depicted a large Current CBAT Practices 107

FIGURE 6.3 Collage of feeling like the elephant in the room. Source: Reprinted from “Should Art Be Integrated into Cognitive Behavioral Therapy for Anxiety Disorders?” (p. 348) by F.J. Morris, in The Arts in Psychotherapy, 41, 2014, with permission from Elsevier. elephant in the bottom center of the paper, which represented feeling “like an elephant in the room” while entering a room full of people. An eye revealed her thought that all eyes were on her in social situations (see Figure 6.3). The identi- fi cation of these cognitions was useful in identifying the client’s thinking that was causally related to her distress, anxiety, and panic responses.

Cognitive Restructuring Cognitive restructuring is the process of identifying a fl awed thought, analyzing it, and helping the client to reduce the emotional intensity of the cognitions to make them more adaptive and realistic. This method was fi rst developed by Ellis (1962). The goal is to restructure rather than eliminate problematic thinking. Cognitive restructuring takes the basic, manifest level of a problematic thought, such as “I am not important,” and asks the client to test out this idea in various environments (Arch & Craske, 2008). Then the person is asked to reframe the thought to one that is more congruent with the fi ndings. For example, Scott might alter this cognition to “Sometimes I am not as effective as I could be, but 108 Current CBAT Practices at other times, I am.” By developing a balanced thought process, the client does not negate that at times they feel as if they are not valued, but now this negative self-statement is mitigated by knowing that there will be other times when their worth is notable. The goal of cognitive restructuring “is the development of rational, adaptive thought patterns” (Rosal, 2001, p. 212).

Case Vignettes Scott, who not only had a negative self-schema but was also bullied at school, needed to challenge his behavior of running away from aggressors and alter his fantasies of hurting them. To counter the problem of dealing with bullies, he was asked what else he could do besides yell or run away crying. He came up with the idea of telling the teacher. When asked, he said this tactic worked when he was younger, but he realized that this might not be the best approach for a 12-year- old. He admitted that when he recently told the teacher about a bullying inci- dent, the other boys teased him even more. After discussion about this issue with the art therapist and the group members, he began to understand that if he was a stronger person, kids would not tease him as much. To begin exploring a stron- ger self-image, he created a self-drawing depicting himself as a more confi dent person (see Figure 6.4). Altering his thinking from someone of no importance to someone with confi dence helped Scott to alter his perspective on how he should be treated and how he could react to bullies.

FIGURE 6.4 Scott’s self-image as a stronger person. Current CBAT Practices 109

FIGURE 6.5 Painting depicting others as only thinking about themselves. Source: Reprinted from “Should Art Be Integrated into Cognitive Behavioral Therapy for Anxiety Disorders?” (p. 349) by F.J. Morris, in The Arts in Psychotherapy, 41, 2014, with permission from Elsevier.

The identifi cation of irrational thoughts led to the implementation of a cogni- tive restructuring activity for the anxious client described above (Morris, 2014). First, she had the client list the cognitions identifi ed through the collage. Then Morris had the client rate the accuracy of these unlikely cognitions from 1 to 10. Next, the client selected one of the unlikely thoughts, “Everyone is judging me,” in order to discuss it and speculate about the accuracy of this thought. Upon real- izing that most people would be judging their own behavior, rather than hers, she used paints to explore the new cognition, “Everyone is thinking about themselves and their own concerns” (p. 170; see Figure 6.5). This intervention is also related to imagery modifi cation as identifi ed by Beck and Emery (1985), where a socially anxious individual is invited to picture others as less frightening or even in absurd situations (e.g., being dressed strangely). The restructured cognition is more adap- tive than the original thought. The realization that most people have doubts of their own not only helped the client in social situations, but also changed her construct of what others are experiencing at social events.

Feelings and Emotions Originally, CBT therapists did not address emotions directly, but they soon found that attending to emotions was an important aspect of CBT because these 110 Current CBAT Practices are cognitions with similar qualities to thoughts. Today, CBT practitioners the- orize that emotions and cognitions are linked and are connected through the cognition of appraisal. As was discussed in Chapter Two, Lazarus (1968) studied the appraisal processes of emotions and found that there are three stages: pri- mary, secondary, and reappraisal. In the primary phase, an individual recognizes a stimulus in the environment that is related to his or her well-being, and will sub- sequently experience an emotion. In the secondary phase, the person summons resources to respond to the situation. Finally, reappraisal occurs when the person re-evaluates the response based on new or revised information. Reappraisal may lead to transformations of diffi cult emotional states. Resonating with the fi ndings of Lazarus, many other theorists have found that emotions arise through a link between the person and the environment, but they added the concept of a feedback loop between emotions and cognitive appraisals. Lewis (1996) cited numerous theorists who ascertained the relation- ship between emotion and appraisal. For example, Lewis mentioned Teasdale, who uncovered a reciprocal relationship between negative thinking (appraisal) and depression (an emotional state), and Matthews, who observed a similar feed- back loop between the appraisal of threats and anxiety. Lazarus (1991) and others realized that there were other components of emotions, particularly physiologi- cal ones (e.g., fear may increase heart rate) and motivational ones (e.g., feeling angry may lead to acting out behaviors), that are important for researchers and therapists to explore. By working with feeling states, CBAT therapists can assist clients with understanding their emotions and how they might lead to problem- atic consequences.

Assessment of Feelings Feelings and emotions are linked with self-appraisals as well as appraisals of the environment. Rhyne (1979b) used an assessment of mind or feeling states as an initial step in therapy. As described in Chapter Four, Rhyne had participants create small black-and-white drawings of 15 feeling states, some of which were opposites (e.g., hopeless vs. hopeful). The drawings formed the basis for discus- sion of the similarities and differences between the drawings and with the feelings themselves. The drawings and discussions created a picture of how individual participants dealt with both positive and diffi cult emotions. For children, the complex set of 15 mind states is often pared down to four (mad, sad, glad, and scared), as most children will have experienced and understand what these states mean and how they make them feel.

Case Vignettes Pifalo (2007) stated that “Art therapy can help the child to delineate, identify, and express multiple feelings without having to rely exclusively on words” and Current CBAT Practices 111 that “the goal of identifying feelings is the fi rst step toward mastery of a traumatic event and now a child must fi nd a safe way to express them” (p. 172). She used a shoe box to help children to identify feelings that were safe to show others, which were placed on the outside of the box, as opposed to those emotions which were diffi cult, or even terrifying, which they put on the inside of the box. This three-dimensional representation not only helped children to identify feel- ings, but also helped them to discriminate between everyday feelings and those that may trigger a diffi cult emotional response. As reported in Chapter Five, Scott, a 12-year-old, struggled not only with problematic behavior, but also with diffi cult emotions, especially anger and sad- ness. As part of a small group of children, he was asked to draw the mad, sad, glad, and scared feeling states. During a discussion of the drawings, the group members correctly identifi ed two of Scott’s drawings (glad and scared), but misidentifi ed the mad and sad drawings, as they thought his drawing of mad looked sad, and vice versa. This led to a new awareness for Scott: when he was sad, he got angry and acted out; when he got angry, he cried (see Figures 5.7 and 5.8). Neither of these emotional responses helped him to resolve situations or cope with his dif- fi cult feelings. For an intervention used in art-therapy treatment with Emma, an adolescent girl diagnosed with Asperger’s syndrome, Elkis-Abuhoff (2008) used a feeling/ expression collage. The intervention was designed to improve Emma’s social engagement abilities and to facilitate her understanding of facial expressions in others and in herself. To assist the client, Elkis-Abuhoff had Emma create a list of emotional expressions and then fi nd pictures of the expressions for a collage project (see Figure 6.6). Once the collage had been completed, Elkis-Abuhoff asked questions such as “When might someone make that expression?”, “Give an example of a time when you observed someone using that expression,” and “Have you ever used that expression?” (Elkis-Abuhoff, 2008, p. 269). Although the client responded to the questions about the feeling states, she continued to have diffi culty relating the expressions to herself. A follow-up project designed to help with identifying her feelings involved the creation of masks. During the discussion of one of the masks, Emma described one mask as sparkling on the inside, but stated that others do not understand her. This time Emma admitted that when she gets angry, sparkles ignite; she also admitted to feeling misun- derstood. Emma’s admission that she had these feelings was a step forward in treatment. Karen, who was diagnosed with depression and suicidal ideation, was referred to art therapy after being discharged from the hospital. She had improved greatly due to treatment during hospitalization, and when asked what she would like to work on as an outpatient, she admitted without hesitation that she could not identify her feelings and would like to know what they were and how to under- stand them. Using Rhyne’s approach, Karen was asked to create drawings of several emotions. She was instructed to list the emotions she wanted to explore 112 Current CBAT Practices

FIGURE 6.6 Emma’s emotion expression collage. Source: Reprinted from “Art Therapy Applied to an Adolescent with Asperger’s Syndrome” (p. 267), by D.L. Elkis-Abuhoff, in The Arts in Psychotherapy, 35, 2008, with permission from Elsevier.

from Rhyne’s list of 15 feeling states, and add any others that came to mind. She was then asked to make sure that each emotion selected had an opposing feeling state. Over several sessions, Karen used Cray-Pas® and pastels to illustrate each feeling. The assessment revealed that the emotions which affected her most were depression and anxiety (see Figures 6.7 and 6.8). As noted by Teasdale (as cited in Lewis, 1996), these emotions led to the negative thinking and the diagnosis of depression.

Making Meaning of Emotions The purpose of CBAT is not only to identify and assess emotions, but also to help the client to make sense of their feelings. The meaning of emotions is often termed appraisal , which is the personal meaning or signifi cance of the emotion to the individual (Lazarus & Smith, 1988). In CBT and CBAT, emotions are like thoughts in that feelings should be viewed as indicators that something is awry and can lead to problematic behaviors or situations. Pifalo (2007) found that “the ability of art to create distance and contain powerful emotions is uniquely suited for affective processing of traumatic material” (p. 172) and that it helps the client to make sense of or gain meaning from diffi cult experiences. Current CBAT Practices 113

FIGURE 6.7 Karen’s drawing of the feeling of depression. Source: From “Cognitive-Behavioral Art Therapy” (p. 222), by M.L. Rosal, in Approaches to Art Therapy: Theory and Technique (2nd ed.), by J.A. Rubin (ed.), 2001, New York, NY: Brunner/Routledge. Re- published with permission of the Taylor and Francis Group, LLC, a division of Infoma plc.

FIGURE 6.8 Karen’s drawing of being anxious.

Case Vignettes Returning to Scott and his newly found understanding of the entwined emo- tions of “mad” and “sad” illuminates the concept of reappraisal. Scott realized that his sad feelings lead to anger, but an intermediate state was still unknown. It is rare that one goes directly from sadness to angry outbursts. To provide a 114 Current CBAT Practices better understanding of Scott’s emotional process, he was asked to go back to his initial idea of telling the teacher when kids bullied him. The painting he created of reporting problems to the teacher revealed his helplessness and his inability to solve problems by himself (see Figure 6.9). His meaning of sadness, which now included helplessness, was revealed and opened up the possibility of fi nding alternative solutions to problematic outcomes of these sensitive feelings. Rather than exploding with anger, Scott realized that he needed to address his helplessness. Similar to Scott, Karen’s emotional states were important indicators of behav- ior. It was important for her to fi nd which emotions were triggers for a looming depressive state. To assist her with this, she was asked to draw a timeline of posi- tive and negative phases of her life. She was then asked to place various feeling- state drawings on the timeline. When times were good, the emotional states of feeling balanced , feeling hopeful , and feeling serene were predominant feelings. When she was at her lowest, depressed , hopeless , and threatened were the major feel- ings. Finally, she was asked what emotions she experienced between the best and worst phases, and she placed anxious on the downward lines (see Figure 6.10). She connected anxious feelings with being threatened , which was one of the feeling states she placed in her lowest moments. Matthews (as cited in Lewis, 1996) con- nected the feeling of being threatened with the onset of anxiety. Realizing that feeling threatened was an antecedent to anxiety, and that anxiety was one of her triggers that led to depression, was a new insight for Karen. She was already on

FIGURE 6.9 Drawing of reporting bullying to the teacher. Source: Reprinted with permission from “Cognitive-Behavioral Art Therapy” (p. 340), by M.L. Rosal, in Approaches to Art Therapy: Theory and Technique, (3rd ed.), by J.A. Rubin (ed.), 2016, New York, NY: Routledge. Reprinted with permission pending. Current CBAT Practices 115

FIGURE 6.10 Karen’s depiction of anxiety on her lifeline and as the primary feeling leading to depression, hopelessness, and feeling threatened.

antidepressant medication, but not on anti-anxiety medication. She agreed to take the drawings to her psychiatrist to discuss anxiety as a precursor to depression. Her doctor agreed and provided her with a prescription for anxiety medication to take when an anxious mood returned (she was also asked to make an appointment to see him if this occurred).

Emotions as Functional and Transformative As illustrated in the above case vignettes, working with the feelings presented in treatment can provide the CBAT therapist with rich material to help the client. Emotions are viewed as important clues to a client’s thinking and perception of the environment. According to Keltner and Gross (1999), emotions serve a func- tion for the individual for both cultural-social situations and physical survival. Emotions alert the individual to pay attention and attend to something in the environment or within the self. For example, with a deeper understanding of her anxiety, Karen could use this feeling as a sign of oncoming depression. In CBAT, emotions can also be transformed or, in Lazarus’ (1968) terminology, reappraised. Reappraisals help a client to make sense of diffi cult emotions, leading to less problematic responses. During the reappraisal process, an individual identifi es a diffi cult emotion and then, rather than reacting, they transform its reactive power into a more adaptive response. 116 Current CBAT Practices

Case Vignettes Scott was beginning to grasp the meaning of his emotions through the mad, sad, glad, and scared intervention. He had connected sad feelings, helplessness, and anger in a previous session. To solidify his understanding of diffi cult emotions, he was asked to select one of the four feeling states to create a mask. He chose anger and created the mask of this emotion (see Figure 5.9). When asked to put on the mask and act angry, he roared. He reported feeling strong when he was wearing the mask. This intervention helped Scott to uncover a new connection between his anger and feeling empowered. When the sad drawing was retrieved, which held indicators of his anger, he realized that his sadness was a response to helplessness. Initially, anger was an internal response to feeling maltreated. This session was a turning point for Scott as he became cognizant of the importance of his feelings, particularly anger. Anger originated from feeling powerless, yet anger was also the impetus for gathering the energy to deal with the situation. In Scott’s case, Keltner and Gross (1999) would understand the function of his anger as giving him the energy for “redressing injustice” (p. 473). Karen, like Scott, was aware that certain feelings were toxic. In Karen’s case, it was the feeling of being depressed . After her awareness that anxiety , which stemmed from feeling threatened , was a possible impetus leading to depression, she wanted to understand the meaning of the emotion of depression. Immedi- ately she related it to hopelessness . In uncovering the source of her feeling of being hopeless (see Figure 6.11), she reported that her father had committed suicide. She was around 10 years old when she found his body. She never knew the reason for the suicide, but she surmised and held the belief that he must have felt hopeless (i.e., today is bad, and there is no hope for any change in the future). Hopeless- ness continued in her family when her mother was unable to help her children to cope with the suicide. Hopelessness is one of three major cognitive distortions in the theory of depression proposed by Beck et al. (1979); the other two concepts in the cognitive triad are negative feelings about one’s self (I am worthless) and about the world (nobody values me). For Karen, the links between being threat- ened, anxiety, and hopelessness led to depression. Karen had drawn depictions of both hopeless and hopeful (see Figure 6.12), and was willing to discuss the two together. Her fi rst response was how opposite they were. Hopeful was light, airy, and upward in movement (see Figure 6.12), whereas hopeless was dense, dark, and heavy, like her depiction of depression. She admitted to feeling hopeful only on rare occasions. She was asked to see if any of her other feeling drawings had similar elements to hopeful , and she pointed to her drawing of serene (see Figure 6.13). The drawing of serene had similar colors and was also described as light and airy. She was asked to think about what stood in the way of feeling hopeful and serene, and at once agreed that anxiety was the culprit. When her attention returned to depression, she realized that depres- sion was not the primary problem, but was a result of an accumulation of other Current CBAT Practices 117

FIGURE 6.11 Karen’s drawing of the feeling of hopelessness. feelings, namely hopelessness, being threatened, and being anxious. Karen recog- nized that she was already working towards coping with anxiety through discus- sions with her doctor, by early identifi cation of threats, and feeling empowered by her job. She was thrilled to learn that depression, which at one time seemed so overwhelming, was a response to these other feelings that were, in her eyes, manageable. Karen was also pleased that she had tangible areas that she could work on—learning what threatened her, uncovering what made her hopeful, and discovering serenity.

Dealing with Feelings In Vivo Emotional processing in the session or in vivo is a process used by art therapists to assist a client to learn new, more realistic beliefs about feared objects or situations and become more comfortable with the experience of fear and dread. This is a direct process whereby the client faces the situation or object in a straightforward manner. Diffi cult feelings are often the target of art-therapy sessions.

Case Vignettes A.W. Zettler (personal communication, June 25, 2017) offered Susie, aged 15 years and diagnosed with post-traumatic stress disorder (PTSD) and dysthymia, 118 Current CBAT Practices

FIGURE 6.12 Karen’s drawing of feeling hopeful.

FIGURE 6.13 Karen’s drawing of being serene. Source: From “Cognitive-Behavioral Art Therapy” (p. 221) by M.L. Rosal, in Approaches to Art Therapy: Theory and Technique (2nd ed.), by J.A. Rubin (ed.), 2001, New York, NY: Brunner/Routledge. Re- published with permission of the Taylor and Francis Group, LLC, a division of Infoma plc.

the opportunity to deal with the overpowering feeling of dread because of her anger towards her mother. Susie reported a situation when she yelled at her mother and her feelings associated with this moment felt like she was “being sucked into a black hole of shame and regret.” She admitted that her response to her mother was uncalled for and out of proportion. Susie was fi rst asked to draw a picture of the black hole of regret while concentrating on her feelings of dread (see Figure 6.14). The drawing was just as devastating as the memory of the situation. To counter this, Susie was then asked to think about the positive aspects of other interactions Current CBAT Practices 119 with her mother. After refl ecting on her relationship and remembering positive moments, she created a second drawing (see Figure 6.15). She used the second drawing to mitigate the feelings represented by the black hole, and pointed out that positive thinking was “squishing down the black hole” (see the bottom left-hand

FIGURE 6.14 Susie’s drawing of the black hole of shame and regret for yelling at her mother. Source: Printed with permission from the personal collection of A.W. Zettler.

FIGURE 6.15 Susie’s drawing of positive emotions squishing down the black hole. Source: Printed with permission from the personal collection of A.W. Zettler. 120 Current CBAT Practices corner of the drawing). For Susie, the second drawing relieved some of the devas- tation felt by her regret and dread that were embodied in the black hole drawing. Walker, Kaimal, Koffman, and DeGraba (2016) found that art therapy was a safe environment for “containment of overwhelming emotion” (p. 11). The authors presented a case study of a male active duty service member experienc- ing PTSD and a traumatic brain injury (TBI). He was offered the opportunity to create a mask representing a warrior identity. The mask he created reminded him of a recurring image of a bloody face (see Figure 6.16). He had experienced the recurring image for over seven years. He was unsure about seeing the mask, and experienced fear and anxiety while looking at it. Because the mask triggered

FIGURE 6.16 A warrior mask created by a combat veteran from an intrusive memory. Source: From “Art Therapy for PTSD and TBI: A Senior Active Duty Service Member’s Thera- peutic Journey” (p. 14), by M.S. Walker, G. Kaimal, R. Koffman, & T.J. DeGraba, in The Arts in Psychotherapy, 49, 2016. http://dx.doi.org/10.1016/j.aip.2016.05.015. Published by Elsevier. This is an open-access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/). Current CBAT Practices 121

FIGURE 6.17 Box as a container for the warrior mask and for the fears and anxieties associated with the mask. Source: From “Art Therapy for PTSD and TBI: A Senior Active Duty Service Member’s Thera- peutic Journey” (p. 14), by M.S. Walker, G. Kaimal, R. Koffman, & T.J. DeGraba, in The Arts in Psychotherapy, 49, 2016. http://dx.doi.org/10.1016/j.aip.2016.05.015. Published by Elsevier. This is an open-access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/ by-nc-nd/4.0/). overpowering feelings, the art therapist suggested the idea of creating a box for the mask so that it could be hidden away. The box served as a container for the client’s fears and anxieties (see Figure 6.17). With the mask hidden in this con- tainer, the client could then take it out only when he was feeling strong enough to do so. According to the art therapist, “He [also] reported that the process of working through and ‘externalizing’ the art work and keeping it physically ‘con- tained’ helped him to overcome the debilitating intrusive images from the past” (Walker et al., 2016, p. 15).

Altering the Self-Schema Self-esteem and self-effi cacy are important for positive, adaptive functioning. Art therapists are familiar with helping clients with low self-esteem. CBAT therapists work on the issue of poor self-schemas and self-concepts directly by fi rst identify- ing negative self-schemas and how they are developed (as discussed with Scott in 122 Current CBAT Practices the case vignette earlier in this chapter). The client is then asked to test out their self-beliefs in a variety of settings or uncover positive attributes and resources that might oppose the negative self-image. In this section, a description of how to uncover how a client views him- or herself will be followed by a discussion of how to help the client to identify strengths and resources. The way in which CBAT therapists can assist the client to develop a cohesive sense of self, and fi nally con- struct self-effi cacy, will then be described.

Identifying Self-Schemas In a similar way to helping a client to identify problematic thinking, CBAT therapists assess a person’s self-schemas or attributes. A drawing as simple as a self- drawing may be all that is needed to get a sense of a client’s self-image. Again, there are several art-therapy assessments that may be useful, and there are evalu- ation measures that may be therapist based.

Case Vignette Nine-year-old John, who had been diagnosed with attention defi cit hyperactiv- ity disorder (ADHD), was referred to art therapy by his parents, who were con- cerned about his poor sense of self. First, he was asked to identify words that he used to describe himself. His descriptors—wild and weird, bored, loser, bad, sad, scared or nervous, and ashamed—indicated a poor self-schema. He was asked to select one descriptor to draw. He selected bored , and talked about his tendency to be easily bored (see Figure 6.18). John elaborated and stated that when he was bored, he got “into things” and bothered people. He identifi ed fun and exciting as the opposite of bored, but admitted that he often became overstimulated when having fun; when in this state, he often crossed a line with his peers and became “wild and weird,” which he was asked to depict (see Figure 6.19). Boredom and easily getting excited led to his assessment that he was a loser, and he often felt ashamed of his behavior. These self-conceptualizations were the focus of his art- therapy treatment.

Identifi cation of Strengths and Resources After a thorough evaluation of the self-schema is complete, the next step is to assist the client to identify positive attributes. This is not as easy as it sounds. Often clients can only identify negative self-features. A group setting may be useful in these cases, because others may see strengths that the client does not, or asking the client to talk with teachers, friends, and relatives about their strengths. Having the client survey those whom they like and trust to identify positive attributes may be more successful than the therapist providing these. CBAT therapists also use art to unearth positive characteristics. FIGURE 6.18 John’s drawing of being bored. Source: From Approaches to Art Therapy with Children (p. 55), by M.L. Rosal, 1996, Burlingame, CA: Abbeygate Press. Reprinted with permission.

FIGURE 6.19 John’s drawing of being wild and weird, with tongue sticking out and enlarged ear. Source: From Approaches to Art Therapy with Children (p. 56), by M.L. Rosal, 1996, Burlingame, CA: Abbeygate Press. Reprinted with permission. 124 Current CBAT Practices

Case Vignette A.W. Zettler (personal communication, June 25, 2017) discussed the case of April, a 17-year-old girl diagnosed as being on the autism spectrum and as having co-occurring adjustment disorder with anxiety. April was smart and artistic, and in fact attended a public magnet school for the arts. She joined a small art-therapy group to address her socialization skills. To begin work on self-concept, group members were asked to identify and illustrate positive self- attributes followed by identifying diffi cult aspects of the self. Finally, using either drawings or words, members were asked to have a conversation between the self and one of the diffi cult attributes (see Figure 6.20). April chose the lonely girl in a corner to discuss, and through the conversation she realized that one of the primary sources of her anxiety came from concerns that she felt judged by others. Feeling that she needed to be part of the crowd was also a source of concern. She decided that the lonely girl is easier to deal with than some of her other feelings or aspects of herself. As a result of this art-therapy exercise, April stated that she was learning to use her positive attributes to soothe her anxiety and to feel safe.

FIGURE 6.20 April’s drawing of both positive and diffi cult self-attributes. Source: Printed with permission from the personal collection of A.W. Zettler. Current CBAT Practices 125

Creating a Cohesive Sense of Self Inconsistent family backgrounds, poverty, bullying, and experiencing traumatic events disrupt the development of a cohesive sense of self. Helping clients to discover their solid sense of self and positive self-identity is part of CBAT. After doing a great deal of self-work, a mask can enable clients to solidify a holistic sense of self.

Case Vignette A.W. Zettler (personal communication, June 25, 2017) worked with Helen, a 15-year-old girl who had been diagnosed with cyclothymia. A child of divorced alcoholics, and with multiple older half-siblings, she attended a rural K-12 public school where she was placed in the gifted program. As a long-term member of small- group art therapy where the focus was on understanding the self, she was asked to create a mask that projected her true self (i.e., not the self commonly presented to others, but the inner self). Helen chose to create a raven mask, which she described as all that is old, wise, opportunistic, and mischievous (see Figure 6.21). Given her diffi cult

FIGURE 6.21 Helen’s raven mask illustrating her true self. Source: Printed with permission from the personal collection of A.W. Zettler. 126 Current CBAT Practices history and diagnosis, she was fi nally able to present a unifi ed sense of self through the mask project representing both positive and negative personality traits.

Self-Effi cacy Development Self-effi cacy is a realized belief that one can accomplish one’s own affairs of daily living in an effective manner. Benight and Bandura (2004) described self-effi cacy as a “core belief that one has the power to produce desired effects by one’s actions” (p. 1131) and stated that it “operates as a cognitive regulator of stress” (p. 1132). The authors found that facilitating mastery events in treatment is useful for cultivating self-effi cacy.

Case Vignettes A.W. Zettler (personal communication, June 25, 2017) worked with Maggie, a 14-year-old girl who had been diagnosed with generalized anxiety disorder, in small- group art therapy. Maggie and the other participants had little sense that they could affect events in their lives. To cultivate self-effi cacy, Zettler chose to have each group member identify an animal that possessed positive attributes they wished to have. Maggie chose to create a bear out of clay, and she talked about how the bear was protective, courageous, independent, and strong—all characteristics of someone with a strong sense of self-agency. In addition, each group member was asked to create a safe habitat for their animal. Maggie’s bear habitat included a home, food, and water, all of which demonstrated that the bear could take care of itself (see Figure 6.22).

FIGURE 6.22 Maggie’s power bear in its habitat. Source: Printed with permission from the personal collection of A.W. Zettler. Current CBAT Practices 127

FIGURE 6.23 Group member’s clay anxiety monster. Source: Printed with permission from the personal collection of A.W. Zettler.

Zettler also worked with a small group of women who were experiencing low self-esteem and lack of self-agency (personal communication, June 25, 2017). After a few weeks of working on feeling states, she asked the group members to create a sculpture of a troublesome feeling state. One of the members created an anxiety monster (see Figure 6.23). The sculpture not only externalized this prob- lematic feeling state, but also helped the client to uncover just how much power she could muster over this monster. By creating the anxiety monster, she could tame these anxious feelings. She also created a container to house and confi ne the monster when necessary.

Using Mental Imagery CBAT work often involves tapping into mental images. The images that clients carry with them can be causal agents for problematic emotional responses or behaviors. Images of how clients see themselves are often rooted in experiences endured in childhood and carried with them into adolescence and adulthood. Other mental images have roots in recent troubling experiences. These images 128 Current CBAT Practices can be created in the art-therapy session, and can be the impetus for discussions of the self-schema and of the possibility of altering or decreasing the emotional impact of the image. Alterations can be made directly to the original drawing, or can be made in a separately created one that can be used for comparisons when the drawings are placed side by side. For example, Sarid and Huss (2010) reported an art-therapy intervention with an adult after a bicycle accident. The 24-year old woman had become fi xated on the fact that she had not noticed a large object in her path, had run into it with her bike, and had ultimately broken her leg. Since she was not able to get the object out of her mind after the accident, she was referred to short-term art therapy (four sessions). First the therapist asked the client to create a drawing of the accident. The authors reported that she drew a large black object in the middle of a road, with a black fi gure next to it. She expressed anger with herself for not seeing the object and for her own stupidity. Next, she was asked to use colors to represent other characteristics she possessed, using a different color for each quality. When this step was completed, she was surprised how bright and colorful the picture was, and even stated that “The black highlights my other colors” (Sarid & Huss, 2010, p. 10). Sarid and Huss concluded that through this process, the client could put the object, and the mental image of that object, in the context of an overall image of herself. Because of this, the emotional impact of the image was reduced; it was no longer intrusive, nor was it the focus of her thinking and overall well-being.

Guided Imagery Guided imagery (GI) can tap into a client’s mental pictures. Therapist-led stories can be individually crafted to uncover a person’s inner resources or coping strate- gies. As understood by Singer (1974) and Lusebrink (1990), mental imagery is most effectively captured when the client is in a relaxed state. Relaxation can be induced through simple breathing exercises, body scans, or progressive relaxation exercises.

The typical [guided imagery] daydream session begins with the relaxation and is followed by the specifi c image suggested by the guide . . . next [there is] an imagined trip with a variety of images occurring and with consider- able concomitant affective expression. (Singer, 1974, p. 70)

At the end of the guided imagery, the client is asked to rest and to refl ect on the experience. Engaging in written refl ections or drawing or painting the important aspects of the guided trip is encouraged. Lusebrink (1990) urged art therapists to begin with basic scenes such as a meadow, water scene, mountains, house, etc., and to go on from there to encoun- ter an obstacle or problem. The guided imagery typically ends with the obstacle being dealt with, or reaching the goal. Lusebrink recommended that art therapists ask clients to paint three scenes from the guided trip. She stated that “paints or Current CBAT Practices 129 watercolors are recommended for the visual depiction, emphasizing the affective component of the experience” (Lusebrink, 1990, p. 154) and also capturing the elusiveness of mental imagery. Guided imagery is primarily used for problem- solving through dealing with obstacles, to empower individuals, and to aid in improving stress relief and coping (Lusebrink, 1990).

Case Vignettes To work on empowerment, the art-therapy group that Scott participated in was provided with a common guided imagery, namely a journey into the cave to fi nd treasure. After a short relaxation exercise, the guided imagery instructs the participant to select items to take into the cave, namely food, backpack, fl ash- lights, and a sword. They are then instructed to overcome an obstacle (in the case of the cave guided imagery, participants must get past a dragon) to fi nd the trea- sure. Using watercolors, Scott created three paintings: (1) a preparation image shows him in front of the cave opening with his sword held high and ready to explore (see Figure 6.24), (2) slaying the dragon that is guarding the treasure (see Figure 6.25), and (3) fi nding the treasure (see Figure 6.26). Scott spoke of his excitement and his strength as well as his ability to enter such a scary place and to deal with a ferocious beast in order to fi nd a treasure chest. Mercer, Warson, and Zhao (2010) were concerned with the stress experi- enced by medical students. Through their research, they found that journal writ- ing not only mitigated the stress and anxiety that were so prevalent in the lives

FIGURE 6.24 Scott’s painting of being prepared to go into the cave from a guided imagery intervention, with a sword held high and a backpack. Source: Reprinted from “Approaches to Art Therapy with Children” (p. 177), by M.L. Rosal, in Art for All the Children by F.E. Anderson (ed.), 1992, Springfi eld, IL: Charles C. Thomas. Reprinted with permission; and with permission from Approaches to Art Therapy with Children (p. 65), by M.L. Rosal, 1996, Burlingame, CA. Reprinted with permission from Abbeygate Press. 130 Current CBAT Practices

FIGURE 6.25 From a guided imagery journey: Scott’s painting of slaying the dragon guarding the treasure.

FIGURE 6.26 From a guided imagery journey: Scott’s painting of fi nding the treasure inside the cave. of graduate students, but also aided their professional and personal development. They set out to study the effects of adding art-making to the journaling pro- cess. Their hypothesis was based on fi ndings which suggested that visual journal- ing was successful in improving development and decreasing stress, but that the addition of art-making to the journaling process was even more effective. The authors stated that “The visual journal successfully combines visual and written interventions, allowing for the experience of both emotional satisfaction and cog- nitive awareness” (Mercer et al., 2010, p. 144). Current CBAT Practices 131

Medical students were seen over two sessions. In the fi rst session, they were taken through a guided imagery visualization: “The visualization focused on their breathing and on identifying their stress-producing emotions” (p. 144). After the visualization, the participants were asked to create a drawing of their stress. A second guided imagery visualization was introduced, and this time they were asked “to envision a new less stressful image” (p. 144). They were asked to draw this more positive image. Although the results were inconclusive due the low number of participants, verbal affi rmations of the process were collected. As reported by Mercer et al. (2010), one participant found the guided journey to be empowering.

Imaginal Exposure (IE) Imaginal exposure (IE) is a specifi c cognitive-behavioral technique designed to help individuals to cope with diffi cult memories, situations, or intrusive images. This is a type of therapist-guided imagery exercise whereby the client is directly confronted with the imagined feared or anxiety-provoking situation (Foa, Hembree, & Rothbaum, 2007). The therapist has the client mentally picture the situation and talk about it, write about it, or, in CBAT, draw it. In most cases, the client is led through a relaxation exercise prior to the therapist-guided imagery. If the client becomes anxious, the therapist stops until the client confi rms that their anxiety or fear has abated; the imaginal exercise then continues (Keane & Kaloupek, 1982).

Case Vignette Reynolds (1999) worked with a client who was experiencing prolonged grief. This woman, who was in her forties, was experiencing feelings of regret, shame, and depression stemming from her desire to move from the original family home to another place. The husband blamed her for the move and for the disrup- tion within the family. The client was not able to look at photographs from the fi rst family home without increasing anxiety, sadness, and regret. Reynolds chose imaginal exposure to help the client to regain the ability to look at the photos without feelings of regret. To do this, Reynolds had the client grade the photos from least threatening to her well-being to most threatening. To begin, the client asked her children for assistance with fi nding the photos in her least threatening list, and as homework she would look at the photos with her supportive children. The intervention was a success, and she moved on to the most diffi cult photos, which were of the garden at her fi rst home. Since look- ing at these photos was so diffi cult, she decided that she could weave the garden images into a tapestry. Although the photos were diffi cult for her to view, after spending several hours each week working on the tapestry, her emotional pain had diminished. Reynolds concluded that the exposure intervention, which was 132 Current CBAT Practices personally relevant to the client, was not only successful but also represented a creative approach to a CBT procedure.

Imagery Rescripting Imagery rescripting (IR) is a CBT technique that is used to mitigate intrusive or involuntary memories and mental imagery associated with traumatic events. According to Arntz (2011), IR has been successful when used with populations with obsessive-compulsive disorder (OCD), depression, PTSD, eating disor- ders, social phobia, and personality disorders. According to Arntz and Weert- man (1999), “with a signifi cant pictorial component . . . the major aim [of IR] is to increase the sense of empowerment” (p. 717). The purpose of IR is to activate troubling memories or mental images, allow the client opportunities to express emotional responses to the memory, provide an environment for alter- ing the emotional intensity of the memory or image, and offer the prospect of changing the beliefs and schemas associated with the event (Arntz, Tiesema, & Kindt, 2007). Grunert, Smucker, Weis, and Rusch (2003) stated that IR is basi- cally imagery modifi cation in which the client is given the opportunity to gain power over traumatic events and eliminate intrusive images and memories, and it includes four types of imagery:

(a) imaginal exposure (accessing and re-experiencing the entire fear memory along with associated affect, (b) imaginal rescripting (replacing victimization/ trauma with mastery/adaptive imagery), (c) self-soothing/self-nurturing imagery (e.g., SURVIVOR-nurturing-VICTIM imagery, ADULT-nurturing- CHILD imagery), and (d) emotional-linguistic processing (transforming the traumatic imagery and accompanying emotions into narrative language while challenging and modifying trauma-related beliefs). (p. 334)

According to Grunert et al., there is a critical empowerment aspect to IR. They used the term Socratic imagery to describe the involvement of the client in using empowerment and adaptive imagery as they process the trauma event and challenge the original trauma narrative.

Case Vignettes Gantt and Tinnin (2007) developed a protocol for people suffering from PTSD and dissociative events. They labeled their protocol intensive trauma therapy (ITT) . Although this approach to treating PTSD has numerous components, one aspect is an example of IR using art therapy. After a verbal narrative processing ele- ment of the trauma event, the clients were asked to draw the trauma narrative. The graphic narrative is divided into seven parts or scenes from the traumatic Current CBAT Practices 133 event: “the startle, the thwarted intention (to fi ght or fl ee), the freeze, the altered state of consciousness, the body sensations (antecedents of body memories), auto- matic obedience . . . and self-repair” (Gantt & Tinnin, 2007, p. 70). Gantt and Tinnin asked that each scene be drawn on a separate piece of paper; before and after pictures complete the series. The therapist then displays the drawings and “re-presents” the trauma story verbally to the client using the past tense. The re- presentation is videotaped and used later in the ITT protocol for the client to view. The authors reported that the verbal and nonverbal processing of the trauma event “usually achieves cognitive closure and imbues the traumatic memory with past tense” (p. 70). The trauma is altered from something held in present time to some- thing that occurred in the past, and assists the client in achieving more adaptive functioning in the here and now. A similar IR process was used by Sarid and Huss (2010), who discussed CBAT with a young man who had been beaten and robbed at a gas station. In addition to utilizing relaxation and cognitive restructuring techniques, they implemented IR for the most disturbing image that the client identifi ed: “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 identifi ed the screams as the most disturbing part of this image” (Sarid & Huss, 2010, p. 9). To help him to rescript this image, the therapist had the client adjust the volume level of his screams and had him envision the attackers as moving further away and getting smaller and smaller. The IR ended with the client drawing a safe place. Sarid and Huss concluded that this intervention restructured the image into “a less intense and integrated memory” (p. 9). Cognitive processing of the trauma narrative was researched by Campbell, Decker, Kruk, and Deaver (2016). They hypothesized that combined art therapy and cognitive processing therapy (CPT) for veterans with PTSD would be more effective than CPT alone. The authors based their intervention on Gantt and Tinnin’s narrative art-therapy approach to processing the trauma, in addition to other CBAT interventions, namely goal setting, mask-making, and mind-mapping to identify diffi cult emotions and emotional triggers, image transformation exer- cise to reconstruct grief, and reconstructing a worldview. After creating a safety collage, the veterans were asked to create six drawings (see Figure 6.27; K.P. Decker, personal communication, August 23, 2017):

1 Create an image of a time before the trauma that you felt peaceful and safe; a positive memory. 2 Create an image of the last moment you remember directly before the trauma. 3 Create an image of what happened during the trauma. 4 Create an image of a moment you can remember right after the trauma. 5 Create an image of a time when you were safe from the physical threats of war. 6 Create an image of a time when you tried to self-soothe. 134 Current CBAT Practices

FIGURE 6.27 Example of six drawings related to a combat trauma event. Source: From the collection of the Department of Veterans Affairs and Eastern Virginia Medical School IRB-approved research project. Printed with permission from Dr. K.P. Decker, MD.

The drawing of the trauma narrative ended with a drawing of a safe place. Like Gantt and Tinnin, the authors taped the drawings up on a wall, and each veteran narrated the trauma story in the past tense. The results indicated that individuals in CPT and art therapy had signifi cantly improved trauma process- ing when compared with the CPT-only group. This positive result supports the inclusion of art therapy in processing the trauma narrative, and in IR.

Problem-Solving Problem-solving is a key component of both CBT and CBAT. Spivack and Shure (1974) introduced problem-solving as a crucial element for the focus of treatment of young people in the early 1970s. This is a practical approach to treat- ment, and it involves “fi nding the most effi cient avenue to a person in confl ict” (Rosal, 2001, p. 212). In this treatment focus, the problems that are plaguing an individual are fi rst identifi ed, and the subsequent interventions involve fi nding real-life solutions (Mahoney, 1977). Kazdin, Siegel, and Bass (1992) described their problem-solving intervention as involving observing and identifying behav- iors and then generating alternative solutions and “engaging in mean-ends think- ing” (p. 736) as a method of dealing with interpersonal turmoil. The ability to problem-solve is a key element of coping with diffi culties (see the section on Current CBAT Practices 135 coping below). Art-making itself has been equated with problem-solving (Curl, 2008; Packard, 1977; Rosal, 2001).

With Children Epp (2008) used CBAT to address the social skill needs of children with autism spectrum disorder (ASD). Her rationale for implementing art therapy with this population was that children on the autism spectrum are often visual and con- crete thinkers, and her research affi rmed that the use of art would help to hold their attention. Also, Epp stated that “Art therapy offers a way to solve prob- lems visually” (p. 29). She worked with small groups with about six children per group. One group art-therapy intervention that targeted problem-solving and socialization involved having each child create an animal (i.e., if you were an animal, what animal would you be? ). Over several subsequent group sessions, each small group created an animal habitat mural where all the animals could live together. For the ASD population, this was a signifi cant challenge to their problem-solving abilities. The group members had to work together to design and complete the habitat, and the directive required working together in a socially acceptable manner.

With Adults Gussak (2009) developed an art-therapy program for reducing depression in prison populations. The program included many aspects of CBAT, and several of the interventions focused on problem-solving as a way of helping inmates to cope with the harsh and sometimes dangerous prison environment. Gussak introduced an art directive where each person had to create a sculptural piece with only white paper and tape. He remarked that the project “stressed individ- ual identity, while addressing problem-solving abilities” (p. 8). The self-symbol sculpture shown in Figure 6.28 was intricate, and required numerous steps and creative thinking to complete the directive. More complex problem-solving was introduced to the group as a whole. Gussak had the group members construct a bridge using only paper and tape, which included elements of the individual sculptures made by each member (see Figure 6.29). As noted by Gussak, “Some of the bridges became quite elaborate, and required much more refi ned problem solving and socialization skills” (p. 8). The results of his study indicated that the art-therapy participants were less depressed and became more internal in their locus of control. He summarized the outcome of the art-therapy group by stat- ing that “The fi nal projects invariably were a fi ne example of complexity and problem-solving” (p. 11). FIGURE 6.28 Self-symbol paper sculpture by a prison inmate demonstrating his problem-solving skills. Source: Reprinted from “The Effects of Art Therapy on Male and Female Inmates: Advancing the Research Base” (p. 8), by D.E. Gussak, in The Arts in Psychotherapy, 36, 2009, with permission from Elsevier.

FIGURE 6.29 Paper sculpture incorporating ideas from all group members to increase problem-solving skills. Source: Reprinted from “The Effects of Art Therapy on Male and Female Inmates: Advancing the Re- search Base” (p. 9), by D.E. Gussak, in The Arts in Psychotherapy, 36, 2009, with permission from Elsevier. Current CBAT Practices 137

Coping Coping is a cognitive strategy that people utilize to deal with stressful events. Laza- rus and Folkman (1984) defi ned coping as “realistic and fl exible thoughts” which “reduce stress” (p. 118). Therefore it is vital to explore the relationship between coping, stress, and stressful events during treatment. There are two major func- tions of coping: fi rst, to manage stressful emotions (internal), and second, to cor- rect problems affecting a person that arise in the environment (external) (Folkman et al., 1986). There is also a link between coping and cognitive appraisal. In the model of coping proposed by Lazarus and Folkman (1984), a person assesses a stressor as either a challenge or a threat. If the stressor is perceived as a challenge, the individual will be able to cope and problem-solve effectively. If the stressor seems threatening, negative emotions may ensue, the person may experience vulnerability, and the ability to cope is decreased. Increasing a client’s ability to cope with diffi culties is an important goal of CBT and CBAT treatment. There are numerous ways to assist others with cul- tivating the ability to cope, including Meichenbaum’s stress inoculation (1975), Kazdin’s covert modeling (1974), and Goldfried’s modifi ed systematic desensi- tization (1971). To begin with, it is recommended that clients identify the cop- ing skills, resources, and support systems currently in use. In a study of coping among women with breast cancer, Oster et al. (2007) borrowed the defi nition of coping resources proposed by Hammer and Marting, who described them “as those resources inherent in individuals that enable them to handle stressors more effectively to experience fewer symptoms upon exposure to a stressor, or to recover faster from exposure’” (as cited in Oster et al., 2007, p. 280). Another strategy is to evaluate the strengths and weaknesses of the coping mechanisms already in place, and to identify alternative skills or supports that may be useful for improved management of stressors. The ability to problem- solve is useful in improving coping skills, and may be a focus of treatment (see the above section on problem-solving). Art therapists have noted that engag- ing in art-making can become a coping mechanism and can be empowering. Art-making provides an outlet for diffi cult emotions, is a way to focus, and may induce relaxation: all of these are helpful when people are under duress. Curl (2008) theorized that art therapy and GI are helpful for organizing one’s thoughts and can be used to process diffi cult situations, aid in problem-solving, and decrease stress.

Case Vignettes John, the 9-year-old with ADHD who experienced low self-esteem, gained a sense of resiliency through work in CBAT. After learning how to cope with his wild side, he could do “battle” with his insecurities in order to feel empowered. His battle was learning how to cope with his ADHD and the related impulsive 138 Current CBAT Practices

FIGURE 6.30 John as a warrior battling his impulsive behavior. Source: From Approaches to Art Therapy with Children (p. 57), by M.L. Rosal, 1996, Burlingame, CA: Abbeygate Press. Reprinted with permission.

instincts and behaviors that kept him from having friends. To cope, he imagined himself as a great warrior ready to drive away his problematic behaviors (see Figure 6.30). Oster et al. (2006) conducted a study to improve the coping resources of women with breast cancer. The authors understood that increasing coping strate- gies is vital to how women view themselves and their bodies after surgery, che- motherapy, and radiation therapy. They also found that “Being able to integrate body image and bodily functions after surgery are important aspects of the cop- ing process” (p. 58). The fi ve-session art therapy program addressed two goals related to body-awareness and coping: fi rst, to provide support in the restoration of body image, and second, to reduce stress and increase the ability to cope with the cancer experience. The art intervention that targeted these goals was the body outline. The therapist outlined the body of each member of an art-therapy group. Each client was then invited to use shapes and colors to express thoughts and feelings about the different parts of her body. Women in the art-therapy group showed improved coping as measured through a coping inventory. The authors also reported that “A positive body image was seen to infl uence self-effi cacy in coping with breast cancer” (Oster et al., 2006, p. 62). Using art therapy to relieve stress and increase coping strategies of 60 health- care workers, Visnola, Sprudza, Bake, and Pike (2010) had participants engage in nine sessions of art therapy over a two-month period. The intervention had three distinct stages, each consisting of three sessions. During the fi rst stage, the participants focused on recognizing and fi nding coping strategies for dealing with stressful situations. The fi rst CBAT intervention was the tree of emotions , where the group had the opportunity to identify various emotional states, including Current CBAT Practices 139 painful ones. This was followed by asking the participants to identify where in their bodies the diffi cult emotional states were held, and to draw and paint what stress felt like. Next, they were given relaxation exercises in order to learn coping skills. Another CBAT intervention followed, which involved identify- ing stressful situations in the workplace and drawing various solutions using both problem-solving and coping-related skills. The participants were asked to identify a positive situation in daily life and draw it as homework for the next session. Cognitive restructuring was the focus of the second stage of the treat- ment program. Expressing feelings on paper, including scribbling to allow the release of anxiety, was introduced. The participants were also asked to identify resources in the workplace and to draw these out with help from other group members. Dealing with lack of time was a major theme in this stage, and coping with time restraints that add to job pressures. The theme of the third stage was self-awareness and uncovering positive emotions. The treatment ended with each participant identifying the resources and achievements garnered from art therapy. The results of the study indicated that state anxiety levels were signifi cantly decreased for the treatment group, but mean stress scores were not signifi cantly different between the treatment and control groups. The treatment group had signifi cantly larger changes in self-esteem and self-confi dence scores. Qualita- tive changes indicated that the members of the treatment group were better able to cope with stress and fi nd solutions to problems. The majority selected the statement “discovered way[s] to solve stressful situations and changed atti- tude toward situation” (p. 89) at post-test to describe what they had learned. The authors were encouraged by the self-noted change in attitude assessed in the study, as this indicates a modifi cation in thinking that takes effort to acquire and maintain.

Adaptation and Resiliency The unifying goal of CBT is behavioral adaptation (Mennin, Ellard, Fresco, & Gross, 2013). Therapists cultivate adaptive qualities in their clients as a means of enabling them to survive and thrive. Those who can adapt to a wide range of cir- cumstances are often labeled as resilient. Resilience is defi ned as “positive adapta- tion in the context of signifi cant challenges, variously referring to the capacity for, processes of, or outcomes of successful life-course development during or follow- ing exposure to potentially life-altering experiences” (Masten, Cutuli, Herbers, & Reed, 2009). Other authors have also linked adaptation and resilience. For exam- ple, Waugh, Fredrickson, and Taylor (2008) conceptualized emotional resilience as the use of emotional resources for adapting to adversity. Cultivating adaptation abilities and resiliency is a culmination of several CBT interventions discussed throughout this chapter. Included in the variety of interventions are problem- solving skills, self-regulation skills for self-control, positive self-perceptions and 140 Current CBAT Practices self-effi cacy, and control of attention, focus, arousal, and impulses (Masten et al., 2009). Adaptation and resilience are characteristics that are fundamental to CBT, and are the ultimate goals of this genre of psychotherapy.

Case Vignettes To improve self-esteem and resiliency, Roghanchi et al. (2013) studied the integration of rational-emotive behavior therapy (REBT) and art therapy. The 10-week intervention program paired REBT techniques with the engraving arts for a group of university students at the institution’s counseling center. Indi- viduals in the treatment group demonstrated increases in both self-esteem and resiliency scores, but neither reached the level of signifi cance. The participants reported that involvement in the art helped with relaxation and calming. The authors noted that there is a paucity of research in the area of art therapy and resiliency. It was diffi cult to fi nd articles that addressed the issue of adaptation and resil- iency directly. However, when reviewing the various case vignettes covered in this chapter, I found that several art therapists were working towards this goal. The use of art therapy to engender adaptability and resiliency can be seen in many of the case vignettes in this chapter. For example, Elkis-Abuhoff (2008), when she began to work with Emma, found her to be socially awkward and, although she was 18 years old, unable to think about planning for the future. Through participation in art therapy, Emma moved from a place of anxiety and social isolation to making future plans for her education. She also cultivated coping strategies which assisted in connecting and interacting with her peers and dealing with feelings of reluctance expressed by her father about her leav- ing home. Ultimately, Emma was prepared for post-secondary education. These therapeutic strides indicated fi nding resiliency and adapting to a new stage in her life. Similarly, Reynolds (1999) found that the use of CBAT, and specifi cally exposure techniques, with an adult woman who was dealing with grief issues led to her feeling less vulnerable to emotional attacks, which is one aspect of resiliency. Scott, the 12-year-old student with behavior problems, also developed resil- iency, which can be observed in his two fi nal drawings in art therapy. When he was asked to draw a picture of something he had learned about himself by engag- ing in art therapy, he drew himself with a wide smile (see Figure 5.9.). When asked to draw a picture of something he had learned about others, he created a drawing of him with a friend (see Figure 6.31). He admitted that he had never had friends before and that it was great to have one now. Embracing himself as a person who was happy was distinctly different from the self he presented to the group in the beginning stages of group art therapy. That he could honestly voice that he had a friend was extraordinary. Prior to treatment, he was surly and bel- ligerent with others, and more often than not his interactions with peers ended Current CBAT Practices 141

FIGURE 6.31 Scott’s drawing of what he learned about someone else in his therapy group. He learned that he could make friends. Source: Reprinted with permission from “Cognitive-Behavioral Art Therapy” (p. 341), by M.L. Rosal, in Approaches to Art Therapy: Theory & Technique (3rd ed.) by J.A. Rubin (ed.), 2016, New York, NY: Routledge. Permission pending. in arguments and tears. These two drawings point to a teen who was becoming more adaptive and resilient. In Figure 6.31, Scott gave a nod to the friend he made in the art-therapy group.

Conclusion This chapter has provided an overview of the most common techniques and interventions that CBAT therapists employ. These practices include identifying the source of problematic cognitions, understanding how these affect behavior, and using art to transform erroneous thoughts. Addressing emotions is a primary goal in CBAT, and methods of addressing diffi cult feelings include assessing and understanding emotional states, unraveling the impact of emotions, mitigating the power of feelings, and using aroused emotional states in the session or in vivo . Altering a negative self-schema is also an essential goal of CBAT. This can occur through fi rst identifying the self-schema as well as strengths and weaknesses. Achieving a cohesive sense of self occurs through integrating both strengths and weaknesses into masks or animal symbols. These artworks reveal a person’s char- acteristics, both positive and negative, that lead to self-knowledge and ultimately to self-effi cacy. Mental imagery is an important practice in CBAT. Therapists are constantly looking for clues to the images that clients carry with them. Recreating these mental pictures on paper or in sculptural form helps the client to recognize and understand both the origin of these mental constructions and the toxic nature of 142 Current CBAT Practices some mental images. Guided imagery can reveal a person’s inner resources and build upon these resources. Imaginal exposure can decrease the client’s fears and anxieties by systematically exposing the person to the feared objects. Increased exposure while the client is in a relaxed state is effective for alleviating pho- bias and anxiety-inducing situations. Imagery rescripting is an important CBAT process whereby the individual creates drawings of each segment of a traumatic event. The pictures tell the trauma narrative and can be verbalized by the client and then retold to the client by the therapist. Drawing what happens after the traumatic event situates the intrusive mental images in the past and within the larger story of the client’s life. Three overarching goals of CBAT are problem-solving, coping, and adapta- tion and resiliency. These can be an overall aspect of CBAT, or they can be addressed as a specifi c outcome of CBAT treatment. As stated above and in Chapter One, art-making in and of itself is a problem-solving enterprise. Yet encouraging problem-solving can be the purpose of various CBAT interventions. This was true of the paper-sculpture exercises given to prison inmates. Increas- ing the coping capabilities of the client is also an underlying function of CBAT. Helping clients to deal with stress leads to increases in coping. A common CBAT method to identify stress is to utilize a body outline and, using various colors, have the client color where in the body stress is felt. Clients can be encouraged to identify previous coping strategies through the use of collage-making, which can reveal coping styles that are adaptive, or identify others that may need bolstering. Learning how to adapt to new or stressful situations is the underlying purpose of CBT and CBAT. Discovering ways to adapt builds resiliency to future stressors and obstacles, and can help to prevent the client from experiencing relapse or recurring major setbacks. Presented in this chapter was a wide array of practices and procedures in CBAT that target specifi c issues related to a client’s diffi culties. The fi rst step is to assess the needs of the client as quickly as possible. Identifying the presenting problems will lead to the development of optimum treatment strategies for that person. Addressing the needs of the client directly is key to CBAT. The specifi c CBAT practices are dependent on the needs presented in therapy. Understand- ing the power of cognitions, emotions, self-schemas, and mental imagery guides the CBAT therapist to identify the most effi cacious practices to employ for the therapeutic progress of an individual.

7 THE MINDFULNESS EVOLUTION OF CBT

“Cognitive-behavior therapists, with their array of practice techniques, can develop many unique interventions based upon the Buddhist psychology of cognition that can be of immense utility in teaching the anxious individual a more adaptive belief system about the nature of their cognitions.” (Toneatto, 2002, p. 78)

The 1940s and 1950s saw the emergence of the fi rst theories and practices of behavioral therapy—the fi rst generation of CBTs. The cognitive revolution of the 1960s and 1970s infl uenced the way that behavior therapy was practiced, and practitioners incorporated the “how and why people think” into the interven- tions of what became known as the second generation of behavioral therapy or CBT. Today the evolution of CBT continues, and there is a new generation of CBT practices. Since the 1990s, CBT has been undergoing a transformation or what some theorists are calling a “third wave” of practices. According to Toneatto (2002), it is a strength of CBT that it is adaptive and few interventions are excluded if empirical evidence is available to validate a particular method. This strength promotes evolutionary advances in this theoretical practice. Although the new practices differ in numerous ways, there is one commonality among these variants—theorists and practitioners have borrowed contemplative and meditative traditions from Buddhist psychology and integrated them into CBT practice. The methods from Buddhist contemplative practices include mindful- ness, acceptance, and compassion (Herbert & Forman, 2011a). The evolutionary nature of CBT is due to its fundamental epistemology, namely that therapeutic treatment should be evidence-based. This means that when an intervention does not work, other practices are employed until one 144 The Mindfulness Evolution of CBT is found that is effective. Although there is no one unifying philosophy upon which CBT is based, it is most closely related to critical rationalism (Hofmann et al., 2013). This is the philosophy that is used to conceptualize numerous natu- ral sciences. One aspect of this philosophical foundation implies a dedication to empiricism where hypotheses are researched and if the uncovered evidence does not support the assumptions, it is falsifi ed. This premise applies to research- ing the effectiveness of an array of CBT practices, and also critical rationalism describes how clients are served by CBT therapists. Clients are also asked to use a scientifi c mindset and are encouraged to uncover and examine the assumptions used in their thinking. If a client fi nds that thoughts and beliefs are erroneous, they can re-examine the perceptions that have led to diffi cult responses from the past. Based on these realizations, the client has opportunities to alter their erroneous cognitions. Today’s third generation or third wave of CBT evolved from practices that did not work for a few diagnostic groups, including clients with relapsing depres- sion. The original CBT strategies with this group of clients were effective for some time, but then clients declined. The search for ways to treat individuals with relapsing depression led CBT researchers on a path that led to the use of mindfulness and meditative practices. The purpose of this chapter is to explore the origins and theories behind this new evolutionary step in CBT.

Initial Inquiries into Third-Wave CBT Practices Two groups of clients, people with borderline personality disorders and individu- als with relapsing depression, are diffi cult to treat or would relapse after undergo- ing treatment using traditional CBT methods. Due to the complexity of treating these two diagnostic groups, therapists began experimenting with additional modalities as a means of fi nding more effective treatment processes. For exam- ple, two treatment models, dialectic behavioral therapy (DBT) , developed by Line- han (1993a), and mindfulness-based cognitive therapy (MBCT) , advanced by Segal, Williams, and Teasdale (2002), included Buddhist psychology-informed methods in their treatment protocols. The incorporation of aspects of Buddhist contem- plative and mindfulness practices was found to be useful when combined with the basic tenets of CBT to treat various diagnostic populations. Although these two very diverse psychological traditions seem to be diametrically opposed, the underlying premises of both Buddhist psychology and CBT are closely related (Tirch, Silberstein, & Kolts, 2016). As stated above, some theorists have termed these recent variants the third wave, or third generation, to describe the evolutionary nature of CBT practices (Herbert & Forman, 2011b). Some psychologists fi nd that there is no need to describe recent CBT therapies as new. Because of the evolutionary nature of CBT, many theorists fi nd the notion that there is a new third wave in this thera- peutic tradition to be erroneous, and fi nd there is little evidence for separating The Mindfulness Evolution of CBT 145 new-wave practices from more traditional CBT interventions. Thus the idea of a third wave is being intensely debated in the literature. For example, Hofmann and Asmundson (2008) argued that the new wave of treatments is essentially rooted in CBT and should not be touted as innovative, but rather should be viewed as another transition in the evolution of CBT therapies. In fact, there are authors who prefer the term variants of CBTs, as opposed to new-wave CBTs. Currently theorists are exploring the similarities and differ- ences between CBT and the new variants. There is one major difference that has been identifi ed to distinguish CBT and its third-wave innovations. Hofmann and Asmundson (2008) defi ned the difference by acknowledging that “CBT techniques primarily (but not exclusively) promote antecedent-focused emotion regulation strategies by focusing on reappraisal of the emotional stimuli; in con- trast Acceptance and Compassion Therapy [and other mindfulness-based CBTs] primarily targets response-focused strategies by discouraging emotional suppres- sion” (pp. 2–3). Otherwise, the mindfulness-based or third-wave treatments have much in common with CBT. In fact, as will be explored in this chapter, contem- plative and mindful practices from the Buddhist tradition have numerous cogni- tive correlates with CBT. Therefore variants is the more accurate term for these new practices, and is preferred by many CBT practitioners as it underscores the evolutionary nature of CBT practices. The relationship between Buddhism and CBT runs deep, and it is important to explore the commonalities of these two psychological traditions to understand how Buddhist principles have become an innovative aspect of CBT. Prior to exploring the new variants of CBT, an overview of Buddhist psychological prin- ciples and practices is needed to lay the foundation for why these practices are now part of CBT and its recent variants. The need to have a basic understanding of Buddhism is necessary to situate contemplative practices in the context of CBT, and this will be presented in the fi rst part of this chapter. Buddhist psychologi- cal practices activate and enhance cognition. The second half of the chapter will focus on identifying and examining the cognitive aspects of Buddhist practices.

Setting the Stage: Buddhist Psychology Buddhist wisdom and psychology “refers to both a tradition of psychological techniques and an applied philosophy of mind, that have been used within Bud- dhism for at least 2,600 years to help people liberate themselves from suffering” (Tirch et al., 2016, pp. 3–4). This tradition of psychological practice evolved through understanding the principles and teaching of the Buddha. As several CBT therapists point out, it is not the religion of Buddhism that has found its way into CBT practice, but rather it is the pragmatic practices that arose from this tradition that have captured the imagination and curiosity of CBT theorists and practitioners; thus Buddhism has become a source for the greater understanding and power of CBT. These two psychological traditions have many concepts in 146 The Mindfulness Evolution of CBT common, but one concept is crucial to understanding how the two traditions have co-evolved: both heavily rely on empirical evidence, and aspects of both practices include investigations and analyses of effi cacy. In Buddhist psychology, it is not the empirical research methods so prevalent in the Western tradition that are employed. Rather, if a Buddhist practitioner fi nds that a strategy does not work, it is dropped and another one is employed. In a discussion of Buddhism in relation to mind science, the Dalai Lama stated that “Once you fi nd a fact, then you accept it. Even if that fact appears contradictory to Buddha’s own words, it doesn’t matter. Because of this, I feel the basic Buddhist attitude is quite similar to the scientists’ attitude. Be open and investigate, fi nd something, confi rm it, then accept it” (Hayward & Varela, 1992, p. 33). Again, Buddhism as a religion is not what contemporary psychologists study; rather it is the teachings of the Buddha as a way of living that have captured the attention of CBT theorists and practitioners (Kuan, 2012). For Bankart, Dockett, and Dudley-Grant (2003) it is the Buddhist mental practice of taking control of one’s mind that has intrigued today’s CBT therapists. The ability to control one’s ideas and beliefs is integral to both CBT and Buddhism. Gaining the awareness that the answers to diffi cult life problems are found within pervades both practices as well. As psychological frameworks, each works towards the relief of suffering. In addition to mitigating suffering, Tirch et al. (2016) found numerous similari- ties between the traditions of CBT and the elements of Buddhist psychology. Although it was in the 1990s that third-wave CBT variants began to take hold, according to Tirch et al. (2016), Buddhism may have been at the core of CBT from its inception. For example, Bankart (2003) cited Mikulas as one of the earli- est psychologists to make connections between behavioral psychology and Bud- dhist tenets by identifying the following key areas of overlap in 1978:

• overriding emphasis on self-control • minimal use of theoretical constructs • focus on real problems in daily living • concern with the objective study of observable behaviors • focus on the contents of conscious experience • symptom-specifi c application of relaxation and biofeedback • ahistorical, here-and-now focus • concern for the common people • discrimination between behavior and personality • increased awareness of subtle cues from the body • focus on behavior change, especially through guided practice • meditation as an adjunct for all forms of therapy • focus on helping the practitioner to be more empathic, and less dogmatic • work to clarify the vantage point of the client • emphasis on peace of mind and happiness achieved through systematic self- observation. (p. 58) The Mindfulness Evolution of CBT 147

Even earlier, Albert Ellis, who conceptualized rational-emotive behavior therapy (REBT) in the late 1950s, stated that “While REBT highlights the norm of people’s dogmatic, fanatical, and rigid beliefs, it has always favored several aspects of Zen Buddhism as a Modus Vivendi” (Kwee & Ellis, 1998, p. 5). Similar to Ellis’ belief that it is diffi cult to live a rational life, Buddhist wisdom determined that “The struggle to live life on the correct path, to take charge of one’s passions, and to rec- ognize the futility of trying to escape from taking responsibility for one’s thoughts, motives, and deeds is indeed diffi cult” (Bankart et al., 2003, p. 22). Overcoming irrational ways of thinking and living connects CBT and Buddhist psychology. Several authors offer detailed background on important Buddhist constructs to provide the context needed for understanding why and how these practices work in CBT today (De Silva, 2005; Dockett, Dudley-Grant, & Bankart, 2003; Hayes, Follette, & Linehan, 2004; Herbert & Forman, 2011a; Mace, 2008). It is beyond the scope of this chapter to provide an exhaustive presentation of Buddhism and how its tenets inform psychology today, yet I fi nd it is important for CBATs to appreciate a general perception of how Buddhists conceptualize suffering and its alleviation. To provide context for the study of the connection between Bud- dhist and Western psychologies, a pared down overview of Buddhist psychology and its relationship to current CBT variants is offered here. During the sixth century bce , India abounded with people who practiced meditation and other aspects of what is now called Buddhism. The historic Bud- dha began a quest to study and understand these practices in light of how effec- tively they helped people to decrease suffering. He conducted two key practices that led to his vast infl uence in India during his lifetime and beyond. First, as a pragmatist he studied the practices commonly associated with Buddhism for effi - cacy and understanding behavior change, and second, he uncovered and refi ned clear aims for these practices (Tirch et al., 2016). These ideas opened the door to the development of an array of practices which now transcend a specifi c set of religious beliefs or the dogma associated with many other spiritual traditions. Consequently, Buddha’s teachings and practices now embody a philosophical and psychological tradition in addition to a religious practice.

Suffering and Mental Health Tse-Fu Kuan (2012) found that the teachings of the Buddha are a path to human actualization, and that its goal is ultimately to achieve perfect mental health. According to Buddha, to be human is to suffer, and his teachings focused on two major concepts—suffering, and how to alleviate suffering. Based on these two main teachings, psychologists today fi nd that his ideology has close ties to psychological treatment. Mace (2008) agreed, and stated that “Overall, Bud- dhist theory has the character of an elaborate and systematic psychology rather than a theology or cosmology” (p. 7). And Fulton (2014) noted that “Despite the growth of Buddhism as a world religion, it originated as something arguably 148 The Mindfulness Evolution of CBT more akin to psychotherapy concerned with freedom from suffering (not sin) that was understood to have psychological and behavioral causes” (p. 210). Thus the connection of current Western psychological practices with the foundation of Buddhist teachings not only makes sense, but is timely. Assuaging suffering, in the Buddhist tradition, begins with the Four Noble Truths, namely the truth of suffering, the origin of suffering, the alleviation of suffering, and the Noble Eightfold Path (Fulton, 2014). According to Tirch et al. (2016):

Both the therapist and the Buddha have been so moved by the suffering that they have witnessed around them, they have dedicated their lives to better understand how the mind works and how they might free their fel- low human beings from suffering through the application of rationality, wisdom, and deep personal inquiry. (p. 20)

Thus both CBT and Buddhist psychology share the goal of alleviating suffering, and both traditions offer strategies to achieve this goal. Meditation is the basis of both practices; thus it makes sense that meditation and mindfulness training (a core skill in meditation) are at the center of third-wave CBT variants. Kuan (2012) acknowledged the use of meditation and mindfulness as a path to fi nding psychological health, but he expressed concerns that the knowledge of some Buddhist concepts, such as who we are, why we suffer, and what practices alleviate suffering, has not been explored thoroughly by CBT therapists. His 2012 article provides context for broadening and deepening understanding of the connection between the two traditions, and is discussed below. Since Buddhist practices, as part of CBT and other forms of Western psychology, are popular and widespread, it is imperative that practitioners have a foundation upon which to build meditative and mindful interventions. Like Kuan, Kudesia and Nyima (2015) advised Western psychologists to be cautious when borrowing concepts from one tradition (Bud- dhism) and then applying aspects of these principles to another tradition (Western psychology). The rationale for these cautionary remarks is that simple transfer of philosophies often lacks context. They argued that practitioners need to know why Buddhist practices, particularly mindfulness, improve mental health. Through an examination of the neuroscientifi c aspects of cognition in Buddhist practice they found three problems with regard to how Eastern practices are applied in Western psychology. First, they found that Buddhist mindfulness is too narrowly defi ned in Western psychology, and is too often used as a type of self-help intervention. To counter this mindset, they urged psychotherapists to grasp the full value of mind- fulness as a means of transforming essential cognitive processes, and not simply to equate suffering with negative affect. Second, rather than conceptualizing mindful- ness as a skill, they advised practitioners to understand mindfulness in the context of Buddhist teachings. By studying Buddhism, the problems that can occur during the practice of meditation can be avoided. 1 Kudesia and Nyima’s third concern was that, in Western psychotherapy, defi nitions of mindfulness are too limited and are The Mindfulness Evolution of CBT 149 often relegated to paying attention to the present moment. Therefore thorough defi nitions of mindfulness are needed.

Defi nition of Mindfulness Most often mindfulness is defi ned as paying attention in the present moment. For example, Kabat-Zinn (1994) offered a defi nition of mindfulness as “paying atten- tion, in a particular way: on purpose, in the present moment, and nonjudgmen- tally” (p. 4). This defi nition emphasizes two key points, namely attention and nonjudgment, and as understood by Mace (2008) it implies effort. These attri- butes are cognitive skills and are worthy cognitions to home in on in CBT inter- ventions. Rappaport and Kalmanowitz (2014) defi ned mindfulness as “a practice of bringing awareness to the present moment with an attitude of acceptance and non-judgment” (p. 24). This defi nition emphasizes awareness, which is vital to CBT practice. More importantly, CBT therapists would propose that mindfulness is a psychological practice for developing metacognition or meta-awareness— that is, the ability to learn how one thinks and to monitor one’s thoughts and feelings. These types of defi nitions pervade the literature of third-wave CBTs, yet according to Kudesia and Nyima (2015), a good working defi nition of mind- fulness needs to be more specifi c, and should advance a deeper understanding of the Buddhist and CBT principles embedded in mindfulness. They crafted the following defi nition of mindfulness, which includes both Western and Buddhist elements of the practice: “mindfulness is a state of heightened meta-awareness in which discursive cognition is diminished and attention is solely focused on and receptive to goal-relevant aspects of the present moment” (p. 923). Kudesia and Nyima’s defi nition is congruent with CBT operations and goals, and provides clarity on how mindfulness is linked with cognitive psychology and science; meta-awareness, focusing of attention, and cultivating an open mindset for shaping goals are all aspects of CBT practice. 2 They claimed that this defi ni- tion has fi ve distinct advantages for psychological practice:

(1) it more fully represents the construct’s Buddhist roots, (2) it describes mindfulness in terms amenable to cognitive neuropsychology, (3) it suf- fi ciently differentiates mindfulness from related constructs, (4) it avoids imposition of exogenous factors related to particular trainings, and (5) it describes the construct rather than its consequences. (p. 923)

Basic Tenets of Buddhism for CBT Practitioners In An Introduction to Tibetan Buddhist Psychology , Matos (1979) explored four fundamental tenets that guide contemporary psychotherapists as well as the funda- mental underpinnings of the third-generation CBTs. The fi rst is that everything 150 The Mindfulness Evolution of CBT in the universe is transitory in nature, and “everything here is born, grows, becomes mature, decays, dies, and is transformed (reborn) into something else” (p. 20). He found that while most people realize this to be true, for some it is unfathomable and they fi nd it to be a depressing fact of life. When the acceptance of this essential principle is untenable, depression and other forms of suffering may ensue. For example, Segal, Williams, and Teasdale (2002) found the concept of impermanence to be one cause of relapsing depression. The second tenet is that although humans perceive the world as being made up of many separate things, in reality everything is one distinct whole. As Matos (1979) stated, “Everything is fl owing in the River of Life-Death-Rebirth, in this Cosmic Dance of Oneness” (p. 20). Although humans see or perceive an endless number of separated entities, this can be easily misconstrued as reality and is thus a misconception. According to Matos, this tenet leads to a third signifi cant concept, that people create a dualistic worldview. A dualistic perspective begins with the development of an ego. With the creation of the ego (or self-schema), individuals begin to perceive a division between the self and the environment. Matos clarifi ed this concept by stating that “This reality may be very useful as long as we know that the conceptual construction is just a mind construction and not what is ” (p. 21). The fi nal tenet Matos discussed relates to the Four Noble Truths, which are the basis of Buddhist psychology and its specifi c methods for healing, the fi rst of which is related to the fundamental quandary of being human. According to Matos, we suffer because we are not able to accept the impermanence of life, and this denial is related to the ego or separateness of self from environment. According to Kudesia and Nyima (2015), the concept of separateness is called interdependent co-arising, and refers to the notion “that neither physical existence nor subjective experience have any inherent existence ( svabha¯va ) apart from the other: the two co-arise and depend on each other” (p. 912).

The Second Noble Truth points out that the cause of suffering is in exactly the way we separate: fi x, cling, or grasp. The Third Noble Truth states that suffering and frustration can be ended; and the Fourth Noble Truth pres- ents specifi c psychological methods for ending this suffering. (Matos, 1979, p. 22)

The method for decreasing suffering is called the Noble Eightfold Path. Accord- ing to Matos, there are a number of psychological interventions in the Buddhist tradition which are used to integrate the mind and body, and he asserted that “med- itation is a primordial technique is this system of psychology. . . . The basic meaning here is fi rstly to bring the mind to a profound state of calmness. In this state, the mind starts to be able to appreciate and understand its own nature” (p. 22). Integral to mitigating suffering are practices to end cravings and desires, which are rooted in the Noble Eightfold Path. De Silva (2005) found the defi nition of craving in the Buddhist psychological tradition diffi cult to translate. Instead, he defi ned the three forms of craving as follows: “craving for sensuous gratifi cation, The Mindfulness Evolution of CBT 151 craving for self-preservation, and craving for annihilation” (De Silva, 2005, p. 60). Western psychology has correlates to these categories of craving, including the need for gratifi cation, pride, egocentrism, and aggression. To mitigate crav- ings, Bankart, Dockett, and Dudley-Grant (2003) explained that the set of Bud- dhist principles embedded in the Noble Eightfold Path are the “so-called eight ‘rights’—right understanding, purpose, speech, conduct, livelihood, effort, mind- fulness, and concentration” (p. 21). Practicing doing right is not just about elimi- nating craving, but it goes even deeper, and as proposed by Bankart, Dockett, and Dudley-Grant, it involves uncovering a new way to think, to develop moral reasoning, and to transform our lives. According to Tirch et al. (2016), many Buddhist approaches to healing begin with meditation to develop mindfulness as one of the rights in the Noble Eightfold Path. Buddhist teachings underscore the need to practice meditation to center our attention and cultivate our mind. It is only through this practice that people can avoid the “‘three consuming fi res’ of greed, hate, and delusion” (Bankart Dockett & Dudley-Grant, 2003, p. 19) and instead work on the rights of the Noble Eightfold Path. Although there are many other principles of Buddhist practice that could be addressed here, I shall include only one, namely compassion. Compassion is a vir- tue integral to Buddhist psychology. According to Makransky (2012), compassion encompasses all of Buddhist practice and is the central aim in Buddhist psychol- ogy. Fulton (2014) stated that in Buddhist thought, compassion refers to the culti- vation of sensitivity to pain and suffering in ourselves and in others. It is not solely the ability to empathize, but includes the motivation and ability to do something to help. Although associated with well-being, according to Fulton it is not self- esteem, but rather it is a self-acceptance despite the foibles of one’s nature. Fulton expanded this by stating that compassion is a radical Buddhist notion as it is “chal- lenging us to extend it—without limit or discrimination—to all beings” (p. 212). In Buddhism, compassion is viewed as an innate human quality; although it may be cultivated, it is in reality a quality that is revealed. Psychologically, compassion serves others, which can promote personal happiness (Fulton, 2014). According to Tirch et al. (2016), compassion is a crucial psychological pro- cess and “compassion can serve as both a process variable and an outcome vari- able in psychotherapy research and practice” (p. 130). The central practice for developing compassion is the metta meditation, and numerous CBT therapists have studied and adopted this practice for treatment of clients with a wide range of diagnoses. Consequently, it has the CBT acronym LKM, which stands for loving-kindness meditation. 3

Cognition Through the Lens of Buddhism As a means of exploring concepts in Buddhist psychology that are relevant to CBT, Kuan (2012) investigated cognitive operations in meditation and mindful- ness that correspond to the practices of cognitive psychology and therapy, namely metacognition, concentration, attention, and imagery. Mindfulness, according to 152 The Mindfulness Evolution of CBT

Kuan, plays a key role in developing concentration and attention; appropriately, he based his exploration of key cognitive operations through this lens. In fact, he found that mindfulness is closely related to sañña ¯ (a concept in Buddhism that is equated with cognition). Mindfulness is the process of assimilation or comprehen- sion in one Buddhist tradition, translated as meaning idea or conception in another tradition, and may be part of the psychology of memory in a third tradition. All of these translations underscore aspects of cognition as defi ned in psychology. Assimilation in the Buddhist tradition can be equated with the conceptualiza- tion of cognitive development and knowledge building through the process of assimilation in Piaget’s developmental theory. As summarized by Kuan, “mindful- ness ( sati) plays a similar role to sañña ¯ in terms of its functions, which also involve memory, recognition, discrimination, and conception” (p. 38). 4

Metacognition According to Kuan (2012), mindfulness is comparable to metacognition in the Western psychological tradition. Metacognition is a person’s ability to recog- nize and understand how they think, as opposed to cognition, which is what they think; therefore metacognition is thinking about thinking (Toneatto, 2002). Herbert and Forman (2011b) stated that there is a detached awareness of one’s thoughts in metacognition, and that the individual understands that thoughts and feelings are mental events rather than a view of reality. Metacognition includes an element of monitoring one’s thoughts and the awareness of any changes in think- ing processes. Without metacognition, people would not be aware of cognitions such as thoughts, feelings, and memories (Toneatto, 2002). Mindful meditation processes parallel aspects of metacognition whereby the practitioner of mindful- ness learns to observe and control thinking, and can also “monitor[ing] the stream of consciousness” (Bishop, as cited in Kuan, 2012, p. 40). Metacognition is a useful tool in therapy as it leads to changing the erroneous beliefs that can plague or interrupt a person’s daily life. According to metacogni- tive theory as advanced by Wells and Matthews (1994), most negative thoughts and feelings are perceived as passing events for most individuals. For others, cog- nitions become a source of anxiety and fear. Practicing mindfulness can help a person to gain insight about how thoughts and feelings can be perceived dispas- sionately or only as events of the mind. Toneatto (2002) proposed that the con- cept of metacognition underscores the purpose of Buddhist practice within the context of CBT. As Kuan (2012) wrote, metacognition

is conformable to the Buddhist doctrine so that the practitioner attains ‘metacognitive insight’ into the nature of things, whereby he is able to fully and accurately recognize that all things are impermanent, that they are unsatisfactory, and that they are not Self. (p. 43) The Mindfulness Evolution of CBT 153

Teasdale (1999) distinguished metacognitive knowledge, which is understand- ing that not all thoughts are accurate, from metacognitive insight or “experienc- ing thoughts as events in the fi eld of awareness, rather than as direct readouts on reality” (p. 146). Teasdale proposed that metacognitive insight (i.e., insight that events are impermanent) could be a signifi cant therapeutic tool for the treatment of several psychological disorders, including relapsing depression. Furthermore, he theorized that the development of metacognitive insight is gained through meditation and mindfulness. Another aspect of mindfulness as related to metacognition in psychology is that clients use mindful skills to learn to be nonjudgmental about thought and feeling events. The purpose of becoming nonjudgmental is acceptance. Accep- tance is key to several variants of current CBTs, most notably acceptance and com- mitment therapy (ACT) (Herbert & Forman, 2011a). In fact, if clients begin to be judgmental about their thoughts, they are said to have pulled away from a state of mindful being. However, in the Buddhist tradition, mindfulness does not always lead to being nonjudgmental. Kuan (2012) reported that, in the Buddhist tradi- tion, mindfulness allows for one to learn all aspects of the mind, including both good and bad thoughts and ideas, and “in Buddhist mindfulness, there can be an evaluative or judgmental element to the attention being paid” (p. 41). He attrib- uted the difference between the two traditions to the level of mindfulness used in practice. Kuan cited four levels of mindfulness awareness in Buddhism (simple, protective, introspective, and deliberately forming conceptions), and observed that “the nonjudgmental type of mindfulness, or simple awareness, probably suffi ces to serve the purposes of clinical practice in psychology and psychother- apy” (p. 41). Mindfulness-based interventions to teach a nonjudgmental mindset have been successful in helping medical patients to manage chronic pain (Kabat- Zinn, 1982) and clients with chronic depression to mitigate ruminations (Segal, Williams, & Teasdale, 2002). Developing a nonjudgmental mindset is critical to the CBT concept of decentering or decoupling, which is the process of step- ping away from automatic negative thoughts and ruminations or, as described in the Buddhist tradition, perceiving these thoughts as events rather than as part of one’s self (Herbert & Forman, 2011b). Kuan (2012) discussed another parallel construct between metacognition and Buddhist psychology. He observed that the concept of the four foundations of mindfulness (contemplation of the body, feelings, mind, and phenomena) resonates with metacognition through the prac- tice of (1) becoming aware of the self in the environment, and (2) being one who gathers and retrieves information. A closely related concept is meta-awareness. Kudesia and Nyima (2015) defi ned the term as the “detached monitoring of mental activity” (p. 918). They proposed that meta-awareness is useful for uncovering the full personality (posi- tive and negative) of the practitioner, including past ways of viewing the world. They proposed that meta-awareness mitigates the intractability of self-schemas 154 The Mindfulness Evolution of CBT and its impact on a person’s character and life. Furthermore, meta-awareness sheds light on the structure of one’s thinking processes, leading to a reduction in the power of entrenched, troubling schemas. The practice of mindfulness and other mind training techniques limit the automatic activation of schemas and eventually allow an individual “to transform the nature of the schemas” (p. 919).

Concentration and Attention Kuan (2012) also found a strong connection between concentration, attention, and mindfulness. This connection is a particularly important concept because Western psychologists use mindful practice to direct a client’s attention towards certain ideas, concepts, and other mental events, and away from others. He even suggested that the two concepts, mindfulness and attention, are used interchange- ably in Buddhism. Kuan mentioned that Teasdale used mindfulness as a means of intentionally controlling attention to learn new ways of thinking and learn- ing. Attention is needed to develop the cognitive process of concentration. In Buddhist psychology, concentration is needed to gain one-pointedness or ekagga , which is concentration on one thing. One-pointedness or concentration is vital to gaining insight. Concentration is focused on the “ever-changing experiences from moment to moment in a way conformable to Buddhist doctrine, so that the practitioner attains the insight of the nature of things” (p. 47).

Mental Imagery When a practitioner of mindfulness can both direct attention and concentrate, they can move away from sensing the world around them, which typically occurs through sound, sight, smell, taste, and touch. When sensation is suspended, stored memories and other cognitive processes come to the fore (Kuan, 2012). Mental imagery or nimatti , the concept of imagery in Buddhism, is one of the cognitive faculties that emerges when sensation is interrupted during mindful meditation. Nimatti occurs primarily in the form of visual imagery. Kuan used the term sañña¯ (interchangeable with cognition) as also meaning both imagery and perception, and underscored the commonalities among cognition, imagery, and perception, all of which are cognitive processes that are enhanced by mindfulness. Therefore he proposed that practicing mindfulness can be a positive force behind both focusing cognition and, he hypothesized, improving and promoting cognitive development. Most importantly, Kuan purported that mindfulness not only pro- duces imagery, but also guards and protects the imagery used to concentrate, which helps the practitioner to deepen their mindful practice. Kuan (2012) also encouraged research between imagery and perception in meditative states, and quoted Kosslyn, who posed the following questions: “Bud- dhists are able to hold onto mental images for 20 minutes. How can brain science engage this? Science needs to know about that ability. Does meditation increase The Mindfulness Evolution of CBT 155 the recruitment of imagery in brain areas used in perception?” (p. 52). To sum- marize his study of the cognitive components of mindfulness, Kuan affi rmed:

Mindfulness picks an object as the focus of ‘selective attention’, that is ekagga ‘one-pointedness’ in Buddhist terminology, and monitors whether attention is focused on the chosen object to ensure that the state of con- centration is maintained. In a deep state of concentration, nimitta ‘imagery’ is generated by a mental faculty that operates independently of sensation, upon which perception is contingent. Psychologists have found that per- ception and imagery may function on the same cerebral or mental mecha- nism. This fi nding supports my view that sañña¯ can act like perception on one hand, and on the other hand sañña¯ can produce nimitta ‘imagery’ in deep meditation where perception and sensation are suspended. (p. 55)

Imagery as discussed in Chapter Two is an essential cognition and is used in both CBT and CBAT as a therapeutic tool. Imagery, or the ability to see pictures in the mind’s eye, is a signifi cant aspect of memory, imaging the here-and-now, as well as the future. 5 Kudesia and Nyima (2015), the fi rst author being a behavioral scientist and the second a Buddhist monk, also examined the cognitive properties of mindfulness, a key Buddhist practice commonly used in third-wave CBTs. Acknowledging that the alleviation of suffering in the Buddhist tradition means altering essential cognitive processes, they began the exploration of mindfulness by explicating that the purpose of Buddhist psychology is twofold: “The fi rst is descriptive in identifying conscious and unconscious factors at work in the conventional mind. The second is prescriptive in that it seeks to remedy ignorance and thereby reveal the enlightened mind” (p. 912).

Descriptive Purpose Buddhism’s descriptive purpose is the explication of how Buddhism views cog- nition and the co-arising of consciousness. Although the work of Kuan (2012) discussed earlier provides a general framework for descriptive understanding of cognition development, Kudesia and Nyima (2015) explicated eight conscious- nesses that together make up what they called “conventional cognition” or the Western view of cognition (p. 916). They also outlined how the dual conscious- ness arises through self-object awareness, and the problem associated with this dualism is what the authors deem to be ignorance. Here is a short summary of these causes:

Non-referential awareness enables conventional cognition. Cogni- tions are based on divisions between self and object, which become 156 The Mindfulness Evolution of CBT

understandings that are referential and produce our consciousness. Con- sciousness is only able to interpret an insignifi cant piece of reality, which can be named and interpreted through language and perception. This thin slice of reality is discerned through our senses. Consequently, real- ity is limited to what can be sensed and cognitive consciousness arises through contact with our senses. Contact between object and perception produces feelings (good, bad, and neutral). Feelings lead to what Kude- sia and Nyima termed “automatic responses or cravings,” which guide a person to try and “prolong pleasant perceptions, remove unpleasant perceptions, and disregard neutral perception” (p. 916). Cravings lead to attachments that reinforce a person to hold onto their sense of self, their worldviews, and behaviors; in turn, this perpetuates a sense of self and the desire to continue providing pleasure to this self. Attachment to the self, worldview, and behavior “enable becoming,” which generates new karmic inertia or apathy (karma is what was learned from past experi- ences that limit perceptual understanding of the world, and ultimately leads to rigid thinking that blocks out aspects of reality that might widen perceptions). Karma needs to be resolved; if not, it leads to the birth of a physical body after the previous body has passed away. It is the mental continuity of karmic inertia and ignorance [which] enables a new body to be born. Finally, the birth of a person in a state of ignorance leads to the process of growing old and death.

This summary is a basic depiction of the descriptive purpose of Buddhist psy- chology and how the construction of duality develops. Although the summary includes some rather complex components, it is closely related to behavior psy- chology where a stimulus prompts an appraisal process that gets fi ltered through one’s self-schema, which leads to action tendencies and, fi nally, to a behavioral response. When the appraisal of a stimulus is emotion-laden, the self-schema may interpret it as dangerous or problematic. A behavioral response that is not adaptive or that causes more problems can ensue from this erroneous appraisal or perception. Understanding the descriptive purpose of Buddhism leads to the second purpose, namely prescriptive Buddhist psychology.

Prescriptive Purpose Kudesia and Nyima (2015) found prescriptions, as established in the Buddhist psychological tradition, to be practical and simple in comparison with the diffi cult and what they termed “esoteric” aspects of the descriptive purpose as outlined above. The prescriptions are based on illuminating the misconceptions devel- oped by an individual and replacing a person’s typical stimulus–response reactions based on past self-schemas and old worldviews. Simply put, the authors proposed that the prescription for psychological troubles is to “uproot the misperception of The Mindfulness Evolution of CBT 157 subject-object duality and thereby enable perception of reality as it is” (Kudesia & Nyima, 2015, p. 916). They theorized that the problems associated with subject- object duality can be eliminated through mind training (study, contemplation, and mindfulness) and may lead to enlightenment. Enlightenment practices alter cognitions, mitigate subject-object duality, interrupt the persistent self-talk that pervades our daily existence (which they label discursive cognition ), and reduce the generation of karmic inertia. Language is rooted in cognitive schemas, and our schemas are rooted in the past; thus it is the inhibition of discursive cognition that opens up new possibilities. Since Buddhist practices are intense and chal- lenging, the authors warned that the exercises of the mind should not be viewed as simple self-help techniques, but rather they should be practiced with care and supervision.

Adaptive Appraisals As stated above, mind training limits discursive cognition, blocks the mind from going into the past, and prevents worry about the future. When discursive cog- nition is limited, self-schemas, which are rooted in the past, are not able to per- vade consciousness, which allows the individual to remain in the present, to question old assumptions, and to imagine new possibilities. In Zen Buddhism, this state of cognizance is termed the beginner’s mind (Kudesia & Nyima, 2015). Mind training mediates troublesome cognitions in three ways: fi rst, it reduces the automatic use of past self-schemas, limiting mental consciousness and reducing the impact of previous perceptions; second, it regulates the power and impact of emotional states; and third, it promotes the use of adaptive appraisals of and responses to emotional states. The fi rst two adaptive appraisals are (1) the recep- tion of a problematical stimulus or troubling emotions with calmness and impar- tiality, and without prejudice, and (2) the act of feeling joy and empathy when good fortune befalls others. The other two adaptive appraisals, which are used when the stimulus is another person, are (3) the use of compassion “to reduce the suffering of others,” and (4) the implementation of the practice of loving kindness “to increase the happiness of others, which improves life satisfaction and removes affl ictive emotions” (Kudesia & Nyima, 2015, p. 918).

Mind Training Techniques Kudesia and Nyima summarized three techniques of prescriptive Buddhist psy- chology that can be used to promote positive cognitions: study, contemplation, and meditation. They recommend that practitioners study Buddha’s three turnings of the wheel, which explore the description purposes of mind training. The sec- ond, contemplation, is the process of refl ecting on the teachings and exploring how they related to the new practitioner. The authors found that contemplative practice to be to understand loving kindness as related to “cultivating the desire 158 The Mindfulness Evolution of CBT to increase the happiness of others, starting with close others and expanding to include all sentient beings” (Kudesia & Nyima, 2015, p. 919). Meditation is the third cognition, and is a quieting of the mind to release problematic schemas and maladaptive thoughts, to decenter, to allow the true personality to emerge, and to let go of ignorance.

Cognitive Correlates of Mindfulness The authors discovered that the most common meditation is mindful attention to breathing. Based on mindful meditation, they conceptualized a model of mind- fulness that embraces both Western and Buddhist psychology, involves under- standing of neuroscience, and incorporates CBT goals. For example, determination is needed to commit to the goal of meditating. Determination to meditate requires two other cognitive processes, namely restraint and attention . Restraint is the power to withdraw from distractions so that one will meditate, and atten- tion refers to attending to one’s breathing so that meditation can commence. Restraint and attention focus the mind on goal-relevant stimuli such as breathing. Another cognition that is activated in mindfulness is recollection . Whereas deter- mination sets a person on the path to meditation and mindfulness, recollection is essential as it is holds the information needed to maintain a meditative practice in one’s working memory. A fi fth cognition, vigilance , is needed in mindful medita- tion. Kudesia and Nyima (2015) found vigilance to be a cognitive process related to recollection, and stated that it “refers to meta-awareness: monitoring of mental activity and noting if it has deviated” (p. 920). Through brain scans, the authors found vigilance to be an executive function located in the anterior cingulate cortex. The cognitive processes (determination, restraint, attention, recollection, and vigilance) infl uence the ability to detach, or decentering, which corresponds to the executive functions of the prefrontal cor- tex. Kudesia and Nyima (2015) summarized by stating that “As such, mindfulness of breath meditation is essentially a training in the core skills of self-regulation: the ability to set goals, maintain them in the face of distractions, monitor for lapses in goal-congruent behavior, and regulate these lapses by applying rem- edies” (p. 921). As stated elsewhere, self-regulation is a core aim of CBT. Fulton (2014) agreed that practices of the mind correlate with changes in brain functions and brain structures. For example, Fulton cited the work of the neuroscientist Lazarus and colleagues as fi nding that the cortex increases in thickness after only eight weeks of mindfulness to reduce stress. Three stages of mindful meditation exist in Buddhist psychology, namely mindfulness, calm abiding, and insight (Kudesia & Nyima, 2015). Each level leads the practitioner closer to enlightenment. In the practice of mindfulness, the meditator achieves meta-awareness and is able to maintain attention on the practice. Calm abiding refers to the ability to notice a troublesome thought or feeling and choose how to respond to these diffi cult schemas rather than The Mindfulness Evolution of CBT 159 reverting to previous maladaptive responses. Insight is a state where the medi- tator notices, with lucidity, each moment. The highest and overriding goal in Buddhist meditative practice is enlightenment. In this state, the individual has reached a state of understanding that “thoughts are just thoughts . . . the sense of subject and object is greatly diminished . . . and, one abides strictly in non- referential awareness without any arising dualistic phenomenon” (Kudesia & Nyima, 2015, p. 921). Although enlightenment is not a stated goal of CBT or its current variants, certainly helping a client to gain clarity of thought is a worthy outcome.

Summary The third wave of CBT includes the practices of Buddhist psychology in its recent variants: DBT, MBSR, MBCT, and ACT. There is evidence that the use of meditative and mindful practices improves cognition and assists clients when traditional CBT is not effective as expected or when clients relapse after CBT interventions. It is important to distinguish between Buddhism as a religious practice and Buddhist psychological practice; it is the psychological practice that informs CBT. Some CBT practitioners study Buddhist psychology to inform their practice, but others may not. Most theorists agree that having some under- standing of Buddhist principles is not only informative but also provides context for the therapy practices that are borrowed from Buddhism. There are four basic tenets of Buddhism that are useful to the CBT practi- tioner. The fi rst of these is the transitory nature of life—nothing is permanent, and everything will pass. Although people perceive the world as made up of many things, the second tenet reveals that there is only one distinct whole. Third, humans create a dualistic view of reality beginning with the development of the ego and the self-schema, which creates longing, anxiety, and suffering. The fi nal tenet, the Four Noble Truths, is the basis of Buddhist psychology and its specifi c methods for healing. The First Noble Truth is that to be human is to suffer, which is the fundamental quandary of being. We suffer because we are not able to accept the impermanence of life, and this denial is related to the ego or separateness of self from environment. The Second Noble Truth points to the cause of suffering, which is the way we see ourselves as separate, which causes us to try and fi x, cling, or grasp. The Third Noble Truth states that suffering and frustration can be ended, and the Fourth Noble Truth presents specifi c psychological methods for ending this suffering. Kudesia and Nyima (2015) utilized these tenets to assist the CBT practitioner, and fi ltered the tenets into the two purposes of Buddhist psychology. The fi rst is descriptive, outlining how individuals come to experience so much suffering, and begins when a person begins to perceive the self as separate from any number of entities in the environment. The second is the prescriptive process for alleviating this suffering. Alleviation is based on mind-training techniques, of which the most important and most often used is mindful meditation. 160 The Mindfulness Evolution of CBT

Mindful meditation is the most prevalent of the Buddhist practices that are used to end suffering, and is a key practice in the new variants of CBT. A sound defi nition of mindfulness is vital to understanding this practice in the CBT con- text. The defi nition used in this book, as penned by Kudesia and Nyima (2015), represents the basic principles of CBT and includes three important cognitive constructs: meta-awareness or metacognition, focused attention, and goal- relevant monitoring of the present moment. Mindful meditation employs several cognitive processes that are needed to improve a person’s mental health. First, mindfulness improves attention and concentration because this meditative prac- tice requires paying attention to one’s breath and to the monitoring of thoughts. It requires will and concentration to maintain focus during mindful meditation. Kudesia and Nyima added the act of being determined to the set of cognitive skills honed through practice. They theorized that an individual needs to utilize determination to devote time and energy to keeping up with mindful practice. Mindful meditation practice activates metacognition or meta-awareness. This skill relates to the monitoring of one’s thoughts to understand not only what one is thinking but also how one structures one’s thinking and the monitoring of changes in thought patterns. Becoming nonjudgmental is another aspect of mind- ful practice and, as related to CBT, it allows a person to accept their thoughts as events, but not necessarily as having an emotional charge. The fi nal cognition improved by mindfulness training is imagery, namely the ability to imagine with- out sensory input. This is a key cognition used in CBT and CBAT, and it opens up new possibilities and enhances cognitive fl exibility. The cognitive correlates of Buddhist practice are evident in the variants of CBT practice, namely determination, restraint, attention, recollection, and vigi- lance. Four major variants of CBT will be explored in the next chapter, namely DBT, MBSR, MBCT, and ACT. Art therapists have embraced Buddhist prac- tices into their practice as well. Therefore an overview of how CBATs have integrated art therapy into each of these variants is important and timely.

Notes 1 Kudesia and Nyima (2015) recommend that readers refer to The sanity we are born with: A Buddhist approach to psychology (Trungpa & Goleman, 2005) for a deeper understand- ing of Buddhism for therapists prescribing mindful and meditation practices for their clients. 2 Kudesia and Nyima’s defi nition of mindfulness will be used in this book because it resonates with the therapeutic value of mindfulness in CBT and CBAT. 3 An example of an LKM can be found in Tirch et al. (2016, pp. 126–128). 4 See Chapter Two for more information on assimilation as a cornerstone of cognitive development. 5 See Chapter Two for more information on the important cognitive aspects of imagery and the connection between imagery and perception, which share common structures in the brain. 8 THIRD-GENERATION VARIANTS OF CBT AND CBAT

“The roots of mindfulness and the arts therapies can also be traced back through the ages to the use of the arts in ritual to enhance spiritual and religious practice, and promote healing and transformation.” (L. Rappaport & D. Kalmanowitz, 2014, p. 32)

The previous chapter laid the philosophical and theoretical foundation of mind- fulness for the cognitive-behavioral therapy (CBT) and cognitive-behavioral art therapy (CBAT) variants that are currently prevalent both in the literature and in treatment practice. Presented in this chapter are basic expositions of four CBT variants along with how CBAT practitioners are using the concepts within each variant to integrate art-therapy interventions and rethink art-therapy practice. I shall begin with dialectical behavioral therapy (DBT) , as this was one of the fi rst vari- ants to incorporate mindful meditation into the treatment protocol. A discussion of two other variants, mindfulness-based stress reduction (MBSR) and mindfulness- based cognitive therapy (MBCT), will follow. Acceptance and commitment therapy (ACT) will be included in this examination of CBT variants and will conclude this chapter.

Dialectical Behavioral Therapy DBT was developed by Marsha Linehan in the 1970s as a means of treating individ- uals with a complex set of clinical issues including treatment resistance and a propen- sity to commit acts of self-harm. She conceived this approach as a basic behavioral therapy treatment model to treat people with a history of multiple suicide attempts. The components of DBT are rooted in evidence-based therapies, including behavior 162 Third-Generation Variants of CBT and CBAT therapy (using learning principles) and cognitive-behavioral treatment (understand- ing maladaptive cognitions) (Brodsky & Standley, 2013). Linehan (1993a) empha- sized that the underlying goal of DBT was to help suicidal individuals to create a life worth living. The success of the program and its reliance on effi cacious interventions led DBT to become the treatment of choice for individuals with borderline person- ality disorder (BPD) and other intractable psychological conditions, including select patient groups with mood, eating, and substance use disorders. According to Robins, Schmidt, and Linehan (2004), focusing solely on behavior change leads to increased arousal rather than de-escalation of emotional intensity, because suicidal and BPD clients are sensitive to criticism. Emotional dysregulation is also a problematic attribute of numerous clients with these dis- orders, and they are quickly triggered when problem behavior is the focus of treatment. Therefore Linehan imagined DBT as including both a skills practice program and an intervention that embraces the needs of the client with accep- tance and compassion. Brodsky and Standley stressed that the acquisition of skills took precedence over the uncovering of maladaptive thinking in this treatment approach because of the sensitive nature of the clients. Linehan highlighted the fact that mindfulness skills are a core component of DBT to provide clients with a means of learning to accept their own plight: “They are the fi rst skills taught and are listed on the diary cards that patients fi ll out every week” (Linehan, 1993a, p. 144). Other major skills taught and practiced in DBT include distress toler- ance, emotional regulation, and interpersonal skills. The use of the term dialectic is important to explore, due to its central focus of DBT. According to Brodsky and Standley (2013), the term dialectic , which is a philosophical construct, was added to this treatment modality to accentuate three therapeutic concepts, namely connectedness, the inevitability of change, and the notion that truth can be derived through understanding opposing ideas. Linehan (1993a) specifi ed that dialectics assumes that every thesis has an opposing antith- esis and that “dialectics stresses interrelatedness and wholeness” (p. 31). Dialectics also has feminist roots, which is appropriate in the treatment of individuals with BPD, who are often female. Robins et al. (2004) outlined four notions of dialec- tics that informed DBT:

• “A whole is a relation of differing parts that hold no independent signifi cance • The whole is more than the sum of its parts • Parts and wholes are interrelated (and defi ned in relation to one another) • Change is an aspect of all systems, and is present at all levels of any given system.” (p. 33)

In DBT, dialectics inform the relationship between the client and the therapist and between the client and the treatment program. Each affects or changes the Third-Generation Variants of CBT and CBAT 163 other. The therapeutic relationship is used as a forum to help clients to accurately perceive their problem behavior in a larger context and how it affects themselves and others in their environment. Thus the therapeutic relationship is structured in such a way as to help clients to recognize that there is not one truth in any interaction; comprehending this notion aids in managing contradictions, which is healing and leads to change. The principles of the healing relationship guide the therapist’s behavior with the client as well: the therapist needs to be a force of acceptance as well as one who pushes for change. Linehan conceptualized DBT as a long-term treatment with a set of learn- ing modules (Butler, 2001). Individual therapy, group skills training, individual phone coaching, and consultation groups or attendance at team meetings are all included in the fi rst module. The overarching goals of the fi rst module are as fol- lows: (1) to identify and solve problem(s), (2) to address behaviors that undermine the therapeutic process, (3) to work on problems that interfere with quality of life, (4) to gain skills related to self-care, self-soothing, and mindfulness, (5) to learn to ask for help when it is needed, and (6) to keep the patient invested in the treatment process through weekly team meetings (Linehan, 1993a). This fi rst module is multifaceted and requires the use of multiple therapists for two reasons: fi rst, to mitigate the possibility that the patient does not become dependent on one individual therapist, and second, to decrease the transference issues that often interfere with the therapeutic process. Mindfulness skills are part of the fi rst module as a means of helping the client to cope with the stresses of beginning the program and to learn self-acceptance. As conceptualized by Clark (2017), the second module lays the foundation for well-being and emotional expression. The third module allows the client to consolidate what was learned in the fi rst two modules. The fourth module is focused on helping the client to feel connected and to give up the notion of an individual ego. This is done through contemplative practices. The second, third, and fourth modules empha- size experiencing diffi cult emotions without suppression or acting out, improving the quality of life, and fi nally living with joy (Butler, 2001). Conducting DBT requires specialized training and is usually practiced using a team approach. Orig- inally conceived as treatment in sequential modules or stages, Linehan quickly changed her mind and suggested applying the module that best fi ts the specifi c treatment needs of a patient (Linehan, 1993b). Another key aspect of DBT as proposed by Linehan (1993a) is the concept of three minds: emotional, reasonable, and wise. Clark (2017) explored these three mindsets. The emotional mind, as often seen in clients with borderline personal- ity disorders, is one in which emotions cloud one’s behavior and thought pro- cesses. The reasonable mind is the opposite of the emotional mind and is ruled by logic. The wise mind is a middle path that marries emotion with reason and allows the individual to deal with fi nding solutions by looking at the whole pic- ture and fi nding inner strength to cope with diffi cult situations. 164 Third-Generation Variants of CBT and CBAT

CBAT and DBT Although the use of art as a mindfulness-based treatment strategy is practiced widely, only a handful of art therapists have written about DBAT in the lit- erature. One current DBAT author stated that she defi ned “DBT-informed art therapy as ‘the strategic use of creative visual exercises to explore, practice, and generalize Stage 1 concepts and skills’” (Clark, 2017, p. 114). Examples of DBAT provide a basis for how art therapists practice within this treatment cur- riculum. DBAT will be explored through various components of the therapeutic process.

DBT-Informed Art Therapy Program Clark (2017) 1 developed an art-therapy program that was informed by DBT prin- ciples and techniques. After a number of experiences, some successful and some not, she found fi ve models of DBT-informed art therapy that were viable. The fi rst is a combined program of teaching social skills and art therapy as integrated in this fi rst module of DBT. An art-therapy intervention is a half-smile collage. In DBT work, the half-smile DBT skill lesson is about how facial expressions can help individuals to accept reality. The collage (beginning with magazine images of people with half-smiles) helps the client to understand the underlying purpose of the half-smile and learn how facial expressions affect mood. The second model is a sequential one where there are two sessions per week. DBT skills are taught on one day, and on the alternating day, an art-therapy exercise is introduced to consolidate the skill that was learned. An example of this is the upside-down drawing, which is introduced to help the client to integrate observation and describing skills with mindful and nonjudgmental skills. A color- ing sheet is given to the client upside down, and the client recreates the coloring sheet drawing upside down. Clark fi nds that clients are surprised by the accuracy of their work once it is turned right side up. The third model, an art-based/parallel process, allows for an unstructured art- therapy intervention that has a DBT theme but does not have a stated set of skills. For example, a visual journaling group utilized DBT prompts. Other examples are an arts-based goals group designed to help patients to structure their time, and a self-esteem workshop focusing on developing a life worth living. The interdisciplinary model incorporates art therapy and DBT skills training within a holistic residential treatment facility. The fi fth model is what Clark labeled a free-standing program, where the art therapy is the predominant focus, but the interventions are based on DBT principles.

Acceptance and Change According to Huckville and Learmonth (2009), DBT is easily integrated into art therapy for patients with chronic mental illnesses. They posited that through art therapy, a patient might be made to feel accepted over the sensitive issues Third-Generation Variants of CBT and CBAT 165 of working towards behavior management. The authors suggested that pushing behavior change invalidates the patient and, based on Linehan’s experience, may be the cause of unnecessary arousal. This is an important issue in DBT. Linehan (1993a) found that acceptance of a patient’s idiosyncrasies was necessary prior to moving forward with an agenda of change. In the case example presented by Huckville and Learmonth (2009), a patient who feared messiness needed to wear gloves and have plastic under the art mate- rials that she used. When the client realized that the therapist would support her by providing these safeguards, she agreed to engage with the art materials. The authors stated that “Acceptance was embraced in the session structure and the relationship. The possibility of change was explored through the art materials. A dialectic between them was opened up for refl ection” (p. 56). Acceptance made it possible for the patient to return to group art therapy, which was pro- vided on the open ward, and to let go of her fear of making a mess. The dialectic of acceptance and change was discussed in an article by Nissimov- Nahum (2008), who conducted research on how art therapists might engage with aggressive children. After surveying art therapists who work with children with behavior problems in educational settings, she offered a conceptual model of how art therapists might work with this type of child. The fi rst principle of her model was to begin with a focus on “establishing a positive relationship, without judgment or criticism” (p. 345). Secondly, it is necessary to help the child to understand the relationship “between feelings, thoughts, and behaviors, while, at the same time, conveying the message that aggressive behavior is not allowed” (p. 346). Nissimov-Nahum also offered suggestions as to how an art therapist may intervene when a child acts aggressively in the art-therapy session, including the setting of clear boundaries and outlining the consequences that will transpire if a violent act is committed. These important guidelines are a vital part of the dialectic approach.

Awareness and Mindfulness Heckwolf, Bergland, and Mouratidis (2014) paired strategic art-therapy principles with their counterparts in DBT. For example, the pairing of cultivating aware- ness in art therapy with mindfulness helps art therapists to understand how they can incorporate DBT goals into their work. Likewise, sublimation was paired with the DBT principle of emotional regulation. By not acting on their impulses, the client has more control over diffi cult emotional states and can begin to live a life that is not ruled by outbursts and impulsive reactions to feelings. Through the case of Anna, Heckwolf et al. (2014) described DBAT with someone who experienced overwhelming anxiety and depression. A painting completed after Anna’s parents had fi nalized their divorce was presented as an example of the sublimation/emotional regulation pairing. The painting was of Anna’s childhood safe place, and included a tree in a park-like setting, yet the sky was fi ery and threatening. Heckwolf et al. theorized that in producing both 166 Third-Generation Variants of CBT and CBAT safe and frightening images on the same page, Anna became aware that oppos- ing emotions could occupy the same space. Through these types of art works, she developed confi dence in problem-solving even when dealing with diffi cult mind states.

Creative Mindfulness The model of creative mindfulness, developed by von Daler and Schwanbeck (2014), integrated art and other expressive modalities with DBT. The authors described their model as an experiment incorporating the creative, sensory, and playful aspects of artistic expressions into skill-based sessions for vulnerable clients who were experiencing emotional dysregulation and self-harm tendencies. As practitioners of DBT, they based their experiment on creative approaches with evidence-based thinking. For this, they incorporated principles of neurological change to assess therapeutic change. According to von Daler and Schwanbeck (2014), if a creative response is paired with a maladaptive behavior, a new behavioral response is generated and a corresponding rewiring of neurological pathways in the brain occurs. An exam- ple that the authors used to explore this theory was a person who, when feeling lonely, might use food to self-soothe. If that person was taught to use an artistic response to the uneasy emotional state of loneliness, rather than reaching for food, a new behavior would be learned and the brain would begin to change. Their assumption was that neuroplasticity is related to experience, and new encounters that involve multiple senses, such as engaging in art, can effect changes in both emotional and cognitive regions of the brain. Thus the learning of new modes of behavior is easier when all of the senses are tapped. This type of learning is crucial in DBT, as it is a skill acquisition therapeutic modality. Based on their theory, von Daler and Schwanbeck outlined a three-phase cre- ative mindfulness/DBAT program: (1) distraction, (2) creating a new experience, and (3) applying the new skills in vivo or in the client’s daily life. These three phases correlate with three major DBT core concepts: (1) distraction/decentering, (2) creating a new experience/range of play, and (3) application/rehearsal and performance. They offered several arts-therapies exercises as examples of their work. One that combines both nonjudgmental and phenomenology skills involves selecting a piece of art from a group member and describing all that can be observed in that artwork (i.e., colors, shapes, lines, etc.). A second strategy involves having clients hold a lump of clay and explore its tactile qualities by encouraging them to pay attention to the various sensory aspects of that medium. Using Linehan’s concept of creating a life worth living , von Daler and Schwanbeck (2014) suggested that “Creative Mindfulness says that the ultimate act of creation is creating a life worth living. Our goal is to support clients by increasing their life-skill palette” (p. 240). Third-Generation Variants of CBT and CBAT 167

DBAT in Action Two art therapists, Sheila Lorenzo de la Peña and Jessica Masino Drass, described how they worked with patients using a DBAT mindset. An art therapist at a major state psychiatric facility in Florida, Lorenzo de la Peña is part of the DBT team (personal communication, November 19, 2014). She practices DBAT in three formats: (1) as part of learning skills-based DBT groups, (2) in DBAT groups, and (3) in individual art-therapy sessions. She infuses art-based experiences with DBT as a means of having patients practice mindfulness, emotional regulation, stress tolerance, and nonjudgmental skills. Drass (2015) worked at a hospital trauma program for women that provided DBT treatment, and she also managed the art-therapy program there. In her studio space, she directed art-therapy group sessions based on DBT principles.

Structure of the sessions Both art therapists stressed the importance of structure and safety in their work. For example, Lorenzo de la Peña plans each session with a clear vision of how to use a particular art medium. From there she thinks about how to convey the handling of a material to the patients, and then teaches them, in tiny incre- ments, how to interact with the art. Since mixing colors can result in surprising yet unwanted hues, she has learned to set out only a few colors for the patients to use. This reduces the risk of unwittingly inducing overwhelming emotional responses. Preparation for each session includes planning from beginning to end. She thinks about the patients’ involvement in set-up, in interacting with the media, and in clean-up. Drass (2015) also emphasized that structure and safety are vital to DABT, and she carefully considered the “physical layout and organization of the art room” (p. 169). Her purpose in attending to structure was to provide the opportunity for patients to internalize that structure. The art materials in the storage area were carefully arranged as well, so that patients had easy access to them and knew where to fi nd the materials they needed. Through the careful structure of the art room and the easy-to-access materials, patients could be autonomous and prac- tice personal control.

Art experiences The art techniques introduced by Lorenzo de la Peña to induce mindful practice include blowing bubbles with liquids infused with both colors and scents, experi- encing materials with assorted textures and thicknesses, and basic media explora- tion. For emotional regulation, Lorenzo de la Peña encouraged patients to pay attention to their breath while they moved paint or other forms of color across large pieces of paper, to use their whole body to swirl a drop of liquid around a piece 168 Third-Generation Variants of CBT and CBAT of paper to form a circle on the page, and to attend to each art process one step at a time until the patient experienced mastery, before moving on to the next step. For both emotional regulation and stress tolerance, Lorenzo de la Peña slowed down the art process, attended to the small steps in art-making, and had the patient use lines to create patterns rather than pictures or specifi c images. To practice nonjudgmental acceptance, she used layers of plastic sheeting with paint dribble and drops in between the layers. Patients shifted the paint around with- out getting messy and without the worry of being judged for making mistakes. If a patient noticed an interesting design in the paint, they used paper to make a mono-print of the pattern that they found enjoyable. Drass (2015) took themes which addressed the treatment goals of DBT, and developed eight art experiences that mirrored these themes. For example, for containment, control, and identity , she had the patients create wise mind books , which were described as three-dimensional collages used to address such ques- tions as “Who do I present to the world?” and “What story do I have to tell?” (p. 170). Another example of her DBAT interventions was distress tolerance baskets . Designed for skill-building and self-soothing, these baskets were crafted using a coiling technique to teach “self-soothing, relaxation, grounding and empowerment” (p. 171).

Suggestions for DBAT practice As a DBAT therapist, Lorenzo de la Peña encouraged two essential aspects of practice: (1) using one’s self as a model for mindful practice, and (2) acquiring a deep understanding of media dimension variables (Kagin & Lusebrink, 1978). She proposed that a thorough understanding of color theory, media properties, and other tools of art practice was essential for DBAT. After some missteps in her DBAT practice she learned to attend to herself before sessions. She also posts thoughtful quotes about nonjudgmental attitudes around her art-therapy space. These serve as cues or reminders for her to pay attention and be present, and to prepare to model mindful actions for her clients. Sometimes she does breathing exercises or her own art experiences before the session to prepare for mindful engagement with the patients. For Drass, three therapeutic issues must be accentuated when working with people with BPD: (1) creating patient-generated art projects, (2) structuring both art-making and therapist-directed tasks, and (3) ensuring choice-making and giv- ing over power to the client. She cautioned group art therapists to stay on a metaphoric level when discussing art work, to protect individuals from disclosing too much personal information and to decrease the likelihood of a discussion arousing emotions or activating triggers. Clark (2017) explored the characteristics of a DBAT therapist. The list is extensive and many of the qualities she cited echo the work of Lorenzo de la Peña and Drass. A few of her other recommendations include being fl exible, Third-Generation Variants of CBT and CBAT 169 egalitarian, and validating. She also encourages art therapists to be dialectical. Clark claims that “Art therapy is naturally dialectical; thus, DBT-informed art therapy is ripe with opportunities for clients to try on a stance in which ‘contra- dictory truths do not necessarily cancel each other out or dominate each other, but stand side-by-side, inviting participation and experimentation’” (p. 159).

Summary These art therapists have creatively introduced art therapy into the complex DBT program developed by Linehan. Six critical DBAT concepts are important to stress. First, it is important for the art therapist to approach each client with accep- tance of their maladaptive behaviors, including problematic demands that might be viewed as untenable in other situations. Second, the art therapist uses the art as a basis for opening sensory pathways that may effect changes in neural pathways. Third, the art helps clients to notice contradictions in their perspectives and allows them to ponder opposing beliefs. Fourth, although structure is needed to form the sessions, allowing for individual choices and decision-making is crucial. Fifth, the art-making process is approached with a dialectical mindset. Finally, the art thera- pist must approach each therapy session with a mindful attitude.

Mindfulness-Based Stress Reduction In 1982, Kabat-Zinn published a research study on the reduction of pain through a mindfulness-based class. He found that mindful meditation uses one’s concen- tration to maintain attention. He created mindfulness-based stress reduction (MBSR) , a class-based, 10-week stress reduction and relaxation program, in which he trained patients in mindful meditation. He defi ned the practice as “the intentional self-regulation of attention from moment to moment” (p. 34). The patients in the study were those who were not improving or who were not satisfi ed with their progress in dealing with chronic pain. The focus of the program was to teach patients how to use their inner resources to manage chronic pain. The underlying goal of the program was to cultivate self-regulation. When pain is chronic, the stress on the affected person can be enormous. Kabat-Zinn (1982) hypothesized that when medication cannot mitigate pain, one’s cognitive skills could be tapped to assist in pain management. Using the cognitive skills of uncoupling, he found that the emotional reaction to pain could be separated from the sensory component of pain, allowing the individual to control reactions to painful stimuli.

The MBSR Program In the original MBSR treatment program developed by Kabat-Zinn, patients attended a 10-week program for two hours per week. Three types of formal mindful meditation practices were taught in the program. The fi rst was a sweeping 170 Third-Generation Variants of CBT and CBAT meditation, or body scan, in which the person, who is lying down, is guided to mentally sweep or brush their body from head to toe, with attention to breath- ing and relaxation. Next, a sitting practice was introduced whereby the patients were taught a breathing meditation. Finally, Hatha Yoga or gentle positions were introduced as meditative exercises to increase the use of parts of the body that were in disrepair or atrophied. Meditation exercises were given as homework, and the patients were also provided with reading materials on stress and coping. The results revealed that, in addition to pain reduction, patients had less pain- related mood disturbances, more energy, and higher levels of coping. Psychiatric symptoms were also tested, and the intensity of depression, anxiety, obsessive- compulsiveness, and somatization was found to be decreased. Qualitative reports of increased self-esteem, communication, and coping were described.

Evaluation of MBSR Programs MBSR has realized great success. Kabat-Zinn was able to delineate a specifi c meditative practice in his class-based program which has allowed him to con- duct many outcome studies with positive results as an evidence-based practice (Dryden & Still, 2006). For example, Bishop (2002) conducted a critical review of MBSR investigations; Baer (2003) conducted an empirical review of several MBSR research studies; Grossman, Niemann, Schmidt, and Wallach (2004) con- ducted a meta-analysis of MBSR treatments for decreasing stress and increasing health benefi ts; and Zainal, Booth, and Huppert (2013) conducted a meta-analysis of MBSR for the mental health of breast cancer patients. Baer (2003) discovered that the mechanisms of change in MBSR that lead to therapeutic improvements include relaxation, self-management, exposure, cog- nitive change, and acceptance. However, Baer noted that the concepts inherent in mindfulness practice (e.g., increased awareness, insight, etc.) were diffi cult to evaluate. She recommended operationalizing mindfulness as a means of allowing more effective outcome studies. Nonetheless, these reviews indicated that MBSR is an effi cacious intervention for stress-related disorders and other diagnoses, such as depression (Marchand, 2012) and chronic traumatic brain syndrome (Azulay, Smart, Mott, & Cicerone, 2013). MBSR is also effective in healthy individuals for dealing with life stressors or improving self-effi cacy (Khoury, Sharma, Rush, & Fournier, 2015; Sibinga et al., 2011). Although the mindful practice that is the keystone of his intervention was based on Buddhist psychology, Kabat-Zinn clarifi ed that he used this practice as separate from Buddhism as a religious tradition. According to Dryden and Still (2006), Kabat-Zinn found that mindfulness was a way of life, not just a short- term intervention to relieve stress. The original 10-week program has since been shortened to an 8-week course, and the sessions have been extended to two and a half hours. This was done to help as many participants as possible to complete the curriculum. Third-Generation Variants of CBT and CBAT 171

Integrating Art Therapy with MBSR The integration of art into MBSR treatment as conceived by Kabat-Zinn has caught the imagination of several art therapists. The short-term, class-based cur- riculum designed to relieve stress and improve self-regulation has applications for numerous client groups. The similarities between using art as a form of mindful practice and the therapeutic benefi ts of mindful meditation create a natural bridge between these two practices.

MBSR and Art Therapy for Pain Management Fritsche (2014) hypothesized that “Art therapy can help to deepen observation of the pain experience and uncover its symbolic aspect” (p. 83). Through his work with patients suffering from chronic pain, he found that engagement in making art mitigates the perception of pain. Using Kabat-Zinn’s program as a model, Fritsche outlined a Mind-Body Awareness Art Therapy Program. The program had seven stages, which consisted of examination, expression, expansion, ener- getic release, redirection, recognition, and relief. The program was conducted in small groups, which met weekly for 10 to 12 weeks. Each session began with a short discussion. Subsequently, a warm-up exercise using art and mindful attention was offered, and fi nally an art directive was introduced. After the art-making had been completed, time was set aside for the group to reconvene and discuss their experiences and insights. Themes for the art directives included body scans, pain awareness and surrounding space, emotions, expressing anger, landscapes, painting in black and white, and opti- mism and empowerment.

MBSR and MBAT for Cancer Patients Two studies have been conducted on the use of MBSR and art therapy for cancer patients. In 2006, Monti et al. conducted a randomized clinical trial of mindfulness-based art therapy (MBAT) for women with cancer. Peterson, an art therapist and one of the lead authors of the cancer clinical trial, described MBAT as the integration of art therapy with Kabat-Zinn’s MBSR program for oncology patients (Peterson, 2014). The MBAT program that Peterson developed consisted of eight weekly ses- sions, each lasting for two and a half hours. She acknowledged that the sessions were designed to follow Kabat-Zinn’s curriculum, except for the seventh ses- sion, in which the clients met in a retreat-oriented setting intended to encourage both mindfulness practice and free time to make art. She stated that mindfulness practice was introduced to her clients earlier in the program than in Kabat-Zinn’s curriculum. However, she included homework and self-reports in the MBAT program, as did Kabat-Zinn. 172 Third-Generation Variants of CBT and CBAT

The second study by Ando, Kira, Hayashida, and Ito (2016) was conducted in Japan, and the participants were 10 female patients with advanced cancer in stage IV or with breast cancer metastases. The MBSR and art-therapy program, also based on the Kabat-Zinn program, was only two individual sessions in length and was titled the Mindfulness Art Therapy Short Version. The sessions were held two weeks apart. The patients were also given a CD with recorded meditations that was used for the participants to practice mindfulness outside of the sessions.

Art therapy interventions The core of Peterson’s program was the introduction of art-making. She began with mindful exploration of art materials (MEAM), which consisted of time- limited experiments with a wide array of art materials. Specifi c instructions were offered for the MEAM exercises and were conceived as a means of inquiry. Another practice was the use of art exercises before and after mindful meditation. Other art-therapy interventions included bringing attention to pain by using a body scan to bring pain into focus, pleasant and unpleasant event pictures, cre- ating art about personal experiences of mindful practices, developing a feeling vocabulary of the body, creation of a healing place, and a new exercise, which she called a walkabout (Peterson, 2014, 2015). In the walkabout, patients are instructed to mindfully walk around outside the hospital or clinic and take pho- tographs of what they see. These photos become the basis for collage-making. After offering mindful practice, Ando et al. (2016) offered the participants an array of art materials, including clay, collage materials, drawing materials, and watercolors. The prompt that they used was “Please express your feelings or emotions freely” (p. 37).

MBAT study results The outcome study based on Peterson’s MBAT program included 56 women in the treatment group and 55 women in the waiting-list control group at similar stages in the disease (45 women completed the study in the treatment group and 48 women in the waiting-list group). Two major hypotheses were tested: (1) that women in the treatment group would report less distress than those in the control group, and (2) that the quality of life (QOL) of the women in the treatment group would improve. The results indicated that the women in the treatment group experienced statistically signifi cant decreases in distress compared with those in the waiting-list group. In terms of QOL, four of the 36 subscales of a QOL scale showed signifi cant improvement for those in the treatment group, namely mental health, general health, vitality, and social functioning. The composite score of the QOL scale did not reach signifi cance. However, these results reveal encouraging fi ndings for interweaving art therapy into Kabat-Zinn’s MBSR program. Ando et al. reported an increase in vigor and a decrease in fatigue on a mood states instrument after two sessions, but the other scales did not show positive Third-Generation Variants of CBT and CBAT 173 changes. The authors also implemented a spiritual well-being test, but found little change after the sessions. Because the participants had lower pre-test scores than the norms on this instrument, they recommended that therapists should study spirituality in future studies of women with late-stage breast cancer.

MBSR and Art Therapy in Community Outreach In 2000, an MBSR program that included art and other expressive therapies was created for individuals with various stress-related medical, mental, and emotional dis- orders for a community outreach program at a major hospital (Isis, 2014). Isis devel- oped the program after studying MBSR with Kabat-Zinn, and theorized that “the integration of expressive arts therapy interventions further offers participants a cre- ative experience designed to deepen self-awareness, emotional regulation, compas- sion, empathy, self and social esteem” (p. 157). Isis postulated that the sensory nature of the arts helps people to stay in the present moment. Two examples of Isis’ MBSR art therapy interventions are the body scan and the mindful doodle. The body scan is a short mindful exercise in which the client refl ects on all parts of the body and notes where he or she is holding emotions and stressors. An outline of a body is then given to the client and he or she is asked to connect a color to various stress areas; the client then labels what the colors represent in the body (see Figure 8.1).

FIGURE 8.1 Illustration of a body scan. Source: Reprinted with permission from the personal collection of P. Isis. 174 Third-Generation Variants of CBT and CBAT

FIGURE 8.2 Illustration of a mindful doodle. Source: Reprinted with permission from the personal collection of P. Isis.

The mindful doodle is used to hone the mindfulness skills of an individual. Holding a mindfulness mind stance, the client is instructed to create a doodle without editing thoughts or judgments (see Figure 8.2). Herring (2014) also adapted an MBSR for a problem created for individuals with severe and persistent mental illness (SPMI) in an outpatient treatment cen- ter. Herring based his 16-week program on the tenets of Kabat-Zinn and the art therapy program conceived by Peterson (described above). Using Kabat-Zinn’s curriculum as a guide, Isis created an eight-week com- bined MBSR and expressive arts program. The themes for each week are as follows:

1 there is more right with you than wrong with you 2 how you do or don’t see things (present-moment awareness) 3 cultivating equanimity: pleasant, unpleasant, and neutral 4 stress reactivity and stress hardiness Third-Generation Variants of CBT and CBAT 175

5 everyday stress and life-changing events and their relationship to our health 6 recognizing stressful communication 7 awareness of signifi cant relationships and social support 8 claiming the practice as your own.

The arts interventions included breath drawings (both positive and negative), body scan awareness drawings, response art to four journey stories, and social atom drawings. Isis concluded that daily meditation is crucial for fully realizing the power of the program. After participation in the program, several clients noted changes in their ability to engage with others, had increased motivation, and self-empowerment; all are crucial to improved daily functioning. The Her- ring program encompassed goals similar to the Isis program, and there was also an overlap with the arts interventions as outlined by Isis. Both Isis and Herring found that several participants used the mindfulness and arts experiences after the conclusion of the program to continue their journey to wellness.

Summary The arts therapies programs using Kabat-Zinn’s MBSR curriculum are remark- ably similar even though they were developed for different purposes—one for pain management, two others to relieve the stress associated with a medical dis- ease, and two to mitigate the emotional distress associated with mental illness. Both Isis and Peterson used an eight-week group program approach, and both included breath and body scans as related to mindful awareness. Each found that involvement in art-based interventions served to deepen the therapeutic pro- cesses of the original MBSR program. Fritsche and Herring expanded on the eight-week model and extended programs for pain relief and for SPMI patients to 16 weeks. The underlying goal of each of these programs was self-regulation and coping. Each author concluded that the power of art strengthened the effects of mindfulness practice. The two outcome studies which researched the effective- ness of the art-therapy program as part of MBSR indicated therapeutic change in some measures of personality factors and with self-reports. The two research reports laid a foundation for uncovering the power of art therapy combined with mindfulness to effect change. It is important to continue research on the integra- tion of art therapy into MBSR programs.

Mindfulness-Based Cognitive Therapy Segal, Williams, and Teasdale (2002) included the acquisition of mindfulness skills as part of CBT for individuals with depression, in order to decrease relapse rates. In mindfulness-based cognitive therapy (MBCT), patients are taught attentional and meditation skills to increase the identifi cation of painful affective states and maladaptive cognitions. The underlying premise of MBCT is that mindfulness 176 Third-Generation Variants of CBT and CBAT is thought to “assist in distancing from automatic and self-perpetuating negative thoughts which characterize depressogenic thinking” (Segal et al., 2002, p. 139). Kenny and Williams (2007) added that the overarching goal of MBCT is to foster metacognitive awareness and the modifi cation of metacognitive processes that perpetuate rumination in patients with depression. As a class-based treatment modality, it combined mindfulness training as developed by Kabat-Zinn with cognitive-behavioral therapy for depression as conceptualized by Beck, Rush, Shaw, and Emery (Kenny & Williams, 2007). Patients are taught to observe their thoughts and feelings and then shift attention to something neutral, such as their breathing or other bodily sensations in the here and now. The other aspect of MBCT is acquiring a nonjudgmental accep- tance attitude towards feelings, even those that are distressing. The patient learns to accept and then let go of even the most diffi cult ideas and emotional states while acquiring a neutral stance about distressing moments.

Rethinking Depression Relapse Mindfulness as integrated into CBT began when therapists noted numerous instances of individuals with depression relapsing after positively responding to a course of CBT treatment. Based on this problem, CBT therapists working with relapsing depression began to search for treatments that could be used for treatment maintenance. Through study, research, and meeting with other CBT thinkers, Segal, Williams, and Teasdale (2002) worked together to develop a model of relapse prevention for depressed patients. Other relapse programs used the same CBT interventions utilized in initial treatment for depression, but Segal et al. wondered whether a different approach might be more effective. First, Segal et al. identifi ed the sequence of events that often left a patient vul- nerable to relapse. A patient who initially did very well after CBT would experi- ence a sad mood. There are two possible responses to a sad mood: (1) negative thinking may be stopped or blocked, or (2) negative thinking may bring back negative thinking patterns (Segal et al., 2002). Most individuals understand that sad moods eventually lift, but for vulnerable people with a history of depression, a sad mood may trigger a return to the dysfunctional thoughts that were respon- sible for an earlier depressive episode. Therefore they next studied the problem- atic thought processes that might lead to relapse. They identifi ed that a ruminative response style might be the key to relapse (Nolen-Hoeksema, as cited in Segal et al., 2002). Individuals who ruminate prolong their sad feeling states, in contrast to people who fi nd something to do to mitigate their sad feelings. Using this model of relapse, Segal et al. began to shift their thinking from the use of CBT techniques to change dysfunctional thought patterns to helping clients to change their relationship to negative or ruminative thoughts as a preventive measure. This shift in focus led the authors to teach decentering of thoughts or distancing thoughts from one’s self. Third-Generation Variants of CBT and CBAT 177

The shift in focus allowed Segal et al. to imagine all sorts of interventions to teach clients how to give themselves permission to decenter negative thoughts. Through connections with Linehan and Kabat-Zinn, they discovered that teach- ing mindfulness to vulnerable patients might be the intervention they were looking for to positively infl uence the process of decentering. They fi rst called their new prevention program, which included both mindfulness and cognitive interventions, attentional control training (Segal et al., 2002, p. 51). The program had three aims: (1) to notice or become aware when a dangerous mood occurs, (2) to use awareness to realize that energy was being used for rumination, and (3) to begin the process of decentering or exiting the “automatic depression- linked patterns of thought that these moods habitually brought to mind” (p. 51). Segal et al. used Kabat-Zinn’s curriculum as a model and developed a group intervention for the pilot study. The program was eight weeks in length, and each session lasted for two and a half hours. Through the pilot study, Segal et al. (2002) found that they were missing the underlying intent of mindfulness:

Based on what we had seen, we concluded that class members were not just exposed to a set of skills or techniques to be used at the fi rst sign of stress. They were actually learning a more general mode of mind that was espe- cially helpful in relating to diffi cult experiences. Participants’ regular meditation was teaching them to understand the nature of their thoughts, simply as thoughts, and to observe the relationship that they had to them. More than that, their meditation also cultivated a new attitude toward all experience, including feelings and body sensations. (p. 61)

MBCT Today After conducting research on their model, it was fi nalized as a class-based treat- ment modality, which combined mindfulness training as developed by Kabat- Zinn with cognitive-behavioral therapy for depression as conceptualized by Beck, Rush, Shaw, and Emery (Kenny & Williams, 2007). Through the pro- gram, patients were taught to observe their thoughts and feelings and then to shift attention to something neutral such as their breathing or other bodily sensations in the here and now. The other aspect of MBCT involves acquiring a nonjudg- mental attitude of acceptance towards feelings, even those that are distressing. The patient learns to accept and then let go of even the most diffi cult ideas and emotional states while acquiring a neutral stance about distressing moments. Today MBCT is practiced in a group class format for eight weeks, with each ses- sion being two hours in length. Other patient groups that have been effectively treated with MBCT include combat veterans with PTSD (King et al., 2013; Luedtke, Davis, & Monson, 2015), people experiencing neuroticism or stress vulnerability (Armstrong & Rimes, 2016), 178 Third-Generation Variants of CBT and CBAT

ADHD (Haydicky, Shecter, Wiener, & Ducharme, 2015), psychiatric and emo- tional disorders (Chiesa & Serretti, 2011; Meekums, 2013), children with anxiety disorders (Semple, Reid, & Miller, 2005), and people with treatment-resistant depression (Eisendrath et al., 2016). Kuyken et al. (2010) studied the components of MBCT in order to identify the mechanisms of change that are involved in this treatment. They found that the development of self-compassion was a signifi cant change mechanism in MBCT effi cacy, as was decoupling of reactivity of depres- sive thinking. To summarize, MBCT is an effective alternative to teaching decentering and relapse prevention skills. It was developed to help patients to recognize when their mood was deteriorating or when depressed mood was being sustained through ruminative thought–affect cycles. Segal et al. created a major shift in the philosophy and theory of treating individuals with depression. Previously, CBT was about changing the thinking processes of the patients, but Segal et al. real- ized that changing the patient’s relationship to these negative thoughts and feelings, or decentering their patterns of thinking, was more effi cacious.

Art Therapy and MBCT Coholic (2011) adapted an MBCT program for children involved in child pro- tection or foster care or those referred from a community mental health cen- ter. After conducting a thorough review of MBCT with children, she adapted the adult program for individuals with depression to a program more suitable for keeping children engaged. This meant reducing the length of sessions to 90 minutes or less, and she added more sensory-based experiential components, including art therapy. Art-based mindfulness-based (ABMB) interventions were formulated for this young population.

Examples of ABMB Two examples of ABMB were the use of a feelings inventory and a jar of thoughts . For the feelings inventory, the children were asked to draw and label shapes for various emotional states that they experienced during the day. These were placed in a drawing of a large circle. Larger shapes meant that the feeling represented was experienced more often during the day. The completed projects led to a discus- sion of how to accept both positive and negative feelings. The jar of thoughts, which was a group project, allowed each participant to put various beads and other small objects into a jar half-fi lled with water. Each child added objects that represented thoughts or feelings to the jar. After all of the participants had added items, the jar was shaken. The group was encouraged to think of the fi lled jar as their mind or brain with all the thoughts and feelings swirling around in it. This exercise became a metaphor for how an overstimulated mind might look. The jar, when all the pieces had settled down, became a metaphor for how the mind Third-Generation Variants of CBT and CBAT 179 calms during mindfulness exercises, and allowed the children to understand how the mind looks after it has been quieted.

Research Results Using a qualitative research protocol, Coholic studied the therapeutic effects of the program. She interviewed both the children and their guardians. The children expressed how much fun they had during the program, and this led to changes in self-awareness, increased positive feelings about the self, emotional regulation, and healthy expression of feelings, “which in turn enabled more effective coping with a variety of challenges, including school” (Coholic, 2011, p. 310). These results were noted by both the caregivers and the children. Coholic found that the results of this study, which included ABMB components, did not differ from research on similar MBCT programs for children that did not use art therapy. Because the results of the qualitative study were positive, Coholic recommended conducting pre-test–post-test control group design studies to further our under- standing of art-based MBCT.

Summary Although I found only one art-therapy-based MBCT article, this does not mean that the MBCT model is not suitable for art therapists. In fact the opposite is true. Based on Coholic’s work, it is possible that more art therapists will adapt the art-based MBCT model for both children and adults. MBCT as developed by Segal et al. (2002) can be easily modifi ed for art therapy to treat individuals with recurring depression and anxiety disorders.

Acceptance and Commitment Therapy Acceptance and commitment therapy (ACT; pronounced as one word, act ) is based upon the work of Hayes and his colleagues in the early 1990s. According to Hayes (2008), ACT “has always been a part of cognitive behavior therapy (CBT)” (p. 286), and was advanced through rigorous research. However, ACT rejected a key CBT construct, namely that thoughts and feelings cause behavior. Rather, ACT theorists considered that thoughts and feelings are important to “the context of a social/verbal community that linked private events to overt actions” (p. 287) and are “explicitly contextualistic and based on a basic experi- mental analysis of human language and cognition” (Hayes, 2004, p. 639).

Philosophical Underpinnings ACT is based upon philosophies and theories that differ from DBT, MBSR, and MBCT. However, I consider it valuable to include this third-generation 180 Third-Generation Variants of CBT and CBAT therapy in this chapter because mindfulness is interwoven with the practice of ACT. Whereas the other therapies in this chapter used Buddhist psychology as a touchstone theory, the theories that Hayes and his colleagues embraced were relational frame theory (RFT) and functional contextualism. Nonetheless, Hayes (2002) found parallels between Buddhism and ACT (i.e., that suffering is part of being human, and that the acceptance of suffering as well as the ending of craving are needed to move towards wellness). Hayes (2004) was adamant that psychologists and therapists need to under- stand that the philosophy of functional contextualism is what undergirds ACT. Functional contextualism has similar assumptions to constructivist ideas. From constructivism came a closer look at contextualizing treatment models as a way of furthering the understanding of human interactions and therapeutic agents of change. Thus all the concepts of ACT “need to be linked to context, defi ned both historically and situationally, because only contextual variables can be directly manipulated and lead directly to both prediction and infl uence” (Hayes, 2008, p. 288). In functional contextualism, an objective reality is unknowable, and as related to psychology, refers to the ability to predict and control human behavior (Flaxman, Blackledge, & Bond, 2011). It is also related to the functionality of ACT treatment concepts, which “all fl ow from the radical pragmatism of its underlying philosophy” (Hayes, 2008, p. 288). Functional contextualism is the foundation of what Levin and Hayes (2009) called contextual behavioral science (CBS), which is a holistic assessment of psychological events, and is fundamental to RFT. ACT was also based on RFT, which explicates that the basis of human lan- guage is relational and necessary for communication, but can also lead to suffering when it is used to manipulate or deceive others (Hayes, 2004). Research con- ducted by Hayes and his associates led to the formulation of a behavioral theory of language and cognition or RFT. The concepts uncovered by research on language and cognition, as well as RFT, form the basis of the ACT therapeutic model. ACT emphasizes that “acceptance, defusion, contact with the present moment, and self in the sense of perspective taking can all be readily derived from RFT” (Hayes, 2008, p. 288). 2

Treatment Constructs There are six core therapeutic constructs in ACT, which include the four noted above as well as values and commitment. Hayes and colleagues identifi ed these six constructs as being the mindfulness and behavior change processes that lead to the development and improvement of psychological fl exibility (Flaxman et al., 2011). Three of the constructs (acceptance, defusion, and self-as-context) are directly related to mindfulness and acceptance processes, and the other three (contact with the present moment, values, and committed action) are related to commitment and change processes. Levin and Hayes (2009) called the composite of these six constructs the hexafl ex . 3 Third-Generation Variants of CBT and CBAT 181

From the earliest days of the development of ACT, research was conducted to verify its therapeutic constructs. Effi cacy studies of ACT range from mitigat- ing anxiety and depression (Dalrymple & Herbert, 2007; Forman et al., 2007) to eating disorders (Juarascio et al., 2013), substance use (Ilgen et al., 2016), chronic pain (Johnston et al., 2010), the effects of trauma (Ojserkis et al., 2014), and psychosis and work-related burn-out (Flaxman et al., 2011). As a treatment modality, ACT stands for “accept, choose, and take action,” and the aims of the interven- tions involved in ACT are as follows:

• to reduce cognitive fusion through the use of exercises, and paradoxical and process-oriented language in therapy • to undermine experiential avoidance by confronting the costs of that avoid- ance and the confl ict it produces with client values • to teach acceptance and willingness as an alternative coping response, and to practice deliberate defused exposure to troublesome thoughts, feelings, bodily sensations, and the like • to help the client maintain contact with a transcendent sense of self that makes acceptance and cognitive defusion less fearsome, through the use of exercises and practices • to clarify life values • to behave in accord with chosen values through behavioral commitment strategies (Hayes, 2002, p. 60).

The ACT therapist has numerous roles, but the most critical ones are to “insti- gate, model, and support psychological fl exibility” (Hayes & Lillis, 2012, p. 68). Hayes and Lillis found that using ACT exercises is the best way to activate the therapeutic process. In addition, the therapist must be emotionally honest with the client, which leads to the role of being a model. The development of psycho- logical fl exibility is initiated by supporting the changes made by the client and by reinforcing the progress made. ACT is widely used and is supported by the research literature. Hayes and his colleagues expect effi cacy research to continue, especially larger outcome-based studies. They would like to see the use of ACT in new domains such as preven- tion, social justice, and even business and industry (Hayes and Lillis, 2012). As with the other mindfulness-based treatment modalities, they would like ACT to be a part of the “alleviation of human suffering and the promotion of health and development” (p. 135).

ACT and Art Therapy Backos and Mazzeo chose ACT as the foundation for their work with veter- ans with post-traumatic stress disorder (PTSD) (Backos & Mazzeo, 2017). An eight-week art-therapy group program, incorporating both ACT principles and 182 Third-Generation Variants of CBT and CBAT treatment recommendations for PTSD framed by Waller and Westrup (as cited in Backos & Mazzeo, 2017), was created for veterans. The program was structured, and “Each module included: a mindfulness art intervention, psycho-education, an ACT art therapy experiential, discussion, and art homework” (p. 169). Since the program was cognitive-based and short-term, they used controllable and familiar media such as markers, pencils, and oil pastels. The art was incorporated into the six modules from the ACT treatment model. A few of the art exercises using the ACT model are described here. For exam- ple, the concept of contact with the present moment was addressed in the fi rst module. Veterans created mandalas at the beginning of each session to ground and focus them on the present moment; also, they were asked to be present throughout all the art-making exercises. The concept of willingness to delve into painful memories was introduced through imaginal exposure. For dealing with the problem of control, group members were asked to compare and contrast art-making with the freedom to choose versus art-making when given instructions and media. The concept of cognitive defusion was based on the monster on the bus metaphor of dysfunctional thoughts, as developed by the work of Hayes, Stroshal, and Wilson (1999, as cited in Backos & Mazzeo, 2017). Each veteran created three monsters “that represent their commonly fused thoughts, as well as externalizing the details of these distorted thoughts via written descriptions including the age of the monster, what the monster says, other related monsters, and what situations bring out each monster” (p. 171). Dividing values into ten categories, the veterans were given ten small pieces of paper on which they wrote about the person they wanted to be in each domain. They crafted each piece of paper into various shapes that echoed their values. Finally, the paper shapes were combined into a mobile that “served as a meta- phor, reminding them that positive changes in one area impact all the other areas” (p. 173) Backos (2016) presented research on the effectiveness of the art therapy/ACT program. Sixteen veterans completed the eight-week program. Eleven of the participants were Vietnam veterans, and the other fi ve were veterans from the wars in Afghanistan and Iraq. Three hypotheses drove the research:

• Hypothesis 1: There will be a signifi cant reduction in self-reported PTSD symptoms (PCL-C). • Hypothesis 2: There will be a signifi cant increase in self-reported acceptance attitudes (AAQ-2). • Hypothesis 3: There will be a signifi cant reduction in self-reported depres- sive symptoms (BDI-II).

Only depression, as measured by the BDI-II, was signifi cantly reduced at post- test. Backos (2016) reported that although the reduction in PTSD was not signifi cant, self-reported trauma symptoms revealed decreases in the effects of Third-Generation Variants of CBT and CBAT 183 trauma. The feedback from the participating veterans was positive: several of them referred peers to the group and continued to use art-making for mind- fulness practice. Backos concluded that “ACT combined with Art Therapy is a promising combination of treatment that offers both verbal and non-verbal approaches to healing from PTSD.”

Summary Art therapy as interwoven with ACT is promising. Based on the work of Backos, it appears that ACT principles are similar to those of DBAT practices. She found that depression was signifi cantly decreased after the eight-week program. Her research indicates that there is potential for the effectiveness of ACT as practiced by art therapists for both depression and PTSD symptoms.

Conclusion The recent variants of CBT include aspects of mindfulness as a meditative prac- tice. Only ACT evolved from a different perspective. However, it still includes some aspects of Buddhist ideals such as acceptance and compassion. Although the similarities between CBT and Buddhist principles are considered new, in fact commonalities between the two traditions were noted as early as the 1950s. Ellis stated outright that REBT had as much in common with Buddhist ideas. Two leading practitioners brought mindfulness into Western therapeutic practices. In the 1970s, Linehan, fi nding that those with suicidal tendencies did not respond well to a problem-focused psychotherapeutic approach, used mind- fulness to increase tolerance-frustration and acceptance of their situation. Many credit Kabat-Zinn with incorporating mindfulness practice into Western medi- cal practices. He began exploring his theory that Buddhist practices could help patients to cope with chronic pain in the early 1980s. From these two pioneers, Segal et al. learned that mindfulness, which infl uences how one views one’s thoughts and feelings, might be the critical addition to CBT to have an impact on relapsing depression. Finally, Hayes and his colleagues began researching the power of language as a key concept in dysfunctional thinking and behavior. Using a relational approach to understand a client’s concern, they developed ACT, which emphasizes both acceptance and compassion when working with clients. CBAT is easily integrated into recent variants of CBT. Art therapists use art as part of DBT. Using art-therapy interventions, such as drawing a situation from two mindsets, can help a client to become aware of cognitive distortions or accepting two opposing thoughts or feelings. Acceptance , a key component of how art therapists practice, is also an important principle in DBT. Juxtaposed with helping to create an atmosphere that embraces change , acceptance can move a client into a space where they may be willing to take steps to try new behaviors. 184 Third-Generation Variants of CBT and CBAT

It is also important to recognize that involvement in art-making can be medi- tative. Certainly, Lorenzo de la Peña and Drass realized this as they conceived an art approach to DBT. Encouraging clients to be aware of their surroundings, emotions, and thoughts while creating art is a major aspect of the new variants of CBAT. Mindfulness, as a signifi cant component of art therapy, must include the practice of self-awareness on behalf of the therapist. Understanding art-media dimensions is of utmost importance to mindful practice. Whether the emphasis is placed on learning skills, understanding diffi cult mental messages, or paying attention to thoughts and feelings, these treatment strategies are evidence-based. Treatment effi cacy is a vital component of all cognitive-based therapy. CBTs target short-term relief of symptomologies and are often the treatment of choice for outpatient clinics. Even DBT, although conducted over a period of several months, is concerned with fi nding strategies to provide relief as quickly as possible, especially when dealing with patients who self-harm. Art therapists who work within the new variants of CBT understand the importance of research to test the effi cacy of their art-therapy programs. Peterson and her colleagues, Ando et al., Coholic, and Backos all conducted research on their art-therapy variants. Although the results were mixed, promising thera- peutic effects were identifi ed. For example, Peterson and her colleagues found that the art-therapy-based MBSR program decreased distress in cancer patients. There were also other promising results, including increases in mental health, general health, vitality, and social functioning. The study by Ando et al. (2016) showed improvements in vigor and decreases in fatigue for the participants with late-stage cancer. Coholic developed a qualitative study of her program based on MBCT and found that at-risk children reported improvements in self-awareness, increased positive feelings of the self, emotional regulation, and healthy expression of feel- ings. These changes indicated that the children had found more suitable ways to cope with challenges. Furthermore, Backos found that art therapy integrated in ACT signifi cantly decreased depression. Self-reported symptoms of PTSD in combat veterans were also reported. In an attempt to uncover the best practices of art therapists working with aggressive children, the results of the study by Nissimov-Nahum concluded that two DBT principles should be included in art therapy practice, namely a focus on forming a positive, nonjudgmental relation- ship with the child, and helping the child to understand the relationship between feelings, thoughts, and behaviors. These studies, although not defi nitive, point to the viability of CBAT as prac- ticed within the parameters of the recent, third-wave CBT variants. It goes without saying that more art-therapy investigations are needed. However, the fact that art therapists are attracted to the current variants of CBT is a good sign for the future of CBAT. Since practitioners of both CBT and Buddhist psychology are adamant that these practices must be effi cacious, it is of utmost importance that Third-Generation Variants of CBT and CBAT 185 art therapists continue to examine the therapeutic components of art-therapy- based mindfulness practices.

Notes 1 See Clark (2017) for a full exploration of her DBT models. 2 RFT is a complex theory. Readers are referred to Blackledge (2003) for a deeper explo- ration of these ideas. 3 For more information, readers are referred to Levin and Hayes (2009). 9 UNRAVELLING CBAT FOR PRACTITIONERS

“Through the art process, clients can imagine other possible selves.” (H. Matto, J. Corcoran, & A. Fassler, 2003, p. 266)

In this book, the trajectory from the early theories of cognition and emotion development through the cognitive aspects of art-making and onto the evolu- tionary arc of CBT and CBAT from behaviorism through the third wave have been presented. This is a great deal of information to process and digest. A goal of this fi nal chapter is to synthesize the material and distill the essence of the mate- rial for ease of application of CBAT with various diagnostic groups. However, there is more to be discussed. In this chapter, I would also like to explore the viability of CBAT and bring closure to the argument against using CBT tenets in art therapy. I shall also propose that CBAT is a vital and important approach to art therapy. To begin with, I shall provide a review of several important points to serve as a summary and as the building blocks of CBAT.

Summary of Signifi cant Principles Seven essential principles inform the development of CBAT: cognitive devel- opment, focus on emotions, the philosophy of constructivism, mental imagery, cognitive aspects of art-making, the shift from behaviorism to the second wave of CBT and CBAT, and the transition to third-wave CBT and CBAT. Each of these principles will be summarized below.

Cognitive Development Cognition is developed from experiences within the individual and through interactions in social environments. The evolution of learning occurs in the form Unravelling CBAT for Practitioners 187 of schemas. Schemas are the building blocks of cognition, and developmental theory informs us that cognition is a constructive process. Cognitive develop- ment applies to the individual, but also applies to how culture is developed. The development of cognition is an adaptive process for humans (Piaget, 1952, 1954), and, as with other animal species, we are continually evolving and adjusting to changes and other new aspects of the environment. Another concept parallel with adaptation is coping; the development of cognition leads to increases in coping strategies (Bruner, 1990). Improving an individual’s ability to adapt and cope is an essential goal of CBT and CBAT. Cognitive development leads to meaning-making through symbolic develop- ment. Piaget found that symbols are also developmental in nature and develop through interactions with one’s environment. Symbolic play is common in child- hood, and often reveals the child’s imitation of what is occurring in the environ- ment, or the fears and anxieties that are experienced through the world around them, all of which hold psychological signifi cance. Piaget’s refl ections on the topic of symbol development fi t within the framework of CBT and CBAT. Piaget conceptualized symbols as having both cognitive and affective compo- nents, and as being constructed through interactions with the environment. In addition, he envisioned symbols as cognitions that could be either primary or secondary. It is the secondary symbols that might be of importance to art thera- pists. These types of symbols are developed when the process of accommodation is diffi cult and the result is an internal struggle. Thus symbols (often in the form of mental images) are created to refl ect these struggles; they reveal an individual’s thinking processes and become a part of his or her reality. Piaget revolutionized the idea of mental imagery formation. Schemas, as building blocks of cognition, are often mental images that hold memories. Piaget also proposed that symbol development and art-making are cognitive activities that augment intellectual development. This principle underscores the theoretical relevance of CBAT. In art-therapy treatment, clients’ drawings depict schemas. Each schema created by a client offers clues to their thinking processes. Changes made to a drawn schema may alter the internal schemas held by the client.

Focus on Emotions It is not possible to separate emotion from cognition. They are both critical aspects of CBT and CBAT. Through a cognitive lens, emotions are related to how situations are appraised. Coppin and Sander (2013) found that the appraisal model of emotions is the most vital and most often used model in psychol- ogy today, and the evaluative cognitive appraisal model is the one upon which CBT theorists and therapists base emotive work. From Lazarus (1968), therapists understand that it is the appraisal of a situation that causes diffi cult emotions. CBT and CBAT therapists target this appraisal, or how one thinks about a situation, for exploration and therapeutic intervention. In third-wave CBT and CBAT, 188 Unravelling CBAT for Practitioners helping clients to develop compassion and loving kindness for their emotional reactions, no matter how irrational, is at the root of treatment.

The Philosophy of Constructivism Constructivism is the philosophical basis of CBAT and is the philosophy of how humans build knowledge and construct meaning. Meaning is constructed through thoughts, memories, symbols, and emotions. Constructivist ideas are based on the theories of cognitive psychology and cognitive science, and are congruent with cognitive approaches to therapy and CBAT. The constructiv- ist model explores the origin of mental imagery, metaphor, and narrative, and identifi es the cognitive operations that make these tasks possible. These cognitive functions are vital to the practice of art therapy whereby the art therapist assists the client in exploring these functions as they create art. Constructivist philosophy and cognitive development are future-oriented ideas. Vygotsky (1978) contemplated how humans use imagination and con- cluded that it is used to recall the past, which allows for playing with memory and its associated images in the here and now. Thus people reconfi gure the past to make meaning of their experiences in the here and now. He also reasoned that people engage imagination and memory to construct or formulate new ideas. According to Vygotsky, this is a uniquely human ability; consequently, people are future-oriented as they construct the person whom they wish to become. Whereas psychoanalytic theories are said to be looking at the past, CBT and CBAT work towards a better future for clients. As stated in Chapter One, art-making is the construction, deconstruction, and reconstruction of personal narratives. The same can be said of CBAT where the reconstruction of diffi cult cognitions, memories, and images can be reimagined and redrawn. The development of human agency is an important principle of constructivist philosophy. Agency means that people construct and determine their own ideas and ways of being. I propose that this is the fundamental phi- losophy of CBAT. Through CBAT, the art therapist allows the client to develop self-effi cacy and personal agency.

Mental Imagery Mental imagery is considered to be one of the main cognition functions as pro- posed by Eisner (2002). The use of imagery in treatment is a major connection between behaviorism/CBT and CBAT. Imagery as used in psychodrama and Gestalt therapy served as the basis for how imagery is used in CBT. In the earli- est stages of behavior therapy, imagery played a crucial role used in systematic desensitization and covert modeling. These behavior therapists asked the client to imagine scenes that were either distressing, causing anxiety and fear; or positive, striving for something constructive and positive for themselves or for the future. Unravelling CBAT for Practitioners 189

Imagery is vital to the development of self-effi cacy as proposed by Bandura (1977). His thinking on imagery was related to symbolic modeling, which means that imagery is developed internally rather than through overt behavioral mod- eling. Symbolic modeling can lead to the development of internal control and self-regulation. Meichenbaum (1978) found that imagery is linked to self-control, re-envisioning problems, and mitigating problem behaviors, all of which may lead to improved coping. Today, imagery is used in CBT to temper problematic imagery and to increase positive imagery in two ways. First, direct CBT interventions are those that address imagery problems in a straightforward way, and they include expo- sure therapy and manipulation of imagery. Second, indirect imagery techniques, which are part of third-wave CBT and mindfulness, employ techniques to address mental images from a compassionate point of view (Hackmann et al., 2011). Illustrations of both direct and indirect uses of mastering imagery have been discussed in this book.

Cognitive Aspects of Art-Making Art-making in and of itself is a cognitive and constructivist process. The act of creating art employs many cognitive processes that contribute to the improved cognitive abilities of the artist. Through art-making, a person uses will and determi- nation, decision-making, problem-solving, and discrimination skills, and engages brain functions. Externalizing the problem in visual form is part of CBAT, and is one of the early steps in art therapy. Alteration of an art image that illustrates a client’s problem or concern can be achieved by asking the artist to redraw the picture from various perspectives, or through reframing the problem. An example of reframing is provided by Matto et al. (2003), who asked teenagers to think of the positive aspects of a set of problematic behaviors. This reframing led the teens to realize that they have strengths that never occurred to them before. Reframing mitigates the emotional charge of the image and presents it in a way that might be construed as something that can be changed, or at least seen from a fresh perspective. Constructivism is crucial to art-making because it is an underlying and guiding principle for how a person constructs and ultimately creates a draw- ing, painting, or sculpture. Art-makers are natural constructivists.

The Shift from Behaviorism to the Second Wave of CBT and CBAT The shift from behaviorism to the infusion of cognitive science and psychology into behavior therapy practice allowed for the integration of art therapy in CBT models to evolve from solely using behavioral principles such as redirection and reinforcement as part of art therapy to understanding art-therapy practice through a cognitive psychology lens. Behaviorism or the fi rst wave of CBT involved specifi c therapeutic techniques to change behavior. Early CBAT therapists used 190 Unravelling CBAT for Practitioners behavior techniques in their practice with children and adults with critical prob- lems such as psychosis and intellectual disabilities. For example, Roth (1978, 1987) worked with children who experienced both intellectual disabilities and psychotic disorders. She employed several behavior therapy interventions such as redirection and reinforcement, but also added a unique art-therapy intervention that she labeled reality shaping. This technique exercised the use of behavior shaping and reinforcement to help children to learn new concepts and enhance the personal meaning of constructs. Other art therapists borrowed behavioral management techniques as needed when clients had diffi culty with staying on task or when they had outbursts that might harm themselves or others. The majority of art therapists did not fully embrace the behavior therapy model in practice. The uneasy perception of CBT began to change for art therapists when cogni- tive psychology and science were introduced into behavior therapy by theorists such as Bandura (1969, 1977), Kelly (1955/1991), Meichenbaum (1974), and Rotter (1954). Collectively, these theorists radically shifted the focus of behavior therapy from understanding behavior as shaped by external events to behavior informed through internal cognitive processes. This shift marked the evolution from the fi rst wave to the second wave of CBT. This second wave of CBT inspired art therapists to take a renewed look at CBT. Although there remains a perception of CBT as overly structured, protocol-heavy, and workbook-focused, this is not the whole picture. With this internal-thought-focused and cognitive- constructivist-based theory, art therapists found a niche in CBT that was ripe for development. Beginning with Carnes (1979) and Rhyne (1979a, 1979b), the cognitive in art therapy was perceived to be a valuable resource for prac- tice. Both art therapy and CBT are active interventions and employ experiential techniques. Art therapy is particularly suited to CBT therapies because making art is an inherently cognitive process that uses thinking, sensing, and identifying and understanding emotional responses. When creating a piece of art, the artist must be involved in uncovering mental images and messages, recalling memories, making decisions, and generating solutions.

The Transition to Third-Wave CBT and CBAT Two goals of CBT include assisting the client to become aware of the role that maladaptive thoughts play in maintaining maladaptive behavior, and training the client to monitor their own thinking processes. These two goals are the basis for the third wave of CBT. Third-wave CBT therapists teach mindfulness and medi- tation practices to train an individual both to become aware of their thoughts and to monitor their cognitions. In addition, basic tenets of Buddhist psychol- ogy parallel behavioral and cognitive therapy principles. For example, in the early 1950s, Ellis found commonalities between rational-emotive therapy and Unravelling CBAT for Practitioners 191

Buddhist practices; in particular, both ask individuals to question distressed think- ing and both employ techniques to help individuals to live a rational life. Metacognition is an important concept with both CBT and mindful medita- tion practice. Simply put, metacognition is the awareness not only of what one is thinking, but also of how one thinks. Metacognition is a key skill in CBT because it leads to changing erroneous and problematic thoughts and beliefs. In mindfulness, an individual learns that these problematic thoughts and feelings are passing events, not necessarily reality-based, and are constructions of his or her own making. Mindful meditation parallels metacognition because it helps a person to monitor their own thoughts, and to observe and control their thinking. Mindful practices also help the client to become less judgmental of their thoughts and more accepting of their own processes. Mindfulness improves attention and concentration, and these are also goals of CBT. The other cognitive correlates of mindful practices include determination, restraint, recollection, and vigilance. Third-wave CBAT practitioners use engagement in art-making to empha- size paying attention in the moment, carefully examining how one is feeling and thinking as one works with media, pairing DBT and other skills with art- therapy exercises. A DBT concept used by Huckville and Learmonth (2009) is the balance between acceptance and change—accepting what is happening in the here and now, and accepting that things will change. Also, the client must feel accepted by the therapist in third-wave CBAT and yet must recognize that treat- ment involves embracing an agenda of change. This diffi cult balance can be part of the art-making experience where accidents may happen as part of completing a piece of art. According to Lorenzo de la Peña, third-wave CBAT therapists also practice mindfulness as they enter a session. Their mindset is one of accepting clients where they are and having a nonjudgmental stance.

Summary CBAT is built upon strong sound philosophical and theoretical principles. The ideas presented above make a strong case for this approach to art therapy. Art therapy is particularly suited to CBT therapies because making art is an inherently cognitive process that uses thinking, sensing, and identifying and understanding emotional responses. When creating a piece of art, the artist must be involved in several cognitive processes, including uncovering mental images and messages, recalling memories, making decisions, and generating solutions. Whether draw- ing or sculpting, creating art involves instant feedback systems and the ongoing reinforcement of satisfying behaviors. Each brush stroke can suggest or promote further action (feedback) as well as delight (reinforce) the artist. Creating art means that there is a concrete record of inner processes. This concrete record can be discussed, altered, and redrawn to satisfaction. It can also be used to recall past events, and as a reminder of positive emotional experiences. 192 Unravelling CBAT for Practitioners

These seven principles provide a cogent argument for CBAT with a wide number of clients and for many diagnostic groups. The theoretical underpin- nings are sound, and include broad concepts such as developmental psychology, the nature of imagery, cognitive science, and the philosophy of constructiv- ism. The practice of behavioral and cognitive-behavioral therapy is ever evolv- ing and, because of its insistence on research, each evolutionary step is based on empirical evidence. CBAT, too, has evolved from the early integration of behavioral practices into art therapy, through the addition of cognition and cognitive psychology to underscore the value of imagery and art-making, and now through the incorporation of third-wave CBT mindfulness traditions into CBAT practices. CBAT techniques for various diagnostic groups are explored below.

CBAT Practice Strategies Several diagnostic groups benefi t from a CBAT approach to therapy. In this sec- tion of the chapter, I shall pull together CBAT techniques for using this approach to art therapy for six diagnostic groups: PTSD, anxiety disorders, depression, psy- chotic disorders, behavior and emotional disorders, and chronic pain and medical conditions (see Table 9.1).

PTSD CBT and art therapy are often the treatments of choice for individuals with PTSD. Since trauma experiences are often stored in memory as mental images, it is advantageous to tap into these images as part of treatment. CBT therapists use traumatic images as part of verbal treatment utilizing techniques such as imagery rescripting. Yet CBATs have an advantage because they can introduce art-therapy protocols alongside the verbal ones. The trauma narrative protocol of Gantt and Tinnin (2007) translates distress- ing trauma memories into a series of drawn images, and these pictures can be used to re-present the narrative of the traumatic event in detail. In Gantt and Tin- nin’s approach, the therapist uses client drawings of the event to retell the story using the past tense to cue the client that the incident occurred in the past and is no longer part of present-day experiences. This process offers refl ective distance from the trauma for the client. Several other art therapists have used similar inter- ventions. For example, Campbell et al. (2016) applied the process of drawing a timeline sequence of a trauma event in six separate images with veterans who had experienced combat-related trauma (see Figure 6.27). Walker et al. (2016) introduced a mask project for a veteran coping with a traumatic brain injury and PTSD. The mask he created was of a bloody face, which was a recurring and intrusive memory from an incident experienced dur- ing a combat event. Because the mask caused him distress and often appeared in TABLE 9.1 CBAT interventions for various diagnostic groups.

Diagnostic Group Author(s) and Date Targeted Symptom CBAT Intervention Outcome

PTSD Gantt & Tinnin (2007) Recurring trauma Intensive trauma treatment;1 Re-presents trauma story from Campbell et al. (2016) memories draw each aspect of trauma third person; provides refl ective event distance; lessens impact of trauma event Walker et al. (2016) Problematic trauma Mask of the recurring face Externalizes the feared image; imagery image; create box for provides a safe place for the disturbing face mask image; promotes control over image Backos & Mazzeo (2017) Need for control Familiar art materials: markers, Gains sense of order and control collage, etc. Contact with present Mandalas at each session and Creates calm attention to the moment request to be attentive during present each art experience Unwanted painful Imaginal exposure; create a Externalizes memory for memories picture of the memory acceptance and control Identify distorted “Monster on the bus” directive Externalizes distorted cognitions thoughts Identify values Values mobile Identifi cation and integration of important and positive beliefs Pifalo (2007) Identify positive and Feelings box of inner and outer Protects diffi cult emotions; frightening feelings emotions increases control over feelings Decrease chaotic Road map of trauma events Brings order to a diffi cult and memories chaotic childhood

(Continued) TABLE 9.1 (Continued)

Diagnostic Group Author(s) and Date Targeted Symptom CBAT Intervention Outcome

Anxiety disorders Morris (2013) Prioritize cognitive Collage of cognitive distortions, Reconstructs cognitive distortion distortions ranking least to most diffi cult and solidifi es realistic thought distortions, discussion of least processes to restructure; painting of restructure cognition Sarid & Huss (2010) Intrusive memory Imaginal review of stressful Client lowers the volume of his event and identifi cation screams in an anxiety-producing of “hot spots” of problem memory memories Anger at self; negative Draw the obstacle and use Decreases negative self-talk and self-talk various colors to express increases positive attributes positive aspects of self Zettler (personal Self-control over anxiety Create the anxiety monster Increases control over anxious communication, August and a container for anxious feelings 5, 2017) feelings Depression Rosal (2001) Improve understanding Personal construct assessment of Increases awareness of feelings and of feeling states mood states emotional triggers, improves understanding that emotions are passing events Cope with distressing Art journal of daily stress events Increases coping with daily stress events and related with feeling states identifi ed feelings Diffi cult moments as a Draw safe places and expression Increases coping and improves trigger for downward of calmness and serenity; use ability to self-soothe spiral as stimulus for destressing Zettler (personal Low self-worth Identify a power animal; Identifi es strengths and other communication, August create a mask of the animal attributes of the self 5, 2017) representing true self Major mental illness Huckville & Learmonth Anxiety about engaging Accommodate patients’ request Increases participation and (2009) in art therapy to make the environment safe improves safety Clark (2017) Diffi culty with Collages and various media Reinforces the DBT skill needed integrating DBT for treatment skills2 Heckwolf et al. (2014) Emotional regulation Pair images of safety with images Increases awareness that both safe of emotional turmoil and frightening images can occupy the same space von Daler & Schwanbeck Behavior substitution Request that client uses Creates adaptive behavior patterns (2014) art expression instead of and new neural pathways indulging in problem behavior Drass (2015) Chaotic inner landscape Structure the art-therapy Encourages the development of a environment to be orderly less muddled inner landscape and neat Uncontained emotions Create wise mind books or 3D Increases sense of self-identity collages to answer questions about the self Diffi cult dealing with Distress tolerance baskets Improves ability to self-soothe and stress grounding Lorenzo de la Peña (2016) Disruption in art-therapy Carefully plan each step of Improves emotional regulation sessions session and every step of art- and reduces diffi cult emotional media use responses

(Continued) TABLE 9.1 (Continued)

Diagnostic Group Author(s) and Date Targeted Symptom CBAT Intervention Outcome

Wandering thoughts Sensory/mindful art experiences Increases attention to art-making such as bubble or dribble tasks and improves mindfulness paintings; non-fi gurative skills art-making Behavioral and Rosal (1985, 1992, 1996, Poorly formed schemas Personal construct drawing Improves self-understanding and emotional disorders 2001, 2016a) and irrational thoughts assessments to identify aids in formation of therapy Ravenette (2005) and emotional problematic schemas and goals responses through processes Rosal (1985, 1992, 1996, Differing problem Draw self in various situations/ Uncovers behavior responses, and 2001, 2016a) behavior dependent settings and corresponding aids in problem-solving on setting feeling states Lack of positive identity Imagery exercises that emphasize Improves self-esteem and self- and power decision-making and effi cacy overcoming obstacles Gussak (2009) Poor problem-solving Create paper sculptures using Increases problem-solving abilities skills only paper and tape Matto et al. (2003) Disruptive behavior Reframing to highlight strengths Improves agency and identifi cation in problem behaviors of positive attributes Stress reduction Isis (2014) Decrease the impact of Breath lines, body scans, and Increases coping strategies for stress mindful doodles stress and stress reduction Visnola et al. (2010) Poor awareness of Using a body outline, use Improves emotion and body emotions different colors for each awareness emotion, and color where the emotion is located in the body Lack of understanding of Draw and write about both Increases coping in the workplace the stressor on the job sources of satisfaction and sources of stress in the workplace Need for consolidation Mandala drawings and positive Solidifi es coping and learned of learned coping skills self-symbols coping skills Medical conditions Monti et al. (2006) Need to uncover coping MEAM: mindful exploration of Prepares for mindfulness exercises Peterson (2014, 2015) resources art media Lack of body awareness Body scans to identify pain and Increases awareness of body’s discomfort response to illness Lack of environmental Walkabout exercise to learn Improves sense of place and awareness about the hospital or mindfulness of illness and clinic; use photographs and treatment collage work to consolidate environment experiences

1 Intensive Trauma Treatment (ITT) is now referred to as the Instinctual Trauma Response (ITR) model of treatment and requires additional training with Gantt and associates. 2 Clark (2017) has provided a comprehensive list of art-therapy interventions used to reinforce DBT skills. 198 Unravelling CBAT for Practitioners his dreams, he agreed to create a box in which to place the mask (see Figures 6.16 and 6.17). With the mask contained and safely out of sight, he was able to control when it was brought out and when it was put away. With this control, the intrusiveness of this image decreased over time. Using the acceptance and commitment therapy (ACT) model, Backos and Mazzeo (2017) created a program for combat veterans. They incorporated art therapy in each of the six ACT modules. In their model, simple, structured art materials were deemed to be the most useful because they are easily controlled. The use of opposites was also introduced. For example, they asked the veterans to compare and contrast free-choice art experiences with those that were more structured and scripted. Monsters and a values mobile were part of the art-making interventions. Pifalo (2007) worked with children who had experienced trauma and found that identifying the feelings of the traumatic event was therapeutic. Using a box, she had her clients put images and words for diffi cult feelings on the inside of the box, and feelings that were safe to show others were placed on the outside. Pifalo also recommended a road-map project of the child’s life to organize trauma events and to help to bring order to the turmoil of an abusive life.

Anxiety Anxiety and stress are components of PTSD, but anxiety is also a disorder in and of itself. Working with clients who experience anxiety is a challenge, as anxiety disorders typically begin in childhood and can be lifelong. Morris (2014) studied CBAT with two individuals, one with panic disorder and agoraphobia (PDA) and the other with generalized anxiety disorder (GAD). She found support for CBAT with both diagnostic groups. Morris specifi ed that “Art therapy may be one way in which some people with PDA and GAD can be empowered to literally create their own image of their fears and envision solutions” (p. 120). Her protocol included systematic desensitization, cognitive restructuring, and art therapy to challenge irrational beliefs about how others’ views of the client were erroneous. First, Morris suggested that clients use collage materials to depict their thoughts about their anxiety. The collage was used to identify problematic cog- nitions related to the anxiety experienced. The next step was to have the client list the cognitions and rate them from least diffi cult to most diffi cult to address in therapy. Beginning with one cognition that held the least amount of emotional impact, Morris helped the client to fi rst question the accuracy of the cognition and then paint an illustration of the cognition adjusted with the new information that was gained from questioning the thought. Through the act of painting the readjusted cognition, the newly formed and more realistic cognition was rein- forced (see Figure 6.5). Sarid and Huss (2010) used CBAT to mitigate acute stress disorders. They reported information on two clients who benefi ted from imagery experiences. These interventions lessened the stress impact of intrusive images from traumatic Unravelling CBAT for Practitioners 199 incidents. They encouraged one client to fi rst narrate and re-imagine the event, and to identify the most diffi cult aspect of the trauma. The most troublesome aspect of the trauma event was remembering his loud screams, the memories of which were frightening. The identifi cation of the loud screams was targeted for intervention by having the client imagining himself turning down the volume of his own screams. This is also an example of identifying the hot-spot moment and using both mental imagery and sound imagery to decrease the emotional impact of the trauma. A similar process was utilized with a woman who had had a bicycle accident when she did not see a large object in her path. They fi rst asked her to draw the accident with the large black object. She focused on her stupidity for not noticing this object. To mitigate her negative self-talk, they asked her to use an array of colors to represent other aspects of herself in the drawing. By add- ing the colors, the woman recognized that she had many positive qualities that decreased the impact of the object. She also reported that the black object actually highlighted the positive colors. Zettler worked with Maggie, a 14-year-old with generalized anxiety disorder who felt that she had little ability to affect her own life. To increase her sense of agency, she had Maggie list the positive attributes of a favorite animal. Maggie was then instructed to create the bear out of clay and ultimately create a habitat for the animal. Maggie’s bear habitat included food, water, and a home (see Fig- ure 6.22). For adults, Zettler introduced the idea of creating an anxiety monster (see Figure 6.23). The clay monster externalized her anxious feelings and gave the woman power over this emotional state. After a container had been made as a safe place for the monster, the woman also had the power to put the anxiety away when she was feeling vulnerable.

Depression Apart from its use for anxiety, treatment of people with depression was an early and signifi cant area of CBT research and practice. Most notably, Beck et al. (1979) developed a protocol to help people with this disorder to gain control of the distorted cognitions and self-talk that ultimately lead to serious depressive states. Awareness of emotional states and irrational thinking can curb the onset of depression. I discussed the case of Karen, whose depressive episode led to a suicide attempt. She realized that the identifi cation and understanding of her emotional states eluded her. Using Rhyne’s personal construct psychology (PCP) assessment utilizing drawings of mood states, Karen learned about several diffi cult feelings. She was even able to link problematic feelings with the possible onset of depressive states. In Karen’s case, anxiety was the key emotion that often trig- gered depression. This is not unusual, as there is a strong connection between anxiety and depression. Working with a teen with a mild form of depression, cyclothymia, it was important to Zettler to help this young woman to gain improved self-awareness. 200 Unravelling CBAT for Practitioners

She was asked to identify a power animal and create a mask that would represent her true self (i.e., as opposed to the side of herself normally shown to others) (see Figure 6.21). The teen selected a raven mask and was surprised to learn that she had attributes such as being old and wise as well as being mischievous. Mindfulness-based cognitive therapy (MBCT) grew out of the need to help people with relapsing depression. CBT treatment worked for a while, but at times the depression would return. Third-wave CBT focused on the goals of decentering and relapse prevention. The central feature of MBCT was a shift from changing people’s depressed and irrational thoughts to helping clients to alter their relationship with these distorted cognitions. This process is called decentering, which helps clients to accept erroneous cognitions as part of who they are. Also, clients were taught that having these thoughts does not mean that they are depressed individuals. One way for CBAT therapists to incorporate MBCT into art-therapy prac- tice is to fi rst ask clients to identify and draw their distressing cognitions and feelings, as was done with Karen. They then request that the clients use an art journal to note when these thoughts appear, and to create art about the event. When engaged in the art-making, the clients are invited to breathe and be aware of the moment. Another intervention is to have the client draw what it is like to feel safe or serene. When depressed thoughts appear, the client then uses the safe drawing as a prompt to do mindful breathing or focusing. Karen’s drawing of serene was the key for her to be reminded that her thoughts and feelings were only passing events (see Figure 6.13). She allowed herself to feel, but not to panic that these events meant she would dip down into depression.

Major Mental Illnesses Art therapists working in psychiatric settings have longed utilized CBAT as part of their practice. Prompting, reinforcing, providing structure, assuring a reality- orientation, and using art-making to shape behavior and to problem-solve are standard practice. Reality-orientations can be easily achieved by having patients create drawings of everyday objects or natural objects such as fl owers and trees. Challenging distorted thinking and promoting emotional regulation is also part of treatment for people with these disorders, as is promoting stress tolerance. Using a DBAT approach, it is also imperative for the art therapist to be accepting of unusual behavior and diffi cult thinking as a means of balanc- ing the diffi cult task of addressing distorted cognitions and disputing problem conduct. Before inviting the patients into the art-therapy room, art therapists need to resolve issues surrounding space and the types of art materials offered. This is an essential skill for practicing CBAT in psychiatric settings. The case study pre- sented by Huckville and Learmonth (2009) is an important example of altering Unravelling CBAT for Practitioners 201 the environment to encourage one patient to engage in art therapy. A patient was anxious about messiness, and the art therapists accommodated her by plac- ing plastic sheets under the drawing or painting paper, and permitting her to wear plastic gloves to prevent soiling of her hands. Their rationale was that if they accepted these demands, the patient would engage in art therapy, and ultimately changes in behavior would occur as she participated in art-therapy sessions. Drass (2015) also emphasized the importance of a purposefully structured art- therapy studio to encourage the bringing of order to the chaotic inner landscape of the patients. Lorenzo de la Peña (2016) deliberately planned each art-therapy session with specifi c goals in mind and with a structured, step-by-step process to promote success for the patients in art-therapy groups at a large state hospital. The art materials used were also deliberately selected for the advantage of creating safety and success for the patient. Media exploration is one of the fi rst interven- tions that Lorenzo de la Peña introduces to her patients. She also uses materials with various textures and colors as part of media exploration. Rather than focus- ing on the end product, she encourages the use of line and color to focus on the process of art-making rather than the product. These exercises promote bodily and sensory awareness. DBAT and mindfulness are additional approaches to working with people with chronic mental illnesses. Heckwolf et al. (2014) recommended pairing frightening and safe images together to help patients to understand that two opposing feelings can occupy the same space. Herring (2014) introduced several DBAT art-therapy exercises, such as body scans and breath paintings. Simple, time-limited, grounding, mindfulness exercises are valuable for this population, including observation exercises (e.g., Notice everything you can about this tree before you draw it ).

Behavior and Emotional Disorders CBAT for individuals with behavior and other emotional disorders centers on re-evaluating poorly developed schemas, erroneous thoughts, and irrational emo- tional responses. Since each thought is uniquely created by the client, the fi rst step in CBAT is to assess or uncover irrational thinking and research how prob- lematic emotional responses were developed. PCP assessment tools may assist in this process. Any PCP tool should be designed for the specifi c population and age group. For example, Ravenette (2005) used a PCP tool where the children drew the faces of kids with various emotional states (e.g., don’t care, intelligent, naughty, etc.) (see Figure 4.5) to explore how the child perceived the responses of others to behavior. Using drawings of opposites is also helpful (e.g., following rules vs. breaking the rules). Adults can handle more intricate PCP assessments as developed by Kelly (1955/1991) and Rhyne (1979a, 1979b). These assessments 202 Unravelling CBAT for Practitioners help to pinpoint problematic thinking and/or feelings, which can be used to formulate goals for treatment. Behavior problems occur in numerous settings, and creating how one feels and experiences the self in the settings that bring out problem behavior is useful. This could lead to artwork based on the emotional states that are experienced in each setting. For example, Scott drew about being bullied at school and drew the situation in three steps: what was going on in the classroom, how the bullying occurred, and his response. Other CBAT interventions for behavior disorders are related to problem-solving. Sometimes problem-solving is addressed directly, as in the case of Scott (i.e., What would you do if . . .?). At other times it can be in the form of metaphors, as in a prison setting. Gussak (2009) had inmates use only white offi ce paper and tape to create sculptures. For inmates, this required a great deal of creativity and solution-oriented thinking, especially when the group was asked to create a single sculpture that incorporated aspects of all the group members’ individual sculptures. Self-effi cacy and empowerment are two additional goals for individuals with problematic conduct disorders. Often disruptive or destructive behavior is a result of feeling inferior or belittled. Building a sense of agency is crucial to the prac- tice of CBAT. This is accomplished by highlighting strengths or reframing dif- fi cult behavior in order to fi nd positive attributes, as Matto et al. (2003) did for teens with substance use problems. It can also be achieved by using metaphors. Empowering guided imagery exercises were useful for Scott both to problem- solve and to fi nd his inner resources.

Stress Reduction Kabat-Zinn (1982) fi rst used third-wave CBT to mitigate acute and chronic stress with medical patients, or mindfulness-based stress reduction (MBSR). The use of mindfulness and meditation is now a common intervention for stress and pain management. Art therapy also uses third-wave CBAT in medical settings. The premise for the use of CBAT for stress reduction is that art-making enhances awareness of the present moment and helps participants to maintain a steady focus on what is going on around them. Simple art exercises such as breath lines, body scans, mindful doodles, and regular journaling exercises help to increase cop- ing skills and self-regulation. Isis (2014), who studied under Kabat-Zinn, offered an eight-week art-therapy program for stress reduction; each week was theme- based. In addition to body scans and breath drawings, she introduced response art to stories and social atom drawings. Workplace stress was addressed in an art-therapy program created by Visnola et al. (2010). Their CBAT program began with identifying emotions and where these feelings reside in the body. Next, the group members identifi ed stressful work situations and ascertained methods of coping and problem-solving. For Unravelling CBAT for Practitioners 203 cognitive restructuring, they had group members paint their feelings to music and then write a story about the painting. Another important art experience involved the members pinpointing both sources of satisfaction in the workplace and resources for coping at their place of employment. Mandalas and positive self-symbols were created to consolidate what they had learned.

Cancer and Chronic Medical Conditions Third-wave CBAT for individuals with chronic pain, cancer, and other chronic medical conditions is most often based on Kabat-Zinn’s MBSR. For example, Monti et al. (2006) based their CBAT protocol on his eight-week program. According to Peterson, who was the art therapist on this research team, the introduction of CBAT into this program for individuals with cancer began with mindful exploration of art materials (MEAM). Peterson wanted these explora- tions to be time-limited and inquiry-based. Simple art exercises prepared the patients for meditation practice. Other CBAT exercises included body scans for identifying pain in the body, using opposing constructs to explore events such as pleasant/unpleasant, and creating a healing place. Peterson (2015) also intro- duced a walkabout intervention to her patients. This process encourages patients to walk around the hospital or clinic and take photographs of their observations and scenes that hold signifi cance. The photographs are then used in subsequent art experiences to enhance their experiences of mindful observations. Although Peterson developed these art-therapy experiences for individuals with cancer, they are therapeutic for individuals with a wide range of chronic illnesses.

Synthesis The overriding goal of CBT is for the client to gain self-control and self-effi cacy in order to achieve adaptability (Bandura, 1997). For adults, CBAT alleviates the power of traumatic images, re-examines erroneous and problematic cognitions, decreases behavioral problems, increases awareness of triggers that lead to self- harm or socially inappropriate behaviors, and improves locus of control. CBAT also aids in achieving focus and mindfulness to alter the meaning of irrational thoughts. Finally, CBAT can improve coping strategies and lead to the adoption of rational solutions for improving one’s life choices. CBAT for children increases behavioral self-control, reduces the impact of abuse, mitigates the effects of bullying, and builds self-effi cacy—all of which are essential for development. Rather than always needing an adult or a system to be in charge, children in CBAT can learn to understand and manage aspects of their own behavior. For people of all ages, increased self-control can lead to more personal choice and freedom, and personal power can in turn lead to a richer and more meaningful life. 204 Unravelling CBAT for Practitioners

Conclusion CBAT is alive and well. The art-therapy literature is peppered with illustra- tions of CBAT interventions. There are many exciting and specifi c CBAT pro- cesses that are employed by art therapists. Authors may not have identifi ed their approach as CBAT, but it is clear that numerous art-therapy interventions in the literature have a CBT base. One way to grasp just how important CBAT is to our fi eld is by reading art-therapy literature through a CBAT lens and looking for key terms such as stress reduction, problem-solving , regulating emotions, developing self-effi cacy , modifying perceptions , and coping strategies (Rosal, 2016b). Embracing the fact that CBT has a central place in the practice of art therapy is important and timely. For example, CBAT is now recognized as an important component of PTSD treatment. The tremendous growth in the number of treat- ment paradigms for PTSD has recently gained momentum due to the number of veterans returning from wars in Afghanistan and Iraq with trauma symptoms, as well as to a renewed focus on societal problems such as childhood physical and sexual abuse and the after-effects of human traffi cking. PTSD treatment involves numerous CBT approaches, including desensitization, coping, identifi cation and reactivation of positive emotions, and enhancing self-effi cacy (Collie, Backos, Malchiodi, & Spiegel, 2006). These authors theorized that art therapy shows promise for the treatment of PTSD, and certainly other art therapists agree with this view (Chapman et al., 2001; Pifalo, 2002, 2007; Rankin & Taucher, 2003). Other art therapists use recent CBT techniques, including cognitive restruc- turing, imagery rescripting, and mindful and meditative practices, to lessen the impact of trauma. Sarid and Huss (2010) compared the tenets of CBT with art-therapy prin- ciples. They examined two individuals with traumatic stress and anxiety, and found that both modalities provided a safe space in which to explore sensory experiences, modulate traumatic memories, construct new cognitions, and improve “the potential of creating new connections and pathways between the physical, emotional, and cognitive components of traumatic memory” (p. 10). The authors were surprised to fi nd that two seemingly different approaches (CBT and CBAT) incorporate parallel components, including “regulatory processes that decrease anxiety and negative emotional responses by inhibiting hypothalamic release of cortisol” (p. 11). These authors also hypothesize that CBT and art therapy have similar outcomes and use similar holistic method- ologies to decrease stress and thereby aid the “restructuring of more positive memories” (p. 11). CBAT is also congruent with art therapy in schools (particularly with behav- iorally disordered students; Rozum, 2001) and in the prison system (Breiner et al., 2011). In these two arenas, increasing positive, prosocial behavior is valuable both for the clients and for the settings. CBAT participants develop a sense of personal success and self-effi cacy, and these settings can become safer and more productive places to inhabit. Unravelling CBAT for Practitioners 205

A strong case for the power of CBAT is now established. CBAT does not negate the importance of the sensory, emotive capacity of art therapy. It embraces the signifi cance of these concepts for envisioning new and adaptive patterns of thinking, behaving, problem-solving, and coping. Visualizing and reframing stressful, traumatic, disturbing thoughts, actions, and events is the domain of CBAT. I imagine art therapists embracing the CBAT concepts discussed not only in this book but also in other CBAT literature. Comprehending, using, and reimagining CBAT constructs will benefi t our clients for years to come.

APPENDIX A

Kelly’s Repertory Grid and Figure List Sheet

The Repertory Grid

Source: Adapted from The Psychology of Personal Constructs (p. 270) by G. Kelly, 1955. Copyright 1991 by Routledge. Permission Pending. 208 Appendix A

Figure List Sheet 1. Write your own name in the fi rst blank here. 2. Write your mother’s fi rst name here. If you grew up with a stepmother, write her name instead. 3. Write your father’s fi rst name here. If you grew up with a stepfather, write his name instead. 4. Write the name of your brother who is nearest your own age. If you have no brother, write the name of a boy near your own age who was most like a brother to you during your early teens. 5. Write the name of your sister who is nearest your own age. If you have no sister, write the name of a girl near your own age who was most like a sister to you during your early teens.

FROM THIS POINT ON DO NOT REPEAT ANY NAMES IF A PERSON HAS ALREADY BEEN LISTED. SIMPLY MAKE A SECOND CHOICE.

6. Your wife (or husband) or, if you are not married, your closest present girl- friend or boyfriend. 7. Your closest girlfriend or boyfriend immediately preceding the person men- tioned above. 8. Your closest present friend of the same sex as yourself. 9. A person of the same sex as yourself who you once thought was a close friend but in whom you were badly disappointed later. 10. The minister, priest, or rabbi with whom you would be most willing to talk over your personal feelings about religion. 11. Your physician. 12. The present neighbor whom you know best. 13. A person with whom you have been associated who, for some unexplained reason, appeared to dislike you. 14. A person whom you would most like to help, or for whom you feel sorry. 15. The person with whom you usually feel most comfortable. 16. A person whom you have recently met whom you would like to know better. 17. The teacher who infl uenced you most when you were in your teens. 18. The teacher whose point of view you have found most objectionable. 19. An employer, supervisor, or offi cer under whom you served during a period of great stress. 20. The most successful person whom you know personally. 21. The happiest person whom you know personally. 22. The person known to you personally who appears to meet the highest ethi- cal standards.

Source: Adapted from The Psychology of Personal Constructs (p. 270) by G. Kelly, 1955. Copyright 1991 by Routledge. Permission Pending. APPENDIX B

Rhyne’s Personal Construct Drawing Template and Repertory Grid

Drawing Template

Source : From Drawings as Personal Constructs: A Study in Visual Dynamics, (p. 114), by J. Rhyne, 1979. (Unpublished doctoral dissertation). University of California, Santa Cruz. 210 Appendix B

Personal Construct Grid for Feeling/Mind States

List of feeling states: fearful, depressed, excited, passive, aggressive, serene, anxious, hoping, threatened, hostile, curious, guilty, innocent, going crazy, and being sane. Source : From Drawings as Personal Constructs: A Study in Visual Dynamics, (p. 102), by J. Rhyne, 1979. (Unpublished doctoral dissertation). University of California, Santa Cruz, CA. REFERENCES

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abstract or abstraction 44–45; abstract 139–140, 142, 165, 178–179, 192–193, thinking 44, 45, 47, 51, 53, 57, 90 195; social anxiety treatment 31–32 acceptance 3, 14, 20, 37–38, 46, 62, 79, applied behavior analysis (ABA) 64 143, 145, 149–151, 153, 162–165, appraisal 16, 34–36, 38, 110, 137, 168–170, 176–177, 183, 191, 193, 198; 156–157, 187; appraise 33, 35, 82; self-acceptance 151, 163, 178, 181, appraisal of cognitions 110; adaptive 196 appraisal 157 acceptance and commitment therapy Arnheim, R. 1, 7–8, 11, 39, 54 (ACT) 14, 153, 159–161, 179–181; Arntz, A. 23, 29–31, 132 ACT and art therapy 181–184, 198 arousal 25–26, 32, 35–38, 64, 140–141, accommodate 6, 43, 65, 195; 162, 165, 168 accommodation 41, 43–46, 52 art and cognition 53–54, 57–59, 83, 97 adaptation 6–7, 12, 34, 40–44, 46, 53, art-based mindfulness-based (ABMB) 58–60, 70, 80, 97–99, 103, 139–140, 178–179 142, 187; adaptive 2, 6, 16–17, 27–28, art-making 2–3, 6–10, 12–14, 38–40, 44, 31, 33–37, 40–42, 46, 66, 68, 70, 80, 47, 49, 52–59, 88, 130, 135, 137, 142, 98, 102, 107–109, 115, 121, 132–133, 168–169, 171–172, 182–184, 186–189, 139, 141–143, 156–157, 187, 195, 205, 191–192, 196, 198, 200–202 224 Asperger’s syndrome 111–112 addiction 7, 9; see also substance abuse assimilation 41–43, 45–46, 52–53, 56, ADHD 122, 137, 178, 217 152 altering cognitions 102, 144 Anderson, F.E. 1, 3, 95, 106, 129 Backos, A. 181–184, 193, 198, 204 antecedent 7, 38, 114, 133, 145; Bandura, A. 2, 6, 27–28, 62, 65–68, antecedent-focused emotion regulation 80–81, 89, 100, 126, 189–190, 37, 145 203 anxiety 6–7, 12, 21, 29, 62, 109–110, Bankart 146–147, 151 114, 129, 152, 159, 170, 181, 188, Bannister, D. 71, 75–76, 216 198–199 Barlow, D.H. 37, 212 anxiety treatment 25–26, 30–31, 37–38, Beck, A. 2, 6, 23–25, 27–28, 32, 36, 65, 70–71, 96, 99–100, 112, 106–107, 38, 62, 69, 100, 104, 109, 116, 144, 115–117, 120, 124, 126–127, 131, 176–177, 199 Index 229 beginner’s mind 157 identifi cation of thought 105– 107; behavior disorders 69, 87, 89, 96, 99, 101, cognitive restructuring 107–109; 202 emotions 109–112; meaning of behavior therapy 2, 4, 14, 19, 24–25, 59, emotions 112–115; transforming 61–65, 78, 80–81, 96, 102, 143, 162, emotions 115–117; feelings in vivo 186, 188–190 117–121; altering schemas 121–124; Berkeley, G. 18 creating sense of self 125; improving borderline personality disorder (BPD) 2, 6, self-effi cacy 126–127; use of imagery 29, 31, 62, 132, 144, 162–163 in 127–131; imaginal exposure 131; brain 3, 12, 20–23, 120, 154–155, 158, imagery rescripting 132–134; problem- 160, 166, 170, 178, 189, 192; cerebral solving 134–136; coping 137–139; 155 adaptation 139–141 Bruner, J. 13–14, 39–40, 50–53, 56, CBAT third wave practice: 58–59, 187 dialectic behavioral art therapy Buddha 145–148, 157; Buddhism 14, practice (DBAT): models 164; 145–149, 151–157, 159, 170, 180 acceptance ad change 164–165; Buddhist psychology 2, 14, 61, 143–149, awareness & mindfulness 165–166: 150–151, 153–159, 170, 180, 184, 190; creative mindfulness 166; structure of Buddhist psychology of cognition 143, session 167; art experiences 167–168; 151–152 suggestions for practice 168–169; Bugelski, B.R. 19–20 mindfulness-based stress reduction bulimia 31 (MBSR art therapy): for pain management 171; for cancer patients calm abiding 158 171–173; for community practice Carnes, J. vii, 13, 71, 79, 81, 83–84, 87, 173–175; mindfulness-based 89, 93, 96, 100–101, 103–104, 190 cognitive art therapy: 178–179; causal 36, 68, 104, 107, 127 acceptance and commitment art childhood abuse 11, 31, 45, 198 therapy: 179–183 203–204 cognitive correlates of meditation and Chapman 3, 204 mindfulness: determination 10, 158, chronic pain 2, 6, 22, 62, 153, 169–171, 160, 189, 191, vigilance 158, 160, 191; 181, 183, 192, 203 attention 149, 151–152, 154–155, 158, Clark, S.M. 30–31, 163–164, 168–169, 160, 166–167, 169–172, 175–177, 184, 185, 195, 197 191, 193, 196; restraint 158, 160, 191; cognition-emotion link 33–35; appraisal recollection 158, 160, 191 and emotion 35–37; 187 cognition and emotions 6, 33, 36–37, cognitive-behavior therapy (CBT) 1–2, 109–110 6–8, 10–11, 16–17, 19, 22–23, 61–78; cognition and neuroscience 148 philosophy of 13; use of imagery cognitive operations 1, 13, 56, 149, 10–11, 16–17, 19, 21–24, 28–32; 152–151, 188 dreams and CBT 25–27; dealing with cognitive processing 12, 22, 133 emotions 33, 36–38; effi cacy of 1, 6–7, cognitive psychology 13, 19, 39–40, 9, 25, 31, 62, 69–70, 102–103, 133, 51–54, 58, 61, 67–68, 71, 80, 89, 96, 144, 170, 177–178 102, 149, 152, 188–190, 192 CBT-art therapy link 5–6, 8–14, 25, cognitive restructuring 36, 107, 109 49–50, 58–60 cognitive science 2, 13–14, 19, 40, cognitive-behavioral art therapy (CBAT) 188–189, 192 history 80–101; fi rst wave 81–82; Coholic, D.A. 178–179, 184 personal constructs compassion 38, 143, 151, 157, 162, 173, CBAT 83–95; second wave 96–100; third 188; self-compassion 178 wave 186–192 compensation 53; compensatory 45 CBAT second wave practice: concentration 20, 151–152, 154–155, 160, understanding cognitions 103–105; 169, 191 230 Index

constructing cognitions 103; identifying & dysregulation 162, 166 exploring cognitions 106–107, 109; dysthymia 117 see also reconstructing constructivism 12–13, 39–40, 180, 186, 188–189, 192; eating disorders 6–7, 10, 62, 99, 132, 162, cognitive-constructivism 39, 40, 49; 181 constructivist 6, 12–14, 39–42, 46, 50, Edwards, D. 17, 24–25, 33, 37, 215 52–54, 104, 180, 188–189 Efl and, A.D. 14, 16, 41–44, 46–48, 54, coping 7, 17, 25, 28, 32, 37, 51, 57, 59, 56–58 117, 134–135, 142, 170, 175, 179, 181, Eisner, E.W. 14, 47, 53–58, 188 187, 189, 192, 203–205, 215, 220, Elkis-Abuhoff, D. 111–112, 140 222 Ellis, A. 2, 6, 34, 69, 100, 107, 147, 183, coping skills & strategies 7, 17, 25, 28, 32, 190 37, 51, 55, 57, 59, 65, 69–70, 98, 100, emotions: 103, 117, 128–129, 134–135, 137–140, emotions as constructs 84–87; emotions 142, 170, 175, 179, 181, 187, 189, 192, and appraisal 16, 34–38, 110, 112–113; 194–197, 203–204 emotions as meaning-making 112–114; covert conditioning 19 transformation of emotions 115–117; covert modeling 17, 27–28, 32, 70, 97, emotions in vivo 117–121; see also mind 137, 188 state drawings creativity 3, 16, 26, 28, 49–50, 77, 80, enhancing cognitions 145 83–84, 135, 202; creative process 3; enlightenment 157–159 creative mindfulness 166; creative epistemology 12–13, 40, 143 thinking 84; creative experience 49, equilibrium 41–44, 46; disequilibrium 72 164, 166, 173 executive function 11–12, 158 expressive therapies continuum ETC) 3, Dalai Lama 146 166, 173–174, 218–219, 224, 226; Darwin, C. 34, 40 see also media dimension variables daydreams 25–26, 90, 128 decentering 70, 153, 158, 166, 176–178, faulty cognition 69–70, 104–105, 141 200 fi rst wave or generation CBT 63, 81 depression 6–8, 22–23, 25–26, 28, 31–32, fl exibility 9, 56, 58–59, 160, 180–181; 62, 69, 110–117, 131–132, 135, 153, fl exible 7, 34, 137, 168 165, 170, 175, 178, 181–184, 192, 194, Four Noble Truths 148, 150, 159 199–200; see also relapsing depression Freud, S. 17, 24, 34 descriptive purpose 155–156, 159 functional contextualism 180 determination 10, 158, 160, 189, 191 dialectical behavior therapy (DBT) 14, 62, Gantt, L. 60, 132–134, 192–193, 197 78, 144, 161–163, 165, 169 Garai, J.E. 3–4 dialectical behavior art therapy (DBAT) generalized anxiety disorder (GAD) 126, 164–169 198–199 disability 100; disabilities 10, 64, 96, 100, Gestalt 4, 24, 37, 188 190, 211, 222; disabled 75 Goldfried, R. 33, 36–37, 70, 88, 102, 137 discursive cognition 149, 157 guided imagery 20, 37, 99, 128–131, 142 distress 6, 17, 21, 23–24, 29–31, 36–38, Gussak, D. 135–136, 196, 202 43–44, 59, 107, 188, 191–192, 194; distress tolerance 162, 167–168, 172, Hackmann, A. 17, 21, 25, 29–32, 60, 189 176–177, 184, 188 Hatha Yoga 170 Drass, J.M. 167–168, 184, 195, 201 helplessness 37, 69, 114, 116 dreams 17, 20, 25–28, 32, 77, 198; Herbert, J.D. 1, 61, 143–144, 147, dream imagery 24–28, 32; dream 152–153, 181 interpretation 17, 26; dream log (DL) here and now 24, 39, 82, 133, 146, 155, 26 176–177, 188, 191 dyslexia 226 Herring, D. 174–175, 201 Index 231

Hofmann, S.G. 6, 33, 36–37, 62, 69, 102, imaginal exposure 31, 131–132, 142, 182, 104, 144–145 193 Holmes, E.A. 17, 20–21, 23–25, 29–31, 38 inner life 52, 58 hot seat 24 in situ 25, 64 hotspot moments 30, 194, 199 in vivo 36–37, 78, 99, 117, 141, 166 Huckville, K. 164–165, 191, 195, 200 Intensive Trauma Therapy (ITT) human traffi cking 204 132–133, 24, 193; Instinctual Trauma Huss, E. 5, 12, 128, 133, 194, 198, 204 Response 197 irrational beliefs & responses 8, 69, 102, imagery 9, 17–19, 21–22, 37–38, 44, 188, 198, 201 53, 56, 59, 64, 67, 71, 80, 83, 88–89, irrational thinking 97, 109, 147, 196, 199, 97–99, 101–103, 109, 128–132, 200–201, 203, 8, 69, 102, 109, 147, 141–142, 152, 154–155, 160, 186–189, 188, 196, 198–201, 203 192–193, 198–199, 202, 204, 211–213, Isis, P. 173–175, 196, 202 215, 217–221, 223, 225, 227; mental image or imagery 7, 9, 11, 13, 16–20, Janet, P. 17, 28, 30, 32, 218 22–24, 39, 46; 51, 53, 55–56, 59, 81, Jung, C. 16–17, 218; Jungian 4, 215 103, 154–155, 160; dream imagery 9, 17, 24–29, 32; see also guided Kabat-Zinn, J. 2, 22, 62, 149, 153, imagery 169–177, 183, 202–203 imagery and affect/emotion 19–20, 29, 38 Kagin, S. 3, 168 imagery assessment 22–23 Kazdin, A.E. 17, 70, 88, 103, 134, 137 image-making 11, 54, 57, 120; drawn Kelly, G. 4, 13, 40, 71–72, 74–78, 81, image 9, 75, 81–83, 89, 96 83–85, 87–88, 90, 93, 99–101, 103, imagery and memory 20–21, 27, 59 105, 190, 201, 207–208 imagery and neuroscience 21–23 knowledge acquisition 40–41, 43, 47, imagery and perception connection 14, 50–53; knowledge building 53, 55–59, 18–19, 21–22; 51, 59 152, 188 imagery and self-effi cacy 7, 27–28, 80–81 Kosslyn, S.M. 18, 22, 154 images of the self 17, 108, 122 Kramer, E. 3–4 imagery in behavior therapy 24–25, 59, Kreitler, H., Kreitler, S. 35–36 64–65 Kuan, T.F. 146–148, 151–155 imagery in cognitive-behavioral art Kudesia, R.F. & Nyima, V.T. 148–150, therapy (CBAT) 80–83, 88–89, 153, 155–160 96–100, 102, 106, 108–109, 121–122, 127–134, 137–139, 141–142, 164, 166, Lazarus, R.S. 25, 31, 34–36, 38, 62, 110, 186–204 112, 115, 137, 158, 187 imagery in cognitive-behavioral therapy learning theory 27, 43 (CBT) 21–24, 29, 44, 59, 67, 70–71, Linehan, M. 144, 147, 161–163, 165–166, 80; image restructuring 19, 21, 30–31; 169, 177, 183 image rescripting (IR) 23, 30–31; liquidation 45, 53 decreasing intrusive or traumatic locus of control (LOC) 12, 16, 66–67, images/memories 21, 23, 29–30, 32, 87–90, 98–100, 135 121; imagery disruption 30; imagery Lorenzo de la Pena, S. 3, 167–168, 191, rehearsal 29; fostering positive imagery 195, 201 29, 31–32 loving kindness meditation 151, 157, 188 imagery in general treatment 21–23, 29, Lusebrink, V.B. 3, 7, 20, 45, 89, 128–129, 59 168 imagination 16–18, 54–57, 64, 70, 78, 84, 88–89, 128, 145, 17 Mahoney, M.J. 66, 68–69, 71, 134 imagine 12, 17, 20, 22, 25–26, 28, 32, 55, Matto, H.C. 7–11, 13, 99–100, 103–104, 64, 70, 78, 88–89, 128, 131, 138, 157, 186, 189, 196, 202 160, 186, 188; see also reimagine media dimension variables 168 232 Index

meditation 2, 14, 22, 62, 146–155, Paivio, A. 17, 19, 30–31 157–161, 169–172, 175, 177, 190–191, Pavlov, I.P. 63–64 202–203; mindful meditation 2, 22, 62, Pearson, D.G. 21–23, 29, 38 152, 154, 158–161, 169, 171–172, 191; perception 8, 14, 18–19, 21–23, 33, see also loving, kindness meditation 36–37, 47–48, 51, 54, 57, 59, 71–72, meditative 2, 20, 143–144, 148, 154, 102, 105, 115, 144, 147, 154–157, 160, 158–160, 170, 183–184, 204 171, 190; self-perception 77, 140 Meichenbaum, D. 2, 17, 28, 62, 68–70, Perky, C.W. 17–18, 21 88, 100, 137, 189–190 Perls, F. 24, 37 memory 24, 30–31, 36–38, 42, 44, personal construct theory 4, 71–78; 48–49, 59, 71, 98, 118, 152, 154–155, personal construct psychology 89, 158, 182, 187–188, 190– 191, 199; 96, 101, 199; personal construct memory and mental imagery 19–21, system 72–78, 83; personal construct 23, 132–132; memory and intrusive drawings 84, 99–100; see also Kelly; see or traumatic imagery 29–31, 120, also repertory grid; see also mind-state 130–133, 192–194, 204 drawings meta-awareness 149, 153–154, 158, 160 Peterson, C. 171–172, 174–175, 184, 197, metacognition 56, 60, 149, 152–153, 160, 203 191; metacognitive 29, 152–153, 176 phobias 21, 24–25, 29, 32, 64, 69, 97, Miller, N.E. & Dollard, J. 6, 67–68, 97, 132, 142 99–100 Piaget, J. 13–14, 17, 24, 39–48, 50, mindfulness 2, 24, 29, 37, 61–62, 143–145, 52–54, 56–59, 103, 152, 187, 223, 226 151–155, 157–158, 160, 161, 163, Piagetian 24 165, 169–172, 174–183, 185, 189–192, Pifalo, T. 11, 110, 112, 193, 198, 204 196–197, 201; defi nition of 148–149 prescriptive purpose 156 mindfulness-based cognitive therapy problem behavior 2, 7, 10, 28, 63, 70–71, (MBCT) 175–178, 200; MBCT and art 78, 82, 88, 100, 102, 104, 111–112, therapy 178– 179 115, 138, 162–163, 165, 169, 195–196, mindfulness-based stress reduction 200, 202–203 (MBSR) 161, 169, 170–171, 202; problem focus 8–9, 12, 16, 41, 77–78, MBSR and art therapy 171–175 102, 128, 183 mind-state drawings 84–85, 87, 93 problem identifi cation 77, 102, 142 Morris, F. 105–107, 109, 194, 198 problematic images & memories 21, 29, 31, 44, 98, 127, 189, 193–194 neurological 3, 59, 166 problems, reframing of 9, 189; neurology 23 reconceptualize problem 28; neuroplasticity 166 externalizing the problem 189 neuropsychology 149 problematic schemas 41, 87, 156, 158, 196 neuroscience 21, 23, 33, 38, 158 problem situations 24–25, 46, 100, 108, Noble Eightfold Path 148, 150–151 127 nonjudgmental stance 3, 149, 153, 160, problem-solving 7–9, 11, 39, 54–55, 67, 164, 166–168, 176–177, 184, 191 69–71, 83, 88–89, 96–97, 103, 129, 134–137, 139, 142, 163, 166, 189, 196, obsessive-compulsiveness disorders 31, 200, 202, 204–205 132, 170 problematic thinking 12, 21, 24–25, 28, operant conditioning 63, 81 30, 32, 46, 64, 69, 72, 74, 78, 82–83, operations 41, 44–45, 51–52, 57, 149, 97–98, 102–107, 110–112, 114–115, 151–152; cognitive operations 1, 13, 122, 127, 138, 141, 155–158, 162–163, 56, 67, 151–152, 188; preoperations 44 169, 176, 182, 189, 191, 193, 198–199, outcome(s) 1, 3–4, 10, 44, 48, 55, 57, 59, 201–203 67, 70, 88, 103, 114, 135, 139, 142, 151, prompt 10, 75, 81–82, 91, 96, 98, 156, 159, 170, 172, 175, 181, 193–194, 204 164, 172; prompting 10, 82, 200 Index 233

PTSD 6–7, 21, 29–32, 37–38, 45, 60, Rhyne, J. 4–5, 7, 13, 60, 71–72, 79, 117, 120–121, 132–133, 177, 181–184, 81, 83–90, 93, 96, 99–101, 103–105, 192–193, 198, 204 110–112, 190, 194, 199, 201 Roghanchi, M. 5, 8, 140 rational-emotive therapy (RET) 69, 190; Rosal, M.L. 7–11, 87, 95–100, 102, 106, rational-emotive behavior therapy 108, 113–114, 118, 123, 129, 134–135, (REBT) 140, 147, 183 138, 141, 194, 196, 204 Ravenette, T. 76–77, 90, 196, 201 Roth, E. 4–5, 7, 10, 15, 80–82, 87, reality shaping 4, 10, 80–82, 86, 96, 96–98, 100–101, 190 97–98, 190, 200; reshaping 81 Rotter, J.B. 6, 66–67, 87, 100, 190 reconstructing 37, 82, 102, 133, 188, 194 Rubin, J. 3–4, 12, 98–99, 113–114, 118, regulation (behavioral) 2, 27–28, 37, 49, 141 65, 80, 145, 169; emotional regulation Russell, B. 2, 33 162, 165–168, 173, 175, 179, 184, 189, 195, 200; dysregulation 162, 166; see Sarid, O. 5, 12, 128, 133, 194, 198, 204 also self-regulation; see also antecedent- schema 10, 24, 27, 31, 36, 38, 41–46, focused emotional regulation, see also 60, 82, 132, 154, 187, 196, 201; self- response-focused emotional regulation schema 103, 105–106, 108, 121–122, reimagine 10, 49, 188, 199 128, 141–142, 150, 153, 156–157, 159 reinforcement 10–11, 32, 62, 64–66, scheme 41, 60 81–82, 96, 98, 189–191, 198; second wave or second generation CBT reinforcing 10, 81, 181, 200 2, 14, 61–62, 67, 77, 80–81, 83, 87, 96, relapsing depression 2, 62, 144, 150, 153, 143, 186, 189–190 176, 179 Segal, Z.V. 62, 144, 150, 153, 175–179, relational frame theory (RFT) 180, 183 183 relaxation 20, 25, 70, 88–89, 100–101, self 30, 32, 48, 70, 83, 92, 105, 116, 122, 146, 168–170 124–125, 152–153, 155–156, 159, 168, relaxation exercises & techniques 7, 32, 179–180, 195 37, 65, 70, 89, 96–97, 100, 128–129, self-administer 65 131, 133, 137, 139–140 self-agency 126–127 repertory grid 74–75, 77, 84, 90, 207–210; self-attributes 124 see also research (repertory grids) self-awareness 28, 80, 139, 173, 179, research (CBT) 1, 5, 61–64, 68, 103, 144, 184–185, 199 179–181, 192, 199 self-beliefs 122 research (Buddhist psychology, self-care, self-help, self-soothing 69, 100, mindfulness) 146, 151, 169–170, 132–133, 148, 157, 163, 166, 168, 176–177 194–195 research (art therapy) 1, 84, 87–88, 129, self-cognition 105 133–136, 140, 165, 175, 179, 182–183, self-concept (identity) 75, 122, 125 184, 201, 203 self-control 9, 11–12, 16, 17, 28, 34, research (development of cognition) 40, 65–67, 80–81, 97–100, 139, 146, 203, 44 189, 194 research (dreams & daydreams) 25, 31 self-description 76 research (emotions) 34–35, 110 self-directed 65 research (mental imagery) 17–23, 25–26, self-drawing 122 29, 31, 154 self-esteem (confi dence, worth) 121, 127, research (self-effi cacy) 27 137, 139–140, 151, 164, 170, 173, 184, research (repertory grids) 75–76 195, 196 resiliency 137, 139–140, 142 self-exploration in treatment 3, 125 response-focused emotional regulation self-expression 3 37, 145 self-evaluate or self-appraise 65–67, 89, Reynolds, F. 5, 7–8, 11, 99–100, 131, 140 110 234 Index

self-effi cacy 12, 16, 27–28, 65–67, 70, symbol 18, 44–47, 51, 53, 59, 135–136, 80–81, 121–122, 126, 138, 140–141, 141, 187–189; see also symbolic 170, 188–189, 196, 203–204; see also system imagery and self-effi cacy symbols in behavior therapy 27, 64 self-harm 2, 161, 166, 184, 203 symbol in human development 41–42, self-image 17, 98, 108, 122 44–47, 50–53, 83, 187 self-instruction training 69, 88 symbol in meaning-making 171, 188 self-knowledge 50, 72, 141 symbolic play 45, 187; primary symbols self-object awareness 155 45, secondary symbols 18, 45 self-observation 24, 83, 146 symbols of self 135–136, 141, 189, 197, self-preservation 151 203 self-regulation (management) 27–28, 41, system 27, 47, 63, 65, 72–78, 83–84, 150, 48, 52–53, 80, 103, 202, 139, 158, 162, 203–204; feedback system 10, 191; 169–171, 175, 189 neural system 18, 22; symbolic system self-reinforcing 65, 67, 69, 81 18, 48; support systes 137; belief system self-schema 103, 105, 108, 121–122, 124, 143 128, 141–142, 150, 153, 156–157, 159 systematic desensitization 7, 17, 19, 21, self-symbols 135–136, 203 24–25, 27–28, 32, 64–65, 70, 96–100, self-talk (statements) 17, 28, 69–70, 80, 137, 188, 19 108, 139, 157, 194, 199 Singer, J.L. 18–19, 26–28, 31–32, 71, 80, traumatic brain injury (TBI) 120–121 128 Teasdale, J.D. 62, 110, 112, 144, 150, Skinner, B.F. 2, 33–34, 63–64 153–154, 175–176 social learning theory 2, 6, 64–68, 70, 78, theoretical orientation 7, 12 80; social cognitive theory 68; social therapy outcome(s) 1, 3–4, 10, 44, 48, learning and social cognitive theory 68; 55, 57, 59, 67, 70, 88, 103, 114, 135, social learning and cognition 78 139, 142, 151, 159, 170, 172, 175, 181, socio-cultural cognition 47, 53 193–194, 204 Spivack, G. & Shure, M.B. 69, 88, 100, third wave CBT or third generation 134 CBT 2, 6, 14–15, 29, 38, 61–62, 79, stoicism 2, 33–34 143–150, 155, 159, 161, 179, 184, stress 88, 96, 100, 129, 131, 135, 139, 186–187, 189–193, 200, 202–203 142, 169–170, 174–175, 177, 196–197, Tinnin, L. 60, 132–134, 192–193 200, 202, 221; stress-related disorders Tirch, D. 144–148, 151, 160 170, 173, 175, 197–198 Toneatto T. 143, 152 stressful 24–25, 32, 70, 131, 137–139, 142, 163, 175, 194, 202, 205 Visnola, D. 138, 196, 202 stressors 45, 100, 137, 142, 170, 173, 197 von Glasersfeld, E. 13, 40–44, 46–47, 59, stress inoculation 70, 88, 96–98, 100, 137 166, 195 stress relief, reduction, regulation, Vygotsky, L.S. 13–14, 39–40, 44, 47–50, resistance 7, 97–98, 126, 129–130, 52–53, 56, 58–60, 188 137–138, 158, 167, 169– 171, 174, 196, 198, 202, 204 walkabout 172, 197, 203 substance abuse 6, 9, 62, 202; see also Western psychology 146–149, 151–152, addiction 154–155, 158, 183 suffering 7, 26, 28, 32, 45, 132, 145–147, Watson, J.B. 2, 17–19, 33–34 150–151, 155, 157, 160, 171, 180; Wilson, G. 62, 64–65, 67, 70, 182 alleviation of suffering 147–148, 155, Wolpe, J. 17, 24–25, 70 159, 181 suicidal 111, 162, 183; suicidality 31; Zettler, A. 117, 119, 124–127, 194–195, suicide 116, 161, 199 199