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