VISUAL JOURNALING IN TREATING 1

Visual Journaling in Treating Childhood Trauma

Matthew Warner, BA

A Thesis Submitted in Partial

Fulfillment of the Requirement

For the Master of Arts in Art Therapy Degree

Department of Art Therapy Graduate Program

Saint Mary-of-the-Woods College

Saint Mary-of-the-Woods, Indiana

May 10, 2021

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 2

ABSTRACT

This researcher investigated the effects of visual journaling on children with trauma symptoms.

Each participant was administered the Child PTSD Symptom Scale (CPSS) before and after each of the five art therapy sessions administered utilizing the “Check, Change What You Need to

Change and/or Keep What You Want” art therapy protocol. The participants then completed an exit interview. The results indicated three overarching themes. These included: (a) trauma symptoms (i.e. , flashbacks, negative feelings, and hyperarousal); (b) quantity and quality of sleep; and (c) overcoming adversity. The results suggested that visual journaling can be used to reduce trauma symptoms in children. The researcher discussed limitations of the current study and possibilities for future research.

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 3

TABLE OF CONTENTS

ABSTRACT ...... 2

LIST OF FIGURES ...... 5

I. INTRODUCTION ...... 6 Problem Statement ...... 6 Research Question(s) ...... 7 Basic Assumptions ...... 7 Statement of Purpose ...... 8 Definition of Terms...... 8 Justification of the Study ...... 9

II. LITERATURE REVIEW ...... 10 Childhood Trauma and Abuse in the United States ...... 10 Challenges of Traumatized Children ...... 11 Trauma and the Brain ...... 17 Developmental Theories ...... 18 Current Treatment Methods ...... 23 Art Therapy and Trauma Therapy ...... 26 Neurobiological-based Art Therapy ...... 29 Expressive Therapies Continuum ...... 31 Visual Journaling ...... 32 Summary ...... 33

III. METHODOLOGY ...... 35 Participants ...... 35 Research Design ...... 35 Research Instruments ...... 36 Data Collection ...... 40 Data Analysis ...... 40 Validity and Reliability ...... 43 Ethical Implications ...... 44 Researcher Bias ...... 44

IV. RESULTS ...... 45 Trauma Symptoms ...... 45 Decrease in Trauma Symptoms ...... 45 Increase in Trauma Symptoms ...... 46 Decrease in Anxiety and ...... 46 Emotional Responses ...... 48 Better Quantity and Quality of Sleep ...... 52 Overcoming Adversity ...... 53

V. DISCUSSION ...... 56 Trauma Symptoms ...... 56 Decrease in Anxiety and Depression ...... 57 VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 4

Emotional Responses ...... 57 Better Quantity and Quality of Sleep ...... 58 Overcoming Adversity ...... 59 Limitations ...... 59 Recommendations ...... 60 Conclusion ...... 60

REFERENCES ...... 62

APPENDICES ...... 85 APPENDIX A: Art Directives ...... 85 APPENDIX B: Exit Interview ...... 89 APPENDIX C: CPSS Scores Table ...... 90

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 5

LIST OF FIGURES

Figure 1. Thematic Analysis Chart ...... 42

Figure 2. Emily’s Drawing “Strengths” ...... 47

Figure 3. Ashley’s Trauma Timeline, Something Ashley Felt Comfortable Depicting ....48

Figure 4. Ashley’s “Something You Can Change” Drawing ...... 49

Figure 5. Ashley’s Optimistic Future...... 50

Figure 6. Emily’s Something You Could Change” Drawing ...... 51

Figure 7. Emily’s Optimistic Future ...... 52

Figure 8 Ashley’s Strengths, Strength’s Part II ...... 54

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 6

CHAPTER I

Introduction

According to Van Westrhenen and Fritz (2014), and Van Westrhenen et al. (2017), trauma has been a growing problem, especially for children. Research indicated that being exposed to traumatic events can leave children feeling stressed, anxious, and worried (Van

Westrhenen, 2017). These findings inspired this researcher to investigate this issue and find a possible solution to this growing concern. Many researchers have already studied possible art therapy treatments to help individuals including adults and children suffering from trauma- related issues (Carr & Hancock, 2017; Elbrecht & Antcliff, 2014; Hass-Cohen et al., 2014, 2018;

Homer, 2015; Kalmanowitz & Ho, 2016; Stace, 2014; Schouten et al., 2013; van Westrhenen et al., 2017, 2019). Visual journaling is one art therapy method that has limited research. Gannim and Fox (1999) created and developed the visual journaling technique and described the process as getting into one’s innermost idea of what a feeling, thought, or emotional response would appear to look like if it were expressed as a color, shape, or line. Visual journaling starts with guided imagery, then moves into creating the image by drawing or painting it and ends with processing questions so clients can write about or dialogue with their imagery (Gannim & Fox,

1999).

Problem Statement

Westrhenen and Fritz (2014) felt that traumatized children need more effective help to process through their trauma and eventually get past it. Children may experience many challenges and tragedies such as abuse, household violence, terrorist attacks, community violence, and natural disasters (Westrhenen & Fritz, 2014). Perry (2001) believed that many countries, the United States included, find themselves in a climate of violence and abuse that may leave children vulnerable to posttraumatic and trauma, and subsequently, they often VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 7 have problems developing relationships based on healthy attachments. This has led to a growing population of traumatized children with problems functioning in daily life and in need of assistance to help with coping skills. After being exposed to a traumatizing event, around 70% of children develop a stress reaction during the first month after the event (Gunes & Guvenmez,

2020). Nineteen percent of injured and 12% of physically ill children have Post Traumatic Stress

Disorder (PTSD; Kahana et al., 2006). Worldwide, it was estimated that around 1 billion children aged 2-17 years have experienced physical, sexual, or emotional violence in the past year (Hillis et al., 2016).

Research Question

This study was guided by the following question, what are the effects of visual journaling in reducing trauma symptoms (flashbacks, nightmares, negative feelings, and hyperarousal) in children?

Basic Assumptions

The researcher believed that teaching children how to draw and reflect on thoughts and feelings surrounding their trauma or immediately journaling when experiencing trauma symptoms could help to reduce trauma-related symptoms such as the reduction of flashbacks, nightmares, intrusive thoughts, and hyperarousal. It was assumed that visual journaling can help to reduce trauma symptoms in children between the ages of 10 and 13 years old. There was limited literature on the effectiveness of visual journaling with children. There was some evidence to support the effectiveness of visual journaling. Sackett and McKeeman (2017) indicated their support for visual journaling and even used a case example to show that the client was able to understand her body image issues better than through verbal methods. Gibson (2018) reported that visual journaling helped with vicarious trauma. While these studies included adult VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 8 participants, one might assume based on these studies that visual journaling could also potentially be effective for children.

Statement of Purpose

The purpose of this study was to investigate the effectiveness of visual journaling on trauma symptoms in children. The results of this study may help to advance the field of art therapy by evaluating and providing more support for the effectiveness of visual journaling as treatment modality. They may also be used in the development of more specific art therapy protocols used to treat trauma in children.

Definition of Terms

Trauma

Trauma was defined as direct exposure or interaction with actual or threatened violence, death, or sexual abuse (APA, 2013). The person can either experience the traumatic event firsthand, witness the traumatic event, learn that that the event occurred to a family member or close friend, or experience repetitive exposure to graphic details of the traumatic event (APA,

2013).

Hyperarousal

This was defined as fear or anxiety that may be triggered by a reminder of the past trauma (Westrhenen & Fritz, 2014). The individual may become very reactive, edgy, and alert about their surroundings. Physiological changes occur such as increased heart rate, a rise in blood pressure, rapid breathing, and the release of adrenaline.

Posttraumatic Stress Disorder (PTSD)

This disorder was characterized by overwhelming feelings of reexperiencing the traumatic event, avoidance of trauma triggers, negative thoughts and feelings, and arousal and reactivity (Westrhenen & Fritz, 2014). VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 9

Victim Mythology

A type of belief that the trauma victim perpetuates that they hope to simply survive and the best guide to living is keeping one’s guard up (Tinnin et al., 2002).

Justification of the Study

This researcher works with traumatized children with PTSD almost every day. He sees these children struggle in school, lose interest in the activities they enjoy, are fearful about everyone and everything, and always seem to be on the lookout for danger. This researcher would like to find another effective art therapy or treatment technique that can help lessen or alleviate symptoms of trauma in children. Therapists have reframed how they interact with clients who have symptoms acknowledge that those symptoms are the body’s responses to upsetting events as a result of this recognition (Malchiodi, 2015).

This study may provide support for art therapy as an important component in the treatment of childhood trauma. Many studies have already shown the important impact that art therapy has had on the treatment of trauma (Carr & Hancock, 2017; Elbrecht & Antcliff, 2014;

Hass-Cohen et al., 2014, 2018; Homer, 2015; Kalmanowitz & Ho, 2016; Schouten et al., 2019;

Stace, 2014; van Westrhenen et al., 2017, 2019). There was also research on how visual journaling can help therapists cope with vicarious trauma (Gibson, 2018). Other researchers used a case example to illustrate visual journaling’s effectiveness (Sackett & Mckeeman, 2017).

However, there was a gap in the research on whether visual journaling works for actual trauma survivors. Most of the previous research studies cited were studies with adult survivors. There seems to be a lack of research on trauma in child survivors and this study may support the use of visual journaling as an effective way to help treat trauma symptoms in children.

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 10

CHAPTER II

Literature Review

Between 2010 and 2020, statistics have shown that childhood trauma and abuse in the

United States is on the rise. Research suggests that children suffering from trauma face many challenges including susceptibility to disease later in life, mental illness, social, emotional, and cognitive problems. Current treatments include creative arts therapy, cognitive behavioral therapy, and play therapy. A review of the literature indicated that there may be a developmental and neurobiological basis to trauma and that neurobiologically-based art therapy may be an effective treatment of trauma. The use of the Expressive Therapy Continuum (Kagin &

Lusebrink, 1978) can help in the treatment of trauma.

Childhood Trauma and Abuse in the United States

According to the National Center for Mental Health Promotion and Youth Violence

Prevention (2012), 26% of children in the United States witness a traumatic event by the time they turn four years old. Four out of every ten children in the United States reported that they have experienced a physical assault during the past year, with one in ten children receiving an assault related injury (Finkelhor et al., 2013). Over two thirds of children in the United States reported at least one traumatic event in their lives by the age of 16 years old (Copeland et al.,

2007). Two percent of all children have experienced sexual assault or sexual abuse during the past year, the rate at nearly 11% for girls aged fourteen to seventeen (Finkelhor et al., 2013).

According to the Child Welfare Information Gateway (2013), every year approximately 10 million children in the United States have been exposed to domestic violence. However, this was thought to be an under reporting because a lot of child exposure to domestic violence was not reported, so the exact number was unknown (Child Welfare Information Gateway, 2013). Nearly VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 11

14% of children reporting abuse experienced maltreatment by a caregiver, including nearly 4% who experienced physical abuse (Finkelhor et al., 2013).

In the United States in 2018, the national average for victims of child abuse and neglect was 678,000 (U.S. Department of Health and Human Services et al., 2018). One in four children was the victim of robbery, vandalism, or theft during the previous year (Finkelhor et al., 2013).

Each year in the United States, the number of children needing hospital attention due to physical assault related injuries would fill every seat in nine stadiums (National Center for Injury

Prevention and Control, 2014). Finkelhor et al. (2013) found that more than 13% of children reported being physically bullied, while one in three said they were emotionally bullied, and one in five children witnessed violence in the family or the neighborhood during the previous year.

Challenges of Traumatized Children

Children may experience a lot of challenges including trauma and abuse, acute and chronic illness, emotional dysregulation, mental illness, and school and relationship issues.

Trauma and Abuse

Children face many challenges/tragedies such as household violence, community violence, terrorist attacks, and abuse that can cause trauma (van Westrhenen & Fritz, 2014).

Abuse includes physical, emotional, verbal, and sexual abuse. Researchers have found that children respond differently to trauma then adults based on development and the relationships with their caregivers that contribute to their resiliency (van Westrhenen & Fritz, 2014). These researchers found that an event that seems insignificant to an adult could be overwhelming to a child. This difference alone makes it difficult to define trauma in children. Children exposed to traumatic events such as abuse and interpersonal violence were more likely to experience psychological problems such as depression, suicidal ideation, and (Jewkes et al.

2010; Suliman et al., 2009). VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 12

Acute and Chronic Illness

Trauma effects children in many ways. There was a direct link between trauma and a person eventually developing a life threatening and chronic illness later in life (van der Kolk,

2005). Meyers found that children may also develop liver disease, cancer, obesity, heart disease, and chronic obstructive pulmonary disease (Meyers, 2014). One study found that those who suffered childhood physical or psychological victimization had poorer health than those who did not and experienced a far more significant health decline over a 10-year period in adulthood

(Greenfield & Marks, 2009). Childhood traumatic experiences have been linked to chronic disease in adulthood deriving from poor immune system functioning or poor heart health

(Mulvihill, 2005; O’Rand & Hamil-Luker, 2005; Springer et al., 2003; Wickrama et al., 2005).

Another study found that odds ratios to get chronic conditions increased between 1.48 for arthritis and 2.7 for chronic pain for individuals who were exposed to trauma as opposed to those that were not (Atwoli et al., 2016). Sexual and physical abuse, unexpected death or traumatic injury or event happening to a loved one increased the odds of nearly all chronic physical conditions (Atwoli et al., 2016). PTSD and other mental disorders have been associated with poor physical health (Boscarino, 2004, 2008; Kubzansky & Koenen, 2009; Qureshi et al., 2009;

Scott et al., 2011). There is evidence that the PTSD symptom of hyperarousal caused led to conditions such muscle tension in localized areas and all over the body, hyperventilation, high blood pressure and increased heart rate, and abnormal endocrine and immune system reactions

(Gupta, 2013; Morina et al., 2018). The autonomic nervous system and the polyvagal nervous system, parts of the limbic system, are responsible for emotional regulation and are also damaged in early relational trauma (Schore, 2003b).

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 13

Emotional Dysregulation

A child’s thoughts and emotions may become dysregulated due to trauma (Richardson,

2015). Emotional dysregulation involved not being aware of or understanding emotions, being impulsive and losing control due to being upset, not accepting one’s emotions, and not being able to regulate emotions such as anger (Erwin et al., 2002; Gratz & Roemer, 2004; Novaco &

Chemtob, 1998). Some emotional problems and challenges traumatized children faced were fear, anxiety, anger, excessive worrying, and depression (Malchiodi, 2015). Children feel helpless, hopeless and disempowered after experiencing trauma (Steele & Raider, 2009). Research also correlated emotional dysregulation with aggressive behavior (Neumann et al., 2010). Research has showed that difficulties with regulating emotions was common among and were key to the development of mental health disorders later in life including substance use disorders, PTSD, depression, and binge eating (Cole et al., 1998; Hopfinger et al., 2016; Jennissen et al., 2016;

Saxena et al., 2011). Emotional dysregulation has lead to problems handling negative emotions and impair functioning, affecting the ability to work, be accepted and understood by others, and enjoy life (Gross, 1998; Kulkarni et al., 2013).

Children that grew up in emotionally abusive homes may have contributed to emotional regulation problems such as avoiding and suppressing emotions (Burns et al., 2012). As a result, individuals have used maladaptive coping skills such as binge eating or substance abuse later in life to avoid or suppress emotions (Heatherton & Baumeister, 1991). Emotional dysregulation was a known factor connecting childhood abuse with adverse outcomes (Cloitre et al., 2006;

Heleniak et al., 2016; Jennissen et al., 2016; Messman-Moore et al., 2017; Moretti & Craig,

2017). For example, childhood abuse was associated with internalizing and externalizing behaviors as well as bad peer interaction among children (ages 6-12) through emotional dysregulation (Kim & Cicchetti, 2010). VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 14

Mental Illness

Posttraumatic Stress Disorder. Children who suffer trauma often develop disorders such as Posttraumatic Stress Disorder (PTSD; Carr & Hancock, 2017). To diagnose PTSD, a child must have been exposed to possible death, serious bodily harm, or sexual abuse through experiencing the traumatic event, witnessing the traumatic event, finding out that a friend or family member experienced the traumatic event, or indirect exposure to details of the traumatic event (APA, 2013). The child must also have one of the following symptoms from Criterion B for over a month; intrusive and upsetting memories of the event, nightmares, flashbacks, becoming emotionally distraught after exposure to reminders of the trauma, or reacting physically after exposure to trauma reminders (APA, 2013).

The child must have one of the following symptoms from Criterion C for over a month, avoiding trauma-related thoughts or feelings or avoiding trauma-related external reminders

(APA, 2013). The child must have two of the following symptoms in Criterion D for over a month; inability to remember an important aspect of the traumatic event, constant and overstated negative beliefs about the world, self, and others, constant cognitive distortions about the cause of traumatic event that causes one to blame themselves or others, constant negative emotional state, diminished interest or participation in activities, feeling detached or estranged from others, or constant inability to experience positive emotions (APA, 2013). The child must also have two of the following from Criterion E for over a month; irritable behavior or angry outbursts in the form of physical or verbal aggression towards people and objects, self-destructive or reckless behavior, hypervigilance, exaggerated startle response, problems with concentration, or sleep disturbance (APA, 2013). Children can regress to early stages of childhood because of trauma

(Carr & Hancock, 2017). VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 15

Major Depressive Disorder. Major Depressive Disorder (MDD), according to the DSM-

V (APA, 2013), was a characterized by a depressed mood or loss of interest or pleasure in daily activities for more than two weeks. The depressed mood was a change from the person’s baseline mood (APA, 2013). To diagnose MDD, person must have five or more out of these nine symptoms nearly every day for at least two weeks. These symptoms include: (a) being depressed or irritable most of the day nearly every day through either self-report (e.g., feels sad and depressed) or through observation of others (e.g., appears to be crying); (b) decreased interest or pleasure in activities, almost all of each day, significant weight loss or gain (5%) or change in appetite; (c) not sleeping () or sleeping too much (); (d) or retardation; (e) fatigue or loss of energy; (f) feelings of guilt or worthlessness; (g) inability or diminished capacity to think or concentrate; and (h) thoughts of death or suicide, or has a plan (APA, 2013).

MDD can lead to suicide, increased death risk, and cognitive decline (Reddy, 2010).

These can be alarming consequences of what childhood trauma can do to child. Numerous studies showed that depression was the result of biopsychosocial interactions (Cattapan-Ludwig

& Seifritz, 2010). Previous studies have found that experiencing maltreatment in childhood was linked to a two-fold increase in risk for depression in adulthood (Li et al., 2016). Another study found that participants who experienced multiple adverse childhood experiences were more likely to report an increase in depressive symptoms (Poole et al., 2017). These findings supported the kindling hypothesis that childhood trauma can lower a person’s stress threshold to activate depression (Monroe & Harkness, 2005, La Rocque et al., 2014). Nelson et al. (2017) felt that childhood trauma and depression obviously share a link and was a risk factor for Major

Depressive Disorder. VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 16

Anxiety Disorders. Childhood trauma was also a risk factor for anxiety disorders (Kuo, et al., 2011). Anxiety disorders were categorized by symptoms such as excessive worry or fear and ensuing avoidance (APA, 2013). Hovens et al. (2010) found that individuals who reported events such as emotional neglect, physical, or sexual abuse were two times more like to report a current than those without a history of childhood trauma. Based on statistics and findings from an international survey taken from over 50,000 adults, the World Health

Organization suggested that eliminating adverse child events such as abuse and neglect would lead to 31% decrease in anxiety disorders worldwide (Kessler et al., 2010). Increased symptoms of anxiety represent a large public health concern, and were related to significant functional impairment (Lowe, et al., 2008), high rates of comorbidity with other disorders (Roy-Byrne et al., 2008), reduced work productivity, and increased health care costs and utilization (Wittchen et al., 2002,Wittchen, 2002).

School and Relationship Issues

Children were more likely to develop behavioral problems such as violent and antisocial behavior (King et al., 2004). Any adverse childhood experiences such as events that caused trauma were a major risk factor for children to develop self-destructive behaviors of all kinds

(van der Kolk, 2005). Some other problems that traumatized children had are increased aggression, an increase in oppositional behavior, poor conflict resolution skills, and poor peer, sibling, or other social relationships (Malchiodi, 2015). Cognitively, traumatized children performed worse in school, had lower cognitive functioning, had inadequate problem-solving skills, and they may also have had issues concentrating and comprehending material (Malchiodi,

2015). One study found that traumatized children had significantly lower test scores on standardized tests and were more likely to need individualized education plans (IEPs; Goodman et al., 2011). Another study found that the dropout rate was 16% among a sample of African VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 17

American, Afro-Caribbean, Asians, Latinos, and non-Latino whites who have experienced childhood trauma and/or childhood psychiatric diagnosis (Porche, et al., 2011). PTSD reduces and limits the psychosocial functioning of children who have not been treated (Gunes &

Guvenmez, 2020). PTSD in children was linked to lower verbal memory function and lower overall cognitive performance (Saltzman et al., 2006; Yasik et al., 2007).

Trauma and the Brain

Research indicated that the right hemisphere of the brain was the dominant hemisphere in the first years of life (Chong, 2015). The right hemisphere regulates affect and assists in the development of coping strategies (Schore 2003b; Sullivan & Gratton, 1999). The right hemisphere also processes socioemotional information beneath conscious awareness and regulatory processes (Schore, 2003b). The right hemisphere regulates emotional and physical states and processing visual or auditory information related to emotional signals (Schore, 2003b).

The right hemisphere is vulnerable to effects from early socialization and development (Schore,

2003b). When trauma happens to a child during this early developmental period, the traumatic event alters the development of the right brain (Schore, 2003a). According to Schore, traumatic pain was stored in the right brain as implicit procedural memory. Trauma in the first two years also damages the orbital prefrontolimbic system, which regulates emotions such as empathy, causeing a person to have the inability to experience empathy. The effects of trauma on a child in early childhood can be devastating and long lasting (Schore, 2003b).

Perry and Pollard (1997) found that trauma can cause a reduction of brain volume due to neglect as shown on a brain scan. Exposure to trauma can cause states of hyperarousal (fight) or hypoarousal (flight) can eventually cause the amygdala to be disrupted and overreactive, resulting in a range of symptoms that can persist for decades (Levine, 1997, 2010). This can greatly affect the creation of social bonds and emotionality (Bachevalier, 2003). Early relational VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 18 trauma also damages the hippocampus which causes it to lose its ability to function as the mediator between the cortex and amygdala, as well as processing information from short-term and long-term memory and special navigation (Rothschild, 2003). This disconnection from the cortex means the pathway that links cognitive reason to emotional response may be cut off

(Rothschild, 2003, Schore, 2003a, 2003b). The result was identified as a bad connection between the left and right hemispheres, which causes emotional memory to be less accessible to verbal consciousness, meaning individuals have trouble accessing memories related to the trauma

(Shore 2003a, 2003b).

Neuroimaging

Frewen and Lanius (2006) reviewed evidence from studies that compared the nonverbal responses to scripted imagery in PTSD subjects to participants in a control group.

They observed differences involving the anterior circulate cortex and other areas of the brain.

The researchers found that the anterior circulate cortex was involved in verbal control of attention in terms of regulating emotional, cognitive, and autonomic responses (Gantt & Tinnin,

2009, 2013). They discovered inactivity in this region of the brain when the PTSD patients were triggered by the scripts. This shows neurophysiologic evidence of flashbacks in which they are reliving the traumatic experience as if they are occurring again while the cingulate cortex was deactivated. This may be physical proof that there are triggered intrusions of nonverbal memories into a diminished verbal cortex (Gantt & Tinnin, 2009, 2013).

Developmental Theories

There were some theories used to explain trauma. Two that will be discussed are attachment theory and neurobiological theories.

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 19

Attachment Theory

One theory used to explain trauma was attachment theory developed by Bowlby (1988).

Attachment theory explains why and how children form bonds with caregivers and parents

(Bowlby, 1988). A principle of attachment theory was that a child depends on the primary caregivers for protection, comfort, and closeness if they are upset or feel endangered

(Lichtenstein & Brager, 2017). If an infant becomes upset, they try to attract comfort and attention from their caregivers through signals such as crying or crawling towards a parent

(Bowlby, 1988). How the parent responds to the child’s needs will develop their style of attachment (Bowlby, 1988). Bowlby recognized that there were three styles of attachment: secure, insecure ambivalent, and insecure avoidant (Bowlby, 1988). If an infant’s caregiver or parent continuously responded appropriately and promptly to an upset infant, they would mostly likely develop a secure attachment. If the parent continuously did not respond appropriately and promptly to an upset infant, they would most likely develop an insecure ambivalent or insecure avoidant attachment (Bowlby, 1988).

Infants with a secure attachment usually get upset when separated from their caregiver, allow themselves to be comforted when reunited with their caregiver, and then actively explore their environment with their caregiver around (Bowlby, 1988). Infants with an insecure ambivalent attachment will become anxious when the caregiver leaves, ambivalent when the caregiver returns, and will having trouble exploring their environment due to being preoccupied with the caregiver (Bowlby, 1988). Infants with an insecure avoidant attachment will appear neither upset or anxious when the caregiver leaves, avoids contact with the caregiver upon return, and directs all their attention to their surroundings not including the caregiver (Bowlby,

1988). A secure caregiving relationship provides the child with ways of handling stress, anxiety, and fear constructively (Lichtenstein & Brager, 2017). The attachment relationship helps the VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 20 child regulate intense emotions (Bowlby, 1988; Fonagy, 2001). When a child has been exposed to domestic violence or sexual abuse within the family, the child may lose their attachment figures (Lichtenstein & Brager, 2017). No one can comfort or protect the child, and they may be left to deal with stressful and overwhelming events on their own (Havenskold & Mothander

2002, Wennerberg, 2010).

Neurobiological Theories

Instinctual Trauma Response. Recent research has demonstrated that posttraumatic disorders and trauma invoke nonverbal mental activity that escapes or overrides verbal thinking

(Perryman et. al, 2019). This theory was supported by two lines of research. In the first line of research, Gantt and Tinnin’s (2014) understanding of evolutionary survival responses lead to the concept of the instinctual trauma response (ITR). The researchers found that a person involved in a traumatic experience may try to intentionally act, then if that fails, their consciousness yields to the flight or fight reflex, and if that fails the person goes into a freeze state. Cannon (1914) introduced the term fight or flight to describe a mammal’s survival strategy of neural activation, autonomic nervous system response, and hormonal exchanges between the brain and adrenal glands, all to mobilize the individual to survive life-threatening danger. Selye (1936) described a state of collapse after this alarm phase where the animal lapses into anesthetic immobility or freezes. In trauma victims, this freeze state numbs the pain, but distorts and alters a person’s consciousness (Tinnin & Gantt, 2014). After emerging from the freeze, they automatically respond with robotic obedience. This sequence makes up the ITR (Gantt &

Tinnin, 2013; Tinnin et al., 2002).

In the face of overwhelming threats, a person’s intentional cognition may be thwarted, and the person’s dominant verbal consciousness fails (Tinnin & Tripp, 2016). The nonverbal mind, which depends on the verbal mind for its direction to time, loses the capacity for narrative VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 21 memory for the entirety of the trauma experience. and thoughts may be stored as fragments in nonverbal memory without order. After the traumatic experience and normal verbal consciousness is recovered, these fragments can intrude into consciousness when a person becomes triggered by certain stimuli (Scaer, 2005). Traumatized individuals may be tormented by state memories in which they have flashbacks about their trauma response (Perry et al.,1991).

These memories can cause a person’s behavior to change and develop psychological symptoms such as affect dysregulation, depersonalization, derealization, or numbness. These symptoms represent the appearance of nonverbal traumatized mental and emotional states (Tinnin & Gantt,

2014). Tinnin and Gantt’s (2013) ITR theory included six universal survival patterns: the startle reflex, thwarted intention or flight of fight pattern, the freeze, the altered state of consciousness, automatic obedience, and self-repair.

Alexithymia. The second line of research involves Alexithymia. It involves problems identifying and labeling emotions (Gantt & Tinnin, 2009, 2013). Frewen and Lanius (2006) believed that defects in conscious awareness of nonverbal bodily states can possibly cause

Alexithymia. They discovered a correlation between the increased activation of the posterior cingulate cortex during the trauma imagery scripts and increased levels of alexithymia. Other research has shown that there is an association between alexithymia and a deficit in interhemispheric communication (Parker et al., 1999).

Involuntary instinctual survival reactions interrupt verbal consciousness and dominate behavior and sensation during the time it takes to recover normal verbal thinking (Tinnin &

Gantt, 2014). The memories of the traumatic experience were stored in a nonverbal realm beyond the reach of verbal prompts (Schore, 2002). When verbal dominance was reestablished, many of the traumatic memories and emotions remain without order or narrative. The communication between verbal right hemisphere and the nonverbal left hemisphere was VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 22 disrupted by the trauma (Gantt & Tinnin, 2009, 2013). The integration between the emotional nonverbal and rational verbal is diminished. Loss of communication between the two hemispheres deprives the right brain of support and guidance by the conscious mind. The nonverbal mind remains overwhelmed by the traumatic fragments and memories that do not recede into the past (Gantt & Tinnin, 2009, 2013). The nonverbal mind may be constantly triggered by reminders of the traumatic experience.

Tinnin et al. (2002) found that if the trauma victim becomes very pessimistic, they may be easily influenced by victim mythology. The trauma victim may appear normal during the day and use the left brain to carry out tasks such as work, but during the night and in bad times the right brain may dominate, victim mythology may take over, and the victim may become very defensive, hypervigilant or hyperarousal to the environment around them and may become sense danger around every corner (Gantt & Tinnin, 2009, 2013). Chong (2015) further expanded on this neurobiological theory of trauma by illustrating how early relational trauma effects a child’s mind.

According to Tinnin (1990b), full trauma recovery requires reconnecting the left brain and right brain and capitulation of the verbal mind’s illusion of mental unity. The trauma victim must overcome the trauma. This can be accomplished by verbal and nonverbal narrative processing (with the possible use of art therapy) of the traumatic experiences (Gantt & Tinnin,

2009, 2013; Tinnin & Tripp, 2016). Traumatic memory becomes acknowledged by the victim and was integrated into personal history. The victim no longer needs to fear re-experiencing the trauma. Alexithymia can be reversed by having a dialogue between the verbal and nonverbal minds. The left brain relaxes control, and the right brain stops it submission that allows for mental duality again and mental unity (Gantt & Tinnin, 2009, 2013).

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 23

Current Treatment Methods

Creative art therapy, cognitive behavioral therapy (CBT) including Trauma-Focused

Cognitive Behavioral Therapy (TF-CBT), and Eye Movement Desensitization and Reprocessing

(EMDR) are all widespread approaches to treating trauma in children (Bradley, et al. 2005;

Malchiodi, 2008, 2015).

Creative Arts Therapy

Creative arts therapy includes therapies such as art therapy, music therapy, dance therapy, drama therapy, poetry therapy, psychodrama, and play therapy (Parker, et al.; van Westrhenen &

Fritz, 2014).

Art Therapy. Art therapy utilizes art media in interventions, counseling, , and rehabilitation with all ages, groups, and families (Edwards, 2004; Malchiodi, 2012b). Rowe and associates (2017) conducted an evaluation of the Burma Art Therapy Program to see if art therapy would help refugee children that suffered from trauma. Results found that the participants’ anxiety and self-concept improved (Rowe et al., 2017). However, the researchers found that more specific benefits of art therapy were not adequately revealed with the tools utilized (Rowe et al., 2017). The study showed some positive effects of art therapy with children with trauma.

Ugurlu and colleagues (2016) conducted a study measuring the effects of an art therapy intervention on PTSD, depression, and anxiety symptoms in Syrian refugee children. They used assessment tools such as the Stressful Life Events Questionnaire, the UCLA PTSD Parent version, Child Depression Inventory, and State-Trait Anxiety Scale to assess baseline and follow-up on their symptoms (Ugurlu et al., 2016). Results indicated that trauma, depression, and trait anxiety symptoms in the children significantly dropped (Ugurlu et al., 2016). However, there was no significant difference in state anxiety scores for pre- and post-assessments (Ugurlu VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 24 et al., 2016). This study suggested that art therapy was an effective treatment for trauma, anxiety, and depression of refugee children.

Cognitive Behavioral Therapy

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) was specifically designed to focus on and treat trauma (Ridings et al., 2018). It was designed for children 3-18 years old and their non-perpetrator parents or caregivers (Brown et al., 2020). TF-CBT was set up in stages and includes creating and processing through a trauma narrative like the art therapy equivalent of a graphic trauma narrative (Gantt & Tinnin, 2009, 2013). Cohen et al. (2017) discussed the different TF-CBT components in the acronym PRACTICE: (a) Psychoeducation; (b) Parenting skills; (c) Relaxation skills; (d) Affective expression and modulation skills; (e) Cognitive coping skills; (f) Trauma narrative and processing of dramatic experiences; (g) In vivo mastery of trauma reminders, (h) Conjoint child and parent sessions; and (i) Enhancing safety and future developmental trajectory. It was broken up into three phases. Phase one includes building skills and stabilizing the client (components a-e), phase two is creating the trauma narrative and processing it (component f), and phase three is consolidation of treatment and closure of the trauma (components g-i; Gonzalez-Prendes et al., 2020).

The theory behind TF-CBT of gradually exposing the client to traumatic stimuli is engrained in the cognitive model of PTSD (Ehlers, 2000). This model theorizes that individuals experiencing PTSD have symptoms of negative thoughts surrounding the traumatic event that create a sense of danger and threat in the present and poor integration of the traumatic memory into autobiographical memory of the individual which results in intrusive memories and flashbacks (Neelakantan et al., 2019). The TF-CBT model is based on reversing this development of PTSD and problems in children such as fear and avoidance, physiological issues, negative thinking, and caregiver-related factors (Brown et al., 2020). VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 25

Eye Movement Desensitization and Reprocessing (EMDR)

Eye Movement Desensitization and Reprocessing (EMDR) was first developed by

Francine Shapiro to help treat PTSD (Shapiro & Brown, 2019). She noticed that when she went for a walk, her eyes were moving back and forth while thinking about upsetting health problems.

She discovered that after that activity she felt better emotionally (Shapiro & Brown, 2019).

Shapiro then used this experience to create a protocol in which the therapist utilizes guided or directive questioning to desensitize the client to the trauma through a brief imagined exposure to the traumatic memory (Shapiro, 2001). The client was first asked to provide a negative or dysfunctional thought regarding the trauma and recognize places in the body where the physical sensations are noticeable.

Then after the client focused on the traumatic memory and the negative thoughts, emotions, and physical sensations associated with the trauma, the therapist gives the client bilateral stimulation (Gonzales-Prendes et al., 2020). This usually or commonly involved creating bilateral eye movements by the therapist moving their fingers back and forth in front of the client’s face after they instructed the client to follow the motion with their eyes (Shapiro,

2018). These types of sessions were repeated until the PTSD symptoms have lessened significantly and the dysfunctional, negative thinking about the trauma has been eliminated

(Shapiro, 2007). There were eight phases in the process of EMDR treatment.

The phases were: (1) gathering a detailed history of the client’s trauma, developing rapport, and mapping out treatment; (2) explanation of EMDR theory and process of therapy, setting expectations, and developing a therapeutic alliance; (3) assessing and identifying the specifics of the traumatic experience(s); (4) reprocessing and desensitizing the traumatic memories; (5) setting up healthier beliefs; (6) scanning the body to process and identify any lingering physical sensations; (7) closure at the end of each session to ensure the clients leaves VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 26 feeling calm and balanced; and (8) reevaluating the client at the beginning of each session to observe the client’s progress from session to session (Shapiro, 2018). The entire therapy process of EMDR involved a three-prong approach that addressed the origination of the traumatic event

(the past), the triggers of PTSD symptoms (the present), and the development of coping skills to deal with upsetting events (the future) (Gonzales-Prendes et al., 2020). EMDR was recommended as an effective treatment for PTSD (Chen et al., 2014; Foa et al., 2009; Spates &

Rubin, 2012).

Art Therapy and Trauma Therapy

Bradley and colleagues (2005) found that 30% of clients suffering from PTSD did not benefit from treatments such as EMDR and TF-CBT. No alternative evidence-based treatment options were available (Bisson et al., 2007). Therefore it may be necessary to explore alternative and adjunctive therapeutic options (Gapen et al., 2016). Studies have shown that different types of art therapy such as doll making, portrait art, working with clay, working with fabric collage, the check protocol, four drawing protocol, creative arts in psychotherapy program (CAP) and mindfulness art therapy have helped clients reduce trauma symptoms (Carr & Hancock, 2017;

Elbrecht & Antcliff, 2014; Hass-Cohen et al., 2014, 2018; Homer, 2015; Kalmanowitz & Ho,

2016; Stace, 2014; Schouten et al., 2013; van Westrhenen et al., 2017, 2019). Other forms of art therapy such as visual journaling could be more effective in treating trauma in children.

When working with trauma survivors, Gantt and Tinnin (2009, 2013) believed that art therapy should be used in a more directive oriented then a non-directive manner of having someone paint what they feel and think right now. The non-directive approach can be time consuming, and it makes more sense to have a focused approach that addresses the root cause.

The trauma, not the depressive symptoms caused by the PTSD, needs to be addressed through trauma processing first and foremost with art therapy. If not, this causes delayed or deferred VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 27 trauma processing which is of no help to the trauma sufferer (Gantt & Tinnin, 2009, 2013). The art therapy techniques utilized must tone down the emphasis of the emotion of the past trauma or it can result in re-living the experience instead of remembering it as something historical. The art therapy needs to involve some form of cognitive processing of the traumatic events. It may be unnecessary to push for an emotional release in therapy when it was not necessary processing the trauma (Gantt & Tinnin, 2009, 2013). The art therapy used should involve more neurobiological healing.

Implications for Art Therapy

Art therapy can be very useful in trauma therapy because it provides a means of communicating with the nonverbal mind and accessing the traumatic memories (Malchiodi,

2012a). An art therapist would attempt to reverse the effects of the traumatic event first before processing through the meaning behind trauma. Other therapies would process through the meaning of the trauma first and then try to reverse the effects of the trauma. Art therapy can be effective for trauma victims because it provides a connection where none existed before

(Perryman et al., 2019). Trauma may disrupt putting it into words, but memories may still be in the nonverbal part of the brain (Malchiodi, 2015). The art therapist can help the survivor to re- associate the experience and words by having them make images of the trauma itself (Malchiodi,

2015). Trauma survivors often can’t describe their experiences in words. Art therapists have the advantage of being able to ask for a picture or image of the experience. Victims can still tap into pictures and images from the traumatic experiences and reproduce them in art forms (Gantt &

Tinnin 2007, 2009, 2013).

Graphic Narrative Processing

A major issue for trauma survivors was that they felt the trauma was happening now or happening again (van der Kolk, 2014). Gantt and Tinnin (2009, 2013) believed that one should VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 28 employ techniques to make it history. Dissociation during trauma has the effect of stopping one’s sense of time (van der Kolk, 1987). Gantt and Tinnin (2009, 2013) felt that it was crucial to organize the trauma memories into a narrative form that the verbal mind can comprehend and process. Gantt and Tinnin (2009, 2013) developed their own art therapy procedure, graphic narrative processing, to use the ITR as the narrative template. It is a technique of art making designed to tell the trauma story and label the trauma state memories with words and historical context.

The therapist explains the ITR and instructs patients to create a narrative of the trauma in pictures, labeling the pictures with the appropriate survival instinct such as startle, fight/flight, freeze, altered state, submission or self-repair (Tinnin & Gantt, 2014; Tinnin et al., 2002). The client draws the scenes including the self as viewed from an emotionally detached perspective of hidden observer. The graphic narrative includes before and after pictures and may also include transition pictures. The completed narrative is displayed on a bulletin board, the client is the audience, and the therapist presents the account depicted by the pictures (Gantt & Tinnin, 2009,

2013). The client or present-day self then engages in an external dialogue or give and take with the part of the self that was stuck in the trauma, speaking, writing, or drawing for each turn

(Gantt & Tinnin, 2009, 2013). The goal was to re-integrate the past self into the present self.

Gantt and Tinnin (2009, 2013) recommended that art therapists develop their own targeted approaches to treating trauma. They further recommend that treatment was based on two neurobiological processes which include re-integrating the fragments of the traumatic experience in a narrative to be affirmed by the verbal mind and by externalizing dialogue between the verbal and non-verbal minds (Gantt & Tinnin, 2009, 2013). Gantt and Tinnin (2009, 2013) believed that art therapy can be used to heal trauma if it was used in a neurobiologically informed manner with graphic narrative being the intervention used. VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 29

Neurobiological-Based Art Therapy

Other art therapists appear to support this neurobiological view of trauma presented by

Gantt and Tinnin (2014). Hass-Cohen, Findlay, Carr, and Vanderlan (2014) went so far as to create their own neurobiological-based art therapy trauma protocol called “Check, Change What

You Need to Change and/or Keep What You Want.” The protocol included five art directives given in this order: (a) autobiographical trauma timeline; (b) trauma image drawing and narration; (c) image alteration; (d) self-strength image; and (e) optimistic future image (Hass-

Cohen et al., 2014). The protocol was based on many current trauma treatment approaches and the neurobiology of fear and resiliency that was reviewed in Gantt and Tinnin’s (2009) article.

The first directive was to draw a timeline of the traumatic event similar to graphic narrative processing (Gantt & Tripp, 2016). Like Gantt and Tinnin’s (2013) narrative, this process allows the client to put the traumatic events in the past, separating them from the here and now. The second directive involves drawing or painting what happened or an aspect of it that a person feels comfortable representing and depicting what it looks like. This activity exposes traumatic memories of the event (Hass-Cohen et al., 2014). The client then comes up with another narrative for that art piece and title to help combine cognitive and emotive processing and reduce cognitive distortions. The participant then holds on to the artwork or saves it digitally. For the third directive, the participant decides which aspect of the previous picture they would want to keep or change and depict that. The therapist explains to the client they can cut out, keep or throw away the cut out, paint over it, draw or paint on it, glue on parts, or glue on the cut out on a fresh page. The client then titles the artwork and compares the two pieces trying to pay attention to the differences between the two pieces (Hass-Cohen et al., 2014). This activity helps encourage a client’s internal sense of control and emotional awareness, and decreases hyperarousal and dissociative responses. The next two directives were designed to encourage VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 30 resiliency and involve “drawing strengths” and “drawing an image of what an optimistic future might look like.” The therapist then provides a choice of media on a nearby table, allowing individuals to select materials and bring them to their space. Moving away from and towards art materials allows them another sense of control and helps reduce freeze actions with therapeutic support (Hass-Cohen et al., 2014). The protocol is designed like Gantt and Tinnin’s graphic narrative therapy to reintegrate the nonverbal and verbal minds.

Gantt and Tinnin (2009, 2013) also cited this loss of communication between emotional memory and verbal consciousness. Chong (2015) also mentions the limits of verbal and cognitive-based therapy to early relational trauma and talks about the need for an extra channel of communication beyond the verbal to connect with survivors of early relational trauma. Fosha

(2003) remarks that emotions are not processed through logic and language, but the right hemisphere speaks a language of images, sensations, and impressions. Therapy must speak the language of the right hemisphere (Fosha, 2003). Schore talks about how trauma remains as somatosensory or iconic form so it must be communicated as such (Schore, 2003a). These findings show the importance of art making in art psychotherapy as a right hemisphere activity to access the right hemisphere, and as a somatosensory activity to connect with amygdala and hippocampus (Chong, 2015). The limbic system (which contains the amygdala and hippocampus) is damaged in trauma, but also has the most capacity to restore a person’s regulation and equilibrium (Elbrecht & Ancliff, 2014).

Emotions were represented in the brain in the form of changes in the activity pattern of somatosensory structures (Damasio, 2000). Emotions can be biologically determined processes, dependent on the brain, and can be activated automatically without thinking (Damasio, 2000,

LeDoux, 1998). Since emotions can be expressed, unconscious based activity could serve as a significant window of expression (Chong, 2015). The bodily processes and emotions produced VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 31 by them are amplified in the process of art making and recorded as artwork that is external, visible, and tangible, which could serve as material for reflection.

Expressive Therapies Continuum

This article highlighted that working with clay can be therapeutic and release complex emotions constructively through touch and activities such as painting can help someone become more in touch with their emotions (Chong, 2015). These are examples of the use of the

Expressive Therapies Continuum through bodily processes, art making as a sensorimotor, body activity (ETC; Kagin & Lusebrink, 1978; Lusebrink, 1990). The ETC can be utilized in the treatment of trauma as well (Lusebrink & Hinz, 2016). The ETC was a conceptual approach to visual expression with different levels including the Kinesthetic/Sensory, Perceptual/Affective,

Cognitive/Symbolic, and the Creative level (Lusebrink & Hinz, 2016). Lusebrink (2004, 2010) theorized that different levels of the ETC correspond with the brain areas and functions involved in creating and processing visual expressions (Lusebrink & Hinz, 2016). The different characteristics of visual expression, and the possible areas of the brain involved were addressed in each level of the ETC (Lusebrink & Hinz, 2016). Each level was presented as a continuum between two polarizations representing different degrees and distinctions in visual expression

(Lusebrink & Hinz, 2016). For example, Kinesthetic at one end of the level while Sensory was at the other end with multiple variations of each of expression in between.

The Kinesthetic/Sensory level represents the use of motor skills with art media and involves either sensory or energy involvement (Lusebrink & Hinz, 2016). Focusing on the

Kinesthetic component decreases awareness of sensory processing (Lusebrink & Hinz, 2016).

Focusing on the Sensory component decreases movement or kinesthetic action because attention was focused on sensations (Lusebrink & Hinz, 2016). This was true of every level of the ETC where the concentration on one element decreases attention on the other hence the polarity. The VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 32

Perceptual/ Affective level involves spatial location of or the utilization of emotion when creating artwork using the formal elements of line, shape, color, and form (Lusebrink & Hinz,

2016). The Cognitive/Symbolic level involves cognitive processing or problem solving or intuitively processing experiences and visual information, the use of sensory and emotional sources, personal sources, and symbolic expressions (Lusebrink & Hinz, 2016).

The Creative level was visualized as a perpendicular intersection of all three levels

(Lusebrink & Hinz, 2016). The creative level can be on each level at the intersection of the two poles, at the same time, and can involve processing from all levels of the ETC (Lusebrink &

Hinz, 2016). Creative visual expression can encompass different characteristics along the whole continuum, ranging from any level of the ETC, where preference for a level was reflected in artistic style (Feldman, 1972, Lusebrink, 1990). Lusebrink theorized that different media and different modes of expression activate different parts of the brain and different levels of the ETC

(Kagin & Lusinbrink, 1978; Lusebrink, 1990). For example, fluid media, like paint may activate an emotional reaction while resistive media, like pencil, will elicit a cognitive response (Hinz,

2009). Therefore, using fluid materials such as paints and pastels will create careful emotion expression associated with successful trauma work (Lusebrink & Hinz, 2016). Resistive media like collage and clay would promote cognitive restructuring in trauma work. These examples illustrate that art therapy can help heal trauma.

Visual Journaling

Sackett and McKeeman (2017) in their article Using visual journaling in individual counseling: A case example give a compelling argument in favor of using visual journaling in therapy. They use a case example to illustrate how visual journaling can be used in therapy

(Sackett and McKeeman, 2017). In the case example, she was able to express how she was feeling and thinking in visual form and could see it on a deeper level. The client was able to use VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 33 visual journaling to heal her wounds and resolve her conflict (Sackett & McKeeman, 2017).

With this limited research on visual journaling, it does show some promise.

What if this activity could be incorporated into treatment for trauma victims? In theory, visual journaling could possibly reduce trauma symptoms in children. If the visual journaling exercises were developmentally appropriate it could work. Research shows that trauma is a non- verbal issue that falls short when treated by traditional therapy (Chong, 2015). Using a non- verbal therapy such as art therapy could be the key to healing trauma in traumatized children.

Visual journaling could give children another outlet to express their difficult emotions and thoughts surrounding their trauma. It could be their own container where they can process the trauma effectively, leave it in the past, move on, and heal. Due to the sequential nature of visual journaling, this could also be seen as particularly helpful to support increases in narrative memory, helping to sequence/organize/sort/ order traumatic memories.

Summary

There is strong evidence that there is a neurobiological basis to trauma (Malchiodi, 2015;

Perryman et al., 2019). When an individual experiences trauma, their cognition may be overridden, and the individual’s verbal consciousness may fail to process appropriately what is happening. The nonverbal mind, which depends on the verbal mind for its orientation to time and events, can lose the capacity for narrative memory for the entirety of the trauma experience. This causes fragmented memories to intrude into the nonverbal mind causing flashbacks when triggered by certain reminders of the trauma (Perryman et al., 2019). Trauma then becomes a nonverbal issue. Traditional therapies cannot address this nonverbal issue effectively. Art therapy is a nonverbal therapy that has been shown to be able to treat trauma affectively with how it allows an individual to process complex thoughts and emotions without needing to use words (van Westherhenen et al., 2014, 2017, 2019). VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 34

Gantt and Tinnin (2009, 2013) believe that a graphic narrative form can help the trauma victim process their experiences, integrate it into memory, put it into the past, and eventually move on from it. Other researchers also believe that trauma is neurobiologically based, is a nonverbal problem, and can only be treated effectively with nonverbal therapy like art therapy

(Hass-Cohen et al., 2014). Visual journaling could be another way to help individuals process through their trauma effectively. Limited research showed that visual journaling may be an effective treatment for traumatized children. A summary of the finding provided evidence for the theory.

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 35

CHAPTER III Methodology

This researcher investigated the effects of visual journaling on children with trauma issues. This study included measuring the number and frequency of trauma symptoms such as negative thoughts, nightmares, flashbacks, and hyperarousal before and after the art therapy interventions. This study utilized pre- and post- Child PTSD Symptom Scale (CPSS) assessments, journaling, and art directives as well as post-study survey and caregiver survey.

Participants

The participants attended an outpatient program after school to help work on the effects of their trauma. There were four participants at the beginning of the study including a 13-year- old Caucasian male, 10-year-old Caucasian female, 13 year-old African American female, and a

12-year-old bi-racial Caucasian/Hispanic female, who suffer from trauma symptoms including negative thoughts, flashbacks, nightmares, and hyperarousal. To protect the anonymity of participants, pseudonyms were used. The male participant, John, participated in two of the five sessions. The other three, Ashley, Amy, and Emily, participated in all five sessions and completed the exit interview. Participants were recruited by the art therapist assisting the researcher by going through client files in their electronic medical records and identifying potential participants. The art therapist then sent the legal guardians the flyer. The researcher then sent the legal guardians the consent forms. Consent was obtained from their legal guardians since they were minors at the time as well as an assent form from the children. Consent to videotape/audio tape was also obtained.

Research Design

Participants completed a pre-Child PTSD Symptom Scale (CPSS; Appendix A) prior to starting each group art therapy/visual journaling session to obtain a baseline of where their trauma symptoms were ranked which approximately took about 5 to 10 minutes. Each participant VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 36 completed artwork related to their trauma per each directive (which lasted 30 minutes per session) and wrote about each art piece in five group art therapy sessions (which lasted about 5 to 10 minutes per session). At the end of each group art therapy session, the participants took a post-CPSS which took another 5 to 10 minutes. After the end of the five weeks, they completed an exit post study survey/interview (see Appendix B) with the researcher.

Research Instruments

Child PTSD Symptom Scale (CPSS)

The Child PTSD Symptom Scale (CPSS; Foa & Capaldi, 2013) was a questionnaire used to rate the severity of trauma or PTSD based on self-reporting. The questionnaire begins with two questions asking what the trauma is and when it occurred. The next section of the questionnaire involves rating how often certain symptoms occur on a scale of 0 to 4. The less frequent a symptom occurs; it is assigned a lower number. The more frequent a symptom occurs; it is assigned a higher number. For example, a value of 0 indicates the symptom occurs not at all while a value of 4 indicates the symptom occurs 6 or more times a week or almost always. The last section asks if the problems mentioned before in the previous section are interfering with different daily activities and the respondent answers with a “Yes” or “No.” The

CPSS was utilized to assess PTSD symptoms before and after the visual journaling.

The first validation study for the CPSS involved 75 school age children from the ages of 8-15 years-old who experienced the 1994 Northridge earthquake (Foa et al., 2001). There was high internal consistency found on the items for re-experiencing, avoidance, and arousal subscales, as well as between subscale and total severity scores (Meyer et al., 2015). Test-retest reliability coefficients of the subscale scores, total severity score, and functional impairment scores were moderate to high (Meyer et al., 2015). The CPSS total score had a high correlation with a VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 37 clinical interview measure and a moderate correlation with measures of depression and anxiety

(Meyer et al., 2015).

Art Directives and Journaling

Participants utilized the “Check, Change What You Need to Change and/or Keep What

You Want” protocol by Hass-Cohen et al. (2014) to participate in a five-week virtual group art therapy study. The study was considered an art therapy study because it involved creating and analyzing artwork. Nelson (2006) mentioned that artwork may stand alone as evidence of research due to process that emerges from the creation, selection, molding, and changing of the material from art making. Valuable data can be collected from the process and product of the artwork. Moon and Hoffman (2014) further elaborated on the topic by talking about when an individual performs art-based research, the insights discovered continue to produce results in the performer’s art making and the viewers perception of that. Data can be collected from viewing the art being made.

McNiff (2011) defined art-based research as the researcher utilizing artmaking as the main method of methodical investigation. In art-based research, through the process and field of artmaking, qualities, themes, arrangements, structures, and messages may radiate and create themselves (McNiff, 2011). Data may emerge in the form of themes and messages in the artwork and artmaking process. McNiff (2011) also mentioned that art is a physical activity that creates empirical data which in certain instances can be counted, measured, and analyzed, and how it cannot be just called qualitative, regardless of its thoughtful aspects. Therefore, art-based research may always be empirical and can be qualitative and/or quantitative, historical, philosophical, heuristic, phenomenological, hermeneutic, ethnographic, and experimental (Mc

Niff, 2011). VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 38

Fish (2006) defined response art as art that art therapists create to hold, investigate, and communicate clinical work. Fish (2019) talked about how images had the potential to reveal information beyond conscious thought to help explore revelations beyond current understanding.

Response art, used as a method for investigation, could be used as data to enlighten research

(Fish, 2019). Fish (2017b, 2017c) produced fiction, created from response art and molded into tales of clinical experience. These stories demonstrated how creativity can support empathy, nurturing understanding (Fish, 2019). This type of social research was the combination of lived experience and was intended to inform academic and public conversation (Fish, 2019).

The research study also involved the process of journaling about their art images after they were completed. Journaling can be used to collect data from recording information that is to be analyzed later (Valimaki et al., 2007). Swenson (2004) also talked about how collecting data from journaling can be used with other methods to enhance information gathered from interviews. Although Smith and Hunt (1997) stated that journaling is the least used method in phenomenological research to collect data, it is still useful to record detailed experiences and feelings associated with them. Data collected from journaling can be utilized to study detailed experiences in natural settings and backgrounds (Simmons-Mackie & Damico, 2001). Valuable information was collected from the journaling aspect of this study.

The research study contained five different art therapy-based directives. In the first directive, the participants drew a graphic trauma narrative in their visual journal. Then they wrote about the narrative on another page. In the second directive, the participants depicted an aspect of something that happened during the trauma or something that happened during the trauma they are comfortable with depicting in their visual journal. The participants were asked to reflect and write about that highlight of their narrative in their journals. The third directive was slightly modified by the researcher. Instead of asking the participants to reflect on the second VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 39 picture and change an aspect of it, the participants were asked to reflect on their second picture and to change the trauma story’s end to one that suited them better. The directive was changed because the participants did not understand the meaning of the original directive. The participants wrote a written response on their thoughts and feelings in response to this change. In the fourth directive, the participants drew their strengths. The participants were asked to reflect on their strengths and write about how they used their strengths to overcome their trauma. In the fifth directive, participants were asked to draw an image of what an optimistic and happy future might look like. The participants were asked to reflect on their images and write about one thing they were going to do this week to work towards their goal of this happy future.

Exit Survey/Interview

Each participant completed an exit survey/interview with the researcher to share their thoughts and experience on the study. The questions asked about what the participants liked about the study, what they thought was challenging about it, what they gained as a result of the study, what trauma symptoms decreased, how their depression and anxiety decreased, and how their quantity and quality of sleep was affected.

Exit surveys and interviews have been used in many studies. Jongsma and colleagues

(2020) conducted a study involving semi-structured in-depth interviews with cognitively impaired individuals. Frost et al. (2020) utilized the qualitative interview in their study to interview participants from sexual minorities of different generations how they have made meaning of social change over past fifty years. Crocker and others (2016) conducted a study to examine the views of patient and public involvement contributors associated with health research regarding the impact of patient and public involvement on research and whether or how it should be assessed (Crocker et al., 2016). Pino and colleagues (2017) conducted a study using interviews to collect data from participants about their views on the usage of video-based VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 40 research in palliative care. Johnson and Turner (2003) believed interviews allowed for good interpretative validity and that there was moderately high measurement validity for well- constructed and well-tested interview protocols.

Data Collection

Participants were given an electronic version of the Child PTSD Symptom Scale (CPSS) through SurveyMonkey before the completion of the group art therapy/visual journaling exercise every week for five weeks and then given an electronic version of the CPSS through

SurveyMonkey at the end of each group visual journaling exercise. The participants were then given a post survey/interview at the end of the study. To protect the anonymity of the participants, there was no identifying information collected through SurveyMonkey. To protect confidentiality, physical data was placed in a locked cabinet at the researcher’s internship site.

The data will be kept for three years and then disposed of properly.

Data Analysis

CPSSs were collected from participants before and after each art therapy visual journaling directive. Pre- and post-assessments were scored using the scoring guidelines attached to administration and scoring instructions. Pre- and post-assessments were compared to each other to analyze scoring trends and to see if the severity of the symptoms has decreased over the five-weeks. Due to the small sample size, any trends that were found were not able to be generalized to other similar populations. Descriptive analysis, the process of analyzing data to find the means, standard deviations, and range of scores for independent and dependent variables, was not utilized (Creswell & Cresswell, 2018). The CPSS was set up in such a way that did not allow for descriptive analysis. The surveys had to be analyzed by other means.

Written responses were reviewed, transcribed, and analyzed for themes. The post-study survey/interviews were also analyzed to see if the symptoms had decreased. Exit VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 41 interviews/surveys were transcribed, reviewed, and analyzed for themes. Thematic analysis of written data and interviews involves many steps. The researcher collected, organized, and prepared the data for analysis (Creswell & Creswell, 2018). The researcher transcribed the exit interviews, typed up the field notes, scanned data, logged all the images, and sorted and arranged data into categories depending on information source. The researcher read and looked at all the data. The researcher wrote notes about what he observed at first. The researcher started coding all the data (Creswell & Creswell, 2018).

Coding was the process of selecting parts of data (such as text or image portions) and writing a word representing that part (Roseman & Rallis, 2012). The researcher took the journaling text and images, sectioned off the sentences and pictures into groupings, and labeled those groupings with a term. The researcher created a description and themes. The researcher used the coding process to create themes from the coding of the images and text for analysis. The researcher figured out how to represent the themes and description in the qualitative narrative

(Creswell & Creswell, 2018). Images from the visual journaling were collected and analyzed thematically.

The thematic analysis of images involves many steps. The researcher prepared his data for analysis. The researcher imported the images into a software application that allowed manipulation of the images. The researcher coded each image by labeling areas of each image and assigning codes to each area (Creswell & Creswell, 2018). The researcher assembled all codes onto a separate sheet of paper. The researcher then looked through the codes to remove any redundant codes or any overlap. The researcher began to condense and cut down the codes to potential themes (Creswell & Creswell, 2018). The researcher assembled codes into a group that have common theme or idea. The researcher assigned the common themes he found to three different categories: expected, surprising, and unusual themes (Creswell & Creswell, 2018). The VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 42 researcher arranged the themes into a conceptual map for the methodology section (Figure 1).

The researcher wrote the narrative for each theme that was put in the results section and a summary that was put in the discussion section for the findings in the study (Creswell &

Creswell, 2018).

Figure 1

Thematic Anaylsis Chart

The researcher utilized and scored the pre- and post-CPSS assessments on every participant, comparing and analyzing pre- and post-scores, and looking for patterns in the assessments to enhance reliability and validity of the study.

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 43

Validity and Reliability

This study involved the collection of both quantitative and qualitative data. Qualitative data involves collecting data from subjective sources such as interviews, observation, documents, and audio-visual elements and analyzing them for themes (Creswell & Creswell, 2018).

Qualitative data collected for this study included the exit interviews that were conducted, the art images, and the journaling entries.

There were some recent studies that utilized qualitative data. Meyappan et al. (2021) conducted a study that explored the views of patients and doctors on a newly designed gout treatment patient decision aid prototype. The researchers used a qualitative descriptive design to collect data from in-depth interviews and focus group discussions (Meyappan et al., 2021).

Sheikhan and colleagues (2021) conducted a study examining the engagement of youth and family in the YouthCan IMPACT randomized controlled trial. Researchers collected qualitative data using semi-structured interviews and a focus group and were analyzed to comprehend the impact of engagement (Sheikhan et al., 2021). Philpott and O’ Connor (2018) conducted a study on men who experienced intimate partner violence. They used psychoanalytically oriented qualitative research tools such as free association and interview to collect data (Philpott &

O’Connor, 2018). Caperton and others (2019) conducted a study on how stay-at-home fathers experience depression and help-seeking. The researchers utilized qualitative methods by conducting in-depth interviews with 12 stay-at-home fathers across the country to gather their data (Caperton et. al., 2019).

Quantitative data involves data collected from assessment tools and instruments that is quantifiable (Creswell & Creswell, 2018). The CPSS-V data was the quantitative data that was utilized. To enhance validity of the study, the researcher employed multiple validity strategies.

The data was triangulated to justify and build on themes. The researcher provided detailed VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 44 descriptions of the study setting (Creswell & Creswell, 2018). Negative or discrepant information was presented that may counter the themes. To enhance reliability of the study, the researcher documented and transcribed the procedures of the study and documented the steps of the procedure (Creswell & Creswell, 2018).

Ethical Implications

The researcher’s main concern was for the safety and security of the participants. The researcher did not want to cause further psychological and emotional harm to the participants by triggering them in anyway with visual journaling exercise. The researcher was concerned that this exercise might trigger more negative thoughts, flashbacks, nightmares, and hyperarousal.

The researcher utilized 4-7-5 count deep breathing exercises to calm the participants if they were triggered. This is included breathing in for 4 seconds, holding the breath for 7 seconds, and breathing out for 5 seconds. The researcher also encouraged participants to visualize a safe place if triggered. The researcher utilized the principles of beneficence and nonmaleficence when conducting this study by ensuring the safety of the participants (AATA, 2013). A licensed art therapist was also present during the Zoom sessions.

Researcher Bias

The researcher conducted this study at his internship site. The researcher had prior knowledge and/or relationship with the participants. The researcher also wanted the children to improve and succeed in the visual journaling process, may have a bias towards the results, and may be inclined to look for trends or improvements that weren’t there. At the time of this study, the researcher was an art therapy graduate student who believes in the power of art to heal.

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 45

CHAPTER IV Results

Quantitative data were gathered from the CPSS scores. Qualitative data were gathered from the artwork, journaling responses, observations of the participants, field notes, and exit interviews. An analysis of the data indicated three overarching themes. These included: (a) trauma symptoms (i.e. nightmares, flashbacks, negative feelings, and hyperarousal); (b) quantity and quality of sleep; and (c) overcoming adversity.

Trauma Symptoms

Trauma symptoms was quite a large theme that emerged from the research. Some sub- themes emerged from this theme such as a decrease in symptoms, increase in symptoms, decrease in anxiety and depression, and emotional response.

Decrease in Symptoms

Participants as a group reported a decrease in flashbacks in the CPSS assessments through most of the duration of the group. During Week 1 one participant reported flashbacks of

4 to 5 times a week (a score of 3). This later decreased to 3 times a week (a score of 2) at the end of the study on Week 5 (see appendix C). The other two participants reported flashbacks of once a week (a score of 1) initially during Week 1 which later decreased to none at all (a score of 0) at the end of the study on Week 5. Ashley and Emily both mentioned that they had “less flashbacks” in their exit interviews.

All participants as a group reported a decrease in nightmares in the CPSS assessments through most of the duration of the group. One participant initially reported during Week 1 nightmares 2 or 3 times a week (a score of 2). The two other participants reported nightmares once a week (a score of 1). All three participants in Week 5 reported no nightmares at all (a score of 0) at the end of the study on Week 5. Ashley reported a reduction in nightmares in her exit interview (see appendix C). VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 46

According to the CPSS assessments, two participants reported a decrease in hyperarousal for a short period of time. The two participants initially reported during Week 1 hyperarousal 1 time a week (score of 1). The next week, they reported no hyperarousal at all (score of 0). All three participants stated in the exit interview that they “thought about it less,” meaning they thought about the traumatic event less (see Appendix C).

Increase in Symptoms

The two participants during Week 1 initially reported having hyperarousal 1 time a week

(score or 1). At the end of week 5, the two participants reported having hyperarousal 5 or more times a week (a score of 4). Given there were only 3 to 4 participants, there were too few participants to make any real conclusions from the scores (see appendix C).

Reduction in Anxiety and Depression

In the exit interview, participants Ashley and Amy reported less anxiety and depression after the study. Emily stated, “My anxiety decreased when I drew positive stuff. It helped me cope better with anxiety and help calm me down.” An example of this is in Figure 2.

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 47

Figure 2

Emily’s drawing, “Strengths”

Emily drew this drawing of her strengths during the fourth week of group. It is an illustration of her making artwork. At the top of a page is what appears to be a drawing and below is what appears to be a painting on an easel. She wrote, “I have used painting and drawing as a form of therapy.” Emily said, “I didn’t really have depression.” The researcher observed the participants becoming less anxious and more comfortable in the group over the course of the study. The participants as a group reported a decrease in negative feelings such as anxiety and depression in the CPSS assessments through most of the study period. Two participants reported negative VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 48 feelings of 6 or more times a week (score of 4) initially in Week 1. This decreased to none at all

(score of 0) in week 5). One participant reported negative feelings 1 time a week (score of 1) in

Week 1. This decreased to none at all (score of 0) in week 5.

Emotional Responses

The researcher discovered a sub-theme of emotional responses to the trauma. Ashley in her exit interview mentioned that “trying to talk about it” was challenging. The researcher observed during the first two group sessions which involved depicting and talking about the trauma that Ashley struggled to be able to talk about the trauma. Ashley appeared very upset, refused to talk about the event, and would only communicate what she wanted to talk about through the Zoom chat. The researcher also observed that John, Amy, and Emily appeared visibly upset during these sessions and had a hard time articulating about the trauma they experienced as well. Ashley had a strong emotional response to the trauma in her first two drawings. In the first directive, Ashley drew a timeline or narrative of the trauma. Ashley depicted her father strangling her mother (see Figure 3a).

Figure 3

(a) Ashley’s Trauma Timeline, and (b) Something Ashley Felt Comfortable Depicting

The caption above reads, “I walked out and was yelling for help.” Right above her father strangling her mother is the word “help.” There were themes of violence, anger, and fear in this drawing. The violence and anger were representative in the drawing of her father strangling her VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 49 mother. The scribbled-out part of the drawing could have indicated that she struggled with drawing this picture because it brought up powerful emotions such as fear. The words she wrote also indicated fear.

In the second directive, she drew an aspect of the trauma timeline she was comfortable depicting (See Figure 3b). Ashley once again drew her father strangling her mother with the words “Let Go” next to it. The words “Be happy” was written on the bottom. Fear, anger, and violence were once again themes. Violence and anger were symbolized in the strangling scene.

Fear was possibly indicated by the scribbled-out picture because she may have been afraid to draw it. Fear was also indicated in the words, “Let go.” The “Be happy” phrase could have been her desire for things to be better between her father and mother.

Ashley drew a picture of something she wanted to change about the traumatic event

(Figure 4).

Figure 4

Ashley’s “Something You Could Change” Drawing

Ashley drew a picture of her Mom and her together with her Dad crossed out. She wrote the words, “Not hear” below her Dad. She also “wrote I wish he wasn’t hear.” If she had her way, her Dad wouldn’t even be around. There appeared to be themes of anger, regret, love, and wistfulness. This drawing seemed to bring out some strong feelings and elicit a powerful VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 50 emotional response. The crossing out of her father could have indicated her anger towards her father. The writings about wishing he wasn’t here could have indicated her regret and wistfulness. Her drawing her mother and her hand in hand could have indicated her strong love for her mother.

Ashley drew a picture of her optimistic future (Figure 5). Ashley depicted herself as an art teacher.

Figure 5

Ashley’s Optimistic Future

There appeared to be a theme of hope in the picture. Ashley was hopeful she would be an art teacher someday.

Ashley later explained in the interview that the art making group helped her “start telling people what happened, and I can start expressing my feelings.” Ashley liked that she could express her feelings through art therapy visual journaling exercises. Amy mentioned how she was a little scared at first in group but that the art making allowed her to “feel not as scared or shy anymore.” Emily “liked being able to draw in a group.” From this comment, one could infer that it was helping her emotionally. She also “liked writing about what we showed in the art.”

This statement could have indicated that the journaling aspect helped Emily heal emotionally as VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 51 well. Emily also talked about how her anxiety lessens when she draws “positive stuff” and she

“calms down.”

In Emily’s drawing where she was able to change an aspect of her original drawing if she wanted to it showed a picture of an open door pouring out light (see Figure 6). It had a theme of emotional healing in it. She even mentioned in the writing part of the exercise that she “felt free” after telling her mother about her trauma which could indicate emotional healing.

Figure 6

Emily’s “Something I Would Change” drawing

For the fifth, week, Emily drew a picture of an optimistic future (Figure 7).

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 52

Figure 7

Emily’s Optimistic future

She drew a picture of herself, a house, a nice car, and other nice things. These drawings could have indicated a theme of hopefulness for the future and optimism. She was hopeful she was going to get all these nice things and be successful. She was very optimistic about her future. She talked about this while processing the artwork during the session.

The results suggested that the visual journaling exercises had a profound emotional healing effect on the participants. The remaining three participants, Ashley, Amy, and Emily showed a visible change in their demeanor after the first two sessions involving the trauma.

During the next three sessions, the researcher observed that they became more visibly relaxed, articulate, and even smiled some. Ashley even joked. The researcher observed that the mood in the room had become visibly lighter and more carefree. The researcher observed in the last session that the mood of the three remaining participants had become very optimistic.

Better Quality and Quantity of Sleep

According to the CPSS results, participants reported better sleep for a short period of time. For another brief span, one participant’s sleep worsened, one’s participant’s symptoms VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 53 remained high, and one participants stayed at a level of none. There was then another decrease in sleep symptoms for a brief period. Then again, one participant’s sleep got worse while the others remained good. Looking at the results, over all for the group it appears that quality and quantity of sleep improved. All three participants talked about having better sleep as a result of the group in the exit interview. Ashley talked about having “less nightmares.” Emily stated in the exit interview that she “takes less time to fall asleep.”

Overcoming Adversity

In the drawing that involved being able to change something about the traumatic event,

Emily drew a picture of an open door with yellow light coming out of it (see Figure 7 above).

There was a theme of hope, resilience, overcoming adversity, and healing in the picture. The open door with light pouring out is symbolic of hope. She wrote, “When I told my Mom, I felt free.” This statement could have indicated a first step for moving on from the trauma, becoming more resilient, a first step to overcoming the trauma, and a first step to healing from the trauma.

In the fourth week, Emily was asked to depict a drawing of her strengths. She drew aspects of art making (drawing and painting) and talked about how art is a form of therapy for her. Emily used art as a coping skill to help her overcome the trauma. It was mentioned earlier that Emily drew a picture of a house, car, and other nice things in her drawing of an optimistic future (Figure 8).

She was asked to write about one thing she could do that week to work towards her goal of an optimistic future. She talked about painting more to increase her skill. There were themes of resilience, determination, bettering oneself, and overcoming adversity in the picture. Although she experienced this trauma, she still showed herself being successful in the future despite everything that happened to her. This clearly showed she was not letting the trauma she experienced get the best of her. Emily also showed despite this trauma, bettering herself and VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 54 becoming successful. Writing about painting more to increase her skill showed her determination to reach her future goals.

Figure 8

Ashley’s Strengths, Strengths Part II

Ashley depicted her engaging in several activities such as reading, helping her brother with her schoolwork, gymnastics, and running. There appeared to be themes of coping, resilience, and overcoming adversity in this picture. Ashley depicted using several healthy coping skills to deal with the trauma of her mother getting strangled by her father. Ashley was shown as resilient, not letting the trauma get the better of her, and engaging in many normal activities despite her challenging situation. Ashley showed herself overcoming the trauma and functioning as a normal, healthy girl.

In her drawing of an optimistic future, Ashley drew herself as an art teacher (see Figure 6 above). The picture could have indicated themes of resilience, bettering one’s self, determination, and overcoming adversity. Even after suffering this horrible trauma, Ashley has moved on and wants to become an art teacher and depicted this. Ashley drew herself becoming VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 55 an art teacher a bettering her life despite her trauma. Ashley also wrote “to work on art to get better at it so I can become an art teacher.” This described her one thing she could work on that week to get towards her goal of an optimistic future. This statement clearly showed her determination to get better at art so she can work towards her goal of a becoming an art teacher.

There was a theme of overcoming adversity because despite this trauma, she still has plans to become an art teacher and drew about it. During the last session, the researcher observed Ashley,

Amy, and Emily talked excitedly about their plans for the future.

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 56

CHAPTER V

Discussion

The question guiding this study was What are the effects of visual journaling in reducing trauma symptoms (flashbacks, nightmares, negative feelings, and hyperarousal) in children?

The study consisted of administering the “Check, Change What You Need to Change and/or

Keep What You Want” art therapy protocol to study participants over a five-week period. At the beginning and end of each session, participants were administered the CPSS-V to measure whether their trauma symptoms reduced. At the end of the study, the researcher conducted an exit interview with each participant. Overarching themes that were found as a result included (a) trauma symptoms, (b) quantity and quality of sleep, and (c) overcoming adversity.

Trauma Symptoms

Hass-Cohen et al.’s (2018) study found a self-reported reduction in negative affect (or feelings) due to four drawing art therapy trauma and resiliency protocol. CPSS results in this study found mixed results with regards to trauma symptoms. The study results indicated a decrease in flashbacks and nightmares from the CPSS results and self-report of the participants, something that recent studies had not presented as evidence. Further evidence showed that all three participants reported that they thought about the trauma less. Van Westrhenen et al.’s

(2019) study showed that both hyperarousal and avoidance symptoms decreased in children involved in ten-week creative arts in psychotherapy program compared to the control group that received no therapy. However, study results concerning an increase in hyperarousal contradicted the past research (Van Westrhenen et al., 2019).

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 57

Reduction in Anxiety and Depression

Participants reported in their exit interviews after involvement in the study that they had less anxiety and depression. One participant went on to further report that the art making helped lower anxiety and calm her down. Art therapy has been known to reduce instances of depression and/or anxiety in individuals before. Chandraiah et al.’s (2012) study using group art therapy found that the mean group depression scale scores decreased significantly from pre to post- treatment. Curry and Kasser (2005) further supported this claim by finding that coloring mandalas or coloring plaid help decrease anxiety significantly more for participants than coloring on a blank page. van der Vennet and Serice (2012) attempted to replicate Curry and Kasser’s

(2005) study and revealed that coloring a mandala reduced anxiety more than coloring a plaid design or coloring a blank page. Ilali et al. (2018) also indicated that participants had a decrease in depression symptoms after completing art therapy sessions. Laurer and van der Vennet (2015) initially found art production caused a greater reduction in negative mood and anxiety, but then later found that time in treatment made in impact more than the art intervention. This evidence doesn’t fully support the theory that art therapy reduces anxiety. However, Kimport and Hartzell

(2015) discovered that clay work greatly reduced anxiety in participants and anxiety reduction was greater for men than women. Hass-Cohen and colleagues (2014) found that their

“Check/Change What You Need to Change and/or Keep What You Want” art therapy protocol helped reduce anxiety in participants.

Emotional Responses

The study showed that the art making had many therapeutic benefits for the participants including being able to tell others what happened, expression of feelings, and using art making to help lower anxiety. Due to the therapeutic benefits of art making, Emily was able to become a more positive, self-confident, and fully whole person. The results of this study were supported by VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 58

Stace’s (2014) findings. In her , the participant was able to manage, express, and experience her intense emotions in a safe environment, was able to better comprehend her complex trauma experiences, increase positive emotions, accept herself, increase self-confidence and self-empowerment, obtain a positive identity, and to feel more fully integrated (Stace, 2014).

Amy reported an increase in confidence due to the art making which in turn supported the evidence presented in Stace’s (2014) study.

Better Quality and Quantity of Sleep

Gibson (2018) reported that after completing her visual journaling exercise, she fell asleep more easily, and slept more soundly which supported the findings of this current study.

There were some other types of therapy and interventions that had shown to improve sleep quality. Williams (2019) found that guided meditation helped a population of incarcerated youth aged 15 to 20 years of age struggling with trauma-induced sleep disorders sleep better. Results showed that there was strong relationship between the use of guided meditation and decrease in insomnia and improvement in the quality of sleep (Williams, 2019). The results in the Williams

(2019) study supported the theory that alternative interventions can help improve sleep quality.

The current study data taken from the CPSS results regarding the frequency of nightmares (see results section and Appendix C) suggested that participants reported an overall increase in the quality and quantity of sleep. This was further supported by the self-report of three of the four participants that completed the study that they slept better as a result of the study. One participant reported less nightmares and another participant talked about taking less time to fall asleep. There was, however, an overall lack of studies that indicated improved sleep quantity and quality due to art therapy interventions. There was also a lack of studies based on art therapy interventions to contrast or refute the theory that visual journaling and/or art therapy improves sleep quantity and quality. VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 59

Overcoming Adversity

The current study garnered support for the visual journaling exercises helping the participants overcome adversity. The researcher observed how resilient the participants were. At first the participants found it extremely hard to discuss the trauma and were shaken up by the visual journaling exercises. As the study continued, the researcher observed the participants become increasingly upbeat, positive, optimistic and cheery. The researcher observed them talking a lot about the positive things they had learned from the trauma and the positive coping skills they had learned as a result of the trauma treatment they underwent.

In terms of overcoming adversity, Hass-Cohen and others (2014) discovered that their art therapy protocol helped improve resiliency in the participants, which helped support the current study results. Hass-Cohen et al.’s (2018) study further supported the current study by showing evidence that using another trauma-informed art therapy protocol increased resiliency traits and resources in participants significantly. However, in van Westerhenen et al.’s (2019) study there was no increase in posttraumatic growth found, contradicting the current study.

Limitations

Due to the small sample involved in the study, only three participants completed the study; the results cannot be generalized to a larger population. There was no control group. The entire study was based on self-reported data. Quantitatively, the study may be weak due to the quantitative data being solely based on self-report from CPSS. The study was limited to children between the ages of 10 to 13 years old due to the ability of children this age to cognitively grasp the concept of visual journaling. Regarding qualitative data (drawings, and interviews), the researcher was not able to obtain all the artwork from all the participants so the results may not give a whole, complete picture of the results. The study was conducted over Zoom so the researcher may not have been able to observe the participants as closely for their reactions to the VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 60 process as opposed to being in person. This might have limited the collection of valuable qualitative data as well.

Recommendations and Future Studies

Further studies are recommended with a larger sample. This study could also be applied to other populations such as older adolescents and adults with trauma symptoms, or children, older adolescents, and adults suffering from depression and anxiety. Future studies should be modified to measure if visual journaling possibly decreases symptoms of depression and anxiety in children by utilizing depression or anxiety scales as the assessment tools instead of the CPSS.

Researchers could have participants document drawings and writings in a visual journal between group art therapy exercises to see if that would also help make a difference in trauma symptoms.

Changing the guiding questions in the directives (see Appendix A) could lead to different results that could be analyzed as well. Maybe a study utilizing Hass-Cohen and colleagues’ (2018) four drawing art therapy trauma and resiliency protocol could be used and modified to study the effects of visual journaling on children instead of adults.

Conclusion

Children suffer from the effects of violence and injury every day (van Westrhenen &

Fritz, 2014; van Westerhenen et al., 2017; van Westrhenen et al., 2019). The aftereffects and trauma that these children suffer with are devastating. Children can develop disorders like

PTSD, anxiety, and depression, develop psychological issues such as suicidality and substance abuse, and have problems forming secure attachments and stable interpersonal relationships.

(Finchman et al., 2009; Jewkes et al., 2010; Perry, 2001; Suliman et al., 2009). Children can suffer from illness later in life as a result of trauma (Meyers, 2014). They can function cognitively lower, and their school performance can suffer (Malchiodi, 2015). Treatments like

TF-CBT and EMDR have been used to combat this problem (Lichtenstein & Brager, 2017; VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 61

Ridings, et al., 2018). Many creative art therapies have been used to treat trauma (Malchiodi,

2015; van Westrhenen, 2014). Children suffering from trauma need healing and hope (van

Westerhen, 2014, 2017, & 2019). Visual journaling might be that tool that they need (Sackett &

McKeeman, 2017). Although this study was limited, the results supported the use of visual journaling to help reduce trauma symptoms in children. Results showed a reduction in nightmares, flashbacks, negative feelings, and hyperarousal. Participants also reported a reduction in anxiety and depression. This study suggested that art therapists may now have another technique to help young trauma survivors get the help they need. This study advanced the field of art therapy by giving it another possible effective art intervention to help treat children with trauma symptoms. Further research is needed to investigate this possibility.

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 62

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APPENDIX A

Art Directives

Session I: Graphic Trauma Timeline/Narrative

The first five minutes the participants would take the CPSS V.

The next five minutes would be a deep breathing exercise to center and calm down the participants.

The next fifteen minutes would be an explanation of the directive which is drawing an autobiographical timeline of the traumatic event in their visual journal.

Guiding Questions:

• Look all around you. What are you seeing?

• What is happening around you?

• What are you thinking about as this is happening? Depict it.

• What are you feeling as this is happening? Depict it.

• Write a written story to the image you just created.

The participants will take thirty minutes to then create their trauma narrative.

The participants will then take five to ten minutes to write about their trauma narrative related to their image.

They will then process through their image and written journal response with the researcher.

The participants will then take the CPSS V at the end of the session again.

Session II: Draw an aspect of what happened that you feel comfortable with and depict what it would look like. VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 86

The first five minutes, the participants will take the CPSS V.

The next five minutes would be a deep breathing exercise to calm down the participants before beginning the activity.

The next fifteen minutes would be an explanation of how the participants will be depicting an aspect of what happened during their traumatic event and draw what it would look like

Guiding Questions

• Think back to the upsetting event. What one specific thing do you

remember happening?

• What do you see in this image?

• What is going on in this image?

• Can you depict any thoughts or emotions that you remember?

• Write a narration to the image you created.

The next thirty minutes would involve participants depicting an aspect of what happened during the traumatic event.

The participants will take five to ten minutes to write about the highlight of the narrative they depicted in their image.

The participants will then process through the image and written response with the researcher.

The participants will take the CPSS V again.

Session III: Check in. Reflecting on your second picture, if you could change the ending of your trauma story, what would it look like?

The first five minutes the participants will take the CPSS V. VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 87

The next fifteen minutes would be explaining the directive by telling them to reflect on their second drawing and change the ending of their trauma story to something they find more desirable.

Guiding Questions:

• If you could change the ending to your trauma story to something better, what

would it look like?

The next thirty minutes would involve the participants drawing an image changing their ending to the trauma story.

They would write about their thoughts and feelings regarding this change for five to ten minutes.

The participants would process through the images with the researcher.

The participants would take the CPSS V again.

Session IV: Self-Strength Image

The participants would take five minutes to complete the CPSS V.

The next fifteen minutes the researcher would explain the next directive to the participants which is to depict an image of strengths you may possess.

Guiding Questions:

• What strengths do you have?

• How would you draw those?

• Write a written response to the image you created.

The participants would draw an image of their strengths for thirty minutes. VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 88

The participants would then take five to ten minutes to write about how they have used their strengths to overcome their trauma.

The participants would take fifteen minutes to process through their images with the researcher.

The participants would take five minutes to take the CPSS V again.

Session V: Optimistic Future Image

The participants would take five minutes to complete the CPSS V.

The researcher would explain the directive which is to create an optimistic or happy image of where they see themselves in the future.

Guiding Questions:

• Where do you see yourself in a week?

• Where do you see yourself in a month?

• Where do you see yourself in a year?

• Where do you see yourself in 5 years?

• Write a written response to the image you created.

The participants will spend thirty minutes creating their optimistic future image.

The participants will spend five to ten minutes writing about one thing they will do this week to work towards the goal of an optimistic future.

The researcher will process through the images with the participants

The participants will take the CPSS V again.

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 89

APPENDIX B

Exit Interview

1. What did you like about the group art therapy visual journaling exercises?

2. What did you find challenging or did not like about the group art therapy sessions?

3. What did you get out of these visual journal exercises?

4. What symptoms did you notice a decrease in after these exercises?

5. How did your anxiety and depression decrease after the study?

6. How was your quantity and quality of sleep affected by this study?

VISUAL JOURNALING IN TREATING CHILDHOOD TRAUMA 90

APPENDIX C

Table 1

CPSS scores at the beginning and end of the study

PARTICIPANT FLASHBACKS NIGHTMARES NEGATIVE HYPERAROUSAL

FEELINGS

(ANXIETY,

DEPRESSION)

Week 1 Week 5 Week 1 Week 5 Week 1 Week 5 Week 1 Week 2 Week 5

EMILY 3 2 2 1 4 0 1 0 4

ASHLEY 1 0 1 0 1 0 1 1 1

AMY 1 0 1 0 4 0 1 0 4

Note. The four columns above represent different sections of the questionnaire. The numbers depicted in the table represent frequency of symptoms. 0 = Not at all; 1 = 1 time a week; 2 = 2 to 3 times a week; 3 = 4 to 5 times a week; 4 = 6 time or more times a week or almost always