Cognitive-Behavioral Art Therapy

From Behaviorism to the Third Wave

Marcia L. Rosal

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781138208421
• eBook ISBN: 9781315459233
• Topic: Psychology
• Subtopic: Psychiatry & Mental Health
• Index: Psychology

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

1
The Uneasy Connection Between Cognitive-Behavioral Therapy and Art Therapy

“Genuine art work requires organization which involves many and perhaps all of the cognitive operations known from theoretical thinking.”

(R. Arnheim, 1969, p. 263)

The time has come for art therapists to embrace one of the most researched and most effective approaches to art therapy today. Cognitive-behavioral therapy (CBT) is not only a meticulous treatment modality, but also an effective and viable approach to art therapy. The longevity of CBT is due to the commitment to research each CBT technique. Any strategies that do not result in positive therapeutic changes are eliminated from CBT protocols. According to Herbert and Forman (2011b), “Hundreds of studies have evaluated various cognitive behavioral theories of psychopathology, and hundreds more have assessed the efficacy of CBT interventions. This scientific literature has placed CBT in a unique position to dominate the field of psychotherapy” (p. 3).

The same is true for cognitive-behavioral art therapy (CBAT). A number of art therapy research studies have investigated the success of CBAT, and according to Anderson (2001) “the evidence supporting it [CBAT] is very strong” (p. 254). Even with positive outcome research and significant efficacy, art therapists are still wary of embracing CBAT. Therefore the mission of this book is to provide a comprehensive examination of CBAT for art therapists and other mental health professionals who want to investigate the power of art therapy as part and parcel of CBT. This will be accomplished by presenting philosophical and theoretical information throughout the evolutionary phases of CBT and CBAT.

There are three distinct stages or waves in the progression of CBT and CBAT practice.¹ Throughout the book, each wave will be examined and deconstructed for practitioners; specific art therapy practices will be illustrated through the use of case vignettes. The foundation of CBT and CBAT begins with the onset of behaviorism or what is now regarded as the first wave of CBT. Behavior theory and behavior therapy were the foundation of this first wave of CBT when behavior therapy was the rule. Problematic behavior was hypothesized to be learned and maintained by the environment. Albert Ellis (1962) and other staunch behaviorists such as Skinner (1953, 1971) and Watson (1913, 1924) used the philosophy of stoicism to undergird their ideas. Stoicism, which emerged in the third century ad, regarded emotions as phenomena that needed to be tamed. In stoicism, emotions are not ignored, but rather the Stoics crafted principles of living that would mitigate purely emotional responses to difficult situations (Russell, 1945). Behaviorists embraced this principle of stoicism and developed interventions to help clients to find a less reactive and more adaptive and rational course of action when dysfunctional behaviors manifested.

The second wave of CBT and CBAT began with the emergence of the new science of cognition and the integration of cognitive science into behaviorism, or what is now termed the second wave of CBT. This new phase of behaviorism began with Albert Bandura (1969) and the development of social learning theory, which proffered that the regulation of human behavior is determined through one’s cognitive processes rather than being regulated by the environment. Beck (1976), Meichenbaum (1974), and other psychologists used this new-found understanding of cognition to develop the early therapeutic mechanisms of CBT.

The integration of Buddhist psychology, mindfulness, and meditative practices into CBT practice is referred to as the third wave or third generation in the evolution of CBT. This evolutionary advancement of CBT began with Kabat-Zinn (1982), who created a successful mindful meditation program for individuals with chronic pain. The purpose of this program was not only to reduce the amount and strength of pain medications required to manage pain, but also to help patients to regain their former lifestyle. Soon thereafter Kabat-Zinn’s ideas were studied by cognitive-behavioral psychologists and were transferred to the treatment of relapsing depression, borderline personality disorders, and other self-harm diagnostic groups. The third wave set of CBT approaches has energized art therapists more so than the first two evolutions of CBT. Today, art therapists are embracing mindfulness and meditative practices as integrated into art-making.

Some Background on Art Therapy

Art therapy is one of several experiential modes of treatment, including the creative arts therapies (e.g., art, bibliotherapy, dance, drama, music, poetry, psychodrama) as well as recreation therapies, which include equine interventions. Experiential treatments engage the client in participating in a creative activity that embodies therapeutic value. When art therapy is employed, clients are encouraged to interact with an assortment of art materials through touching, smelling, and manipulating art media. The therapeutic value of using art materials has been explored by numerous art therapists, and there are many books and journal articles that advance the use of art therapy with a multitude of diagnostic groups. Understanding the therapeutic application of the many art materials available to art therapists is explored through the expressive therapies continuum (Kagin & Lusebrink, 1978; Lusebrink, 1990, 2016; Hinz, 2009, 2016) as well as investigations of both traditional and contemporary media by C. Moon (2010). The manipulation of art materials was initially discussed by Kramer (1971), who found that forming a product out of raw art materials can be empowering and ego-building.

Manipulating art materials can assist in advancing self and environmental awareness. According to Lorenzo de la Peña (2016), “Individuals naturally turn toward their environment when translating the emotive experience into concrete form” (p. 146). Body awareness is one of the areas that can be improved through interacting with art materials (L. Wilson, 1977; Anderson, 1992). Understanding where the body is in space is one possible outcome of art therapy. Spatial awareness is another (Packard, 1977). And, as proposed by Uhlin (1972) and Silver (1987), improvement in developmental and cognitive abilities is also possible through interacting with art materials. Most recently, there is evidence that art therapy can address neurological issues and can enhance brain functions (Chapman, 2014; King, 2016).

The work of the art therapist includes encouraging the client to engage with art materials as a means of self-exploration and self-expression, and most importantly, utilizing art materials to move the client towards healing. For the non-art therapist, it might seem, from an objective perspective, that conducting art therapy is simple—just supply an array of art materials to a client and arrange some time and space for them to engage with these materials. Although engaging in art-making has many benefits, the practice of art therapy involves more than just providing materials, space, and time. In addition to a thorough understanding of the therapeutic properties of art media, art therapists are also versed in aspects of creativity and the power inherent in the creative environment and the creative process (Lusebrink, 1990). For example, several art therapists have found that being engaged in a creative act can have both transcendent and therapeutic effects (Garai, 1987; McNiff, 1998; Rubin, 1984). In addition, the creative product is one that exudes meaning not only for the client, but also for the viewer of the art.

The experiential and creative aspects of art therapy require art therapists to provide an environment where choice of media and a welcoming setting are of utmost importance. A place of nonjudgmental acceptance is vital to the success of art therapy treatment. This type of climate was first proposed by both C. Rogers (1951) and N. Rogers (2001), and regardless of the theoretical perspective embraced by an art therapist, this type of acceptance has been integral to the art therapeutic process. Art therapists carefully think through each encounter with a client with an understanding of the issues faced by that person, framing goals and objectives for what needs to be accomplished in each session, and formulating outcomes. The endeavor is not and should not be atheoretical.

The Need for a Theoretical Foundation

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

Art Therapists Adhere to Theoretical Perspectives

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

CBT and CBAT

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

Obstacles to Adopting CBAT

The obstacles to adoption of CBAT are many, and need to be addressed. Here the arguments against the use of CBAT will be challenged. There are at least five significant obstacles to the use of CBT in the practice of art therapy. The first is a concern about the sense that CBT is a “cookbook approach” to the practice of therapy. It is true that there are numerous CBT workbooks regularly used by CBT mental health practitioners. Often step-by-step manuals are perceived as rigid, not allowing for the individuality of the client to inform the therapist of where and how to go next in treatment. Although there is a kernel of truth to this concern, most CBT therapists are significantly influenced by the immediate needs of a client, and do not allow a workbook to hinder them from veering away from a specific intervention in order to address a client’s troublesome worries.

The second concern was outlined by Sarid and Huss (2010), and is related to the first obstacle. They pointed out that CBT is often identified as a top-down therapeutic process. By this they mean that the shape of the treatment is developed by the therapist and then provided to the client. Yet art therapy is recognized as a bottom-up treatment modality, in which the client shapes the course of treatment. Although there is some evidence that this is accurate, CBT does not always circumvent the client’s input. In fact, one of the strengths of CBAT is that the art itself brings to the fore the trajectory of the treatment process.

The third perceived problem is that CBT and CBAT do not address the emotional content of client issues. Again this is inaccurate. Feelings and emotions are considered to be cognitive processes, which are therefore important to examine and address as part of treatment. According to Hofmann, Asmundson, and Beck (2013), both cognitive therapy and CBT address the interplay of cognition and emotion. In current CBT and CBAT practice, there are specific interventions for tackling the emotional intensity and affective content of anxiety, PTSD, and other diagnostic groups, such as depression and chronic pain.²

Assisting a client in making sense or making meaning out of difficulties has been a vital part of the practice of art therapy. Therefore the fourth reason why art therapists may shun CBAT is because there has been a lack of discourse on how it helps a client to make sense of their dilemmas. Meaning-making is a key component of CBAT. In fact, the incorporation of art-making into CBT increases the probability that finding the significance of life events will be possible. Meaning can be constructed through art-making and can be understood through the lens of constructivist theory.³

Fifth, the perception that CBT is about the power of positive thinking is unfounded. Rather CBT is about helping someone to think and act more rationally, and this is the root of CBT and CBAT. Rational thinking, as first introduced by Albert Ellis, is crucial to adaptation and to adjusting more effectively to problematic situations. In CBT and CBAT, rational thought patterns mitigate or modify maladaptive ones and lead to adaptive behaviors. Both CBT and CBAT therapists believe that rational thinking may help clients to construct a life with less upheaval and distress.

An Argument for CBAT

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

Therefore one argument for the use of CBT in art therapy is important to note: CBT has significance in the psychology world because of the massive amount of evidence for its effectiveness for treating individuals suffering from numerou...

Table of contents

• Cover
• Title
• Copyright
• Contents
• List of Figures
• List of Tables
• Preface
• Acknowledgments
• 1 The Uneasy Connection Between Cognitive-Behavioral Therapy and Art Therapy
• 2 Creative, Imaginal, and Emotional Aspects of Cognitive-Behavioral Therapy
• 3 Art-Making as a Cognitive-Constructivist Process
• 4 The History of CBT
• 5 The Historic Roots of CBAT
• 6 Current CBAT Practices
• 7 The Mindfulness Evolution of CBT
• 8 Third-Generation Variants of CBT and CBAT
• 9 Unravelling CBAT for Practitioners
• Appendix A: Kelly's Repertory Grid and Figure List Sheet
• and Repertory Grid
• References
• Index