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CONCEPTUAL FRAMEWORKS PHASE 2EXECUTIVE SUMMARY REPORT
DECEMBER 30, 2020
December 2020
Prepared for Creative Forces®: NEA Military Healing Arts NetworkAmericans for the ArtsNational Endowment for the ArtsU.S. Department of DefenseU.S. Department of Veterans Affairs
Prepared by ProgramWorksShawn Bachtler, Ph.D.Candace Gratama, Ed.D.
The authors wish to acknowledge the members of the technical review group, who provided valuable expertise and guidance throughout this project: Sharon Goodill, Ph.D., Clinical Professor and Chairperson, Creative Arts Therapies Department, College of Nursing and Health Professions, Drexel University; Lori Gooding, Ph.D., Assistant Professor, Music Therapy, Florida State University; Girija Kaimal, Ed.D., Associate Professor, Creative Arts Therapies Department, College of Nursing and Health Professions, Drexel University; and Nicholas Mazza, Ph.D., Dean Emeritus, Patricia V. Vance Professor of Social Work Emeritus, Florida State University.
TABLE OF CONTENTS
INTRODUCTION ...................................................................................................................................................... 2
CREATIVE FORCES CLINICAL RESEARCH .............................................................................................................. 2
CREATIVE ARTS THERAPIES CONCEPTUAL FRAMEWORKS ....................................................................................... 6
CONCEPTUAL FRAMEWORK DEVELOPMENT PROCESS ...................................................................................... 6
ART THERAPY CONCEPTUAL FRAMEWORK ............................................................................................................. 9
PRIORITIZED RESEARCH QUESTION ................................................................................................................... 9
RESEARCH DESIGN .............................................................................................................................................. 9
PROTOCOLS AND MEASURES ........................................................................................................................... 11
CONCEPTUAL MODEL ....................................................................................................................................... 11
MUSIC THERAPY CONCEPTUAL FRAMEWORK ...................................................................................................... 17
PRIORITIZED RESEARCH QUESTION .................................................................................................................. 17
RESEARCH DESIGN ............................................................................................................................................ 18
PROTOCOLS AND MEASURES ........................................................................................................................... 20
CONCEPTUAL MODEL ....................................................................................................................................... 20
DANCE/MOVEMENT THERAPY CONCEPTUAL FRAMEWORK ................................................................................. 27
RESEARCH DEVELOPMENT ............................................................................................................................... 27
RESEARCH DESIGN ............................................................................................................................................ 30
PROTOCOLS AND MEASURES ........................................................................................................................... 31
CONCEPTUAL MODEL ....................................................................................................................................... 31
THERAPEUTIC WRITING CONCEPTUAL FRAMEWORK (UNDER DEVELOPMENT) ................................................... 35
THERAPEUTIC WRITING PRACTICES AND RESEARCH ....................................................................................... 36
PROCESS FOR MOVING FORWARD ................................................................................................................... 38
SELECT RESOURCES .......................................................................................................................................... 43
APPENDIX A – TEAM AND WORKING GROUP AFFILIATIONS ................................................................................ 44
APPENDIX B – ORIGINAL RESEARCH QUESTIONS ................................................................................................. 47
APPENDIX C – PROTOCOLS AND MEASURES ......................................................................................................... 50
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INTRODUCTION
CREATIVE FORCES CLINICAL RESEARCH
The Creative Forces®: NEA Military Healing Arts Network is committed to conducting and disseminating rigorous biomedical and behavioral research conducted in clinical settings, focusing on the biological, psycho-social, and comparative cost effectiveness of impacts and effectiveness of art therapy, music therapy, dance/movement therapy, and therapeutic writing on service members, veterans, families and social networks. Creative Forces has already published a number of studies of creative arts therapies and is now gearing up to implement a systematic research program. Findings will be used to further advance research and treatment for military-connected populations, as well as other clinical treatment groups. Creative Forces also aims to promote research collaboration across the partnering federal agencies, private foundations, state agencies, etc., to advance knowledge, leverage subject-matter expertise, and promote the use of best practices to benefit targeted patient populations. Specifically, the research will identify the optimal content, timing, frequency, duration, and candidates for these therapies.
The Creative Forces Research Strategic Framework identified three priority research areas for the Five-Year Research Agenda (2018-2022).1 Two additional priorities, telehealth and neuroimaging, have been incorporated to yield the following Creative Forces research priorities:
• Targeted Deployment of Creative Arts Therapies Interventions
• Creative Arts Therapies in Integrated Care, Co-Treatment, and Telehealth
• Population Characteristics and Relationships to Creative Arts Therapies Implementation and Outcomes
• Neuroimaging and Creative Arts Therapies
Creative Forces is committed to improving clinical outcomes for the military-connected populations, and this commitment drives the research into creative arts therapies and therapeutic practices. Creative Forces seeks objective, evidence-based answers to the following questions about creative arts therapies and therapeutic writing.
1. Do these therapies affect outcomes for traumatized military-connected populations (i.e., traumatic brain injury (TBI), psychological/behavioral health conditions including post-traumatic stress disorder, and chronic pain)? If so, how extensive and durable are treatment effects?
2. What are the relationships among population/patient characteristics, treatment variables, and outcomes?
3. How does the treatment context affect patient outcomes? How can treatment contexts be optimized?
4. What are the mechanisms of action of the various therapies?
To advance the use of creative arts therapies and therapeutic writing in military-connected populations, Creative Forces research will initially focus on the first three questions. These questions assess the effectiveness of the
1 https://www.arts.gov/sites/default/files/CF-Clinical-Research-Framework-and-Agenda-6.26.18.pdf
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interventions and identify the participant variables (e.g., diagnosis, length of time since injury, previous exposure and experience with the arts, self-efficacy), intervention variables (e.g., timing, intensity, duration, delivery method, individual or group therapy), and treatment context (e.g., integrated versus stand-alone treatment, telehealth) associated with outcomes. Findings from these questions should point to potential underlying mechanisms to investigate for the fourth question. Neuroimaging represents a powerful pathway for uncovering underlying mechanisms of injury and recovery. Future studies of mechanisms will be guided by Creative Forces research, the theoretical bases of the therapies, and research in those fields. The Creative Forces priority research areas map onto these questions as shown in the table below.
The creative arts therapies bear similarities with some other psychotherapies, emphasizing the therapeutic relationship, having clear clinical goals, and occurring in individual, family, and group settings. Creative arts therapies draw from similar theoretical foundations, particularly object relations, psychodynamic, cognitive developmental, and humanistic theories.2 However, the creative arts therapies distinctly integrate creative practices into the therapeutic process through self-expression, active participation, imagination/creativity, and mind-body connections. Unlike most standard psychotherapies, the patient generates a physical manifestation of the therapeutic process, which is witnessed by the therapist and, in some settings, by peers.
While there are differences among the creative arts therapies in clinical practice and artistic media used, they are grounded in the “therapeutic relationship” or “therapeutic alliance.” The American Psychological Association defines this as:
a cooperative working relationship between client and therapist, considered by many to be an essential aspect of successful therapy. Derived from the concept of the psychoanalytic working alliance, the therapeutic alliance comprises bonds, goals, and tasks. Bonds are constituted by the core conditions of therapy, the client’s attitude toward the therapist, and the therapist’s style of relating to the client; goals are the mutually negotiated, understood, agreed upon, and regularly reviewed aims of the therapy; and tasks are the activities carried out by both client and therapist.3
Creative Forces clinical research will study the relationships between variables associated with the delivery of creative arts therapies (patient, therapist, therapeutic alliance/relationship, intervention, and treatment milieu) and their impact on patient and system outcomes. The figure below illustrates the relationships among the elements of creative arts therapies and the intended outcomes for Creative Forces patients and similar populations. Treatment Protocol refers to therapeutic activities, such as mask making or lyric analysis, which are
Creative Forces Creative Arts Therapies (CATs) Research Priorities and Overarching Questions
2 Karkou, Vicky. (2006). Therapeutic Trends across Arts Therapies. 10.1016/B978-0-443-07256-7.50008-5. 3 https://dictionary.apa.org/therapeutic-alliance; When the term therapeutic alliance is used, it is recognized that the term is similar in meaning to therapeutic relationship, a term also used frequently in the literature to describe the same phenomenon.
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implemented using standardized, discipline-specific protocols (duration, frequency, etc.). The Creative Process is the patient’s therapeutic journey, documented through behavioral observation and self-report. The Creative Product is created by the patient and may be tangible, such as a drawing, or intangible, as with movement or singing. The creative arts therapies occur within a Treatment Milieu, such as the integrated care setting of the National Intrepid Center of Excellence, or within an inpatient or outpatient setting in a DoD or VHA facility.
Based on Creative Forces research, clinician observations at Creative Forces sites, and the theoretical models and research in creative arts therapies covered later in this document,4 it is hypothesized that service members and veterans participating in creative arts therapies will experience one or more short-term benefits and, ultimately, accelerated healing, enhanced readiness to serve and/or to navigate the challenges of daily life, improved transitions within the military and from military to civilian life, and enhanced resilience. Research, using an array of measures, will determine the effects of the creative arts therapies for patients.
4 See also Phase 2 inputs, page 7
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CREATIVE ARTS THERAPIES CONCEPTUAL FRAMEWORKS
CONCEPTUAL FRAMEWORK DEVELOPMENT PROCESS
Conceptual frameworks for art therapy, music therapy, dance/movement therapy, and therapeutic writing will guide Creative Forces research proposals toward the clinical needs of military-connected patients served by Creative Forces patients and similar programs. The Creative Forces Research Strategic Framework and Five-Year Research Agenda (2018-2022) stated:
There are many layers of complexity surrounding discipline-specific interventions and research. The creative arts therapies differ on multiple dimensions [such as scopes of practice, standards of practice, education standards, and credentialing/licensure requirements]. Further, within each discipline, a variety of theoretical frameworks are currently used to drive clinical practices and explain treatment outcomes. For an effective and rigorous research program within and across creative arts therapies, there is a need for theory-driven research guided by compelling research questions and hypotheses. To that end, a Conceptual Framework will be developed for each Creative Forces creative arts therapies discipline. The Conceptual Framework will identify the intended outcomes for that discipline and explain how the intervention achieves those outcomes. This is essential groundwork for theory-driven research.5
To establish a theoretical foundation for its research activities, Creative Forces has been developing Conceptual Frameworks for its clinical therapeutic practices.
5 https://www.arts.gov/sites/default/files/CF-Clinical-Research-Framework-and-Agenda-6.26.18.pdf, page 19
As programmatic clinical research gets underway, Creative Forces will concentrate on one or two larger experimental, prospective studies using a randomized controlled design (RCT) in partnership with the Department of Defense or the Department of Veterans Affairs. The rigor of RCTs allows greater understanding of the cause-effect relationships between interventions and outcomes. Creative Forces will solicit proposals to advance research and to strengthen outcomes for military-connected populations through creative arts therapies.
Development of Creative Forces Conceptual Frameworks occurred in two phases. Phase 1 convened separate clinical research workgroups in art therapy, music therapy, dance/movement therapy, and therapeutic writing to develop an inventory of research in the respective areas, draft logic models, conceptual models, concept maps, and research questions for each area. Phase 1 was a combined work effort over five months to facilitate and coordinate the efforts of four workgroups comprised of Creative Forces creative arts therapists and researchers with subject matter expertise in their respective discipline as pertaining to military-connected populations. Phase 2 built on this work, refining these materials toward creation of Conceptual Frameworks for research in the four clinical areas, each consisting of:
• A prioritized research question based on Creative Forces clinical priorities, Creative Forces existing research, and the field’s theoretical and research foundations;
• Research study scaffolds to address the prioritized research question;
• Inventory of current, vetted research protocols and measures appropriate for use in studies in and across clinical areas that address prioritized research questions; and
• Conceptual model that describes the primary, theoretically-based mechanisms of the four therapeutic practices and the outcomes within the context of an integrated care system such as Creative Forces.
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While commonalities exist across the creative arts therapies and therapeutic writing, they differ in theoretical explanations, status of research development, and availability of valid and reliable measures. Within Creative Forces, there are also differences in implementation of creative arts therapies and in research practices across sites. These distinctions impact how Creative Forces research will unfold. While the “next steps” in research for the creative arts therapies and therapeutic writing are customized accordingly, all proposed studies are hypothesis-driven targeting priority, well-defined outcomes. With the development of standardized protocols, they will provide opportunities from multi-site research.
PHASE 2 INPUTS In addition to accessing Creative Forces materials, Phase 2 relied heavily on input from key stakeholders. The following sources contributed to Phase 2.
• Phase 1 Creative Forces Conceptual Frameworks for Clinical Research (August 6, 2019)
• Creative Forces Research Strategic Framework with Five-Year Research Agenda (2018-2022)
• Supplemental literature review
• Interviews with representatives of: • Veterans Health Administration • Defense and Veterans Brain Injury Center/Military Health System TBI Pathway of Care • Department of Defense
• One or more input sessions with each of the following: • Creative Forces National Leadership Team (see Appendix A for members and affiliations) • Creative Forces Technical Working Group (see Appendix A for members and affiliations) • Creative Forces Core Planning Team (see Appendix A for members and affiliations) • Arts Endowment Office of Research and Analysis • Creative Forces art therapists • Creative Forces music therapists • Creative Forces dance/movement therapists • Creative Forces creative arts therapist subgroup for writing
• Review process with a Technical Review Group established exclusively for Phase 2 to develop and review the Conceptual Frameworks and consisting of four external researchers and subject matter experts in art therapy, dance/movement therapy, music therapy, and poetry therapy, identified by the Creative Forces Senior Military Medical Advisor, Clinical Research Advisor, and other members of the Phase 2 project team established (see Appendix A for members and affiliations)
CREATING CONCEPTUAL FRAMEWORKS
Art therapy, music therapy, dance/movement therapy and therapeutic writing are at different stages of clinical and research development in the Creative Forces program, and this is reflected in the individual Conceptual Frameworks. Phase 2 resulted in full Conceptual Frameworks for art therapy and music therapy. A progressive research program was designed for dance/movement therapy, leading to a Conceptual Framework. The proposal for therapeutic writing creates a foundation for using common protocols across Creative Forces sites and for exploratory research.
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The process began with identification of multiple research questions for each area. Criteria for research questions were:
1. Focused, yet suitable for generating programmatic research;
2. Specific to the intervention area (art therapy, music therapy, dance/movement therapy, therapeutic writing);
3. Directed toward the health conditions or wellness indicators which are high priorities for Creative Forces clinical partner sites at the Department of Defense and Veterans Affairs; and
4. Expected results should be important to civilian populations.
Note: the identification of the research priorities is not intended to exclude other Creative Forces research investments.
The conceptual frameworks reflect the differences in the level of development of clinical practice and research in art therapy, music therapy, dance/movement therapy, and therapeutic writing. For art therapy and music therapy, the proposed research questions included underlying hypotheses based on theory and research in the respective fields. Through stakeholder input and an iterative review process, one question was prioritized for each of the two disciplines and serves as the basis for the RCT proposed in those Conceptual Frameworks. For dance/movement therapy and therapeutic writing, initial research questions were more exploratory and aimed at developing research protocols and lines of study. Stakeholder feedback suggested all of the original questions are relevant to Creative Forces clinical and research programs, and they have been documented in Appendix B.
FINAL CONCEPTUAL FRAMEWORKS
The following sections present the Conceptual Frameworks for art therapy, music therapy, and dance/movement therapy. Art therapy and music therapy frameworks include a prioritized research question, an RCT to address that question, and a conceptual model supporting the question and study. The Conceptual Framework for dance/movement therapy identifies a series of research questions and studies that will move the discipline toward an eventual RCT. The Conceptual Framework for therapeutic writing is under development and currently reflects next steps for clinical and research efforts.
In addition to research questions, study designs, and a conceptual model, the Conceptual Frameworks identify current research protocols and measures appropriate for use in the studies. They are organized into three categories (see Appendix C):
Creative Forces standardized protocols/measures for use across all four Creative Forces therapeutic practices to collect patient, therapist, implementation, and treatment context data.
Practice-based and research standardized protocols/measures used within specific creative arts therapies or therapeutic writing practice or research.
General outcomes measures of behavioral, physical, social, and biological measures relevant to the therapeutic outcomes of Creative Forces patients and applicable across disciplines.
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ART THERAPY CONCEPTUAL FRAMEWORK
PRIORITIZED RESEARCH QUESTIONCreative Forces has produced a body of research in in art therapy, primarily through case studies and retrospective studies. The priority research question, while focused, allows for development of ongoing prospective research using RCT designs and mixed-methods data collection and analyses.
Art therapy research question: How and to what extent does art therapy affect emotional processing and self-regulation for service members and veterans?
Underlying hypothesis: Art therapy interventions improve self-expression, emotional awareness, and self-regulation (Collie et al., 2006; Haeyen et al., 2018; Haeyen, 2019; Johnson, Lahad, & Gray, 2009; Kaimal et al., 2018b). These changes are associated with improved executive functioning and increased activity in the speech centers of the brain (Walker et al., 2016; Rauch et al., 1998, Shin et al., 1997). Participation in art therapy should result in improved emotional regulation and communication leading to improved affect and goal-directed behavior, ultimately resulting in improved community integration.
Rationale: In clinical case studies and correlational examinations, art therapy has been found to help most with self-expression and emotional processing (Kaimal et al., 2019; Kaimal et al., 2018b; Jones et al., 2018; Walker et al., 2017; Walker et al., 2016) These outcomes need to be studied systematically to confirm initial findings.
KEY DEFINITIONS
Emotional processing is “the process of becoming aware of, expressing, and having a non-judgmental and accepting attitude toward emotions as they arise and are experienced” (Czamanski-Cohen et al., 2019, p. 2).
Emotional regulation “refers to a collection of cognitive and behavioral strategies that effect when, for how long and with how much intensity an emotion is experienced and expressed” (Czamanski-Cohen & Weihs, 2016, p. 9).
Self-regulation is “the capacity not only to control one’s impulses, but also to be able to soothe and calm the body’s reactions to stress. It is the ability to modulate affective, sensory, and somatic responses that impact all functioning, including emotions, somatic responses, and cognition. Additionally, it refers to the brain’s executive function, which can delay actions or initiate them if necessary” (Malchiodi, 2020, p. 165).
RESEARCH DESIGNTo date, Creative Forces has conducted program evaluations, clinical case studies, and correlational studies to document patient experiences and outcomes from art therapy interventions. Findings have suggested art therapy improves patient self-expression and emotional processing (Jones et al., 2019). Researchers have noted that the need for further investigation using more rigorous research paradigms is necessary to understand the nature of patient outcomes in these areas (e.g., Berberian et al., 2018; Kaimal et al., 2018b). Two proposed study designs address the priority research question: a pre/post feasibility study followed by an RCT. The studies
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will use a standardized intervention protocol (to hold constant, e.g., duration and frequency) and art therapy directive (e.g., mask-making, painting, collage).
Study 1: A feasibility study will determine how and to what extent service members with TBI who participate in a series of art therapy sessions experience improvements in emotional processing and self-regulation. The study may also measure perceived stress, affect, and post-traumatic stress disorder (PTSD) symptoms, to study their relationships to the primary outcomes. The purpose of the study is to develop and test protocols and to identify target outcomes for the RCT, as well as to get information needed for power analyses. The prospective design increases rigor and may suggest causality (Thiese, 2014).
Study 2: An RCT based on the efficacy study and comparing outcomes for art therapy patients with controls. Primary outcomes include emotional processing and self-regulation. The study will also measure perceived stress, affect, and post-traumatic stress symptoms, to study the relationships to the primary outcomes.
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PROTOCOLS AND MEASURESThe proposed studies will use Creative Forces standardized protocols to document (see Appendix C):
Patient variables Therapist variables Implementation variables Treatment context variables
General outcomes measures include (see Appendix C for details):
Emotional Processing Scale (EPS) General Self Efficacy Scale (GSES) Generalized Anxiety Disorder-7 (GAD-7) Patient Health Questionnaire (PHQ-9) Perceived Stress Scale (PSS) Positive and Negative Affect Schedule (PANAS) Post-Traumatic Stress Disorder/PTSD Checklist – 5 (PCL-5) Self-regulation Questionnaire (SRQ)
There are no measures specific to art therapy in the study designs.
CONCEPTUAL MODELTHEORIES OF ART THERAPY AND MECHANISMS OF CHANGE
Several prominent theories identify therapeutic outcomes and explain mechanisms of change associated with art therapy. Relevant to the priority research question for Creative Forces art therapy research, the following theories address emotional processing and self-regulation, although from different perspectives. Drawing from the substantial, long-standing bodies of literature on the neural and physiological mechanisms involved in perception, emotion, attention, and cognition, there is growing theoretical and scientific development on the physiological and neurological systems related to art therapy.
The Expressive Therapies Continuum (Lusebrink et al., 2013) asserts there are three sequential levels through which the patient progresses: 1) kinesthetic/sensory, 2) perceptual/affective, and 3) cognitive/symbolic. Across these levels, the patient moves from preverbal experience and expression of emotion, to identification and healthy expression of emotion, to symbolic expression and ultimately integration of emotion. This process enhances self-regulation. The three levels are interconnected by a creative axis, which is characterized by wholeness, healing, and well-being resulting from engaging in the creative process and self-expression at any of the three levels.
The Art Therapy Relational Neuroscience model (ATR-N; Hass-Cohen & Clyde Findlay, 2015) integrates art therapy, interpersonal neurobiology, and relational neuroscience. The model suggests there are six principles in “conceptualizing how interpersonal neurobiology of emotion, cognition, and action are expressed in the dynamic interplay of brain and bodily systems during art therapy.” Those principals are creative embodiment, relational resonating, expressive communicating, adaptive responding, transformative integrating, and empathizing and compassion. Together, these principles take into account the relational aspect of art therapy, as well as the interpersonal neurobiology of emotion, cognition and action of art therapy. Multiple ART-N principles address emotional processing and self-regulation. For example, social interactions that occur during art therapy and their underlying neurological processes have the potential to stabilize emotional regulation.
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The Bodymind model delineates specific psychological and physiological mechanisms that account for changes that result from art therapy (Czamanski-Cohen & Weihs, 2016). The model highlights interacting neural systems that are involved in the generation, perception, and regulation of emotion. The model postulates four core therapeutic processes of art therapy: 1) a triangular relationship between the art therapist, the art process and the art product leads to attachment similar to a patient’s primary relationships; 2) patient self-engagement with balanced arousal and attention occurs within the framework of that triangular relationship and the safety of the space for art making; 3) self-expression through art making enables patients to express somatic knowledge that is not easily translatable into words; and 4) the opportunity to engage in art making allows the patient to externalize emotional and cognitive material in a concrete form and then take time to engage in a reflective process provides the opportunity for both perspective taking and meaning making.
The Adaptive Response Theory (ART; Kaimal, 2019) explains the mechanisms of change in art therapy from the lens of evolutionary biology and human development. The theory is based on human instinctual survival responses to threats to well-being (bio-physiological and psycho-social-spiritual) and on how art making and imaginative processes align with the conceptualization of the brain as a predictive machine. The theory suggests that art therapy works through the dynamic interplay of the art therapist, the patient, the art making process, and the art product, which enables patients to shift from maladaptive to adaptive responses through the interpersonal and intrapersonal learning that occurs in the session. The art therapist encourages creative self-expression to improve mood and affect and reduce stress, among other outcomes. Relevant to emotional processing and self-regulation, patients learn to recognize their responses to threats and make adaptive choices.
These models of art therapy and possible mechanisms of change consider the general population in therapy. However, they highlight the interplay between art making, the artwork, and the patient-therapist relationship, and address areas of research interest for military-connected patients with PTSD and TBI. In identifying and overcoming challenges during art making, and in viewing and describing their art products, patients develop empathy for themselves and others and are better able to communicate their feelings and experiences in a healthy way, improving self-reflection, emotional processing, self-regulation, communication, relationships, and sense of belonging (Walker et al., 2016; Walker et al., 2017). Being witnessed and bearing witness to the art therapy process and products provide valuable information to both the patient and therapist (Jones, Drass, & Kaimal, 2019; Walker et al., 2016). The therapist can better assess the patient’s needs, and the patient can better assess his/her own needs. In the group setting, the patient also feels more connected to others through shared feelings and experiences (Jones, Drass, & Kaimal, 2019). These shared connections create a sense of community and belonging for patients, decreasing isolation and empowering them to open up to others, as well as encouraging others to open up. This decreases feelings of guilt and shame, and patients also become more open with their other health providers, their families, and their peers (Kaimal et al., 2021). They often do this by sharing their art therapy products – sometimes in the media and in public exhibits.
IMPLICATIONS FOR CREATIVE FORCES RESEARCH
Improved emotional processing and self-regulation are key outcomes for Creative Forces. Emotional processing consists of emotional awareness, emotional expression, and emotional acceptance (Czamanski-Cohen et al., 2019). Emotional awareness occurs when sensorimotor or other bodily information become explicit and enter consciousness. In emotional expression, feelings are conveyed to others. Finally, emotional acceptance occurs when the patient develops a nurturing attitude toward their feelings and emotional state. Emotional awareness and acceptance are essential elements of emotional and self-regulation, as they enable patients to make choices about how to attend and respond to their emotions.
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The art therapy process within a personalized, patient-centered care model begins with patient assessment, evaluation and treatment planning by the therapist, and aims to be a mechanism of change for the patient, the providers, the patient’s community (family, military unit, peers), and society. Within the art therapy process at a micro/clinical level, exists relationships between the patient, the art therapist, the art making, and the art product. While art therapy provides nonverbal methods of expression and communication, verbal communication of thoughts and feelings are part of the process (Walker, Kaimal, Gonzaga, et al., 2017). Verbalization occurs in planning stages, in production, and in processing the end result (Berberian, Walker, & Kaimal, 2018; Kaimal et al., 2018a; Kaimal et al., 2018b).
The graphics below present art therapy research within the Creative Forces research model (top model) and feature one theoretical approach to emotional processing and regulation (bottom model). Through art therapy and as part of emotional processing, patients develop verbal and nonverbal self-expression to improve their ability to communicate with others. This model is a simplified understanding. In practice, emotional processing and self-expression are integrated, complex, and individualized.
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REFERENCES
Berberian, M. G., Walker, M. S., & Kaimal, G. (2018). Master my demons: Montage paintings by active duty military service members with PTSD and TBI. Medical Humanities, 45(4), 353-360. DOI: 10.1136/medhum-2018-011493
Ceausu, F. (2018). The healing power of art therapy. Review of Artistic Education, 16, 203-211. DOI: 10.2478/rae-2018-0022
Collie, K., Backos, A., Malchiodi, C., & Spiegel, D. (2006). Art therapy for combat-related PTSD: Recommendations for research and practice. Art Therapy, 23(4), 157-164
Czamanski-Cohen, J., & Weihs, K. L. (2016). The Bodymind Model: A platform for studying the mechanisms of change induced by art therapy. The Arts in psychotherapy, 51, 63–71 https://DOI.org/10.1016/j.aip.2016.08.006
Czamanski-Cohen, J., Wiley, J., Sela, N., Caspi, O., & Weihs, K. (2019). The role of emotional processing in art therapy (REPAT) for breast cancer patients. Journal of Psychosocial Oncology, 37, 1-13. DOI: 10.1080/07347332.2019.1590491
Hass-Cohen, N., and Findlay, J. C. (2015). Art therapy and the neuroscience of relationships, creativity, and resiliency: Skills and practices. New York: W.W. Norton and Company.
Haeyen, S. (2019). Strengthening the healthy adult self in art therapy: Using schema therapy as a positive psychological intervention for people diagnosed with personality disorders. Frontiers in Psychology, 10, 644. https://DOI.org/10.3389/fpsyg.2019.00644
Haeyen, S., van Hooren, S., van der Veld, W., & Hutschemaekers, G. (2018). Measuring the contribution of art therapy in multidisciplinary treatment of personality disorders: The construction of the Self-Expression and Emotion Regulation in Art Therapy Scale (SERATS). Personality and Mental Health, 12(1), 3-14.
Johnson, D. R., Lahad, M., & Gray, A. (2009). Creative therapies for adults. In E. B. Foa, T. M. Keane, M. J. Friedman, & J. A. Cohen (Eds.), Effective treatments for PTSD. Practice guidelines from the International Society for Traumatic Stress Studies, 2nd ed. (479-490). New York: The Guilford Press.
Jones, J. P., Drass, J. M., & Kaimal, G. (2019). Art therapy for military service members with post-traumatic stress and traumatic brain injury: Three case summaries highlighting trajectories of treatment and recovery. The Arts in Psychotherapy, 63, 18-30. DOI:10.1016/j.aip.2019.04.004
Kaimal, G. (2019) Adaptive Response Theory: An evolutionary framework for clinical research in art therapy. Art Therapy, 36(4), 215-219.
Kaimal, G., Jones, J. P., Dieterich-Hartwell, R., Acharya, B., & Wang, X. (2018a). Evaluation of art therapy programs for Active Duty Military service with TBI and post-traumatic stress. The Arts in Psychotherapy, 62, 28-36. DOI: 10.1016/j.aip.2018.10.003
Kaimal, G. Jones, J. P., Dieterich-Hartwell, R. M., & Wang, X. (2021). Long-term art therapy clinical interventions with military service members with traumatic brain injury and post-traumatic stress: Findings from a mixed methods program evaluation study. Journal of Psychology, 33(1), 29-40. DOI: 10.1080/08995605.2020.1842639
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Kaimal, G., Walker, M.S., Herres, J., French, L.M, & Degraba, T.J. (2018b). Observational study of associations between visual imagery and measures of depression, anxiety and stress among active duty military service members’ with post-traumatic stress and traumatic brain injury. BMJ Open, 8(8). DOI: 10.1136/bmjopen-2017-021448
Lusebrink, V. B., Mārtinsone, K., & Dzilna-Šilova, I. (2013). The Expressive Therapies Continuum (ETC): Interdisciplinary bases of the ETC. International Journal of Art Therapy, 18(2), 75-85. DOI: 10.1080/17454832.2012.713370
Malchiodi, C. (2020). Trauma and Expressive Arts Therapy: Brain, Body, and Imagination in the Healing Process. New York: Guilford Press.
Rauch, S. L., Savage, C. R., Alpert, N. M., et al. (1997). The functional neuroanatomy of anxiety: A study of three disorders using positron emission tomography and symptom provocation. Biological Psychiatry, 42, 446–52.
Shin, L. M., McNally, R. J., Kosslyn, S.M., et al. (1997). A positron emission tomographic study of symptom provocation in PTSD. Annals of the New York Academy of Sciences, 821, 521–3.
Thiese, M. (2014). Observational and interventional study design types; an overview. Biochemia medica, 24, 199-210. DOI: 10.11613/BM.2014.022.
Walker, M., Kaimal, G. Koffman, R., & DeGraba, T. J. (2016). Art therapy for PTSD and TBI: A senior active duty military service member’s therapeutic journey. The Arts in Psychotherapy 49(2), 10-16. DOI: 10.1016/j.aip.2016.05.015
Walker, M., Kaimal, G. Myers-Coffman, K., Gonzaga, A.M.L., & DeGraba, T. J. (2017). Active duty military service members visual representations of PTSD and TBI. Therapeutic journey. International Journal of Qualitative Studies on Health and Well-being, 12(1). DOI: 10.1080/17482631.2016.1267317
Walker, M., Kaimal, G., Gonzaga, A. M. L., Myers-Coffman, K. A., & DeGraba, T. J. (2017). Active duty military service members’ visual representations of PTSD and TBI in masks. International Journal of Qualitative Studies on Health and Well-being, 12(1). DOI: 10.1080/17482631.2016.1267317
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MUSIC THERAPY CONCEPTUAL FRAMEWORK
PRIORITIZED RESEARCH QUESTION
Creative Forces has produced eight studies in music therapy primarily through case and retrospective studies. The priority research question allows for development of programmatic research. It points to an RCT and mixed-methods data collection and analyses.
Music therapy research question: How and to what extent does music therapy affect the perception of chronic pain in service members and/or veterans who experience chronic pain?
Secondary outcomes include the impact of music therapy on anxiety and emotional state, along with pain medication use (number of agents, dose, frequency). Music therapy specific factors will be integrated, including willingness to use the techniques outside of the session and identifying aspects of the intervention perceived as helpful and engaging by patients.
Underlying hypothesis: Adherence to a specified regimen of music therapy perception diminishes negative pain perception (e.g., frequency, intensity, duration, distress) in service members and/or veterans experiencing chronic pain.
Secondary hypothesis: Adherence to a specific regimen of music therapy will reduce medication use, decrease anxiety and stress, improve emotional regulation, support community integration, etc.
Rationale: Chronic pain is a common reason for medical evaluation and medical boards among active duty service members, and 66% of veterans with PTSD also experience chronic pain (Center for Deployment Psychology, n.d.).6
Nonpharmacological treatment of service members in the United States Army with chronic pain is associated with fewer adverse outcomes after transition to the Veterans Health Administration (Meerwijk et al., 2020).
Music interventions have been shown to improve management of chronic pain (e.g., Bradt, 2010; Bradt et al., 2016a; Bradt et al., 2016b; Garza-Villarreal et al., 2017; Low et al., 2020).
The FY20 Defense Appropriations Act provides funding to the Department of Defense Chronic Pain Management Research Program (CPMRP) that supports research intended to improve the health and quality of life of service members and veterans living with chronic pain (CDMRP, 2020).7
6 See https://deploymentpsych.org/ 7 See https://cdmrp.army.mil/
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RESEARCH DESIGNTwo studies address the priority research question: an interim study, which serves as a pilot and feasibility study, followed by an RCT.
Study 1: The purpose of the pilot or feasibility study is to explore the impact of music therapy on pain perception in service members and/or veterans who experience chronic pain. The study design should explore the impact of a music therapy protocol on pain perception, emotional state (e.g., anxiety, depression, etc.), music therapy factors such as willingness to use various music therapy interventions and intervention characteristics perceived as helpful and engaging. Participants will engage in a music therapy protocol with pre, post, and longer-term follow-up measurements of pain, emotional state, and music therapy factors (e.g., willingness to use techniques outside of therapy, helpfulness of different interventions). Follow-up could occur 24 hours post-session, at the conclusion of the course of treatment, and at specified time post treatment (i.e., 3-6 months post treatment). Analgesic use could be gathered from the medical record following the music therapy session, at pre-determined intervals, to gauge whether or not use was impacted.
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Study 2: The purpose of this study is to explore the effects of music therapy intervention and psychoeducation on the perception of chronic pain in service members and/or veterans experiencing chronic pain. Secondary outcomes, including the impact of the music therapy intervention on emotional state (e.g., anxiety, depression, etc.), and opioid use, will also be explored, along with music therapy factors such as willingness to continue using the music intervention and identifying the music therapy intervention characteristics perceived as helpful/engaging. An option to include QST or other neuroimaging measures may be included.
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PROTOCOLS AND MEASURESThe proposed studies will use Creative Forces standardized protocols to document (see Appendix C):
Patient variables Therapist variables Implementation variables Treatment context variables
General outcomes measures may include (see Appendix C for details):
Bond Lader VAS Brief Pain Inventory Defense and Veterans Pain Rating Scale Defense and Veterans Pain Rating Scale Generalized Anxiety Disorder (GAD-7) Hospital and Anxiety and Depression Scale International Classification of Functioning, Disability, and Health (ICF) Pain Catastrophizing Scale Patient Reported Outcomes Measurement Information System (PROMIS) instruments short forms for anxiety, depression, and sleep disturbance Quantitative Sensory Testing
CONCEPUTAL MODELThe section below comes from the Arts Endowment’s Phase 1 Work (2019) Conceptual Frameworks for Clinical Research. Through that work, the following descriptions emerged.
CLINICAL MUSIC THERAPY
The Therapeutic Process The music therapy clinical process is based on the therapeutic alliance between the music therapist and the patient to address the needs, goal areas, and presenting symptomatology of the patient. Throughout the Creative Forces Network, music therapy is employed within an interdisciplinary, patient-centered care model that encompasses assessment, evaluation, goal setting, treatment planning, clinical intervention, termination, and strategies for continued music engagement to support community integration. Engagement in music therapy interventions can assist in the treatment of patients’ functional rehabilitation and behavioral health issues. Specifically, music therapy can be used to address areas of cognition, motor, speech and language, and psychosocial status to assist with emotional and psychological processing.
Music as an Art Form As an art form, music is uniquely social and requires verbal and non-verbal communication, using lyrical and instrumental structure, prose, and/or sound-associations to relay information. Considerations of social order are also a factor in music therapy, specifically during active music making, where the non-verbal interplay between instruments can demonstrate harmonies and/or tensions in relationships. In music therapy, patients are empowered to find and use their voices, whether it be the literal voice, through spoken word or singing, or conveying emotion through intentional sound selection and instrumentation. Rhythm is a fundamental component of music that is intertwined with communication and conveys both physiological and psychological state across physical, psychological, conceptual, spiritual, and emotional realms.
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Individual Music Therapy Expectations of individual music therapy treatment are presented and discussed during initial evaluation session. The patient role in individual music therapy is to utilize self-insight gleaned from clinical experiences and expertise of the music therapist to identify ways that assist in personal goal attainment, specific areas of personal growth and development, and overall well-being. The music therapist encourages the patient to be present and mindful throughout various components of the music therapy process.
Group Music Therapy Group music therapy sessions focus on individual identity within a group context with consideration to social dynamics, functional roles, communication, and awareness-building. The patient role in group music therapy is to gain perspective and insight of self and others through the process of fostering understanding of others’ situations, perceptions, and responses and establishing roles and relationships in the therapeutic setting. The music therapist supports the patients in being open to new experiences and perspectives by being attuned to the needs of individuals and the group.
Music Therapist’s Role Whether facilitating individual or group sessions, the music therapist is actively involved in the therapeutic process from commencement to completion. Direct participation of the music therapist includes facilitating the patients’ engagement in task-oriented musical behavior, providing supportive music or accompaniment to engage the patients, enhancing the patient experience, offering feedback on patient progress and performance throughout the music therapy process, and presenting a plan for follow-up music therapy and/or resources for continued music engagement outside of the clinical environment.
MUSIC THERAPY AND PAIN
Early research found that over forty-nine percent of music therapists used music for pain management (Michel & Chesky, 1995), and music therapy is believed to impact pain. From a neurological standpoint, research has shown that attention-based activities can attenuate the activation of areas associated with pain processing (Petrovic et al., 2000). Overlap in pain and music processing is seen in the anterior cingulate cortex, which suggests that both pain and music processing have the ability to elicit attention (Hernandez-Ruiz, 2019; Petrovic et al., 2000; Rodriguez-Wolfe, 2014). Likewise, the anterior cingulate cortex is involved in both pain and anxiety conditions (Zhuo, 2016). As such, music, especially preferred music , may elicit attention and be a successful tool for managing pain perception (Mitchell & MacDonald, 2006; Rodriguez-Wolfe, 2014). Research also suggests that music is effective as an analgesic because of its ability to serve as cognitive distraction, ties to emotional associations, and neurobiological underpinnings (Lunde et al., 2019).
Music therapy has been shown to diminish negative pain (Tan et al., 2010). Music therapy interventions refocus attention, thereby reducing the individual’s ability to focus on the competing pain stimulus. Previous research has shown that music interventions can reduce state anxiety (Davis & Thaut, 1989) and reduce both pain and anxiety in those with chronic pain (Guetin et al., 2012). Music interventions to promote relaxation and distraction in pain management have resulted in decreased pain scores and successful use outside of music therapy sessions (Colwell, 1997).
The theoretical constructs for music therapy as a pain management strategy is based on (a) constructivism, or the idea that task engagement can establish a construction of reality that replaces pain as a competing construction (Bradshaw et al., 2012), (b) affective components, (c) entrainment, or the linking of diverse behaviors, like heart rate or respiration, to an external beat (Stegemoller, 2017) (d) the Iso-Principle, altering musical characteristics to promote relaxation response (Altschuler, 1948), and (e) sociocultural factors (e.g., patient preference, culturally-relevant music, clinical empathy). These constructs are explained as follows:
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• Constructivism: Music can be used to capture attention, thereby managing pain perception. Music that is culturally relevant, familiar, and preferred has been shown to be most effective at capturing attention (Flowers, 2001; Zhu et al., 2009), and research has suggested that the music must be meaningful to be effective (Mitchel et al., 2006).
• Constructivism and Affect/Emotional State: Music assisted relaxation has been shown to improve pain perception (Tan et al., 2010). Essentially, music intervention such as deep breathing to music, is used to refocus attention, thereby reducing the individual’s ability to focus on the competing pain stimulus.
• Entrainment and Iso-Principal: Music assisted relaxation integrates not only attentional engagement, but also the use of music to reduce pain and/or anxiety. It involves the use of rhythmic and/or auditory cues to promote entrainment, and when paired with the Iso-Principle, which is the altering of musical characteristics to increase the relaxation response (Altschuler, 1948), music therapy has the potential to decrease physiological arousal. Music assisted relaxation techniques that use verbal communication have been shown to be most effective (Pelletier, 2004). Therefore, these techniques would not only integrate entrainment and the Iso-Principle, but also verbal facilitation to increase effectiveness. Use of music therapy paired with relaxation is important because music entrainment has been shown to positively impact emotional state (Bradt, 2010).
• Social Cultural Factors: Music that is culturally relevant, familiar, and preferred has been shown to be most effective at capturing attention (Flowers, 2001; Zhu et al., 2009), and research has suggested that the music must be meaningful to be effective (Mitchel et al., 2006).
The graphic on page 23 presents music therapy research within the Creative Forces research model. On page 24 is an illustration of one theoretical approach to chronic pain perception (Griffiths, 2017). Music therapy helps patients gain in-sight in multiple realms and develop skills to reach their goal of pain management, which transfers outside the clinical music therapy session. The model is simplified as chronic pain is complex and individualized.
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REFERENCES
Altschuler, I. M. (1948). A psychiatrist’s experience with music as a therapeutic agent. In D. Schullian & M. Schoen (Eds.), Music and medicine (pp. 250-275). New York: Books for Libraries Press.
Bradshaw, D. H., Chapman, C. R., Jacobson, R. C., & Donaldson, G. W. (2012). Effects of music engagement on responses to painful stimulation. The Clinical Journal of Pain, 28(5), 418–427. https://DOI.org/10.1097/AJP.0b013e318236c8ca
Bradt, J. (2010). The effects of music entrainment on postoperative pain perception in pediatric patients. Music and Medicine, 2(3), 150-157.
Bradt. J., Dileo, C., Magill, L., & Teague A. (2016a). Music interventions for improving psychological and physical outcomes in cancer patients [update]. Cochrane Database of Systematic Reviews, 2016(8). Art. No.: CD006911. DOI: 10.1002/14651858.CD006911.pub3.
Bradt, J., Norris, M., Shim, M., Gracely, E. J., & Gerrity, P. (2016b). Vocal music therapy for chronic pain management in inner-city African Americans: A mixed methods feasibility study. Journal of Music Therapy, 53(2), 178-206, DOI: 10.1093/jmt/thw004. PubMed PMID: 27090149 (IF = 1.694; Rehabilitation: 28/69)
Colwell, C. M. (1997). Music as distraction and relaxation to reduce chronic pain and narcotic ingestion: A case study. Music Therapy Perspectives, 15(1), 24–31. https://DOI-org.proxy.lib.fsu.edu/10.1093/mtp/15.1.24
Davis, W. B. & Thaut, M. H. (1989). The influence of preferred relaxing music on measures of state anxiety, relaxation, and physiological responses. Journal of Music Therapy, 26(4), 168–187. https://DOI-org.proxy.lib.fsu.edu/10.1093/jmt/26.4.168
Flowers, P. J. (2001). Patterns of attention in music listening. Bulletin of the Council for Research in Music Education, 148, 48-59.
Garza-Villarreal, E. A., Pando, V., Buust, P., & Parsons, C. (2017). Music-induced analgesia in chronic pain conditions: A systematic review and meta-analysis. Pain Physician, 20(7), 597-610.
Griffiths, M. (2017). Living well with chronic or persistent pain: A guide for patients and relatives. Aintree University Hospital NHS Foundation Trust. https://www.aintreehospital.nhs.uk/media/6478/living-well- with-chronic-pain-patient-guide.pdf
Guétin, S., Giniès, P., Siou, D. K. A., et al. (2012). The effects of music intervention in the management of chronic pain: A single-blind, randomized, controlled trial. The Clinical Journal of Pain, 28(4).
Hernandez-Ruiz, E. (2019). How is music processed? Tentative answers from cognitive neuroscience. Nordic Journal of Music Therapy, 28(4), 315–332.
Low, M., Lacson, C., Zhang, F., Kesslick, A., & Bradt, J. (2020). Vocal music therapy for chronic pain: A mixed methods feasibility study. The Journal of Alternative and Complementary Medicine, 26(2), 113-122. https://DOI.org/10.1089/acm.2019.0249
Lunde, S. J., Vuust, P., Garza-Villarreal, E. A., & Vase, L. (2019). Music- induced analgesia: How does music alleviate pain? Pain, 160(5), 989-993.
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Meerwijk, E. L., Larson., M. J., Schmidt, E. M., et al. (2020). Nonpharmacological treatment of army service members with chronic pain is associate with fewer adverse outcomes after transition to Veterans Health Administration. Journal of General Internal Medicine, 35(3), 775-783.
Michel, D. E., & Chesky, K. S. (1995). A survey of music therapists using music for pain relief. The Arts in Psychotherapy, 22(1), 49-51.
Mitchell, L. A., & MacDonald, R. A. R. (2006). An experimental investigation of the effects of preferred and relaxing music on pain perception. Journal of Music Therapy, 63, 295–316. https://DOI-org.proxy.lib.fsu.edu/10.1093/jmt/43.4.295.
Pelletier, C. L. (2004). The effects of music on decreasing arousal due to stress: A meta-analysis. Journal of Music Therapy, 41(3), 192-214.
Petrovic, P., Petersson, K. M., Ghatan, P. H., Stone-Elander, S., & Ingvar, M. (2000). Pain-related cerebral activation is altered by a distracting cognitive task. Pain, 85(1), 19–30. https://DOI.org/10.1016/S0304- 3959(99)00232-8.
Rodriguez-Wolfe, M. (2014). The effect of music listening on cold-pressor pain perception, tolerance, and attention. 10.13140/2.1.1396.8965.
Stegemöller, E. L. (2017). The neuroscience of speech and language. Music Therapy Perspectives, 35(2), 107–112. DOI.org/10.1093/mtp/mix007.
Tan, X., Yowler, C. J., Super, D. M., & Fratianne, R. B. (2010). The efficacy of music therapy protocols for decreasing pain, anxiety, and muscle tension levels during burn dressing changes: A prospective randomized crossover trial. Journal of Burn Care & Research, 31(4), 590–597. https://DOI.org/10.1097/BCR.0b013e3181e4d71b
Zhuo, M. (2016). Neural mechanisms underlying anxiety–chronic pain interactions. Trends in Neurosciences, 39(3), 136–145. https://DOI.org/10.1016/j.tins.2016.01.006.
Zhu, W., Zhang, J., Ding, X., Zhou, C., Ma, Y., & Xu, D. (2009). Crossmodal effects of Guqin and piano music on selective attention: An event-related potential study. Neuroscience Letters, 466, 21-26.
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DANCE/MOVEMENT THERAPY CONCEPTUAL FRAMEWORK
RESEARCH DEVELOPMENT
Dance/movement therapy (DMT) is newer to Creative Forces and still developing at the National Intrepid Center of Excellence (NICoE), where it has been integrated into the Intensive Outpatient Program (IOP) as well as longitudinal programming. As a newer program, therapists are in the process of developing, executing, and revising protocols, while also establishing a research program. An initial, unpublished case study found that IOP patients experienced improvements in self-expression, social connection, mind-body integration, self-efficacy, and overall sense of well-being while participating in the DMT program (Freeman, 2018).
Researchers suggest that building standardized treatment protocols or manuals and testing both the treatment and the outcomes can improve research quality, as well as progress to a randomized controlled study (Bryl & Goodill, 2020; Roslvsjord et al., 2005). The figure below details the progression of research for Creative Forces DMT, as the program develops research capacity, conducts studies, builds upon knowledge, and is adapted from suggestions from other researchers (Bryl & Goodill, 2020; Rolvsjord et al., 2005).
The capacity building phase is designed to develop partnerships to conduct research (academic institutions, researchers), publish results using extant data to build the program, develop treatment protocols for use in an initial case study, incorporate training, adopt the use of routine dance/movement therapy assessments, and develop processes to obtain consent and videotape sessions to conduct retrospective studies. The revise and adapt phases focus on learning from the previous research, improving treatment protocols and manuals, and identifying the salient outcomes to be tested in the research program.
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The research questions are designed to inform development and targeted outcomes of DMT research. The proposed research progression begins with case studies and progresses toward a randomized controlled trial (RCT), advancing the rigor of the program.
Using this progression, the initial case study will focus on several dependent variables: coping, resilience, interoception, emotional expression/regulation, readiness for life transitions, and family relationships. The findings from the early studies will inform which dependent variables will be included in the pre-experimental and RCT.
Throughout the process, retrospective studies can be conducted by collecting data, systemically from previous studies and with permission, through the treatment program. This will require standard protocols, routine DMT assessments, and a process to systematically document clinical data (see examples, Jones, Drass, & Kaimal, 2019; Walker et al., 2016).
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RESEARCH DESIGN
The case study, described below, is the first step in advancing the clinical and research program. This study will provide pilot data and findings to inform future studies, help develop the clinical program protocol for future studies, and produce a publication. It will also help develop a clearer therapy program, with sequenced therapeutic treatments and associated outcomes. It will also facilitate development of data collection and outcome measures for future studies.
This study uses a mixed methods, randomized, multiple single case study design. In this design, data are collected on days patients participate in DMT as well as on days with no DMT to compare across conditions. The randomized multiple single case study design (Stewart, McMullen, & Ruben, 1994) controls for the multiple treatment confounds and isolates the impact of DMT. This approach can also identify when outcomes will be met using a staged treatment approach. Interviews at the beginning and end of the study will provide information about transitions and the subjective experience of DMT.
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PROTOCOLS AND MEASURES
The proposed studies will use Creative Forces standardized protocols to document (see Appendix C): Patient variables Therapist variables Implementation variables Treatment context variables
Measures specific to dance/movement therapy include (see Appendix C for details): DMT Outcomes Framework with Movement Assessment and Reporting App (MARA) Multidimensional Assessment of Interceptive Awareness (MAIA)
General outcomes measures include (see Appendix C for details): Interviews COPE Inventory PROMIS Measures
CONCEPTUAL MODEL
Service members (SMs) recovering from TBI and associated psychological health conditions are engaged in DMT treatment at the NICoE. The NICoE program is built on a 4-week integrative treatment model. Based on the acute nature of the program, the population served, and the emphasis on group therapy, the initial focus of DMT work is on establishing safety among patients. This is achieved through addressing expectations and establishing a foundation of basic mindfulness concepts. The work then shifts to resource building through individual development of confidence in mind-body skills (i.e., diaphragmatic breath, meditation, yoga, and biofeedback), with a focus on helping SMs better understand their own mind-body connection and how to use that as a resource to address their needs in any situation. To build their capacity for flexible coping strategies, the DMT therapists provide opportunities for SMs to build personal resilience, appropriately regulate and express affect, and increase their interpersonal communication skills by expanding their movement repertoire.
As SMs become more able to tolerate the present moment and increase feelings of safety, creative movement work is introduced as clinically indicated. Expressive movement-based interventions can allow SMs to reflect on the past and present and visualize the future, creating embodied rehearsals for life to help SMs begin to actualize change and transition between roles with greater ease (i.e., parent, service member, and spouse) (Krantz, 2012). Creative movement can also help SMs build kinesthetic empathy and reciprocity, increase their ability to improvise, increase their understanding of how to create physical, mental and emotional comfort, increase feelings of self-efficacy, process and heal trauma, and to increase regulatory flexibility.
The graphic below combines the treatment conceptual model from Phase 1 and the Phase 2 proposed research design. While the underlying treatment model remains the same, the study will identify which activities accomplish each goal and outcome, as well as the order in which patients should expect to accomplish the goals and outcomes. Because the research is developmental, the activities may change as protocols are developed. Below is a list of constructs this study should impact.
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MODEL CONSTRUCTS
Coping: Healthy strategies people adopt to face specific stressors. As measured through the COPE Inventory, these include problem-focused coping strategies and emotion-focused coping strategies (Carver et al., 1989).
Emotional Expression/Regulation: On the DMT Outcomes Framework, emotional expression is the “ability to express an internal emotional or affective state through embodied behaviours or movement and vocal (including verbal) expressions.” Emotional regulation is the “response to ongoing demands of experience with a range of emotions, that is socially tolerable and sufficiently flexible, and both permits and delays spontaneous reactions.” (Dunphy et al., 2020, p. 25)
Family Relationships: The DMT Outcomes Framework includes a social domain that focuses on the therapeutic experience around relationships, the connections between people, and the way they communicate with each other. The instrument includes three subdomains which can be applied to family, including: embodied (non-verbal) communication, social reciprocity, and expressive (verbal and vocal) communication (Dunphy et al., 2020).
Interoception: Interoceptive awareness is the awareness of inner body sensations, involving the sensory process of receiving, accessing, and appraising internal bodily signals (Craig, 2015). In DMT, the MAIA is used to measure interoception through several subscales: noticing, not-distracting, not-worrying, attention regulation, emotional awareness, self-regulation, body listening, and trusting (Mehling et al., 2012).
Readiness for Life’s Transitions: (Still under development) – may include a self-efficacy measure or Outcome Domain 6: On the DMT Outcomes Framework: Integration: Wholeness, Vitality, Aliveness.
Resilience: Psychological resilience is the ability to grow and adapt in the face of stressors. For example, resilience related to pain is associated with attitudes and beliefs, catastrophizing tendencies, social responses, coping style, and health care and medication usage. The COPE Inventory has been used in previous DMT research to measure resilience (Shim et al., 2017).
Therapeutic Alliance: The therapeutic relationship is developed between the DMT therapist and the patient, and characteristics include personal awareness and insight, trust, respect, safety, authenticity, acceptable, empathy and collaboration. DMT focuses on movement behavior as it emerges in the therapeutic relationship, and expressive, communicative, and adaptive behaviors are all considered for group and individual treatment.8
8 https://www.adta.org/what-is-dancemovement-therapy
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REFERENCES
Bryl, K., & Goodill, S. (2020). Development, execution, and acceptance of a manualized dance/movement therapy treatment protocol for the clinical trial in the treatment of negative symptoms and psychosocial functioning in schizophrenia. American Journal of Dance Therapy, 42, 150-175. https://DOI.org/10.1007/s10465-019-09312-8.
Carver, C. S., Scheier, M. F., & Weintraub, J. K. (1989). Assessing coping strategies: A theoretically based approach. Journal of Personality and Social Psychology, 56, 267-283.
Craig, A. D. (2015). How do you feel? An interoceptive moment with your neurobiological self. Princeton, NJ: Princeton University Press.
Dunphy, K., Lebre, P., Mullane, S. (2020). Outcomes framework for dance movement therapy, 78. http://www.makingdancematter.com.au/
Freeman, L. K. (2018). Dance/movement therapy program review. Unpublished case study conducted at the National Intrepid Center of Excellence.
Jones, J. P., Drass, J. M., & Kaimal, G. (2019). Art therapy for military service members with post-traumatic stress and traumatic brain injury: Three case reports highlighting trajectories of treatment and recovery. The Arts in Psychotherapy, 63, 18-30.
Krantz, A. M. (2012). Let the body speak: Commentary on paper by Jon Sletvold. Psychoanalytic Dialogues: The International Journal of Relational Perspectives, 22(4), 437-448.
Mehling, W. E., Price, C., Daubenmier, J. J., Acree, M., Bartmess, E., Stewart, A. (2012). The multidimensional assessment of interoceptive awareness (MAIA). PLoS One, 7(11). https://DOI.org/10.1371/journal.pone.0048230
Rolvsjord, R., Gold, C., & Stige, B. (2005). Research rigour and therapeutic flexibility: Rationale for a therapy manual developed for a randomized controlled trial. Nordic Journal of Music Therapy, 14(1), 15-32.
Shim, M., Johnson., R. B., Gasson, S., Goodill, S., Jermyn, R., Bradt., J. (2017). A model of dance/movement therapy for reliance-building in people living with chronic pain. European Journal of Integrative Medicine, 9, 27-40.
Stewart, N. J., McMullen, L. M., & Rubin, L. D. (1994). Movement therapy with depressed inpatients: A randomized multiple single case design. Archives of Psychiatric Nursing, 7(1), 22-29.
Walker, M. S., Kaimal, G., Koffman, R., & DeGraba, T. J. (2016). Art therapy for PTSD and TBI: A senior active during military service member’s therapeutic journey. The Arts in Psychotherapy, 49, 10-18.
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THERAPEUTIC WRITING CONCEPTUAL FRAMEWORK (UNDER DEVELOPMENT)
THERAPEUTIC WRITING IN CREATIVE FORCES Therapeutic writing (or “expressive writing”) is the use of writing activities to achieve therapeutic outcomes, either as a stand-alone intervention or in combination with other therapies. Poetry therapy is the only credentialed therapeutic writing discipline. As a practice, it requires minimal resources and can be easily implemented. It is adaptable to telehealth and can be self-directed outside clinical settings. When used as a stand-alone intervention, the effects are typically smaller than resource-intensive psychotherapies. However, given the potential for larger reach, the total population effect could be greater than those resource-intensive therapies (Sayer et al., 2015).
Although Creative Forces does not currently have a comprehensive writing program or a team member with a Poetry Therapy credential or other writing certification, a number of Creative Forces therapists received training in writing techniques in their therapy training programs or through workshops. Several incorporate elements of writing into their clinical directives. Each method of writing is unique to the therapeutic goals of the patient and associated art, music, or movement interventions.
Creative Forces therapists either use existing protocols or developed their own for the writing activities they use. The table below reflects therapeutic writing interventions used within Creative Forces as of August 2020.
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THERAPEUTIC WRITING PRACTICES AND RESEARCHPRACTICES
The practices and impacts of therapeutic writing have been championed for several decades (for example: Adams, 2013; Anderson & MacCurdy, 2000; Mazza, 2017; Pennebaker, 1997; Smyth, 1998). Therapeutic writing interventions may occur in single or multiple sessions and take many forms: journal entries, poetry, lyrics, stories, letters, etc. Similar to the creative arts therapies, therapeutic writing occurs within and as part of the therapeutic alliance. It is used as individual and group interventions and results in individual or collective writing products. Creative arts therapists may use writing as a response to a creative activity or incorporate music, art, or movement as an alternative form of response to writing (for example: Beaumont, 2018; Garland et al., 2007; Jones et al., 2019; Landless et al., 2019; Pizarro, 2004).
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Additional examples of therapeutic writing and poetry therapy activities appear in the following table.
With military-connected populations, patients may write about traumatic events and transition processes. The Veterans Health Administration Office of Patient Centered Care and Cultural Transformation has produced a tool for clinicians and patients (see Resources section below). Writing may not only be beneficial for the veteran or service member: it has the potential to contribute to societal reflection and discourse on conflict, war, and military service (Usbeck, 2018). Self-expressive writing as a therapeutic intervention has also been used with veterans and their families (Nevinski, 2013).
RESEARCH
Research on the clinical use of therapeutic writing is difficult to synthesize. Part of the problem is terminology. Therapeutic writing has been linked to poetry therapy, journal therapy, autobiography, narrative therapy, bibliotherapy, reading therapy, literatherapy, scriptotherapy, writing therapy, and biblionarrative therapy. In addition, studies have used a variety of writing forms and implementation protocols across a wide range of population and treatment variables (e.g., clinical setting, demographics, diagnoses). In spite of these challenges, literature reviews typically report benefits to therapeutic writing (Frattaroli, 2006; Pavlacic et al., 2019; Sloan et al., 2015; Smyth, 1998). Further, rigor in research is moving the field forward through RCTs (Regev & Cohen-Yatziv, 2018). However, these findings are not universal (Meads & Nouwen, 2005; Mogk et al., 2006). Researchers note that outcomes vary with specific writing instructions, parameters of the experimental design, the type of trauma or illness studied, setting, and participating population, among other variables. Further, disparate outcome measures and comparison groups have been used. Mugerwa (2012) cautioned, “Because writing may be thought of as a psychotherapeutic activity, it is reasonable to compare it with other therapies aimed at the same end.”
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PROCESS FOR MOVING FORWARDAmong Creative Forces therapists who integrate writing into their interventions, there is commitment to expanding the tools, practices, and research for therapeutic writing. Creative Forces presents opportunities to: 1) develop and implement evidence-based writing techniques for use with creative arts therapies, 2) evaluate use of writing activities within Creative Forces treatment milieus, and 3) research outcomes related to use of writing activities within creative arts therapies for military-connected populations.
RECOMMENDATIONS FOR NEXT STEPS
Stakeholders and subject matter experts believe Creative Forces should consider adapting existing, evidence-based clinical writing models to the military populations served in Creative Forces clinical settings. In addition, telehealth and on-line self-directed options should be explored. Research can be advanced using case studies, group comparisons, and Computerized Content Analysis (LIWC). While there is interest in eventually developing a conceptual model for and conducting research in therapeutic writing, additional development is needed beforehand. Recommended steps, with approximate timeframes over 12 months, are:
1. Gather all writing protocols and ad hoc writing practices currently in use within Creative Forces. (Month 1)
2. Select a subset of writing activities currently in use within Creative Forces to advance for further development. (Month 1)
3. Develop a Creative Forces playbook for specific therapeutic writing practices to expand and align writing practices across sites and create an implementation plan. (Months 2 – 3)
4. Develop an evaluation plan. (Month 4)
5. Evaluate the use of therapeutic writing in Creative Forces (see below). (Months 5 – 10)
6. Develop a conceptual model and research plan for therapeutic writing. (Months 11 – 12)
Individual studies have shown benefits for military-connected individuals. A study compared veterans using online expressive writing about transitioning to civilian life compared to controls using factual writing or no writing. The findings showed greater reductions in physical complaints, anger, and distress compared with veterans who wrote factually and greater reductions in PTSD symptoms, distress, anger, physical complaints, and reintegration difficulty compared with veterans who did not write at all. Veterans who wrote expressively also experienced greater improvement in social support compared to those who did not write (Sayer et al., 2015).
A study of the effectiveness of a brief expressive writing intervention on the marital adjustment of military couples reuniting post-deployment found that when soldiers, but not spouses, wrote expressively, the couple’s marital satisfaction increased over the following month (Baddeley & Pennebaker, 2011). Observational and qualitative results from an 18-month poetry therapy group conducted in a veteran’s center suggested the group built camaraderie and bonding (Deshpande, 2010). Potential benefits were also found in a case study with veterans using therapeutic writing (Nevinski, 2013).
Theories about the mechanisms of change are based in emotional catharsis, cognitive processing of traumatic memories, the process of finding meaning in the traumatic experience, exposure, and emotional inhibition and confrontation (Baikie & Wilhelm, 2005; Mugerwa & Holden, 2012).
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Therapeutic Writing Playbook (#3). Creative Forces therapists recommended developing a playbook for therapeutic writing to serve as a resource for practice and to align writing practices across therapists. The playbook should provide descriptions and tools/protocols for each writing activity and a cross-referencing table with key variables allowing therapists to match the activity to the patient and practice. Standardized protocols enable Creative Forces to evaluate and conduct research on therapeutic writing.
Recommended contents of the playbook include:
I. Full description of activity, including prompts, amount of time required, and whether the activity is single or multiple session
II. Resources for the activity
III. A table that can assist therapists in choosing the writing intervention in alignment with therapeutic goals. Variables may include:
• Therapeutic goals • Pre/post outcome measures • Diagnoses most responsive to intervention • Length of time needed for activity • Prerequisites (Is the intervention appropriate for novice patients? For patients experienced with therapeutic writing?) • Number of sessions required • Suitability for individual, group, couple, and family therapy • Suitability for treatment settings (inpatient/outpatient, telehealth/in-person, integrated/stand- alone treatment)
Therapeutic Writing Evaluation (#4, #5). During Phase 1, Creative Forces developed a logic model and evaluation questions to guide evaluation of therapeutic writing at Creative Forces sites (see the 2019 Creative Forces Conceptual Frameworks for Clinical Research, Phase 1 document, pages 87-91). Once the playbook is completed, Creative Forces will need to 1) update the logic model and evaluation questions, 2) develop an implementation plan for the selected therapeutic writing activities, 3) develop and execute an evaluation plan, and 4) adjust protocols and implementation plans based on evaluation results. At the outset of this work, it will be important to confirm the intended outcomes of therapeutic writing for Creative Forces.
Conceptual Framework and Research Plan (#6). The therapeutic writing protocols, playbook, and evaluation, together with the Phase 1 concept maps, provide the foundation for a conceptual framework and research plan. Additional resources may be needed, depending on target outcomes and whether therapeutic writing occurs adjunctive to the creative arts therapies and/or a standalone intervention.
The following figure graphically displays the developmental steps for Creative Forces therapeutic writing from current practices to development of a research plan.
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REFERENCES
Adams, K. (2013). Expressive writing: Foundations of practice. New York: R & L Education.
Anderson, C. N. & MacCurdy, M. N. (Eds.) (2000). Writing & healing: Toward an informed practice. Urbana, IL: National Council of Teachers of English.
Baddeley, J., & Pennebaker, J. (2011. A postdeployment expressive writing intervention for military couples: a randomized controlled trial. Journal of Traumatic Stress, 24(5). 581-5. DOI: 10.1002/jts.20679
Baikie, K., & Wilhelm, K. (2005). Emotional and physical benefits of expressive writing. Advances in Psychiatric Treatment, 11. 338-346. DOI: 10.1192/apt.11.5.338.
Beaumont, S. L. (2018) The art of words: Expressive writing as reflective practice in art therapy. Canadian Art Therapy Association Journal, 31(2), 55-60. DOI: 10.1080/08322473.2018.1527610
Creative Forces (2019). Creative Forces conceptual frameworks for clinical research: Phase 1. Unpublished report. Washington, DC: Author.
Deshpande, A. (2010). Recon mission: Familiarizing veterans with their changed emotional landscape through Poetry. Journal of Poetry Therapy, 23(4), 239-251. DOI: 10.1080/08893675.2010.528222
Garland, S., Carlson, L., Cook, S., et al. (2007). A non-randomized comparison of mindfulness-based stress reduction and healing arts programs for facilitating post-traumatic growth and spirituality in cancer outpatients. Supportive Care in Cancer, 15, 949–961. DOI: https://DOI.org/10.1007/s00520-007-0280-5
Jones, J., Drass, J., & Kaimal, G. (2019). Art therapy for military service members with post-traumatic stress and traumatic brain injury: Three case reports highlighting trajectories of treatment and recovery. The Arts in Psychotherapy, 63. 10.1016/j.aip.2019.04.004.
Landless, B. M., Walker, M., & Kaimal, G. (2019). Using human and computer-based text analysis of clinical notes to understand military service members’ experiences with therapeutic writing. The Arts in Psychotherapy, 62, 77-84. DOI: 10.1016/j.aip.2018.10.002.
Mazza, N. (2017). Poetry therapy: Theory and practice, 2nd Ed. New York: Routledge.
Meads, C., & Nouwen, A. (2005). Does emotional disclosure have any effects? A systematic review of the literature with meta-analyses. International Journal of Technology Assessment in Health Care, 21(2), 153-64. PMID: 15921054.
Mogk, C., Otte, S., Reinhold-Hurley, B., & Kröner-Herwig, B. (2006). Health effects of expressive writing on stressful or traumatic experiences - a meta-analysis. Psycho-social medicine, 3, Doc06.
Mugerwa, S., & Holden, J. D. (2012). Writing therapy: A new tool for general practice? The British Journal of General Practice, 62(605), 661–663. https://DOI.org/10.3399/bjgp12X659457
Nevinski, R. L. (2013). Self-expressive writing as a therapeutic intervention for veterans and family members. Journal of Poetry Therapy, 26(4), 201-221. DOI: 10.1080/08893675.2013.849044
Pavlacic, J. M., Buchanan, E. M., Maxwell, N. P., Hopke, T. G., & Schulenberg, S. E. (2019). A meta-analysis of expressive writing on posttraumatic stress, posttraumatic growth, and quality of life. Review of General Psychology, 23(2), 230–250. https://DOI.org/10.1177/1089268019831645
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Pennebaker, J. W. (1997). Writing about emotional experiences as a therapeutic process. Psychological Science, 8(3), 162–166.
Pizarro J. (2004). The efficacy of art and writing therapy: Increasing positive mental health outcomes and participant retention after exposure to traumatic experience. Art Therapy, 21, 5–12. DOI: 10.1080/07421656.2004.10129327
Regev, D., & Cohen-Yatziv, L. (2018). Effectiveness of art therapy with adult clients in 2018-What Progress Has Been Made? Frontiers in psychology, 9, 1531. https://DOI.org/10.3389/fpsyg.2018.01531
Sayer, N. A., Noorbaloochi, S., Frazier, P. A., Pennebaker, J. W., et al. (2015). Randomized controlled trial of online expressive writing to address readjustment difficulties among U.S. Afghanistan and Iraq war veterans. Journal of Traumatic Stress, 28(5):3, 81-90. DOI: 10.1002/jts.22047. PMID: 26467326.
Sloan, D. M., Sawyer, A. T., Lowmaster, S. E., Wernick, J., & Marx, B. P. (2015). Efficacy of narrative writing as an intervention for PTSD: Does the evidence support its use? Journal of Contemporary Psychotherapy, 45(4), 215–225. https://DOI.org/10.1007/s10879-014-9292-x
Smyth, J. M. (1998). Written emotional expression: Effect sizes, outcome types, and moderating variables. Journal of Consulting and Clinical Psychology, 66, 174–184.
Usbeck, F. (2018) Writing yourself home: US veterans, creative writing, and social activism. European Journal of American Studies, 13-2. DOI : https://DOI.org/10.4000/ejas.12567.
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SELECT RESOURCES
Center for Journal Therapy (https://journaltherapy.com/) Kay Adams and the Center for Journal Therapy provides resources and training in journal writing and instruction. The Therapeutic Writing Institute (TWI) is the professional training division of the Center for Journal Therapy, Inc.
Dulwich Centre (https://dulwichcentre.com.au/) Dulwich Center supports practitioners in different parts of the world through narrative approaches to therapy and community work through training, publishing, and co-hosting international conferences.
International Federation for Biblio/Poetry Therapy (https://ifbpt.org/) The International Federation for Biblio/Poetry Therapy “sets standards of excellence in the training and credentialing of practitioners in the field of biblio/poetry therapy and authorizes qualified individuals to practice as mentor/supervisors.”
Journaling.com (https://www.journaling.com) Journaling.com provides journaling activities and resources in collaboration with researchers and practitioners.
National Association for Poetry Therapy, Inc. (https://poetrytherapy.org) The National Association for Poetry Therapy, Inc. is an international and interdisciplinary nonprofit organization promoting growth and healing through written language, symbol, and story. Members represent a wide range of professional disciplines and writers of all styles. The site provides information about credentialing, academic programs, conferences, and journals.
Pongo (https://www.pongoteenwriting.org) Pongo is a nonprofit organization that uses personal poetry writing to heal youth who have experienced trauma and other difficult experiences. The website includes writing activities and teaching resources.
Veterans Writing Project and O-Dark-Thirty (https://veteranswriting.org; https://o-dark-thirty.org) The Veterans Writing Project provide no-cost creative writing seminars and songwriting workshops for veterans, service members, and their adult family members and publishes a quarterly literary review of writing, O-Dark-Thirty.
VHA Office of Patient Centered Care and Cultural Transformation: Therapeutic Journaling Clinical Tool (patient https://www.va.gov/WHOLEHEALTHLIBRARY/tools/therapeutic-journaling.asp); clinician http://projects.hsl.wisc.edu/SERVICE/modules/12/M12_CT_Therapeutic_Journaling.pdf) The Therapeutic Journaling Clinical Tool, with different versions for patients and clinicians, explains the use of journaling and provides a protocol and research.
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APPENDIX A – TEAM AND WORKING GROUP AFFILIATIONSPHASE 2 TEAM AND WORKING GROUP AFFILIATIONS
Phase 2 engaged four teams/working groups: Creative Forces National Leadership Team, Creative Forces Core Planning Team, Creative Forces Technical Working Group, and the Phase 2 Technical Review Group. Members and affiliations for each are provided below.
Acronyms AFTA – Americans for the Arts DHA – Defense Health Agency DoD – Department of Defense DVBIC – Defense and Veterans Brain Injury Center HJF – Henry M. Jackson Foundation for the Advancement of Military Medicine NCCIH – National Center for Complementary and Integrative Health NEA – National Endowment for the Arts NICoE – National Intrepid Center of Excellence NIH – National Institutes of Health VA – Veterans Affairs VHA – Veterans Health Administration WRNMMC – Walter Reed National Military Medical Center
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APPENDIX B – ORIGINAL RESEARCH QUESTIONSDevelopment of the conceptual frameworks began with multiple research questions in each area, all of which were deemed relevant and important by stakeholders. For art therapy and music therapy, proposed research questions included underlying hypotheses related to existing research in the field and were aimed at RCT(s). For dance/movement therapy and therapeutic writing, initial research questions were exploratory and aimed at developing research protocols and lines of study. The table below documents the original research questions considered but not selected for development at this time. The many discussions with Creative Forces and stakeholders throughout this project revealed there is also considerable interest in research that spans two or more creative art therapies. A sample of those topics is also included at the end of the table. See Phase 1 documentation for additional research questions, as well as program evaluation questions and models.
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APPENDIX C – PROTOCOLS AND MEASURES
Creative Forces standardized protocols to document: Patient variables • Demographics (age, gender) • Diagnosis (PTSD, TBI, comorbid conditions) and disease state • Trauma exposures (lifetime) • Combat exposure • Medical utilization • Service status (active duty, transition within active duty, transition to veteran, veteran) • Military history (branch, component, rank, time since deployment) • Time since injury • Employment status • Occupation • Housing status • Marital/family status (includes caregivers) • Medications (for neuro/bio studies) • Art/music/dance/writing exposure • Art/music/dance/writing identity
Therapist variables • Years of experience
Implementation variables • Individual or co-treatment (creative arts therapies) • Therapeutic discipline • Therapeutic activity • Individual, family, couple, or group therapy • Number of sessions • Length of sessions • Art products • Telehealth (including hybrid)
Treatment context variables • Setting • Individual or co-treatment (integrative medicine)
Appendix C provides protocols and measures in the following sections:
• Creative Forces Standardized Protocols and Measures • Art Therapy Protocols and Measures • Music Therapy Protocols and Measures • Dance/Movement Therapy Protocols and Measures • Therapeutic Writing Protocols and Measures • General Outcome Measures • Outcome Measures used by the Department of Defense and Veterans Affairs
CREATIVE FORCES STANDARDIZED PROTOCOLS AND MEASURES
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k, V
. B. (
2010
). As
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men
t and
ther
apeu
tic a
pplic
ation
of t
he e
xpre
ssiv
e th
erap
ies c
ontin
uum
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plic
ation
s for
bra
in st
ruct
ures
and
func
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. Art
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177.
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0129
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. (20
15).
Expr
essiv
e Th
erap
ies C
ontin
uum
: Use
and
Val
ue D
emon
stra
ted
with
Ca
se S
tudy
. Can
adia
n Ar
t The
rapy
Ass
ocia
tion
Jour
nal,
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3-50
. htt
ps:/
/doi
.org
/10.
1080
/083
2247
3.20
15.1
1005
81.
Face
Stim
ulus
Ass
essm
ent (
FSA)
Perf
orm
ance
-bas
ed d
raw
ing
asse
ssm
ent b
ased
on
rese
arch
with
pe
ople
who
hav
e co
mm
unic
ation
di
sord
ers a
nd c
ogni
tive
chal
leng
es
https
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onna
bett
sphd
.wor
dpre
ss.c
om/2
016/
09/0
3/th
e-fa
ce-s
timul
us-a
sses
smen
t-fsa
/de
scrip
tion,
inst
rum
ent a
cces
s, re
fere
nces
Form
al E
lem
ents
Art
The
rapy
Sc
ale
(FEA
TS)
A m
easu
rem
ent s
yste
m w
ith 1
4 sc
ales
for a
pply
ing
num
bers
to g
loba
l va
riabl
es in
two-
dim
ensio
nal a
rt
(dra
win
g an
d pa
intin
g)
Lind
a M
. Gan
tt &
Fra
nces
And
erso
n (2
009)
The
For
mal
Ele
men
ts A
rt T
hera
py S
cale
: A
Mea
sure
men
t Sys
tem
for G
loba
l Var
iabl
es in
Art
, Art
The
rapy
, 26:
3, 1
24-1
29,
https
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OI.o
rg/1
0.10
80/0
7421
656.
2009
.101
2937
2
Hum
an F
igur
e Dr
awin
g (H
FD)
Deve
lopm
enta
l and
em
otion
al
indi
cato
rs(s
ee: D
eave
r, 20
09; G
olom
b, 1
974;
Har
ris, 1
963;
Kop
pitz
, 196
8; N
aglie
ri, 1
988)
52CO
NCE
PTU
AL
FRA
MEW
ORK
S PH
ASE
2 E
XECU
TIVE
SU
MM
ARY
REP
ORT
| D
ECEM
BER
30, 2
020
CREA
TIVE
FO
RCES
®: N
EA M
ILIT
ARY
HEA
LIN
G A
RTS
NET
WO
RK |
CRE
ATIV
EFO
RCES
NRC
.ART
S.G
OV
Mas
k M
akin
g Pr
otoc
olPe
rfor
man
ce-b
ased
art
ther
apy
asse
ssm
ent
Kaim
al, G
., W
alke
r, M
. S.,
Herr
es, J
., et
al.
Obs
erva
tiona
l st
udy
of a
ssoc
iatio
ns b
etw
een
visu
al im
ager
y an
d m
easu
res o
f dep
ress
ion,
anx
iety
and
pos
t-tra
umati
c st
ress
am
ong
activ
e-du
ty m
ilita
ry se
rvic
e m
embe
rs
with
trau
mati
c br
ain
inju
ry a
t the
Wal
ter R
eed
Nati
onal
M
ilita
ry M
edic
al C
ente
r BM
J pen
201
8;8:
e021
448.
htt
ps:/
/DO
I.org
/10.
1136
/bm
jope
n-20
17-0
2144
8
Neu
rolo
gica
l/Bi
olog
ical
Mar
kers
EEG
, fN
IRS,
fMRI
, Mob
ile
B
rain
/Bod
y Im
agin
g (M
OBI
)
Neu
rolo
gica
l and
phy
siolo
gica
l acti
vity
King
, J. L
., &
Kai
mal
, G. (
2019
). Ap
proa
ches
to R
esea
rch
in A
rt T
hera
py U
sing
Imag
ing
Tech
nolo
gies
. Fro
ntier
s in
hum
an n
euro
scie
nce,
13,
159
. htt
ps:/
/DO
I.org
/10.
3389
/fn
hum
.201
9.00
159
Self-
expr
essi
on a
nd E
moti
on R
egul
ation
in A
rt
Ther
apy
Scal
e (S
ERAT
S)9-
item
scal
e as
sess
es se
lf-ex
pres
sion
and
emoti
onal
re
gula
tion
Haey
en S
, van
Hoo
ren
S, v
an d
er V
eld
WM
, Hu
tsch
emae
kers
G. (
2018
). M
easu
ring
the
cont
ributi
on o
f ar
t the
rapy
in m
ultid
iscip
linar
y tr
eatm
ent o
f per
sona
lity
diso
rder
s: T
he c
onst
ructi
on o
f the
Sel
f-exp
ress
ion
and
Emoti
on R
egul
ation
in A
rt T
hera
py S
cale
(SER
ATS)
. Pe
rson
ality
and
Men
tal H
ealth
. 12(
1):3
-14.
htt
ps:/
/DO
I.org
/10.
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/pm
h.13
79de
velo
pmen
t, ite
ms,
psy
chom
etric
s
MU
SIC
THER
APY
PRO
TOCO
LS A
ND
MEA
SURE
SM
easu
re (a
lpha
betic
al b
y na
me)
Dom
ain
Whe
re to
Fin
d In
form
ation
/Exa
mpl
esM
usic
Moo
d-Re
gula
tion
Scal
e (M
MRS
) O
ther
ver
sion:
Brie
f Mus
ic in
M
ood
Regu
latio
n Sc
ale
(B-M
MR)
40-it
em (o
r 21-
item
) sel
f-re
port
surv
ey to
ass
ess s
even
di
ffere
nt m
usic
rela
ted
moo
d-re
gula
tion
stra
tegi
es.
Hew
ston
, R, L
ane,
A.,
& K
arag
, C. (
2008
). De
velo
pmen
t and
initi
al v
alid
ation
of t
he M
usic
Moo
d-Re
gula
tion
Scal
e. E
-Jour
nal o
f App
lied
Psyc
holo
gy, 4
: 15-
22. D
OI:
10.7
790/
ejap
.v4i
1.13
0de
velo
pmen
t, va
lidati
on Sa
arik
allio
, S. (
2012
). De
velo
pmen
t and
Val
idati
on o
f the
Brie
f Mus
ic in
Moo
d Re
gula
tion
Scal
e (B
-MM
R). M
usic
Per
cepti
on: A
n In
terd
iscip
linar
y Jo
urna
l, 30
(1),
97- 1
05.
DOI:1
0.15
25/m
p.20
12.3
0.1.
97de
velo
pmen
t, va
lidati
on
53CO
NCE
PTU
AL
FRA
MEW
ORK
S PH
ASE
2 E
XECU
TIVE
SU
MM
ARY
REP
ORT
| D
ECEM
BER
30, 2
020
CREA
TIVE
FO
RCES
®: N
EA M
ILIT
ARY
HEA
LIN
G A
RTS
NET
WO
RK |
CRE
ATIV
EFO
RCES
NRC
.ART
S.G
OV
DAN
CE/M
OVE
MEN
T TH
ERAP
Y PR
OTO
COLS
AN
D M
EASU
RES
Mea
sure
(alp
habe
tical
by
nam
e)Do
mai
nW
here
to F
ind
Info
rmati
on/E
xam
ples
DMT
Out
com
es F
ram
ewor
k w
ith
Mov
emen
t Ass
essm
ent a
nd
Repo
rting
App
(MAR
A)
An a
sses
smen
t with
six
dom
ains
: Ph
ysic
al, C
ultu
ral,
Emoti
onal
, Co
gniti
ve, S
ocia
l, an
d In
tegr
ation
.
https
://w
ww
.mak
ingd
ance
matt
er.c
om.a
u/w
p-co
nten
t/up
load
s/O
utco
mes
-fram
ewor
k-fo
r-DM
T-V.
-70-
Engl
ish-2
5.4.
2020
.doc
x (D
unph
y, Le
bre,
& M
ulla
ne, 2
020)
htt
ps:/
/ww
w.m
akin
gdan
cem
atter
.com
.au/
abou
t/m
ara-
feat
ures
/Fu
nctio
nal A
naly
sis o
f Mov
emen
t an
d Pe
rcep
tion
(FAM
P)20
-item
inst
rum
ent a
ddre
ssin
g 8
cate
gorie
s: b
ody
sche
me,
sp
atial
orie
ntati
on a
nd ju
dgm
ent,
perc
eptu
al m
otor
abi
lities
, rhy
thm
ic
disc
rimin
ation
, mot
or p
lann
ing,
tim
ed
mot
or a
ctivi
ty, d
elay
ed m
otor
acti
vity
, an
d fu
nctio
nal r
ange
of m
otion
.
Berr
ol, C
.F., O
oi, W
.L. &
Kat
z, S
.S. D
ance
/Mov
emen
t The
rapy
with
Old
er A
dults
Who
Ha
ve S
usta
ined
Neu
rolo
gica
l Ins
ult:
A De
mon
stra
tion
Proj
ect.
Amer
ican
Jour
nal o
f Da
nce
Ther
apy
19, 1
35–1
60 (1
997)
. htt
ps:/
/DO
I.org
/10.
1023
/A:1
0223
1610
2961
ca
tego
ries a
nd it
ems
Kest
enbe
rg M
ovem
ent P
rofil
e (K
MP)
Asse
sses
mov
emen
t patt
erns
in
dica
tive
of in
trap
sych
ic a
nd re
latio
nal
func
tioni
ng w
ithin
the
dyna
mic
s of
natu
rally
occ
urrin
g m
ovem
ent.
http:
//w
ww
.kes
tenb
ergm
ovem
entp
rofil
e.or
g/ap
plic
ation
sres
earc
h.ht
mde
scrip
tion,
rese
arch
, ref
eren
ces
Mov
emen
t Psy
chod
ynam
ic
Inve
ntor
y52
item
inst
rum
ent w
ith 1
0 su
bsca
les
Cruz
, R.F.
(200
9) V
alid
ity o
f the
Mov
emen
t Psy
chod
iagn
ostic
Inve
ntor
y: A
Pilo
t Stu
dy.
Amer
ican
Jour
nal o
f Dan
ce T
hera
py 3
1: 1
22.
https
://D
OI.o
rg/1
0.10
07/s
1046
5-00
9-90
72-4
Va
lidati
on st
udy,
subs
cale
s, re
fere
nces
Mul
tidim
ensi
onal
Ass
essm
ent o
f In
terc
eptiv
e Aw
aren
ess (
MAI
A)
and
vers
ion
2 (M
AIA-
2)
32- i
tem
inst
rum
ent (
vers
ion
2 ha
s 37
item
s) m
easu
re m
ultip
le d
imen
sions
of
inte
roce
ption
(8 sc
ales
)
https
://o
sher
.ucs
f.edu
/res
earc
h/m
aia
ques
tionn
aire
, ref
eren
ces
54CO
NCE
PTU
AL
FRA
MEW
ORK
S PH
ASE
2 E
XECU
TIVE
SU
MM
ARY
REP
ORT
| D
ECEM
BER
30, 2
020
CREA
TIVE
FO
RCES
®: N
EA M
ILIT
ARY
HEA
LIN
G A
RTS
NET
WO
RK |
CRE
ATIV
EFO
RCES
NRC
.ART
S.G
OV
THER
APEU
TIC
WRI
TIN
G P
ROTO
COLS
AN
D M
EASU
RES
Mea
sure
(alp
habe
tical
by
nam
e)Do
mai
nW
here
to F
ind
Info
rmati
on/E
xam
ples
Poeti
c In
quiry
A m
ediu
m fo
r qua
litati
ve re
sear
chM
cCul
lis, D
. (20
13).
Poeti
c in
quiry
and
mul
tidisc
iplin
ary
rese
arch
. Jou
rnal
of P
oetr
y Th
erap
y, 2
6(2)
, 83-
114.
DO
I: 10
.108
0/08
8936
75.2
013.
7945
36
Ling
uisti
c In
quiry
and
Wor
d Co
unt
Ling
uisti
c In
quiry
and
Wor
d Co
unt
(LIW
C) is
a w
ord
coun
ting
softw
are
prog
ram
that
refe
renc
es a
dic
tiona
ry
of g
ram
mati
cal,
psyc
holo
gica
l, an
d co
nten
t wor
d ca
tego
ries.
LIW
C ha
s be
en u
sed
to e
ffici
ently
cla
ssify
text
s al
ong
psyc
holo
gica
l dim
ensio
ns a
nd to
pr
edic
t beh
avio
ral o
utco
mes
, mak
ing
it a
text
ana
lysis
tool
wid
ely
used
in th
e so
cial
scie
nces
.
Chun
g, C
. & P
enne
bake
r, J.
(201
2). L
ingu
istic
Inqu
iry a
nd W
ord
Coun
t (LI
WC)
: pr
onou
nced
“Lu
ke”
and
othe
r use
ful f
acts
. In
P. M
. McC
arth
y &
C. B
oont
hum
-Den
ecke
(E
ds.),
App
lied
Nat
ural
Lan
guag
e Pr
oces
sing:
Iden
tifica
tion,
Inve
stiga
tion
and
Reso
lutio
n (p
p. 2
06-2
29).
IGI G
loba
l. DO
I: 1
0.40
18/9
78-1
-609
60-7
41-8
.ch0
12
Penn
ebak
er, J
. W.,
Boot
h, R
. J.,
& F
ranc
is, M
. E. (
2007
). Li
ngui
stic
Inqu
iry a
nd W
ord
Coun
t: LI
WC
[Com
pute
r soft
war
e]. A
ustin
, TX:
LIW
C.ne
t.
Writt
en re
port
sW
ritten
repo
rts i
n w
hich
pati
ents
de
scrib
e th
eir s
ubje
ctive
exp
erie
nces
w
ith th
erap
eutic
writi
ng a
fter
com
pleti
ng p
artic
ipati
on in
trea
tmen
t pr
ogra
m. T
he re
port
s are
resp
onse
s to
open
-end
ed q
uesti
ons:
• C
ould
you
talk
abo
ut h
ow y
ou
exp
erie
nced
writi
ng a
bout
wha
t
c
once
rns y
ou?
•
Cou
ld y
ou d
escr
ibe
how
it a
ffect
ed
you
then
and
affe
cts y
ou n
ow to
w
rite
abou
t you
r exp
erie
nces
,
t
houg
hts a
nd fe
elin
gs?
•
How
wou
ld y
ou d
escr
ibe
the
h
elp
that
writi
ng h
as g
iven
you
in
rai
sing
awar
enes
s of y
ours
elf
(th
roug
h th
ough
ts a
nd fe
elin
gs)
and
you
r situ
ation
?
Furn
es, B
. and
Dys
vik,
E. (
2012
) The
rape
utic
Writi
ng a
nd C
hron
ic P
ain:
Exp
erie
nces
of
Ther
apeu
tic W
riting
in a
Cog
nitiv
e Be
havi
oura
l Pro
gram
me
for P
eopl
e w
ith C
hron
ic P
ain.
Jo
urna
l of C
linic
al N
ursin
g, 2
1, 3
372-
3381
. htt
ps:/
/DO
I.org
/10.
1111
/j.13
65-2
702.
2012
.042
68.x
55CO
NCE
PTU
AL
FRA
MEW
ORK
S PH
ASE
2 E
XECU
TIVE
SU
MM
ARY
REP
ORT
| D
ECEM
BER
30, 2
020
CREA
TIVE
FO
RCES
®: N
EA M
ILIT
ARY
HEA
LIN
G A
RTS
NET
WO
RK |
CRE
ATIV
EFO
RCES
NRC
.ART
S.G
OV
GEN
ERAL
OU
TCO
ME
MEA
SURE
SA
varie
ty o
f wid
ely-
used
mea
sure
s of b
ehav
iora
l, ph
ysic
al, a
nd b
iolo
gica
l mea
sure
s are
rele
vant
to th
e th
erap
eutic
out
com
es o
f Cre
ative
For
ces p
atien
ts a
nd
appl
icab
le a
cros
s the
rapi
es. T
his t
able
iden
tifies
mea
sure
s, th
eir d
omai
ns, a
nd li
nks t
o ba
sic in
form
ation
. Add
ition
al p
sych
omet
ric in
form
ation
for v
ario
us p
opul
ation
s an
d se
tting
s can
be
easil
y fo
und
for m
ost m
easu
res t
hrou
gh b
asic
sear
ches
(ent
er “
NAM
E O
F M
EASU
RE p
sych
omet
rics”
).M
easu
re (a
lpha
betic
al b
y na
me)
Dom
ain
Whe
re to
Fin
d In
form
ation
/Exa
mpl
esBe
ck D
epre
ssio
n In
vent
ory-
II (B
DI=I
I)21
-item
mea
sure
of d
epre
ssio
nhtt
ps:/
/ww
w.a
pa.o
rg/p
i/abo
ut/p
ublic
ation
s/ca
regi
vers
/pra
ctice
-setti
ngs/
asse
ssm
ent/
tool
s/be
ck-d
epre
ssio
n ps
ycho
met
rics,
refe
renc
es
https
://w
ww
.pea
rson
asse
ssm
ents
.com
/pro
fess
iona
l-ass
essm
ents
/pro
duct
s/pr
ogra
ms/
beck
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ily-o
f-ass
essm
ents
.htm
lBe
ck fa
mily
of i
nstr
umen
ts, p
sych
omet
rics
Bond
Lad
er-V
AS16
- ite
m sc
ales
use
d to
rate
subj
ectiv
e fe
elin
gshtt
ps:/
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ovid
e.m
api-t
rust
.org
/inst
rum
ents
/bon
d-la
der-v
as-m
ood-
ratin
g-sc
ale#
basic
_de
scrip
tion
Brie
f Pai
n In
vent
ory
– Sh
ort F
orm
O
ther
ver
sion:
Lo
ng F
orm
: Brie
f Pai
n In
vent
ory
(32
item
s)
9-ite
m q
uesti
onna
ire u
sed
to e
valu
ate
the
seve
rity
of a
pati
ent’s
pai
n an
d th
e im
pact
of t
his p
oint
on
the
patie
nt’s
daily
func
tioni
ng
https
://w
ww
.phy
sio-p
edia
.com
/Brie
f_Pa
in_I
nven
tory
_-_S
hort
_For
m
desc
riptio
n, re
fere
nces
DVBI
C Br
ief T
raum
atic
Brai
n In
jury
Scr
een
3-ite
m sc
reen
ing
tool
to id
entif
y se
rvic
e m
embe
rs w
ho m
ay n
eed
furt
her e
valu
ation
for m
ild tr
aum
atic
brai
n in
jury
https
://w
ww
.mire
cc.v
a.go
v/do
cs/v
isn6/
5_TB
I_3_
Que
stion
_Scr
eeni
ng_T
ool.p
dfin
stru
ction
s, sc
reen
ing
tool
Schw
ab, K
. A.,
Bake
r, G.
, Ivi
ns, B
., Sl
uss-
Tille
r, M
., Lu
x, W
., &
War
den,
D. (
2006
). Th
e Br
ief T
raum
atic
Brai
n In
jury
Scr
een
(BTB
IS):
Inve
stiga
ting
the
valid
ity o
f a se
lf-re
port
inst
rum
ent f
or d
etec
ting
trau
mati
c br
ain
inju
ry (T
BI) i
n tr
oops
retu
rnin
g fr
om
depl
oym
ent i
n Af
ghan
istan
and
Iraq
. Neu
rolo
gy, 6
6(5)
(Sup
p. 2
), A2
35.
56CO
NCE
PTU
AL
FRA
MEW
ORK
S PH
ASE
2 E
XECU
TIVE
SU
MM
ARY
REP
ORT
| D
ECEM
BER
30, 2
020
CREA
TIVE
FO
RCES
®: N
EA M
ILIT
ARY
HEA
LIN
G A
RTS
NET
WO
RK |
CRE
ATIV
EFO
RCES
NRC
.ART
S.G
OV
Depl
oym
ent R
isk
and
Resi
lienc
e In
vent
ory-
2 (D
RRI-2
) Com
bat
Expe
rienc
e Sc
ale
(CES
)
Mul
tiple
scal
es m
easu
re e
xpos
ure
to
com
bat-r
elat
ed c
ircum
stan
ces
https
://w
ww
.pts
d.va
.gov
/pro
fess
iona
l/ass
essm
ent/
depl
oym
ent/
com
bat-e
xper
ienc
es-
scal
e.as
p#ob
tain
m
anua
l, in
stru
men
t
Vogt
DS,
Pro
ctor
SP,
Kin
g DW
, Kin
g LA
, Vas
terli
ng JJ
. (20
08).
Valid
ation
of s
cale
s fro
m
the
Depl
oym
ent R
isk a
nd R
esili
ence
Inve
ntor
y in
a sa
mpl
e of
Ope
ratio
n Ira
qi F
reed
om
vete
rans
. Ass
essm
ent,1
5(4)
: 391
-403
.htt
ps:/
/DO
I.org
/10.
1177
/107
3191
1083
1603
0va
lidati
on st
udy
COPE
Inve
ntor
y O
ther
ver
sion:
Sh
ort F
orm
: Car
ver B
rief C
OPE
In
vent
ory
(28
item
s)
60-it
em m
ulti-
dim
ensio
nal i
nven
tory
to
ass
ess c
opin
g st
rate
gies
, with
five
sc
ales
: 1) a
ctive
cop
ing;
2) p
lann
ing;
3)
supp
ress
ion
of c
ompe
ting
activ
ities
; 4)
rest
rain
t cop
ing;
and
5) s
eeki
ng o
f in
stru
men
tal s
ocia
l sup
port
.
http:
//em
otion
alpr
oces
sings
cale
.org
/ de
scrip
tion,
inst
rum
ent,
psyc
hom
etric
s, re
fere
nces
Emoti
on R
egul
ation
Str
ateg
ies f
or
Artis
tic C
reati
ve A
ctivi
ties S
cale
(E
RS-A
CA)
18 it
em m
easu
ring
inst
rum
ent
mea
sure
s em
otion
al re
gula
tion
stra
tegi
es (a
void
ance
stra
tegi
es,
appr
oach
stra
tegi
es, s
elf-d
evel
opm
ent
used
whe
n en
gagi
ng in
arti
stic
crea
tive
activ
ities
Fanc
ourt
, D.,
Garn
ett, C
., Sp
iro, N
., W
est,
R., &
Mül
lens
iefe
n, D
. (20
19).
How
do
artis
tic c
reati
ve a
ctivi
ties r
egul
ate
our e
moti
ons?
Val
idati
on o
f the
Em
otion
Reg
ulati
on
Stra
tegi
es fo
r Arti
stic
Crea
tive
Activ
ities
Sca
le (E
RS-A
CA).
PloS
one
, 14(
2), e
0211
362.
htt
ps:/
/DO
I.org
/10.
1371
/jour
nal.p
one.
0211
362
Emoti
onal
Pro
cess
ing
Scal
e (E
PS)
25-it
em q
uesti
onna
ire to
iden
tify
emoti
onal
pro
cess
ing
styl
es a
nd
pote
ntial
defi
cits
with
fie
subs
cale
s: 1
) su
ppre
ssio
n; 2
) sig
ns o
f unp
roce
ssed
em
otion
; 3) c
ontr
olla
bilit
y of
em
otion
; 4)
avo
idan
ce; a
nd 5
) em
otion
al
expe
rienc
e
http:
//em
otion
alpr
oces
sings
cale
.org
/ de
scrip
tion,
dev
elop
men
t, ps
ycho
met
rics,
refe
renc
es
57CO
NCE
PTU
AL
FRA
MEW
ORK
S PH
ASE
2 E
XECU
TIVE
SU
MM
ARY
REP
ORT
| D
ECEM
BER
30, 2
020
CREA
TIVE
FO
RCES
®: N
EA M
ILIT
ARY
HEA
LIN
G A
RTS
NET
WO
RK |
CRE
ATIV
EFO
RCES
NRC
.ART
S.G
OV
Gen
eral
Sel
f Effi
cacy
Sca
le
Oth
er v
ersio
n:
S
hort
For
m: G
ener
al S
elf-
E
ffica
cy S
cale
(GSE
-6)
10-it
em q
uesti
onna
ire m
easu
res
“a g
ener
al se
nse
of p
erce
ived
self-
effica
cy w
ith th
e ai
m in
min
d to
pre
dict
co
ping
with
dai
ly h
assle
s as w
ell a
s ad
apta
tion
after
exp
erie
ncin
g al
l kin
ds
of st
ress
ful l
ife e
vent
s”
http:
//us
erpa
ge.fu
-ber
lin.d
e/he
alth
/eng
scal
.htm
desc
riptio
n, in
stru
men
t, ps
ycho
met
rics,
refe
renc
es htt
ps:/
/ww
w.n
cbi.n
lm.n
ih.g
ov/p
mc/
artic
les/
PMC3
5782
00/
psyc
hom
etric
stud
y
Gen
eral
ized
Anxi
ety
Diso
rder
-7
(GAD
-7)
7-ite
m q
uesti
onna
ire m
easu
res a
nxie
ty
sym
ptom
seve
rity;
can
also
be
used
as
a sc
reen
ing
mea
sure
of p
anic
, soc
ial
anxi
ety,
and
PTSD
https
://w
ww
.phq
scre
ener
s.co
m/s
elec
t-scr
eene
rin
stru
men
t, in
stru
ction
man
ual,
refe
renc
es
https
://w
ww
.phq
scre
ener
s.co
m/im
ages
/site
s/g/
files
/g10
0162
61/f
/201
412/
inst
ructi
ons.
deve
lopm
ent,
psyc
hom
etric
s
https
://w
ww
.mire
cc.v
a.go
v/ci
h-vi
sn2/
Docu
men
ts/C
linic
al/G
AD_w
ith_I
nfo_
Shee
t.pdf
VA
info
shee
t: re
fere
nces
, int
erpr
etati
onHo
spita
l Anx
iety
and
Dep
ress
ion
Scal
e14
-item
que
stion
naire
that
det
erm
ines
le
vels
of a
nxie
ty a
nd d
epre
ssio
n a
pers
on is
exp
erie
ncin
g
https
://w
ww
.svri.
org/
sites
/def
ault/
files
/atta
chm
ents
/201
6-01
-13/
HADS
in
stru
men
t
Leve
ls o
f Em
otion
al A
war
enes
s Sc
ale
(LEA
S)20
scen
ario
s pos
ed to
mea
sure
re
spon
dent
s’ a
war
enes
s of a
nd a
bilit
y to
des
crib
e em
otion
al e
xper
ienc
es
http:
//el
east
est.n
et/
desc
riptio
n, p
sych
omet
rics,
refe
renc
es, i
nstr
umen
t acc
ess
Inte
rnati
onal
Cla
ssifi
catio
n of
Fu
nctio
ning
, Dis
abili
ty, a
nd
Heal
th (I
CF)
A fr
amew
ork
for d
escr
ibin
g fu
nctio
n an
d di
sabi
lity.
Incl
udes
four
qua
lified
sc
ales
to re
cord
impa
irmen
t, ac
tivity
lim
itatio
ns, a
nd e
nviro
nmen
tal b
arrie
rs
and
faci
litat
ors
https
://w
ww
.phy
sio-p
edia
.com
/Int
erna
tiona
l_Cl
assifi
catio
n_of
_Fun
ction
ing,
_Disa
bilit
y_an
d_He
alth
_(IC
F)
desc
riptio
n, m
easu
rem
ent t
ools,
refe
renc
es, i
nstr
umen
t
58CO
NCE
PTU
AL
FRA
MEW
ORK
S PH
ASE
2 E
XECU
TIVE
SU
MM
ARY
REP
ORT
| D
ECEM
BER
30, 2
020
CREA
TIVE
FO
RCES
®: N
EA M
ILIT
ARY
HEA
LIN
G A
RTS
NET
WO
RK |
CRE
ATIV
EFO
RCES
NRC
.ART
S.G
OV
Med
ical
Out
com
es S
tudy
Sho
rt-
Form
Hea
lth S
urve
y (S
F-36
) O
ther
ver
sion:
Vet
eran
s SF-
36
36-it
em q
uesti
onna
ire; g
ener
al
indi
cato
r of h
ealth
-rel
ated
qua
lity
of li
fe in
8 a
reas
: 1) l
imita
tions
in
phys
ical
acti
vitie
s bec
ause
of h
ealth
pr
oble
ms;
2) l
imita
tions
in so
cial
ac
tiviti
es b
ecau
se o
f phy
sical
or
emoti
onal
pro
blem
s; 3
) lim
itatio
ns in
us
ual r
ole
activ
ities
bec
ause
of p
hysic
al
heal
th p
robl
ems;
4) b
odily
pai
n; 5
) ge
nera
l men
tal h
ealth
; 6) l
imita
tions
in
usu
al ro
le a
ctivi
ties b
ecau
se o
f em
otion
al p
robl
ems;
7) v
italit
y (e
nerg
y an
d fa
tigue
); an
d 8)
gen
eral
hea
lth
perc
eptio
ns
War
e, J.
E., &
She
rbou
rne,
C.D
. (19
92) T
he M
OS
36-it
em sh
ort-f
orm
hea
lth su
rvey
(SF-
36):
conc
eptu
al fr
amew
ork
and
item
sele
ction
. Med
ical
Car
e, 3
0: 4
73-4
83
https
://w
ww
.cdc
.gov
/me-
cfs/
pdfs
/wic
hita
-dat
a-ac
cess
/sf3
6-do
c.pd
f SF
-36
inst
rum
ent
https
://w
ww
.ncb
i.nlm
.nih
.gov
/pm
c/ar
ticle
s/PM
C419
4890
/SF
-36
com
pare
d to
Vet
eran
s SF-
36
Mili
tary
to C
ivili
an Q
uesti
onna
ire
(M2C
-Q)
16-it
em in
stru
men
t ass
essin
g pa
st-
mon
th re
inte
grati
on d
ifficu
ltyhtt
ps:/
/ww
w.c
cdor
.rese
arch
.va.
gov/
CCDO
RRES
EARC
H/Re
sour
ces/
M2C
Q.p
df
inst
rum
ent
Saye
r, N
. et a
l. (2
011)
. Mili
tary
to C
ivili
an Q
uesti
onna
ire: A
mea
sure
of p
ostd
eplo
ymen
t co
mm
unity
rein
tegr
ation
diffi
culty
am
ong
vete
rans
usin
g De
part
men
t of V
eter
ans
Affai
rs m
edic
al c
are.
Jour
nal o
f Tra
umati
c St
ress
, 24:
660
-70.
htt
ps:/
/DO
I.org
/10.
1002
/jts.
2070
6 ps
ycho
met
ric st
udy
Pain
Cat
astr
ophi
zing
Sca
leTh
is sc
ale
mea
sure
s cat
astr
ophi
c th
inki
ng re
late
d to
pai
n an
d is
used
in
both
clin
ical
and
rese
arch
pra
ctice
s
https
://w
ww
.phy
sio-p
edia
.com
/Pai
n_Ca
tast
roph
izing
_Sca
lede
scrip
tion,
inst
rum
ent,
psyc
hom
etric
s, re
fere
nces
Patie
nt H
ealth
Que
stion
naire
(P
HQ-9
)9-
item
que
stion
naire
mea
sure
s em
otion
al a
nd so
mati
c de
pres
sion
indi
cato
rs
https
://w
ww
.phq
scre
ener
s.co
m/s
elec
t-scr
eene
rin
stru
men
t, in
stru
ction
man
ual,
refe
renc
es
59CO
NCE
PTU
AL
FRA
MEW
ORK
S PH
ASE
2 E
XECU
TIVE
SU
MM
ARY
REP
ORT
| D
ECEM
BER
30, 2
020
CREA
TIVE
FO
RCES
®: N
EA M
ILIT
ARY
HEA
LIN
G A
RTS
NET
WO
RK |
CRE
ATIV
EFO
RCES
NRC
.ART
S.G
OV
Patie
nt-R
epor
ted
Out
com
es
Mea
sure
men
t Inf
orm
ation
Sy
stem
(PRO
MIS
)
PRO
MIS
[NIH
Tool
box]
incl
udes
ov
er 3
00 m
easu
res o
f phy
sical
, m
enta
l, an
d so
cial
hea
lth fo
r use
w
ith th
e ge
nera
l pop
ulati
on a
nd
with
indi
vidu
als l
ivin
g w
ith c
hron
ic
cond
ition
s
https
://w
ww
.hea
lthm
easu
res.
net/
expl
ore-
mea
sure
men
t-sys
tem
s/pr
omis/
intr
o-to
-pr
omis
mea
sure
s, d
evel
opm
ent,
psyc
hom
etric
s, re
sear
ch
Perc
eive
d St
ress
Sca
le (P
SS)
10-it
em sc
ale
mea
sure
s the
leve
l of
per
ceiv
ed st
ress
deg
ree
in li
fe’s
situa
tions
http:
//w
ww
.min
dgar
den.
com
/doc
umen
ts/P
erce
ived
Stre
ssSc
ale.
inst
rum
ent
Inte
rper
sona
l Rea
ctivi
ty In
dex
(IRI)
Four
7-it
em su
bsca
les m
easu
ring
inte
rper
sona
l rea
ctivi
ty:
pers
pecti
ve ta
king
, em
path
ic
conc
ern,
per
sona
l dist
ress
, fan
tasy
https
://w
ww
.eck
erd.
edu/
psyc
holo
gy/ir
i/ in
stru
men
t, ps
ycho
met
rics,
refe
renc
es
Posi
tive
and
Neg
ative
Affe
ct
Sche
dule
(PAN
AS)
20-it
ems a
cros
s tw
o m
ood
scal
es,
one
mea
surin
g po
sitive
affe
ct, t
he
othe
r mea
surin
g ne
gativ
e aff
ect
https
://w
ww
.bra
ndei
s.ed
u/ro
ybal
/doc
s/PA
NAS
-GEN
_web
site_
PDF.p
df
info
shee
t: in
stru
men
t, ps
ycho
met
rics
Post
-Tra
umati
c St
ress
Dis
orde
r/PT
SD C
heck
list –
5 (P
CL-5
) O
ther
ver
sion:
PCL
-M (m
ilita
ry)
20-it
em se
lf-re
port
che
cklis
t of
PTSD
sym
ptom
s bas
ed o
n th
e DS
M-5
crit
eria
https
://is
tss.
org/
clin
ical
-res
ourc
es/a
sses
sing-
trau
ma
desc
riptio
n, in
terp
reta
tion,
psy
chom
etric
s, re
fere
nces
htt
ps:/
/ww
w.p
tsd.
va.g
ov/p
rofe
ssio
nal/a
sses
smen
t/ad
ult-s
r/pt
sd-c
heck
list.a
spin
stru
men
t, de
scrip
tion,
inte
rpre
tatio
n, re
fere
nces
Blev
ins,
C. A
., W
eath
ers,
F. W
., Da
vis,
M. T
., W
itte,
T. K
., &
Dom
ino,
J. L
. (20
15).
The
Postt
raum
atic
Stre
ss D
isord
er C
heck
list f
or D
SM-5
(PCL
-5):
Deve
lopm
ent a
nd in
itial
ps
ycho
met
ric e
valu
ation
. Jou
rnal
of T
raum
atic
Stre
ss, 2
8(6)
, 489
-498
. DO
I:
10.1
002/
jts.2
2059
de
velo
pmen
t, ps
ycho
met
rics
https
://d
eplo
ymen
tpsy
ch.o
rg/s
yste
m/fi
les/
mem
ber_
reso
urce
/4-P
CL-M
PC
L-M
inst
rum
ent
60CO
NCE
PTU
AL
FRA
MEW
ORK
S PH
ASE
2 E
XECU
TIVE
SU
MM
ARY
REP
ORT
| D
ECEM
BER
30, 2
020
CREA
TIVE
FO
RCES
®: N
EA M
ILIT
ARY
HEA
LIN
G A
RTS
NET
WO
RK |
CRE
ATIV
EFO
RCES
NRC
.ART
S.G
OV
Qua
lity
of L
ife S
cale
(QO
LS)
17-it
em m
easu
re o
f qua
lity
of li
fe
indi
cato
rs: m
ater
ial a
nd p
hysic
al
wel
l-bei
ng; r
elati
onsh
ips w
ith o
ther
pe
ople
; soc
ial,
com
mun
ity, a
nd c
ivic
ac
tiviti
es; p
erso
nal d
evel
opm
ent a
nd
fulfi
llmen
t; re
crea
tion
https
://li
nk.s
prin
ger.c
om/a
rticl
e/10
.118
6/14
77-7
525-
1-60
au
thor
’s de
scrip
tion,
dev
elop
men
t, ps
ycho
met
rics,
inst
rum
ent a
cces
s
Self-
regu
latio
n Q
uesti
onna
ire (S
RQ)
63-it
em m
easu
re o
f sel
f-reg
ulati
on:
the
abili
ty to
dev
elop
, im
plem
ent,
and
flexi
bly
mai
ntai
n pl
anne
d be
havi
or
https
://c
asaa
.unm
.edu
/inst
/Sel
fReg
ulati
on%
20Q
uesti
onna
ire%
20(S
RQ).p
df
info
shee
t: de
velo
pmen
t, ps
ycho
met
rics,
refe
renc
es, i
nstr
umen
t Br
own,
J. M
., M
iller
, W. R
., &
Law
endo
wsk
i, L.
A. (
1999
). Th
e se
lf-re
gula
tion
ques
tionn
aire
. In
L. V
ande
Cree
k &
T. L
. Jac
kson
(Eds
.), In
nova
tions
in c
linic
al p
racti
ce: A
sour
ce b
ook,
Vol
. 17
(p.
281–
292)
. Pro
fess
iona
l Res
ourc
e Pr
ess/
Prof
essio
nal R
esou
rce
Exch
ange
.Sy
mpt
om C
heck
list R
evis
ed
(SCL
-90-
R)90
-item
mea
sure
of 9
prim
ary
sym
ptom
dim
ensi
ons:
som
atiza
tion,
ob
sess
ive-
com
pulsi
ve, i
nter
pers
onal
se
nsiti
vity
, dep
ress
ion,
anx
iety
, ho
stilit
y, p
hobi
c an
xiet
y, pa
rano
id
idea
tion,
psy
choti
cism
https
://w
ww
.pea
rson
asse
ssm
ents
.com
/ in
stru
men
t
WHO
Qua
lity
of L
ife-B
REF
(WHO
QO
L-BR
EF)
26-
item
s mea
sure
of f
our q
ualit
y of
life
indi
cato
rs: p
hysic
al h
ealth
, ps
ycho
logi
cal h
ealth
, soc
ial
rela
tions
hips
, and
env
ironm
ent
https
://w
ww
.who
.int/
subs
tanc
e_ab
use/
rese
arch
_too
ls/w
hoqo
lbre
f/en
/ de
scrip
tion,
inst
rum
ent a
cces
s htt
ps:/
/dep
ts.w
ashi
ngto
n.ed
u/se
aqol
/WHO
QO
L-BR
EF
desc
riptio
n, d
evel
opm
ent,
psyc
hom
etric
s, re
fere
nces
Wor
king
Alli
ance
Inve
ntor
y (W
AI)
Oth
er v
ersio
n: W
orki
ng A
llian
ce In
vent
ory-
Sh
ort R
evise
d (W
AI-S
R)
36-it
em m
easu
re o
f the
ther
apeu
tic
allia
nce
https
://w
ai.p
rofh
orva
th.c
om/
auth
or’s
page
: dev
elop
men
t, in
stru
men
t Ho
rvat
h, A
. O.,
& G
reen
berg
, L. S
. (19
89).
Deve
lopm
ent a
nd v
alid
ation
of t
he W
orki
ng
Allia
nce
Inve
ntor
y. Jo
urna
l of C
ouns
elin
g Ps
ycho
logy
, 36(
2), 2
23–2
33.
https
://D
OI.o
rg/1
0.10
37/0
022-
0167
.36.
2.22
3
https
://p
ubm
ed.n
cbi.n
lm.n
ih.g
ov/2
0013
760/
WAI
-SR
com
para
tive
stud
y ps
ycho
met
rics
Qua
lity
of L
ife S
cale
(QO
LS)
17-it
em m
easu
re o
f qua
lity
of li
fe
indi
cato
rs: m
ater
ial a
nd p
hysic
al
wel
l-bei
ng; r
elati
onsh
ips w
ith o
ther
pe
ople
; soc
ial,
com
mun
ity, a
nd c
ivic
ac
tiviti
es; p
erso
nal d
evel
opm
ent a
nd
fulfi
llmen
t; re
crea
tion
https
://li
nk.s
prin
ger.c
om/a
rticl
e/10
.118
6/14
77-7
525-
1-60
au
thor
’s de
scrip
tion,
dev
elop
men
t, ps
ycho
met
rics,
inst
rum
ent a
cces
s
Self-
regu
latio
n Q
uesti
onna
ire (S
RQ)
63-it
em m
easu
re o
f sel
f-reg
ulati
on:
the
abili
ty to
dev
elop
, im
plem
ent,
and
flexi
bly
mai
ntai
n pl
anne
d be
havi
or
https
://c
asaa
.unm
.edu
/inst
/Sel
fReg
ulati
on%
20Q
uesti
onna
ire%
20(S
RQ).p
df
info
shee
t: de
velo
pmen
t, ps
ycho
met
rics,
refe
renc
es, i
nstr
umen
t Br
own,
J. M
., M
iller
, W. R
., &
Law
endo
wsk
i, L.
A. (
1999
). Th
e se
lf-re
gula
tion
ques
tionn
aire
. In
L. V
ande
Cree
k &
T. L
. Jac
kson
(Eds
.), In
nova
tions
in c
linic
al p
racti
ce: A
sour
ce b
ook,
Vol
. 17
(p.
281–
292)
. Pro
fess
iona
l Res
ourc
e Pr
ess/
Prof
essio
nal R
esou
rce
Exch
ange
.Sy
mpt
om C
heck
list R
evis
ed
(SCL
-90-
R)90
-item
mea
sure
of 9
prim
ary
sym
ptom
dim
ensi
ons:
som
atiza
tion,
ob
sess
ive-
com
pulsi
ve, i
nter
pers
onal
se
nsiti
vity
, dep
ress
ion,
anx
iety
, ho
stilit
y, p
hobi
c an
xiet
y, pa
rano
id
idea
tion,
psy
choti
cism
https
://w
ww
.pea
rson
asse
ssm
ents
.com
/ in
stru
men
t
WHO
Qua
lity
of L
ife-B
REF
(WHO
QO
L-BR
EF)
26-
item
s mea
sure
of f
our q
ualit
y of
life
indi
cato
rs: p
hysic
al h
ealth
, ps
ycho
logi
cal h
ealth
, soc
ial
rela
tions
hips
, and
env
ironm
ent
https
://w
ww
.who
.int/
subs
tanc
e_ab
use/
rese
arch
_too
ls/w
hoqo
lbre
f/en
/ de
scrip
tion,
inst
rum
ent a
cces
s htt
ps:/
/dep
ts.w
ashi
ngto
n.ed
u/se
aqol
/WHO
QO
L-BR
EF
desc
riptio
n, d
evel
opm
ent,
psyc
hom
etric
s, re
fere
nces
Wor
king
Alli
ance
Inve
ntor
y (W
AI)
Oth
er v
ersio
n: W
orki
ng A
llian
ce In
vent
ory-
Sh
ort R
evise
d (W
AI-S
R)
36-it
em m
easu
re o
f the
ther
apeu
tic
allia
nce
https
://w
ai.p
rofh
orva
th.c
om/
auth
or’s
page
: dev
elop
men
t, in
stru
men
t Ho
rvat
h, A
. O.,
& G
reen
berg
, L. S
. (19
89).
Deve
lopm
ent a
nd v
alid
ation
of t
he W
orki
ng
Allia
nce
Inve
ntor
y. Jo
urna
l of C
ouns
elin
g Ps
ycho
logy
, 36(
2), 2
23–2
33.
https
://D
OI.o
rg/1
0.10
37/0
022-
0167
.36.
2.22
3
https
://p
ubm
ed.n
cbi.n
lm.n
ih.g
ov/2
0013
760/
WAI
-SR
com
para
tive
stud
y ps
ycho
met
rics
61CO
NCE
PTU
AL
FRA
MEW
ORK
S PH
ASE
2 E
XECU
TIVE
SU
MM
ARY
REP
ORT
| D
ECEM
BER
30, 2
020
CREA
TIVE
FO
RCES
®: N
EA M
ILIT
ARY
HEA
LIN
G A
RTS
NET
WO
RK |
CRE
ATIV
EFO
RCES
NRC
.ART
S.G
OV
Neu
rolo
gica
l/Bi
olog
ical
Mar
kers
Biom
arke
rs: h
eart
rate
va
riabi
lity,
cor
tisol
, ne
uroi
nflam
mat
ory,
etc.
N
euro
imag
ing/
brai
n ac
tivity
: EE
G, fN
IRS,
fMRI
, Mob
ile
Brai
n/Bo
dy Im
agin
g (M
OBI
)
Galv
anic
skin
resp
onse
King
, J. L
., &
Kai
mal
, G. (
2019
). Ap
proa
ches
to R
esea
rch
in A
rt T
hera
py U
sing
Imag
ing
Tech
nolo
gies
. Fro
ntier
s in
hum
an n
euro
scie
nce,
13,
159
. htt
ps:/
/DO
I.org
/10.
3389
/fnh
um.2
019.
0015
9 M
icho
poul
os, V
., N
orrh
olm
, S. D
., &
Jova
novi
c, T.
(201
5). D
iagn
ostic
Bio
mar
kers
fo
r Pos
ttra
umati
c St
ress
Diso
rder
: Pro
misi
ng H
orizo
ns fr
om T
rans
latio
nal
Neu
rosc
ienc
e Re
sear
ch. B
iolo
gica
l psy
chia
try,
78(
5), 3
44–3
53.
https
://D
OI.o
rg/1
0.10
16/j.
biop
sych
.201
5.01
.005
Sc
hmid
t, U.
, Kal
twas
ser,
S. F.
, & W
otja
k, C
. T. (
2013
). Bi
omar
kers
in
postt
raum
atic
stre
ss d
isord
er: o
verv
iew
and
impl
icati
ons f
or fu
ture
rese
arch
. Di
seas
e m
arke
rs, 3
5(1)
, 43–
54. h
ttps
://D
OI.o
rg/1
0.11
55/2
013/
8358
76
Nor
rhol
m, S
. D.,
Jova
novi
c, T.
, Ger
ardi
, M.,
Brea
zeal
e, K
. G.,
Pric
e, M
., Da
vis,
M
., Du
ncan
, E.,
Ress
ler,
K. J.
, Bra
dley
, B.,
Rizz
o, A
., Tu
erk,
P. W
., &
Rot
hbau
m,
B. O
. (20
16).
Base
line
psyc
hoph
ysio
logi
cal a
nd c
ortis
ol re
activ
ity a
s a p
redi
ctor
of
PTS
D tr
eatm
ent o
utco
me
in v
irtua
l rea
lity
expo
sure
ther
apy.
Beh
avio
ur
rese
arch
and
ther
apy,
82,
28–
37. h
ttps
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OI.o
rg/1
0.10
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brat
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6.05
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62CO
NCE
PTU
AL
FRA
MEW
ORK
S PH
ASE
2 E
XECU
TIVE
SU
MM
ARY
REP
ORT
| D
ECEM
BER
30, 2
020
CREA
TIVE
FO
RCES
®: N
EA M
ILIT
ARY
HEA
LIN
G A
RTS
NET
WO
RK |
CRE
ATIV
EFO
RCES
NRC
.ART
S.G
OV
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