colorful recovery: art therapy for substance abuse and...

Colorful Recovery: Art Therapy for Substance Abuse and Addiction Treatment

by Courtney Chandler

An undergraduate thesis submitted in partial completion

of the Metropolitan State University of Denver Honors Program

December 2015

Dr. Anna Ropp Dr. Katherine Hill Dr. Megan Hughes-Zarzo

Primary Advisor Second Reader Honors Program Director

RunningHead:ARTTHERAPYFORSUBSTANCEABUSETREATMENT 1


Courtney Chandler

Metropolitan State University of Denver

ARTTHERAPYFORSUBSTANCEABUSETREATMENT 2

Abstract Does art therapy enhance the process of recovery and therefore increase the probability of

long-term sobriety for individuals seeking treatment from substance abuse addiction?

This paper will discuss the benefits of art therapy, when used as a therapeutic

intervention that complements another substance abuse treatment modality (such as CBT,

DBT, or a 12-step program). Research over the past few decades has demonstrated that

art therapy has been successful in reducing shame (Grosch, 1994) and anxiety (Curry &

Kasser, 2011; van der Vennet & Serice, 2012), which is paramount to overcoming

addiction (Wilson, 2012). The interwoven relationship between art and spirituality will be

discussed with specific emphasis on how art therapy can increase a sense of spiritual

connection (Miller, 1995) and therefore be valuable to the recovery process. Mindfulness

practices shall be explained in detail as they align with similar philosophies of art

therapy, thus supporting the argument that art therapy is a uniquely beneficial

complement to existing substance abuse treatment programs, and is likely to enhance

overall success rate probability for long-term sobriety. Plans for further research, which

include a proposed research study to obtain quantitative data, will also be discussed.


“The aim of art is to represent not the outward appearance of things,

but their inward significance.” –Aristotle

Acknowledgements

I am eternally grateful to my family and friends for their support and their ever-

inspiring love and enthusiasm for my endeavors. I am also grateful to all my professors,

staff, and the Honors Program at Metropolitan State University of Denver, for their

assistance, support and encouragement throughout my Undergraduate career. I give

special thanks and recognition to my thesis committee advisors, Katherine Hill, Ph.D.,

Anna Ropp, Ph.D., and Cynthia Sutton, Ph.D.


Table of Contents

Abstract ............................................................................................................................ 2

Acknowledgements .......................................................................................................... 3

Table of Contents .............................................................................................................4

Introduction ......................................................................................................................5

Art Therapy ..................................................................................................................... 6

Substance Abuse / Addiction .......................................................................................... 7

Historiography / Literature Review ............................................................................... 9

Existing Outcome Studies ............................................................................................. 17

Art Therapy & Clinical Neuroscience ..........................................................................19

Meaningful Engagement ............................................................................................... 20

Mindfulness-Based Relapse Prevention ....................................................................... 21

Art Therapy & Mindfulness ......................................................................................... 26

Spirituality ...................................................................................................................... 29

Shame Reduction ........................................................................................................... 33

Anxiety Reduction .......................................................................................................... 34

Limitations of Existing Research .................................................................................. 35

Proposal for New Assessment Tools & Recommendations for Further Research ... 36

Conclusion ...................................................................................................................... 41

References ....................................................................................................................... 43

Appendices ...................................................................................................................... 54



Life can be difficult and challenging—this is an agreed upon fact. Everyone

manages their struggles in life slightly differently, but we are all human; therefore, we are

all flawed. Gaining acceptance of flaws and ‘weaknesses’ is a feat that some people may

struggle with more than others, for a variety of biological and psychosocial reasons. For

some, the effects of the mental and emotional turmoil encountered throughout life’s

hardships can be too much to bear, making life feel hopeless and seemingly without

purpose.

So what happens when addictive substances become the ‘solution’ to a problem?

What happens when drugs or alcohol are used and abused in an effort to cover up dark

emotions—to avoid struggles or challenges—creating an illusion of manageability? For

many, this coping mechanism can spiral into the depths of dependency and addiction,

ultimately creating even more problems that result in lonely despair. However, full-blown

addiction is not necessarily a result of choice, and there is always an argument of nature

versus nurture to consider. Research has found evidence that addiction may be largely

linked to genetics, as supported through clinical studies on twins (Ruden & Byalick,

1997). Research findings suggest that addiction is not a matter of choice, but rather a

biological predisposition associated with heredity (Cloninger, 1987; Pitkens & Svilkis,

2000; Ruden & Byalick, 1997). Luckily—regardless of the cause—there is hope; there is

a solution.

The field of psychology offers many forms of therapy to aid in substance abuse

treatment and addiction recovery, spanning from cognitive-behavioral therapy (CBT),

dialectical-behavioral therapy (DBT), or humanistic applications of psychotherapy


(Tanner-Smith, Wilson, & Lipsey, 2013). Other treatment forms with positive efficacy

rates are non-therapy based, such as 12-step programs including Alcoholics Anonymous

and Narcotics Anonymous (Bogenschutz, 2008; Borkman, 2008; Laudet, 2003), which

provide members with a sense of purpose, helping others with shared experiences while

reinforcing rewards of staying sober (Pagano et al., 2004). However, there is one

relatively new form of treatment that is lesser known, but uniquely beneficial for helping

those who suffer from addiction—this is the field of art therapy (Johnson, 1990; Mahony,

1999; Miller, 1995). While research has yet to specifically evaluate the efficacy of art

therapy to treat addiction, this paper aims to support the following hypothesis: Art

therapy, when used in conjunction with an addiction treatment program, can enhance the

process of recovery for the individual by improving mindfulness, building a means of

spiritual connection, and reducing shame and anxiety, therefore increasing the likelihood

of long standing sobriety.

Art Therapy

Since its emergence in 1969, art therapy is a mental health treatment that utilizes

traditional processes of counseling and psychotherapy integrated with creative processes

of artistic expression (American Art Therapy Association, 2014). This treatment modality

helps people resolve conflict(s), reduce stress and anxiety, manage grief, increase self-

esteem and wellbeing, and work through maladjusted behaviors, attitudes, or conditions

(Allen, 1995; American Art Therapy Association, 2014; Holt & Kaiser, 2009; Wilson,

2012).

Art therapy is a creative, therapeutic engagement between therapist and client,

largely focused on art making as a form of emotional expression. Often, specific art


projects are offered by the art therapist in a treatment plan specifically geared towards the

client needs, but other times the art making is free from constraints and can be

spontaneous. Regardless, the art therapist places “emphasis on empowering the

participant to self-interpret their non-verbal expression, with the guidance of the art

therapist” (American Art Therapy Association, 2014). The art created is not to be

diagnosed, as is a common misconception; rather, the goal of therapy is fostered between

and within the client-therapist relationship (similar to other traditional forms of

psychotherapy). In other words, it is not the final aesthetical product of the artwork that is

of interest; it is the experience of creating art and the growth of self-awareness,

transformation, and emotional exploration that comes from the process of art making in a

therapeutic setting that is of primary benefit. As eloquently stated by de Button and

Armstrong (2013), “art is one resource that can lead us back to a more accurate

assessment of what is valuable by working against habit and inviting us to recalibrate

what we admire or love” (p. 98).

Substance Abuse / Addiction

Drug and alcohol addiction is a huge problem in the United States today—it is a

terrifying epidemic, destroying the lives of millions. Even those who do not abuse

substances themselves are likely to be negatively impacted by the effects of addiction in a

secondary sense, watching someone they know and love suffer under the grips of

chemical dependency (National Council on Alcoholism and Drug Dependence, 2015).

According to the 2014 National Survey on Drug Use and Health (NSDUH), 21.5 million

people in the United States were found to have a substance use disorder (SUD) within the

past year (Substance Abuse and Mental Health Services Administration, 2015), while an


estimated 27.0 million people (ages 12 and older) self-reported they used prescription

drugs for nonmedical purposes within the past 30 days (National Council on Alcoholism

and Drug Dependence, 2015). Statistically speaking, approximately one out of every ten

people in the U.S. admits to frequently abusing drugs and/or alcohol, or are already

addicted; many of those who are not yet claiming to be addicted are dangerously teetering

the risky fine line of dependence (National Council on Alcoholism and Drug

Dependence, 2015; Substance Abuse and Mental Health Services Administration, 2015).

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines

substance dependence as a maladaptive pattern of drug use leading to impaired distress,

presenting with symptoms (such as increased tolerance, withdrawal, continuing to use

drugs despite negative consequences, etc.) lasting for a period longer than one year

(DSM-VI, cited in Wilcox and Erickson, 2000). The addicted individual eventually loses

the ability to control thoughts, emotions, or behaviors, and may begin to completely lose

sight of his/her own ‘self’ once the substance has completely taken over (Ruden &

Byalick, 2000; Wilcox & Erickson, 2000). Upon habitual intake, the individual’s brain

and body functioning will become fully reliant on the presence of the drug (physiological

dependence), and a persistent phenomenon of craving (psychological dependence) will

also occur (National Council on Alcoholism and Drug Dependence, 2015).

Most addictive substances infringe their way into the nucleus accumbens (the

pleasure center of the brain), linking themselves with dopamine function. When the

substance reaches the brain, it produces a surge of dopamine, flooding the limbic system,

allowing the individual to experience heightened ‘pleasure.’ As this initial on-set

chemical reaction of the drug wears off, “it must also rebound below the initial baseline


of neural activity before returning to it” (Wilcox & Erickson, 2000, p. 121). This

‘rebound’ effect evolves into an intense craving—both a physiological and psychological

phenomenon—insisting on a new dose of the substance to be taken in order to return to

homeostasis. Eventually, this cycle continues to the point of no return; the brain can no

longer maintain homeostasis without the drug, yet due to tolerance levels increasing, the

drug no longer produces the desired effect. When the brain is unable to produce (or

regulate) adequate levels of dopamine, the individual is subsequently left with an

unmanageable chemical dependency, depression, and hopeless despair (Ruden &

Byalick, 2000; Wilcox & Erickson, 2000).

Historiography / Literature Review

A review of art therapy literature shows that over the past 30 years, art therapy

has been used in various forms of application to treat substance abuse, yet there is a

minimal amount of published quantitative studies relating to its effectiveness. Through

anecdotal accounts from therapists working with substance abusing clients and qualitative

research studies involving participants answering Likert-scale questionnaires, there have

been a handful of studies in support of the therapeutic rationale behind art therapy for

substance abuse (Chickerneo, 1993; Feen-Calligan, 2007; Holt & Kaiser, 2009; Horay,

2006; Mahony, 1999; Matto, 2002). Although the effectiveness has yet to be thoroughly

researched at the quantitative level, the work that is being conducted in the field of art

therapy for addictions shows promise.

Feen-Calligan (1996; 2007) developed art therapy programming surrounding the

traditions of 12-step groups such as Alcoholics Anonymous. By focusing her art therapy

sessions on issues and concepts relevant to the 12-steps (such as powerlessness,


unmanageability, and connecting with a Higher Power), clients can experience

cohesiveness with concepts they are already dealing with in their recovery program

outside of the art therapy intervention. Feen-Calligan (2007) asserts that art therapy is an

exceptionally powerful tool that can be used as relapse prevention, by “encouraging

patients to visualize their relapse triggers or other barriers that might prohibit recovery,

and in particular, how to recognize feelings as potential relapse triggers” (p. 19). Further,

she describes the experience of art as therapy as being a meditative, inspiring, and

spiritual practice, and that recovery, art, and spirituality share qualities that provide a

supportive bond of treatment for addiction (Feen-Calligan, 1995).

Chickerneo (1993) offered her contribution with an extensive exploration of art

therapy as it relates to spirituality (not necessarily linked with the spiritual aspects of 12-

step programs). More specifically, she has many documented case studies of her

experiences using art therapy with people suffering from chemical dependency and/or co-

dependency and claims that, “all addiction is attachment, and the recovery process from

all addiction requires breaking the attachment” (p. 7). Chickerneo argued within the

philosophical construct that art is a way to break free from the chaos of the fast-paced

culture that we live in as prisoners of the clock, and relearn how to find peace, sanity, and

balance in life.

Matto (2002) published practice guidelines and techniques for art therapists that

are beneficial for use in substance abuse treatment in a short-term, inpatient hospital

setting. Though she does not have a set curriculum, Matto claims that art directives

should be short, simple, and promote movement toward change and taking action in a

way that is both challenging and exciting. Short-term treatment goals focus on expressing


feelings, identifying safe places and new behaviors for coping and self-exploration, as a

construct to approach long-term goals. Matto (2002) promotes art therapy to occur in a

group setting in an inpatient substance abuse treatment facility, as it can be a valuable,

supportive additive for clients struggling in early recovery. By encouraging healthy risk-

taking (trying something new through art making), enhancing self-awareness, and

establishing interconnectedness, Matto claims that art can be used to broaden

relationships and increase active participation and engagement in treatment.

Cox and Price (1990) developed art therapy treatment plans to have their

adolescent substance abusing clients use “Incident Drawing” to facilitate acceptance of

the disease of addiction, through creative, nonthreatening confrontation with their

experiences of denial, loss, shame, and guilt. These treatment plans were developed with

the goal of resolving any underlying trauma that resulted in substance abuse. The goal of

the “Incident Drawing” technique is to offer insight into the unmanageability of the

individual’s addiction, so he/she can clearly see that many of the traumatic incidents were

linked to drug use.

Cox and Price designed this specific art therapy intervention to be integrated into

any substance treatment program at least twice per week for 45-minute sessions, in a

group format. Each art therapy session under this technique is to be introduced with the

instruction, “draw about an incident that occurred during the time you were

drinking/drugging. (…) Recall a significant event and express the incident visually” (Cox

& Price, 1990, p. 335). Tempera paint is intentionally the only media provided, as it is

more difficult to use than pencils or markers, thus acting as somewhat as a metaphor for

the unmanageability of addiction.


Once completed, the incident drawings (along with any emotions that may have

surfaced) are discussed among the group. Because the group focus can be directed on the

drawings rather than as a spotlight on the individual, the individual may feel less

threatened and therefore more apt to divulge feelings and attitudes (Cox & Price, 1990).

After the group discussion, the art therapist will ask the individual to explore the

following five questions, writing answers to them on the back of their drawing to

promote further contemplation and self-appraisal: “What was your thinking pattern at the

time? What were your feelings at the time? What were the values contradicted? What

relationships were affected? What would a sober person do in this situation?” (Cox &

Price, 1990, p. 338).

Holt and Kaiser (2009) constructed art therapy directives related to themes within

the 12-step recovery model that are geared toward targeting denial and identifying

ambivalence, which give rise to eventual acceptance of new lifestyle changes in order to

live a life of sobriety. The five directives developed by Holt and Kaiser, called “The First

Step Series,” were designed to be used during the initial stages of substance abuse

treatment and exhibit an active mind-body strategy believed to be especially helpful

throughout the recovery process.

Rooted in the treatment models of Motivational Interviewing (MI) and Stages of

Change (SOC), “The First Step Series” serves as a strategy for taking an active role in

recovery. MI is a client-centered counseling model that approaches client defensive

mechanisms (such as denial) to understand how and why people change, with the goal of

enhancing intrinsic motivation for change (Holt & Kaiser, 2009; Miller & Rollnick,

2002). The SOC model uses a five-stage continuum progressing from pre-contemplation


through contemplation, preparation, action, and finally maintenance, to delineate the

client’s readiness or willingness for change (DiClemente & Velasquez, 2002; Holt &

Kaiser, 2009). Both MI and SOC emphasize that motivation for change is imperative to

the recovery process, which occurs in progressive stages. Research suggests that active

engagement in treatment models of MI, also referred to as Motivational Enhancement

Therapy (MET), help individuals with chemical dependency significantly decrease

alcohol consumption (Project MATCH Research Group, cited in Polcin, 2002).

Using a similar five-stage continuum to increase motivation for change, “The

First Step Series” uses five specific art directives. The first is a Crisis Directive that was

designed to evaluate the individual’s perception of the situation at hand, and target any

ambivalence for letting go of his/her substance of choice, or readiness for change. This

art directive specifically asks the client to “depict the crisis or incident that brought you

to treatment” (Holt & Kaiser, 2009, p. 247). This directive offers a parallel to Step One in

12-step programs, which states: “We admitted we were powerless over alcohol—that our

lives had become unmanageable” (Alcoholics Anonymous, 2001, p. 21). The drawings

are then openly discussed in a group therapy setting, for which any personal dilemmas or

traumatic experiences brought forth through the imagery can be incorporated into a

treatment plan (Holt & Kaiser, 2009).

The second directive is a Recovery Bridge Drawing, where the task is to

“complete a bridge depicting where you have been, where you are now, and where you

want to be in relation to your recovery” (Holt & Kaiser, 2009, p. 247). Imagery that

emerges from this prompt can provide insight into any anxiety, ambivalence, or hesitation

felt about entering treatment. This is particularly true in regards to working toward a


dramatic life change from active substance abuse to sobriety. If the metaphorical bridge

was drawn with the inclusion of fire, for example, the individual will likely discuss the

intensity of fear or anxiety associated with the process of getting sober (Holt & Kaiser,

2009). A group therapy session also follows this directive to allow for further insight to

be discussed in a supportive setting.

The third activity is a Costs-Benefits Collage, which asks the individual to “make

a collage exploring the costs and benefits of staying the same, and the costs and benefits

of changing” (Holt & Kaiser, 2009, p. 248). Again, opportunity for ambivalence and/or

fear surrounding the recovery process can be identified and discussed. In practice, this art

exercise has also offered individuals the opportunity to address any cravings to use

substances, which can be beneficial for relapse prevention (Holt & Kaiser, 2009).

Further, open exploration of these two realities (changing versus staying the same)

clarifies there is a choice between seeking a life of sobriety or remaining physiologically

and psychologically addicted.

The fourth directive is a popular art therapy exercise that encourages self-

reevaluation with the intention to raise conscious awareness through imagining future

scenarios (Holt & Kaiser, 2009). Building off topics explored in the previous directive,

this fourth task has two components. First, to “depict yourself as you imagine you will be

in a year if you make the changes that support recovery” and second, “depict yourself as

you imagine you will be in a year if you do not make the changes” (Holt & Kaiser, 2009,

p. 249).

The fifth and final directive in “The First Step Series” prompts the individual to

“make a picture that illustrates the barriers you see to making the changes necessary for


recovery” (Holt & Kaiser, 2009, p. 249). Real or perceived issues, fears, stresses, or

concerns can be addressed within this prompt, which can be helpful to the therapist (or

treatment team) regarding individualized care. For the individual, it can be especially

beneficial for understanding ambivalence, and/or unveil what may be a hindrance

underlying the motivation to change (Holt & Kaiser, 2009).

Through their experiences as art therapists, Holt and Kaiser (2009) find that the

act of creating art is a process that engages the individual in a profound self-assessment

of thoughts and emotions. Through “The First Step Series,” individuals can use artwork

as a safe container to work through perceptions, beliefs, doubts, and fears, to ultimately

open up a window of opportunity to support motivation for change.

Horay (2006) decided to take a more broad range of focus for his own practice,

after he noticed that the majority of art therapy in the substance abuse treatment field was

derived from the 12-step model. Understanding that many individuals who receive

treatment for addiction held ambivalent feelings about recovery, Horay based his art

therapy treatment approach off of SOC and MI therapeutic models that would address

such ambivalence through various phases along the road to recovery (Hinz, 2009; Horay,

2006). Horay (2006) conceives that art therapy is unique to encouraging self-efficacy

within the individual seeking treatment, claiming:

Artmaking, no matter what media or directive, generally involves utilizing those

same cognitive processes of valuing, choosing, and deciding. Additionally, the

creative process itself—carried out through gathering materials, exploring media,

choosing tools, and active making and revising—corresponds remarkably well to

the five stages of change. (p. 17).


Horay’s (2006) art therapy program outlined a combination of both individual and

group art therapy sessions within an outpatient addiction treatment setting. To address—

and ultimately move beyond—ambivalent thoughts and feelings about recovery, several

specific art directives are suggested. First, the individual is asked to create a Pro-Con

Collage, assembling magazine images and/or word clippings to represent either “the pros

of using” and “the cons of using,” or, “the pros of not using” and “the cons of not using”

(Horay, 2006, p. 18). The second art therapy session entails creating a Hypothetical

Greeting Card, whereas the individual will create a card as if it were to be sent to

him/her, from someone they care about. This exercise is intended to examine what the

individual values in relationships, which can be used as motivational support for relapse

prevention (Horay, 2006).

All subsequent art therapy sessions utilize Check-In Drawings to identify any

feelings and emotions recently experienced. For these art exercises, individuals can chose

from a variety of materials to use to illustrate their current emotional state. Through these

less structured directives, individuals exhibit self-efficacy and free choice (a primary aim

of MI and SOC) as they explore their ambivalence and progress in recovery (Horay,

2006).

As detailed above, art therapy is used in the treatment of addiction through several

methods of application. Many art therapy programs align with 12-step philosophies,

while others use art directives with the theoretical underpinnings of MI and SOC to

increase motivation to change. Regardless of the approach, the intention of increasing

self-awareness to support progress through recovery is of primary interest in the art

therapy process.


Existing Outcome Studies

Slayton, D’Archer, and Kaplan (2011) published a comprehensive review of

outcome studies found in the literature which had an isolated focus of art therapy as the

specific intervention (rather than an addition to another treatment modality), completed

between 1999-2007. Their review summarized that the authors of all qualitative studies

(seven total) yielded benefits from the art therapy interventions (Slayton, D’Archer, &

Kaplan, 2011). The population focus for each of these seven studies was different; one

focused on young children with attachment disorders (Ball, 2002), another with adults

with Lupus (Nowicka-Sauer, 2007). Also researched were a group of incarcerated adult

women who experienced a death of a loved one during incarceration (Ferszt et al., 2004),

mothers and toddlers (Hosea, 2006), elder adults with Alzheimer’s disease (Seifert &

Baker, 2002), adults in forensic institutions (Smeijsters & Cleven, 2006), and 10 year old

children with family grief (Gersch & Sao Joao Goncalves, 2006). The art therapy

interventions for each of these studies were different, but all occurred in a group setting.

Interviews with the participants and/or the art therapist were conducted to compile a

qualitative analysis of the studies. Results reflected that issues were successfully

addressed by art therapy, and participants reported that art therapy helped them cope with

their emotions, safely explore grief, and identify positive change/growth (Slayton,

D’Archer, & Kaplan, 2011).

Also examined within the aforementioned outcome studies review were research

designs utilizing control groups. Four clinical trials were completed, for which three of

the four resulted in statistically significant findings. The three studies were focused on

individual art therapy sessions with adult cancer patients (resulting in improvements in


depression and fatigue levels) (Bar-Sela et al., 2007), group art therapy interventions with

adolescent girls convicted of felonies (resulting in improved self-esteem) (Hartz & Thick,

2005), and group art therapy sessions for medical staff working with oncology patients

(resulting in decreased burnout) (Italia et al., 2008). The trial that did not conclude with

significant findings focused on group art therapy for children with leukemia, which was

documented to be beneficial in promoting cooperative behavior during painful

interventions (Favara-Scacco et al., 2001), yet the tools/measurement data were not

available (Slayton, D’Archer, & Kaplan, 2011). The other quantitative data were obtained

through pre/post-test design studies, which appeared to be the most prevalent (a total of

20 studies conducted), for which 55% of studies resulted in statistically significant

findings; all others were reported to have positive trends (Slayton, D’Archer, & Kaplan,

2011).

This review of findings of outcome studies reflects a wide range of art therapy

interventions involving numerous measurement tools and populations (Slayton,

D’Archer, & Kaplan, 2011), yet does not include any focused studies of populations of

substance abusers and/or addicts. Similarly, the American Art Therapy Association

(2015) has a publicized up-to-date list of art therapy outcome studies. This bibliographic

list specifies only three studies that have been conducted on art therapy interventions to

treat chemical dependency and/or substance abuse, each of which were of the qualitative

nature (American Art Therapy Association Research Committee, 2015).

After noticing in the literature that there was almost an absence of art therapy

being provided for people with substance abuse issues, Mahony (1999) carried out a

research project with the intention to explore and potentially explain why art therapy was


not being widely utilized as a treatment approach for this population. As such, she sent

out questionnaires to 26 different addiction treatment facilities (in the UK), of which 16

provided responses. Of the 16 facilities, only one replied that they had a registered art

therapist on staff. Half of the treatment programs confirmed they do integrate art

activities into their treatment plans, just not through a licensed art therapist. The

questionnaire responses also provided information as to why art therapy was not offered;

financial reasons and limitations of facility space were popular answers. Four of the eight

facilities that reported to have no art program offerings stated that it was a deliberate

choice, yet did not specify why. However, the eight facilities that had no art offerings

were also found to not employ any medical staff or psychologists. Mahony (1999)

concluded her findings by pointing out there is an overall interest to provide art therapy

in treatment programs, but there seems to be a lack of access, in addition to a lack of

awareness of such programs altogether.

Art Therapy & Clinical Neuroscience

The practice of creating art (whether or not it is for the purposes of therapy) can

yield an experience of pleasurable thrill and provide the individual with a rewarding

feeling of achievement, so long as anxiety or learning struggles do not create too much of

a hindrance throughout the process. This sense of ‘reward’ is attributed to dopamine

(DA), which is intrinsic to the underlying neurochemical processes of many of the

activities and outcomes of art therapy (Hass-Cohen & Carr, 2008). According to

neurological research findings, “movement related actions, basic emotions, visceral

functions, reward-based learning and decision-making emerge from the DA pathways”

(Hass-Cohen & Carr, 2008, p. 82).


The mesocortical DA pathway becomes active when something known is

challenged, and has been found to be involved with meta-cognitive changes that occur

during art therapy. Having too little DA in the brain has been linked to depressed feelings

such as worthlessness, social withdrawal, poor concentration, and unbalanced emotional

perception (Hass-Cohen & Carr, 2008). Although acute use of many drugs increases DA

levels, habitual substance abuse leads to huge deceases in the natural production of DA.

Therefore, creating art that helps promote DA pathway activation can be especially

beneficial for people in recovery to produce DA without the use of drugs.

Meaningful Engagement

Lambert (2008) theorized that depression could be conquered without the use of

antidepressant drugs through meaningful psychomotor endeavors, such as problem

solving combined with movement; specifically, through use of the hands to produce

effort-driven rewards. To test her theory, Lambert (2008) focused specifically on

studying the nucleus accumbens, explaining:

The accumbens is positioned in proximity to the brain’s motor system, or stratum,

which controls our movements, and the limbic system, a collection of structures

involved in emotion and learning. Essentially, the accumbens is a critical interface

between our emotions and our actions. The closely linked motor and emotional

systems also extend to the prefrontal cortex, which controls our thought

processes, including problem solving, planning and decision making. (p. 35).

Lambert (2008) refers to this system—that connects processes of movement,

emotion, and thinking—as the “accumbens-stratal-cortical network,” or, the “effort-

driven-rewards circuit” (p. 35). Through her research on rats (who have all the same parts


of the brain as humans, just smaller and less complex), Lambert (2008) found that

“working rats” (who were engaged in activities that actively engaged the effort-driven-

rewards circuit) were 60% more persistent to solve challenges to seek a reward, and less

likely to give up, than non-working rats. These findings suggest that when faced with a

challenge in life, attending to meaningful-activities can engage the brain in a way that is

beneficial to mental health. By participating in activities that actively stimulate the effort-

driven-rewards circuit, the brain can get a boost of ‘rewarding’ neurochemicals, such as

serotonin, endorphins and dopamine, without the use of drugs (Lambert, 2008).

Through art therapy, an individual will connect emotion, thought, and movement

(with the hands) to create a work of art, which will arouse his/her effort-driven-rewards

circuit resulting in a neurochemical ‘reward’ boost. As such, this active form of creative

expression can promote self-esteem and overall sense of wellbeing. Furthermore, creating

art is a form of meaningful engagement that an individual can easily and realistically

utilize even after treatment ends, thus supporting sustainable, long-term sobriety.

Mindfulness-Based Relapse Prevention

In early recovery, after the individual has detoxed from the substance(s), he/she

will experience physiological and psychological urges, cravings, and temptations to use

the substance again (Ruden & Byalick, 2000; Wilcox & Erickson, 2000). In order to

handle these intense impulses without consuming drugs and/or alcohol, the individual

must essentially relearn how to cope with stress in order to ward off relapse. Based on the

cognitive-behavioral model, the most critical predictor of relapse is the individual’s

ability to implement effective coping mechanisms to deal with stressful, tempting and/or

dangerous situations (Witkiewitz et al., 2005).


Practices of mindfulness have been found to enhance awareness and cultivate

healthy alternatives to impulsive thinking and behavior (Farmer, 1994; Marcus, 1974;

Rosenthal, 2011; Witkiewitz et al., 2014). According to Farmer (1994), “In the context of

addictions, mindfulness might mean becoming aware of triggers for craving…and

choosing to do something else which might ameliorate or prevent craving, so weakening

the habitual response” (p. 189). On this concept, Mindfulness-Based Relapse Prevention

(MBRP) programs have been created and adopted with the goal of utilizing mindfulness

skills for the development of coping strategies and acceptance of uncomfortable reactions

and sensations experienced during substance withdrawal, therefore decreasing the

probability of relapse (Witkiewitz et al., 2005).

There have been several preliminary studies over the past 40 years reflecting

positive outcomes from mindfulness-based practices in the addictions field. The first

documented studies relating to meditation and substance abuse date back to the early

1970s, with the emergence of a practice referred to as a Transcendental Meditation (TM)

technique (Aron & Aron, 1983; Marcus, 1974; Witkiewitz et al., 2005). TM is a

meditation practice that involves sitting comfortably for a period of 20 minutes (ideally,

twice daily; once in the morning and once in the evening) while silently repeating a

mantra, with a goal to achieve a profound state of physical and mental relaxation and

awareness (Rosenthal, 2011). The repetitive silent/mental mantra used for meditation is a

sound—or a word without meaning—that is believed to be the central ingredient for TM,

allowing attention to be shifted inward (Marcus, 1974).

Five different survey studies were conducted in the 1970s and 1980s that looked

at TM for substance abuse treatment, involving various participant group sizes (ranging


from 60 to 1,862 subjects). Each of these five studies resulted in positive outcomes,

suggesting that this mindfulness meditation technique is effectively capable of reducing

stress, anxiety, and tension (Aron & Aron, 1983; Marcus, 1974, Transcendental

Meditation, 2015). As the aimed goal of drug use by abusers is often parallel to that of

the TM outcomes (to be relieved from stress, anxiety, etc.), it is suggested that TM may

be an effective treatment option for relapse prevention (Marcus, 1974).

While many of these early studies of TM draw subjective conclusions, there have

been some that included questionnaires directed at monitoring the amount of drug use for

a prolonged period of time after the TM practices were introduced. More specifically, in a

1983 study, it was reported that substance abuse had gradually decreased or ceased

altogether among participants who integrated a TM practice into their daily lives for a

period of two years (Aron & Aron, 1983). A similar study in 1984 that was replicated in

1986 used a randomized trial to measure the efficacy of relaxation techniques, including

TM, as a means of substance abuse reduction; participants (all heavy-drinking college

students) who were administered the TM treatment were compared to a “no treatment”

control group. Results reflected that the participants in the TM group self-reported a

significant reduction in drug and alcohol use compared to the control group (Murphy et

al., 1986; Witkiewitz et al., 2005).

More recently, in 2009, a Mindfulness-Based Stress Reduction program (MBSR),

initially developed by Kabat-Zinn in 1990 (Rappaport, 2014) found successful outcomes

when implemented as a relapse prevention method at a community-based addiction

treatment program for women. The MBSR program used for this 2009 study involved

body scan exercise techniques to improve mind-body awareness, seated meditation aimed


toward non-judgmental thought awareness and impulse control, mindful hatha yoga to

encourage self-care and attentiveness to sensations in the body, and walking meditations

to practice mindfulness of living in the present moment (Vallejo & Amaro, 2009).

The MBSR framework was constructed to have participants gain the ability to

observe their emotions, bodily sensations, and thoughts in a systematic way that was free

from judgment. This would initiate freedom to choose how to respond to urges, cravings,

and unwanted mental noises that commonly present in early recovery, instead of acting

on impulse (Vallejo & Amaro, 2009). Though the attrition rate of this study was high

(57% of the 101 participants dropped out of the substance abuse treatment program—a

statistic that is not uncommon in the field of addictions), the remainder who did complete

the program self-reported positive feedback in relation to the MBSR. This study was

based on participant ratings on 13 items relating to the MBSR, at three different intervals

throughout the eight-week substance abuse treatment program (Vallejo & Amaro, 2009).

Of the rating comparisons, 11 of the 13 survey response items were found to have

statistically significant improvements between the beginning and end of the eight-week

program (Vallejo & Amaro, 2009).

Mindfulness-Based Relapse Prevention (MBRP) was developed as an adaptation

of MBSR targeted to the needs for individuals with addictive behaviors (Bowen et al.,

2009; Rappaport, 2014). According to Bowen et al. (2009), MBRP practices “focus on

increasing acceptance and tolerance of positive and negative physical, emotional, and

cognitive states, such as craving, thereby decreasing the need to alleviate associated

discomfort by engaging in substance use” (p. 296). As designed, each 50-minute bi-

weekly session of the MBRP is to begin with a brief guided meditation (e.g., body scan


meditation, or seated meditation) specifically focusing on using mindfulness-based skills

to decrease reactivity of high-risk situations that could lead to relapse, followed by a

group discussion. Participants of MBRP are also assigned exercise “homework”

(provided via handouts) to practice on their own between sessions (Witkiewitz et al.,

2014). Through its intentionally mindful application, MBRP is designedto raise

awareness of internal and external triggers and recognize onset of cravings, while at the

same time foster more skillful behavioral choices (Bowen et al., 2009; Witkiewitz et al.,

2014).

There is exciting research data supporting the efficacy of MBRP. A pilot study

published in 2009 used a randomized-controlled trial to evaluate the feasibility and

efficacy of an eight-week MBRP program at an outpatient treatment facility (Bowen et

al., 2009). Assessments were administered to the participants at the MBRP program

initiation, upon the completion of the eight-week program, and at two and four months

post-intervention. The assessments focused on measurements of craving, acceptance,

awareness, and days of substance use. Results indicated participants who received MBRP

treatment had statistically significant decreases on all items measured, compared to the

control group who received treatment as usual (Bowen et al., 2009).

More recently, in 2010-2011, a randomized trial comparing MBRP to standard

Relapse Prevention (RP) was conducted with female offenders who were referred to a

residential addictions treatment program through the criminal justice system (Witkiewitz

et al., 2014). Assessments were provided to 105 participants upon initial admission to

treatment (baseline), at the midpoint of treatment, and completion of treatment. Follow-

up assessments were also provided to participants at 15-weeks post-treatment (of which


80 participants completed). Statistically significant results of the study indicated that

participants who received MBRP compared to RP had 96% fewer days of drug use at the

15-week follow up date (Witkiewitz et al., 2014).

The outcomes research on TM, MBSR and MBRP all suggest that mindfulness

practices can bring happiness or contentment, release stress and tension, and expand

awareness of consciousness without the use of substances (Marcus, 1974; Murphy et al.,

1986; Witkiewitz et al., 2005), and can therefore be a useful mechanism for managing

physiological and psychological urges and cravings during early recovery.

Art Therapy & Mindfulness

Art and mindfulness have deep and profound connections in both application and

experience (Bowen et al., 2009; Rappaport, 2014; Rosenthall, 2011). When used in

conjunction with one another, these treatment methodologies are found to promote a

balance of inward reflection through mindfulness and outward expression through art. As

stated by Rappaport (2014):

Together, they help to develop skillfulness in being able to become more aware of

various dimensions of inner experience—feelings, thoughts, sensations, and

energies; and transform them through mindfulness practices and/or creative

means, release them in constructive ways, access inner wisdom, cultivate self-

compassion and compassion toward others. (p. 16).

Art therapy has been implemented as an adaptation of, and in addition to, other

mindfulness practices. In 2012, a Music, Imagery, and Mindfulness group was held at an

undisclosed drug and alcohol rehabilitation facility for 10 weeks in an outpatient setting

(van Dort & Grocke, 2014). Each bi-weekly session within the 10-week treatment series


lasted for 90 minutes, and was comprised of mindfulness relaxation (listening to music)

followed by a moment for silent mental imagery reflection, and concluded with members

drawing a mandala—art created in a circular form used to explore the unconscious self

(Malchiodi, 2010)—relating to their experience of the music provoked mental imagery

(van Dort & Grocke, 2014). Prior to each session, participants were led into the

music/imagery component with a mindfulness relaxation induction by the facilitator,

where they were asked to focus on the sensations of each breath as it moved through each

part of the body. Participants were asked to become aware of any images that arose

behind closed eyes, and allow them to take shape; free from judgment, criticism, or

grasping. To conclude each session, participants were asked to share their mandala

drawing of their experience in the group setting. Documented interviews with the

participants reflect that the mindful art exercises produced rich, emotional experiences

that could be explored in a safe environment, offering new realizations and understanding

of “self” (van Dort & Grocke, 2014).

The integration of art therapy and mindfulness blend so nicely that there has been

an emergence of new practice applications with positive outcomes. Peterson (2006)

created an eight-week treatment program known today as Mindfulness-Based Art

Therapy (MBAT), combining art therapy with Kabat-Zinn’s Mindfulness-Based Stress

Reduction (MBSR) model (Monti et al., 2006; Rappaport, 2014). The overall goal of

MBAT is to decrease levels of distress and improve quality of life, through use of both

verbal and nonverbal expression. In a supportive group format, MBAT is structured to

enhance support, promote self-regulation, and expand coping strategies (Monti et al.,

2006). The eight-week MBAT program design includes body scan and loving-kindness


meditations, walking meditations, gentle yoga, and guided imagery practices, coupled

with mindful art activities, such as self-picture assessments and free art-making open

studio time (Monti et al., 2006). A detailed outline of the eight-week MBAT program

curriculum is referenced herein as Appendix A.

A randomized, controlled trial was conducted to investigate the MBAT treatment

program for women with cancer, and test the hypothesis that MBAT (alongside usual

medical care) would reduce symptoms of distress and improve health-related quality of

life, compared to those who received medical care alone (Monti et al., 2006). Through

use of pre/post-test surveys, distress was measured using the Symptoms Checklist

Revised (SCL-90-R), which assesses 90 varying indicators of stress levels, including

depression, anxiety, paranoid ideation, hostility, etc. Health-related quality of life was

measured by the Medical Outcomes Study Short-Form Health Survey (SF-36), which

focused on assessing 36 different health concepts such as bodily pain, general health

perception, limitations in activities due to health problems, vitality (energy and fatigues),

etc. Survey data was also obtained at a 16-week follow-up date. As consistent with the

hypothesis, this study found that patients who received the MBAT intervention

demonstrated statistically significant decreases in distress compared to those who

received medical treatment alone, as well as statistically significant increased

improvements of many of the 36 items within the quality of life measurements, such as

mental health, general health, social functioning, and vitality (Monti et al., 2006). Follow-

up survey results reflected slight increases between week 8 and week 16, which suggest

positive maintenance of treatment effect (Monti et al., 2006, p. 369).


As previously discussed, there has been encouraging and significantly beneficial

research findings for Mindfulness-Based Relapse Prevention (MBRP). In the past few

years, art therapy has been blended with mindfulness practices. It can be reasonably

hypothesized therefore, that mindful art therapy would have similar outcome findings if

researched at the quantitative level. Unfortunately, the emergence of MBAT is so new

that such trials have yet to be conducted.

Spirituality

Hopelessness is a serious internal battle that many cannot combat successfully

alone. Many successful addiction recovery programs are rooted in spiritual principles, as

a means to offer support and guide the individual through (and eventually out of) the state

of hopelessness, comforting them to know they are not going through this battle alone.

Clinical research has found that spirituality is a critical component of quality of life,

especially for those who are suffering from chronic or terminal disease, and is a crucial

resource for individuals coping with illness (Monod et al., 2011).

A theory held by Alcoholics Anonymous (2001) suggests that addiction is a

disease deep-rooted in trauma, and is often a result of a spiritual malady. But what is

spirituality? According to Oriah Mountain Dreamer (2005):

Our spirituality is our direct experience of that which is paradoxically both the

essence of what we are, the stuff of which everything is made, and that which is

larger than us. We can call it God, the Sacred Mystery, the Great Mother, the

divine life force, fertile emptiness, clear light awareness, love, beauty, truth. The

possibilities are endless. (…) Fully present we experience a presence within and

around us, an all-inclusive vastness that is beyond words or thoughts. These


moments of being awake to the divine within and around us offer us a sense of

purpose and meaning, an appreciation for the wholeness of life even as what we

experience in these moments may be impossible to articulate or explain. (p. 5).

Spirituality has been a primary foundation for the recovery process within 12-step

programs since their emergence in 1935 with the founding of Alcoholics Anonymous. In

a 12-step program, the person in recovery is advised that it is essential to discover a

Power greater than him/herself, and rediscover what is important in life: “Just to stop

drinking without other growth or change would simply frustrate a person who had not

learned any other way to meet basic human needs” (Farley-Hansen, 2001, p. 102).

Maintaining and developing spiritual connectedness (a key component to finding success

in recovery) involves recognizing the spiritual aspect of the “self”—discovering one’s

own values and priorities, while learning what is true and meaningful in life, and

ultimately create (or re-create) a life worth living.

Treating substance abuse/addiction through a 12-step program suggests that all

individuals must adopt a belief in a “Higher Power” in order to be successful in recovery

and personal growth. One must essentially trade their belief that a substance—drugs or

alcohol—is what gives them what they need, for a belief that there is a Power in the

Universe that can help them remain clean and sober. This idea is strongly emphasized not

only in early recovery, but also as a means of achieving long-term sobriety. According to

the book of Alcoholics Anonymous (2001), “In nearly all cases, their ideals must be

grounded in a power greater than themselves, if they are to re-create their lives” (p.

xxviii).

Although fellowship (social support) in 12-step programs can encourage


successful sobriety (Borkman, 2008; Pagano et al., 2004), many individuals have a strong

resistance toward trusting in a Power greater than his/herself, and are therefore unwilling

to work the steps of the program as outlined (Laudet, 2003); without willingness, no true

individual progress can be made (Pagano et al., 2004). Art therapy can be a vehicle for

spiritual connection for those who are unwilling to adopt a Higher Power in early sobriety

(Feen-Calligan, 1995). The simple act of creating art is therapeutic by nature (Malchiodi,

2012) and can be expression of spirituality aside from believing in a Higher Power. For

example, unconscious thoughts can be visually realized through art making (Chickerneo,

1993), which can be a humbling and meaningful endeavor (Feen-Calligan, 1995). In this

regard, art therapy could potentially be a recovery tool more beneficial than a 12-step

program for individuals who are not open-minded about spirituality.

Art therapy interventions have been successful in promoting spirituality for

individuals seeking recovery from addiction. Miller (1995) documented a clinical art

therapy program where weekly art groups were held with the primary goal of spiritual

growth. Upon treatment intake, patients/clients complete a questionnaire on spirituality.

Throughout treatment, participants attend weekly art groups that specifically aimed to

promote awareness of personal spirituality, while defining his/her relation to a Higher

Power. At the end of treatment, a second spirituality questionnaire was administered.

Findings validated that 90% of patients self-reported that art group increased their

spiritual awareness (Miller, 1995).

There is an intimate relationship that exists between art and spirituality. Farley-

Hansen (2001) states:

Its fruits resemble the outcome of many spiritual practices: a heightened


awareness of self and other, a reawaking of the senses and the body, a new ability

to inhabit fully the present moment, a sense of awe at the mysterious ways that the

images which visit us speak of realities beyond our conscious understanding, a

greater sense of acceptance for all aspects of ourselves and others, love,

compassion and gratitude for some larger, deeper, ineffable presence to which we

all (human beings, animals, plants) belong. (p. 24).

Art therapy allows emotional turmoil, which may be difficult or uncomfortable to

explain with words, to be expressed nonverbally (Farley-Hansen, 2001; Wilson, 2012). It

provides the individual with a unique outlet for creativity to be brought into the recovery

process, granting personal freedom and a gentle invitation into spiritual health. As Feen-

Callahan (1995) states, “Recovery, art, and spirituality share certain qualities that lend

support to the use of art as therapy in addiction treatment: Recovery, art, and spirituality

all require commitment and consistent effort to know them” (p. 48).

12-step programs can be helpful in treating addiction (and achieving long-term

sobriety) not only due to their emphasis on following spiritual principals, but also

because of their format of offering strong social support connections with other

individuals seeking the same goal—being free from the grips of addiction—in order to

live a full, happy life (Borkman, 2008). The nature of art therapy as a treatment process

aligns with the principals of 12-step programs, as it offers a creative outlet for expression,

acts as a vessel for spiritual connection, encourages relaxation and meditation, and in a

group setting, can offer positive social engagement and support (Feen-Calligan, 2007;

Holt & Kaiser, 2009). Addicts seeking sobriety must essentially rediscover their emotions

without the mask of the substance(s), which can be a painful process. These individuals


likely have lost sight of who they are, how they feel, and what is important to them, and

may feel lost and alone in the world (Wilson, 2002). 12-step programs and art therapy

group practices alike can be successful in guiding addicted individuals through a

transformative, emotional process, with the support of others who have personally gone

through the similar process—sharing the common goal (and therefore means of bonding)

of achieving sobriety.

Shame Reduction

Shame and addiction appear to have an interwoven relationship; shame is

attributed to being both the catalyst for addictive behaviors and a reason that they

continue (Wilson, 2012). Reducing shame is crucial to the recovery process, but has been

noted to be rather difficult to directly address during treatment (Johnson, 1990; Wilson,

2012). According to Wilson (2012), “shame, by its very nature, seems difficult to

describe with words or even to access through cognitive processes since shame is largely

an unconscious experience defended against by a variety of maladaptive responses” (p.

305).

Addicts in early recovery are often confronted with intense and overwhelming

feelings of shame and remorse when faced with the reality of past behaviors and

potentially traumatizing experiences. Art therapist Marie Wilson (2012) feels the

expressive art therapy approaches are well suited to reduce shame. She claims “shameful

feelings may flow more easily and be more directly accessed via nonverbal, creative

approaches since they bypass rather than actively confront well-practiced defenses” (p.

305), and can teach recovery concepts so the addict can address shame in a supportive

manner, yet be held accountable. Additionally, art therapy can help addicts recognize and


identify their own manifestations of shame, by learning how to label it, separate shameful

feelings from reality, and decrease cognitive distortions (Grosch, 1994; Wilson, 2012).

Anxiety Reduction

Anxiety and addiction often overlap, existing concurrently (DuPont, 1995). Acute

anxiety is a common unpleasant effect of drug and/or alcohol withdrawal, but is also a

reason many people abuse substances in the first place, as a means to self-medicate

(DuPont, 1995; Kushner, Sher, & Beitman,1990). Reducing anxiety (a psychological and

physiological stress response) is a necessary and important in order for an individual to

make progressive strives in treatment (Malchiodi, 2012; Wilson, 2012). Art therapy is a

unique, beneficial tool that can be used to uncover and identify sensory aspects of stress

in the body, through visual expression (Malchiodi, 2012). Additionally, the act of making

art can be a soothing, mindful activity, and thus reduce stress and anxiety (Curry &

Kasser, 2011; Malchiodi, 2012; van der Vennet & Serice, 2012).

The act of coloring in symmetrical, complex patterns (such as a mandala) has

been documented to induce a calming state of mind-body similar to meditation (Curry &

Kasser, 2011; Malchiodi, 2010). Curry and Kasser (2011) conducted a study to examine

the effectiveness of various art activities in relation to stress reduction. Anxiety levels

were measured at three intervals throughout the study, occurring at the beginning

(baseline), after a brief anxiety induction, and again after the coloring exercise. Three

comparison groups were used where all three groups were asked to write for four minutes

about a time they experienced intense fear, as a means of inducing anxiety. Participants

were then randomly assigned to one of three groups—either to color a mandala, a plaid

design, or a blank piece of paper (to free-form draw/color)—where they would color for a


period of 20 minutes. Anxiety measurements reflected that both the mandala and plaid

coloring groups had statistically significant reduction in anxiety levels after the 20-

minute coloring period, from baseline anxiety. Findings were attributed to the notion that

coloring complex designs has meditative qualities (Curry & Kasser, 2011). These

outcomes were consistent within a replication study conducted one year later (van der

Vennet & Serice, 2012), suggesting that coloring a symmetrical, pre-drawn design can be

an effective way to reduce anxiety.

Limitations of Existing Research

There are only a handful of published research studies found in the art therapy

literature that demonstrates treatment specific for substance abuse and addiction. As

Slayton, D’Archer and Kaplan (2011) pronounced, “it is ever more important that art

therapists provide evidence to support our intuitive knowledge that art heals” (p. 108).

The vast majority of research supports evidence for the therapeutic rationale for using art

therapy as a treatment modality, rather than its measured efficacy. Moreover, the studies

conducted thus far in relation to art therapy for addiction have limitations of efficacy

findings due to the data being qualitative rather than quantitative, making them largely

subjective by nature. Those that are quantitative are quasi-experimental, so evaluating the

efficacy of art therapy is difficult. Nearly all of the published articles and books available

on the subject reference the need and recommendation for additional research.

It is impossible not to wonder…why? Why has there not been any research to

quantify the efficacy of art therapy as a treatment for addiction? Perhaps it is due to the

fact that it is extremely difficult to conduct research within the addiction population due

to such high attrition rates. As evidenced within a recent review, approximately 75% to


80% of substance use disorder treatment seekers in the U.S. disengage and do not

complete their treatment program (Loveland & Driscoll, 2014). Since the attrition rate is

so high within the completion of treatment programs themselves, it can be sensibly

predicted that efficacy research involving post-treatment follow-ups would have similarly

high, if not higher, attrition rates. As such, obtaining accurate data on long-term sobriety

success/failure seems arduous and unattainable.

Mental illness co-occurring along with a substance use disorder (known as

comorbidity) is another factor posing a challenge for efficacy research to be accurately

conducted within this population. Comorbidity is a factor that may not be known by the

researcher or the participant. Therefore, it is nearly impossibly to evaluate the efficacy of

treatment for only the substance abuse disorder. As explained by Nora Volkow (2010):

It is often difficult to disentangle the overlapping symptoms of drug addiction and

other mental illnesses, making diagnosis and treatment complex. Correct

diagnosis is critical to ensuring appropriate and effective treatment. Ignorance of

or failure to treat a comorbid disorder can jeopardize a patient’s chance of

recovery. (p. 1).

Proposal for New Assessment Tools & Recommendations for Further Research

As the literature promotes, art therapy is an important tool that is currently being

utilized in the treatment of addiction, yet there is a lack of research. Due to an absence of

studies with respect to the efficacy of art therapy for substance abuse and addiction, it is

recommended that quantitative research measures be sought in order to obtain data. This

research is necessary in order to demonstrate the degree of effectiveness, and provide

insight as to why it is effective. It would be valuable for further studies to test the


following hypothesis: Art therapy, when integrated into an addiction treatment program,

will decrease participants’ levels of shame and anxiety, while increasing mindfulness and

spiritual connection, thus reducing risk of relapse.

The proposed study to test this hypothesis is envisioned to have the design of a

controlled experiment. Ideally, this study would take place at an inpatient addiction

rehabilitation treatment facility (30 day program), as opposed to using an outpatient

treatment program, to reduce confounding variables. In order to evaluate treatment

efficacy, two groups would be compared. The control group of participants would receive

treatment as usual (TAU), while the experimental group would participate in art therapy

interventions in addition to TAU. Similar to randomized-controlled trial research design

studies that were conducted to test efficacy of Mindfulness-Based Relapse Prevention

(MBRP) programs (Bowen et al., 2009; Witkiewitz et al., 2014), art therapy intervention

sessions for this proposed study shall be 50-minutes in length, offered four times per

week. During the time the experimental group receives art therapy interventions, the

control group will participate in 50-minutes of small-group talk therapy.

Assessments (in the form of surveys using a Likert-scale format) are to be

administered initially at the beginning of treatment (admittance) to obtain baseline data,

again at the end of week two (midway through treatment), and week four (prior to

discharge). Follow-up surveys will be administered at three months and six months post-

treatment. A rolling admission format would be necessary for this population (Witkiewitz

et al., 2014) to allow for the desired total number of participants in the sample size

(N=88, or more) to be monitored from beginning through post-treatment assessment

marks, to account for likely high attrition rate and aim for a margin for random error


(MRE) to be no more than 10% (Fox, Hunn, & Mathers, 2009). Art therapy sessions

facilitated through licensed art therapists for this proposed study will take place in both

group (twice per week) and individual settings (twice per week), and explore themes

related to recovery, including but not limited to powerlessness, acceptance, spirituality,

grief, and gratitude.

For statistical analysis, biographical information will be requested at the top of the

initial survey administered upon admittance. An identification number will be assigned to

each participant to ensure confidentiality; each survey will be tracked by participant ID

numbers. Relevant questions for each of the assessments for this proposed study are

intended to measure shame, anxiety, spirituality, mindfulness, frequency and strength of

urges to use, and perceived helpfulness of the art therapy interventions. Follow-up

assessments will also investigate days of alcohol and/or drug use, using the Timeline

Followback (TLFB) measurement model. The TLFB is a self-report survey method that

asks individuals to retrospectively report days of cigarette, alcohol, and drug use within

the past week (Sobell & Sobell, 2000). This survey was initially developed in the 1970s,

but even today appears to be the most commonly used follow-up method to obtain

quantitative data relating to drug use in clinical research (Robinson et al., 2014).

Existing assessment instruments commonly used in other various clinical studies

have been reviewed and will be used for the purposes of this proposed study, as an effort

to support validity and reliability of what is being evaluated. Levels of shame will be

measured with the State Shame and Guilt Scale (SSGS) (Marschall, Sanftner, &

Tangney, 1994). The SSGS is a widely used instrument to measure shame and/or guilt,

and contains 10 questions on a five-point Likert scale (Rusch et al., 2007). An example of


the SSGS is referenced herein as Appendix B.

Levels of anxiety will be evaluated through the Beck Anxiety Inventory (BAI), a

reliable measurement of anxiety (separate from depression). The BAI is a 21 questions

survey that uses a four-point Likert scale. Self-report items describe physiological

symptoms (e.g. heart pounding) and cognitive aspects of anxiety (e.g. fear of dying).

Individuals are asked to rate items according to how bothered they are by each symptom

(Fydrich, Dowdell, & Chambless, 1992). An example of the BAI survey is referenced

herein as Appendix C.

Spirituality will be measured by the Spirituality Index of Well-Being (SWBS), a

commonly used assessment of spirituality and health outcomes in clinical research

pertinent to substance abuse treatment (Monod et al., 2011). The SWBS consists of 20

questions in four categories to assess overall general perceived well-being and life

satisfaction, on a five-point Likert scale: belief in God, search for meaning, feeling of

security, and mindfulness (Ellison & Paloutzian, 1982). For the purposes of this proposed

study, questions that contain the word “God” have been slightly modified to instead

reference “Higher Power,” to remove religious connotation. An example of this modified

SWBS is included as Appendix D.

Mindfulness will be evaluated using the Five Facet Mindfulness Questionnaire

(MMFQ), which consists of 39 questions on a five-point Likert scale, specifically

intended to measure levels of mindfulness. The five facets measured within the FFMQ

design are categorized as follows: observing (the ability to observe experience),

describing (the ability to describe emotions), acting with awareness (the tendency to pay

attention to thoughts and actions), non-judging (the capacity to accept emotions without


judgment), and non-reactivity (the capacity to accept emotions without reacting)

(Fernandez et al., 2010). An example of the FFMQ is referenced herein as Appendix E.

Cravings will be assessed through the Penn Alcohol Craving Scale (PACS),

which has been found in clinical trials to be the strongest predictor of drinking (Flannery

et al., 2003). The PACS only contains five questions, and is measured on a six-point

Likert scale. For the purposes of this proposed study, the PACS questionnaire wording

will be slightly modified to include “and/or using [drugs]” in addition to alcohol, to make

the verbiage more inclusive to measure cravings for any addictive substances—not just

alcohol. An example of the modified PACS survey is included herein as Appendix F.

Questions to evaluate whether or not there is a relationship between the efficacy

of art therapy and having an interest in the arts will be administered through an additional

questionnaire. Referred to herein as the Art Interest Questionnaire (AIQ), this

questionnaire contains 10 items on a five-point Likert scale, and was developed for the

purposes of this proposed study. An example of the AIQ is provided in Appendix G.

These six surveys (SSGS, BAI, SWBS, FFMQ, PACS, and AIQ) will be

administered as a packet for all individuals to complete at each of the time intervals

previously stated: admittance, end of week two, and discharge. Post-treatment surveys

will be administered (at 3 months and 6 months post-treatment), consisting of the six

questionnaires plus the TLFB assessment to also capture data on alcohol consumption

and/or drug use. An example of the TLFB is incorporated herein as Appendix H.

A comparative analysis will be conducted to evaluate responses between groups

at the various times surveys were administered throughout the duration of the study.

Expected results would reflect a greater decrease in shame as well as anxiety for


participants who received the art therapy interventions, compared to TAU, within the

treatment timeframe. Survey results are also expected to indicate a greater increase of

mindfulness and spiritually in the art therapy (experimental) group compared to the TAU

(control) group. Additionally, it is expected that the frequency and intensity of cravings

will decrease within both groups throughout treatment, but slightly more for the

experimental group.

Post-treatment comparisons should indicate whether or not adding an art therapy

component to an existing substance abuse treatment program improves treatment

outcomes. Days of alcohol consumption and/or drug use reported on the TLFB surveys

can be examined between comparative groups, and determine if there are any interesting

relationships. For example, if both cravings and days of use are lower in the experimental

group, than the treatment outcomes for art therapy are more effective than TAU. In

addition to quantifying the efficacy of art therapy for substance abuse treatment and/or

relapse prevention, the results that may come from this proposed study would help inform

addiction treatment programming.

Conclusion

Art therapy alone is not capable of treating the initial physiological effects of

chemical dependency; therefore, an individual should seek necessary medical treatment

in order to safely withdraw from substances. However, once the substance(s) are

completely removed from the body and withdrawal symptoms are lifted, psychological

cravings may likely remain (Ruden & Byalick, 2000). Additionally, the physical and

emotional struggle of anxiety that likely accompanies the addiction (DuPont, 1995) may

make it all the more difficult for the individual to move toward sobriety. Art therapy


interventions can guide the addicted individual through the process of recovery, helping

him/her discover new ways to handle life, cope with cravings (Malchiodi, 2012), and

ultimately learn how to express any raw, harsh emotions freely, without the numbness of

a drug. Furthermore, art making is a healthy, creative outlet that can be utilized even after

treatment ends, to promote anxiety and stress reduction (Curry & Kasser, 2011; van der

Vennet & Serice, 2012).

Through mindful engagement and emotional release, the act of creating art in and

of itself is therapeutic (Malchiodi, 2012) and can support sustainable sobriety. Art

therapy is a unique treatment method that allows for creative, expressive means of

reconnecting to the true ‘self,’ while fostering new, healthy means of navigating life

without drugs and/or alcohol. Art making can replace the desire and false need to depend

on a substance to be the sole provider of comfort and joy by fostering spiritual

transformation (Farley-Hansen, 2001), and by stimulating natural (drug-free),

neurochemical ‘reward’ boosts through meaningful engagement (Lambert, 2008). Art

therapy can help individuals find acceptance around struggles and challenges, so they can

be viewed through a different perspective. Creative self-expression allows the

unconscious to become conscious, so emotional turmoil can be brought to the surface and

no longer be buried in fear. Through expressive art therapy, addictive thoughts and

behaviors no longer need to take control of the body and mind leaving one feeling

hopeless—life’s challenges can be a canvas for colorful growth through recovery.


References

Alcoholics Anonymous. (2001). Alcoholics anonymous (4th ed.). New York, NY:

Alcoholics Anonymous World Services, Inc.

Allen, P. B. (1995). Art is a way of knowing: A guide to self-knowledge and spiritual

fulfillment through creativity. Boston, MA: Shambhala.

American Art Therapy Association. (2014). History and background. Retrieved from

http://www.americanarttherapyassociation.org/aata-history-background.html.

American Art Therapy Association Research Committee. (2015). Art Therapy Outcome

Bibliography. Retrieved from

http://arttherapy.org/upload/outcomebibliographyresearchcmte.pdf.

Aron, E. & Aron, A. (1983). The patterns of reduction of drug and alcohol use among

transcendental meditation participants. Bulletin of the Society of Psychologists in

Addictive Behaviors 2(1), 28-33.

Baer, R. A., Smith, G. T., Hopkins, J., & Toney, L. (2006). Using self-report assessment

methods to explore facets of mindfulness. Assessment, 13, 27-45.

Ball, B. (2002). Moments of change in the art therapy process. The Arts in

Psychotherapy, 29(2), 79-92.

Bar-Sela, G., Atid, L., Danos, S., Gabay, N., & Epelbaum, R. (2007). Art therapy

improved depression and influenced fatigue levels in cancer patients on

chemotherapy. Psycho-oncology, 16, 980-984.

Beck, A. T., & Steer, R. A. (1990). Manual for the Beck Anxiety Inventory. San Antonio,

TX: Psychological Corporation.


Bogenschutz, M. P. (2008). Individual and contextual factors that influence AA

affiliation and outcomes. In M. Galanter, & L. A. Kaskutas (Eds.), Recent

Developments in Alcoholism Volume 18: Research on Alcoholics Anonymous and

Spirituality in Addiction Recovery (413-433). Totowa, NJ: Springer.

Borkman, T. (2008). The twelve-step recovery model of AA: A voluntary mutual help

association. In M. Galanter, & L. A. Kaskutas (Eds.), Recent Developments in

Alcoholism Volume 18: Research on Alcoholics Anonymous and Spirituality in

Addiction Recovery (9-35). Totowa, NJ: Springer.

Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., et al. (2009). Mindfulness-

based relapse prevention for substance use disorders: A pilot efficacy trial.

Substance Abuse, 30(4), 295-305.

Chapman, L., Morabito, D., Ladakakos, C., Schreier, H., & Knudson, M. M. (2011). The

effectiveness of art therapy interventions in reducing post traumatic stress

disorder (PTSD) symptoms in pediatric patients. Art Therapy: Journal of the

American Art Therapy Association, 18(2): 100-104.

Chickerneo, N. B. (1993). Portraits of spirituality in recovery: The use of art in recovery

from co-dependency and/or chemical dependency. Springfield, IL: Charles C.

Thomas.

Cloninger, C. R. (1987). Neurogenetic and adaptive mechanism in alcoholism. Science,

236: 410-16.

Cox, K., & Price, K. (1990). Breaking through: Incident drawings with adolescent

substance abusers. The Arts in Psychotherapy 17, 333-337.


Curry, N. A. & Kasser, T. (2011). Can coloring mandalas reduce anxiety? Art Therapy:

Journal of the American Art Therapy Association, 22(2), 81-85.

Davis, B. J. (2015). Mindful art therapy: A foundation for practice. Philadelphia, PA:

Jessica Kingsley Publishers.

de Botton, A., & Armstrong, J. (2013). Art as therapy. New York, NY: Phaidon Press.

DiClemente, C. C., & Velasquez, M. M. (2002). Motivational interviewing and the stages

of change. In W. R. Miller, & S. Rollnick (Eds.), Motivational interviewing:

Preparing people to change (pp. 201-216). New York, NY: Guilford Press.

DuPont, R. L. (1995). Anxiety and addiction: A clinical perspective on comorbidity.

Bulletin of the Menninger Clinic, 52(2), A53-A72.

Ellison, C. W. & Paloutzian, R. F. (1983). Spiritual well-being: Conceptualization and

measurement. Journal of Psychology and Theology 11(4): 330-340.

Farley-Hansen, M. (Ed.). (2001). Spirituality and art therapy: Living the connection.

Philadelphia, PA: Jessica Kingsley Publishers.

Favara-Scacco, D., Smirne, G., Schiliro, G., & Di Cataldo, A. (2001). Art therapy as

support for children with leukemia during painful procedures. Medical Pediatric

Oncology, 26(4), 478-480.

Feen-Calligan, H. (1995). The use of art therapy treatment programs to promote spiritual

recovery from addiction. Art Therapy: Journal of the American Art Therapy

Association, 12(1), 46-50.

Feen-Calligan, H. (2007). The use of art therapy in detoxification from chemical

addiction. Canadian Art Therapy Association Journal, 20(1), 16-28.


Fernandez, A. C., Wood, Mark D., Stein, L. A. R., & Ross, J. R. (2010). Measuring

mindfulness and examining its relationship with alcohol use and negative

consequences. Psychology of Addictive Behavior, 24(4): 608-616.

Ferszt, G. G., Hayes, P. M., DeFedele, S., & Horn, L. (2004). Art therapy with

incarcerated women who have experienced the death of a loved one. Art Therapy:

Journal of the American Art Therapy Association, 9(4), 191-199.

Flannery, B. A., Poole, S. A., Gallop, R. J., & Volpicelli, J. R. (2003). Alcohol craving

predicts drinking during treatment: An analysis of three assessment instruments.

Journal of Studies on Alcohol, 64(1), 120-126.

Flannery, B. A., Volpicelli, J. R., & Pettinati, H. M. (1999). Psychometric properties of

the penn alcohol craving scale. Alcoholism: Clinical Research and Experimental

Research, 23(8): 1289-1295.

Fox, N., Hunn, A., & Mathers, N. (2009). Sampling and sample size calculation. The

National Institute for Health Research. Retrieved from

http://www.researchgate.net/file.PostFileLoader.html?id=54d7ce52cf57d78c6f8b

4585&key=9473a565-6f3a-4867-8b94-

2476bb1a9844&assetKey=AS%3A273695229054978%401442265435766.

Fydrich,T.,Dowdall,D.,&Chambless,D.(1992).ReliabilityandvalidityoftheBeck

AnxietyInventory.JournalofAnxietyDisorders,6,55-61.

Gersch, I., & Sao Joao Goncalves, S. (2006). Creative arts therapies and educational

psychology: Let’s get together. International Journal of Art Therapyy, 11(1), 22-

32.


Grosch, W. M. (1994). Narcissism: Shame, rage and addiction. Psychiatric Quarterly,

65(1), 49-63.

Hartz, L., & Thick, L. (2005). Art therapy strategies to raise self-esteem in female

juvenile offenders: A comparison of art psychotherapy and art as therapy

approaches. Art Therapy: Journal of the American Art Therapy Association,

22(2), 70-80.

Hass-Cohen, N. & Carr, R. (Eds.). (2008). Art therapy and clinical neuroscience.


Hinz, L. D. (2009). Order out of chaos: The expressive therapies continuum as a

framework for art therapy interventions in substance abuse treatment. In Brooke,

S. L. (Ed.), The use of creative therapies with chemical dependency issues (51-

68). Springfield, IL: Charles C. Thomas Publisher.

Holt, E., & Kaiser, D. H. (2009). The first step series: Art therapy for early substance

abuse treatment. The Arts in Psychotherapy, 36, 245-250.

Horay, B. J. (2006). Moving towards gray: art therapy and ambivalence in substance

abuse treatment. Art Therapy: Journal of the American Art Therapy Association,

23(1), 14-22.

Hosea, H. (2006). The brush’s footmarks: Parents and infants paint together in a small

community art therapy group. International Journal of Art Therapy, 11(2), 69-78.

Italia, S., Favara-Scacco, C., Di Cataldo, A., & Russo, G. (2008). Evaluation and art

therapy treatment of the burnout syndrome in oncology units. Psycho-oncology,

17(7), 676-680.


Johnson, D. R. (1990). Introduction to the special issue on creative arts therapies in the

treatment of substance abuse. The Arts in Psychotherapy, 17, 295-298.

Johnson, L. (1990). Creative therapies in the treatment of addictions: The art of

transforming shame. The Arts in Psychotherapy, 17, 299-308.

Kass, J. D., & Trantham, S. M. (2015). Perspectives from clinical neuroscience:

Mindfulness and the therapeutic use of the arts. In Rappaport, L. (Ed.),

Mindfulness and the arts therapies: Theory and practice (288-315). Philadelphia,

PA: Jessica Kingsley Publishers.

Kushner, M. G., Sher, K. J., & Beitman, B. D. (1990). The relation between alcohol

problems and the anxiety disorders. American Journal of Psychiatry, 147(6), 685-

695.

Lambert, K. (2008). Lifting depression: A neuroscientist’s hands-on approach to

activating your brain’s healing power. New York, NY: Basic Books.

Laudet, A. B. (2003). Attitudes and beliefs about 12-step groups among addiction

treatment clients and clinicians: Toward identifying obstacles to participation.

Substance Use & Misuse, 38(14): 2017-2047.

Loveland, D., & Driscoll, H. (2014). Examining attrition rates at one specialty addiction

treatment provider in the United States: A case study using a retrospective chart

review. Substance Abuse Treatment, Prevention, and Policy, 9(41): 1-13.

Mahony, J. (1999). Art therapy and art activities in alcohol services: A research project.

In Waller, D., & Mahony, J. (Eds.) Treatment of addiction: Current issues for art

therapies (pp. 117-140). New York, NY: Routledge.


Malchiodi, C. (2010). Mandala drawing: It’s the circle game that soothes and illuminates

the self. Retrieved from https://www.psychologytoday.com/blog/arts-and-

health/201003/cool-art-therapy-intervention-6-mandala-drawing.

Malchiodi, C. A. (2012). Art therapy with combat veterans and military personnel. In

Cathy A. Malchiodi (Ed.), Handbook of art therapy (pp. 320-334). New York,

NY: The Guilford Press.

Matto, H. C. (2002). Integrating art therapy methodology in brief inpatient substance

abuse treatment for adults. Journal of Social Work Practice in the Addictions,

2(2), 69-83.

Marcus, J. B. (1974). Transcendental meditation: A new method of reducing drug abuse.

Drug Forum, 3, 113-136.

Marschall, D. E., Sanftner, J. L., & Tangney, J. P. (1994). The State Shame and Guilt

Scale (SSGS). Fairfax, VA: George Mason University.

Miller, M. A. (1995). Spirituality, art therapy, and the chemically dependent person. In

Kus, R. J. (Ed.), Spirituality and chemical dependency (135-144). New York, NY:

Harrington Park Press.

Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people to

change (2nd ed.). New York, NY: Guilford Press.

Monod, S., Rochat, E., Martin, E., Rochat, S., & Bula, C. J. (2011). Instruments

measuring spirituality in clinical research: A systematic review. Society of

General Internal Medicine, 26(11), 1345-57.


Monti, D. A., Peterson, C., Kunkel, E. J. S., Hauck, W. W., & Pequignot, E. (2006). A

randomized, controlled trial of mindfulness-based art therapy (MBAT) for women

with cancer. Psycho-Oncology, 15(5), 363-373.

Murphy, T. J., Pagano, R. R., & Marlatt, G. A. (1986). Lifestyle modification with heavy

alcohol drinkers: Effects of aerobic exercise and meditation. Addictive Behaviors,

11(2), 175-186.

National Council on Alcoholism and Drug Dependence, Inc. (2015). Alcohol and drug

information. Retrieved from https://ncadd.org/about-addiction/faq/facts-about-

drugs and https://ncadd.org/about-addiction/alcohol/facts-about-alcohol.

Nowicka-Sauer, K. (2007). Patients’ perspective: Lupus in patients’ drawings: Assessing

drawing as a diagnostic and therapeutic method. Clinical Rheumatology, 26(9),

1523-1525.

Oriah Mountain Dreamer. (2005). What we ache for: Creativity and the unfolding of your

soul. New York, NY: HarperCollins Publishers, Inc.

Pagano, M. E., Friend, K. B., Tonigan, J. S., & Stout, R. L. (2004). Helping other

alcoholics in Alcoholics Anonymous and drinking outcomes: Findings from

project MATCH. Alcohol, 65, 766-773.

Petrillo, L. D., & Winner, E. (2011). Does art improve mood? A test of a key assumption

underlying art therapy. Art Therapy: Journal of the American Art Therapy

Association, 22(4), 205-212.

Pickens, R. W., & Svilkis, D. S. (1991). Genetic influences in human substance abuse.

Journal of Addictive Disorders, 10, 205-213.


Polcin, D. L. (2002). What if they aren’t ready? Increasing motivation for treatment.

Counselor: The Magazine for Addiction Professionals, 3(4), 34-38.

Rappaport, L. (Ed.). (2014). Mindfulness and the arts therapies: Theory and practice.


Robinson, S. M., Sobell, L. C., Sobell, M. B., & Leo, G I. (2014). Reliability of the

timeline followback for cocaine, cannabis, and cigarette use. Psychology of

Addictive Behaviors, 28(1), 154-162.

Rosenthal, N. E. (2011). Transcendence: Healing and transformation through

transcendental meditation. New York, NY: Tarcher/Penguin Group.

Ruden, R. A., & Byalick, M. (2000). The craving brain (2nd ed.). New York, NY:

HarperCollins Publishers, Inc.

Rusch, N., Corrigan, P. W., Bohus, M., Jacob, G. A., Brueck, R., & Lieb, K. (2007).

Measuring shame and guilt by self-report questionnaires: A validation study.

Psychiatry Research, 150(3), 313-325.

Seifert, L. S., & Baker, M. K. (2002). Art and Alzheimer-type dementia: A longitudinal

study. Clinical Gerontologist, 26(1/2), 3-15.

Substance Abuse and Mental Health Services Administration (2015). Behavioral health

trends in the United States: Results from the 2014 national survey on drug use and

health. Retrieved from http://www.samhsa.gov/data/sites/default/files/NSDUH-

FRR1-2014/NSDUH-FRR1-2014.pdf.

Slayton, S. C, D’Archer, J., & Kaplan, F. (2011). Outcome studies on the efficacy of art

therapy: A review of findings. Art Therapy: Journal of the American Art Therapy

Association, 27(3), 108-118.


Smeijsters, H., & Cleven, G. (2006). The treatment of aggression using arts therapies in

forensic psychiatry: Results of a qualitative inquiry. The Arts in Psychotherapy,

33(1), 37-58.

Sobell, L. C., Maisto, S. A., Sobell, M. B., & Cooper, A. M. (1979). Reliability of alcohol

abusers’ self-reports of drinking behavior. Behavior Research Therapy, 17, 157-

160.

Sobell, L. C., & Sobell, M. B. (2000). Alcohol timeline followback (TFLB). In American

Psychiatric Association (Ed.), Handbook of psychiatric measures (pp. 477-479).

Washington, DC: American Psychiatric Association.

Tanner-Smith, E. E., Wilson, S. J., & Lipsey, M. W. (2013). The comparative

effectiveness of outpatient treatment for adolescent substance abuse: A meta-

analysis. Journal of Substance Abuse Treatment, 44(2), 145-158.

Transcendental Meditation. (2015). What’s the evidence?: Reduced Substance Abuse.

Retrieved from https://www.tm.org/research-on-meditation.

Vallejo, Z., & Amaro, H. (2009). Adaptation of mindfulness-based stress reduction

program for addiction relapse prevention. The Humanistic Psychologist, 37(2),

192-206.

van der Vennet, R., & Serice, S. (2012). Can coloring mandalas reduce anxiety? A

replication study. Art Therapy: Journal of the American Art Therapy Association,

29(2), 87-92.

Van Dort, C., & Grocke, D. (2014). Music, imagery, and mindfulness in substance

dependency. In Rappaport, L. (Ed.) Mindfulness and the arts therapies: Theory

and practice (pp. 117-128). Philadelphia, PA: Jessica Kingsley Publishers.


Volkow, N. D. (2010). Comorbidity: Addiction and other mental illness. National

Institute on Drug Abuse: Research Report Series. Retrieved from

https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf.

Waller, D., & Mahony, J. (Eds.). (1999). Treatment of addiction: Current issues for arts

therapies. New York, NY: Routledge.

Wilcox, R. E., & Erickson, C. K. (2000). Neurobiological aspects of addictions. Journal

of Addictions Nursing, 12(3/4), 117-132.

Wilson, M. (2012). Art therapy in addictions treatment: Creativity and shame reduction.

In Cathy A. Malchiodi (Ed.), Handbook of art therapy (pp. 302-319). New York,

NY: The Guilford Press.

Witkiewitz, K., Marlatt, G. A., & Walker, D. (2005). Mindfulness-based relapse

prevention for alcohol and substance use disorders. Journal of Cognitive

Psychotherapy: An International Quarterly, 19(3), 211-228.

Witkiewitz, K., Warner, K., Sully, B., Barricks, A., Stauffer, C., Thompson, B. L., et al.

(2014). Randomized trial comparing mindfulness-based relapse prevention with

relapse prevention for women offenders at a residential treatment center.

Substance Use & Misuse, 49(5), 536-546.


Appendix A

Mindfulness-Based Art Therapy (MBAT) eight-week program curriculum developed by Monti et al., 2006.


Appendix B

State Shame and Guilt Scale (SSGS) developed by Marschall, Sanftner, & Tangney, 1994.

The following are some statements that may or may not describe how you are feeling. Please circle the rating for each statement based on how you are feeling right now.

I do not feel this way at

all

I feel this way

somewhat

I feel this way very strongly

I want to sink into the floor and disappear. 1 2 3 4 5

I feel like I am a bad person. 1 2 3 4 5

I feel worthless, powerless. 1 2 3 4 5

I feel humiliated, disgraced. 1 2 3 4 5

I feel small. 1 2 3 4 5

I feel bad about something I have done. 1 2 3 4 5

I feel like apologizing, confessing. 1 2 3 4 5

I cannot stop thinking about something I have done. 1 2 3 4 5

I feel tension about something I have done. 1 2 3 4 5

I feel remorse, regret. 1 2 3 4 5


Appendix C

Beck Anxiety Inventory (BAI) developed by Beck and Steer, 1990.

Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much you have been bothered by that symptom during the past month, including today, by circling the number in the corresponding space in the column next to each symptom.

Not At All Mildly but it didn’t bother me much.

Moderately - it wasn’t pleasant at times

Severely – it bothered me a lot

Numbness or tingling 0 1 2 3 Feeling hot 0 1 2 3 Wobbliness in legs 0 1 2 3 Unable to relax 0 1 2 3 Fear of worst happening 0 1 2 3 Dizzy or lightheaded 0 1 2 3 Heart pounding / racing 0 1 2 3 Unsteady 0 1 2 3 Terrified or afraid 0 1 2 3 Nervous 0 1 2 3 Feeling of choking 0 1 2 3 Hands trembling 0 1 2 3 Shaky / unsteady 0 1 2 3 Fear of losing control 0 1 2 3 Difficulty in breathing 0 1 2 3 Fear of dying 0 1 2 3 Scared 0 1 2 3 Indigestion 0 1 2 3 Faint / lightheaded 0 1 2 3 Face flushed 0 1 2 3 Hot and/or cold sweats 0 1 2 3 Column Sum Scoring - Sum each column. Then sum the column totals to achieve a grand score. Write that score here ____________ . Interpretation A grand sum between 0 – 21 indicates very low anxiety. A grand sum between 22 – 35 indicates moderate anxiety. A grand sum that exceeds 36 is a potential cause for concern.


Appendix D

Spiritual Well-Being Scale (SWBS) developed by Ellison and Paloutzian, 1983.

Please rate each of the following statements by circling the number that best describes your own opinion of what is generally true for you.

Never or very

rarely

Rarely true

Sometimes true

Often true

Always or very often true

I trust in a Higher Power. 1 2 3 4 5

My faith helps me to cope with problems. 1 2 3 4 5

I trust in my faith for decisions. 1 2 3 4 5

I feel the love of a Higher Power. 1 2 3 4 5

I feel that a Higher Power is my friend. 1 2 3 4 5

My life means searching and asking. 1 2 3 4 5

I look for insight and coherence. 1 2 3 4 5

I try to open my mind. 1 2 3 4 5

I try to expand my soul. 1 2 3 4 5

I search for the spirit. 1 2 3 4 5

I try to deal consciously with others. 1 2 3 4 5

I deal consciously with environment. 1 2 3 4 5

I try to help others. 1 2 3 4 5

I try to be patient and tolerent. 1 2 3 4 5

I try to be empathetic with others. 1 2 3 4 5

I feel peace deep inside me. 1 2 3 4 5

My life is peace and joy. 1 2 3 4 5

I feel at one with the world. 1 2 3 4 5

I see a friendly world around me. 1 2 3 4 5

I feel there is a lot of love in the world. 1 2 3 4 5


Appendix E

Five Facet Mindfulness Questionnaire (FFMQ) developed by Baer, Smith, Hopkins, and Toney, 2006.

Five Facet Mindfulness Questionnaire (FFMQ)

Please rate each of the following statements with the number that best describes your own opinion of what is generally true for you.

Never or very rarely

true Rarely

true Sometimes

true Often true

Very often or always

true

FFQM1

When I’m walking, I deliberately notice the sensations of my body moving. (OBS)

1

2

3

4

5

FFQM2

I’m good at finding words to describe my feelings. (D)

1

2

3

4

5

FFQM3

I criticize myself for having irrational or inappropriate emotions. (NJ-R)

5

4

3

2

1

FFQM4

I perceive my feelings and emotions without having to react to them. (NR)

1

2

3

4

5

FFQM5

When I do things, my mind wanders off and I’m easily distracted. (AA-R)

5

4

3

2

1

FFQM6

When I take a shower or bath, I stay alert to the sensations of water on my body. (OBS)

1

2

3

4

5

FFQM7

I can easily put my beliefs, opinions, and expectations into words. (D)

1

2

3

4

5

FFQM8

I don’t pay attention to what I’m doing because I’m daydreaming, worrying, or otherwise distracted. (AA-R)

5

4

3

2

1

FFQM9

I watch my feelings without getting lost in them. (NR)

1

2

3

4

5

FFQM10

I tell myself I shouldn’t be feeling the way I’m feeling. (NJ-R)

5

4

3

2

1

FFQM11

I notice how foods and drinks affect my thoughts, bodily sensations, and emotions. (OBS)

1

2

3

4

5

FFQM12

It’s hard for me to find the words to describe what I’m thinking. (D-R)

5

4

3

2

1

FFQM13 I am easily distracted. (AA-R)

5

4

3

2

1

FFQM14

I believe some of my thoughts are abnormal or bad and I shouldn’t think that way. (NJ-R)

5

4

3

2

1

FFQM15

I pay attention to sensations, such as the wind in my hair or sun on my face. (OBS)

1

2

3

4

5

FFQM16

I have trouble thinking of the right words to express how I feel about things. (D-R)

5

4

3

2

1

FFQM17

I make judgments about whether my thoughts are good or bad. (NJ-R)

5

4

3

2

1

FFQM18

I find it difficult to stay focused on what’s happening in the present. (AA-R)

5

4

3

2

1


Never or

very rarely true

Rarely true

Sometimes true

Often true


true

FFQM19

When I have distressing thoughts or images, I “step back” and am aware of the thought or image without getting taken over by it. (NR)

1

2

3

4

5

FFQM20

I pay attention to sounds, such as clocks ticking, birds chirping, or cars passing. (OBS)

1

2

3

4

5

FFQM21

In difficult situations, I can pause without immediately reacting. (NR)

1

2

3

4

5

FFQM22

When I have a sensation in my body, it’s difficult for me to describe it because I can’t find the right words. (D-R)

5

4

3

2

1

FFQM23

It seems I am “running on automatic” without much awareness of what I’m doing. (AA-R)

5

4

3

2

1

FFQM24

When I have distressing thoughts or images, I feel calm soon after. (NR)

1

2

3

4

5

FFQM25

I tell myself that I shouldn’t be thinking the way I’m thinking. (NJ-R)

5

4

3

2

1

FFQM26

I notice the smells and aromas of things. (OBS)

1

2

3

4

5

FFQM27

Even when I’m feeling terribly upset, I can find a way to put it into words. (D)

1

2

3

4

5

FFQM28

I rush through activities without being really attentive to them. (AA-R)

5

4

3

2

1

FFQM29

When I have distressing thoughts or images, I am able just to notice them without reacting. (NR)

1

2

3

4

5

FFQM30

I think some of my emotions are bad or inappropriate and I shouldn’t feel them. (NJ-R)

5

4

3

2

1

FFQM31

I notice visual elements in art or nature, such as colors, shapes, textures, or patterns of light and shadow. (OBS)

1

2

3

4

5

FFQM32

My natural tendency is to put my experiences into words. (D)

1

2

3

4

5

FFQM33

When I have distressing thoughts or images, I just notice them and let them go. (NR)

1

2

3

4

5

FFQM34

I do jobs or tasks automatically without being aware of what I’m doing. (AA-R)

5

4

3

2

1

FFQM35

When I have distressing thoughts or images, I judge myself as good or bad depending what the thought or image is about. (NJ-R)

5

4

3

2

1

FFQM36

I pay attention to how my emotions affect my thoughts and behavior. OBS)

1

2

3

4

5


Never or

very rarely true

Rarely true

Sometimes true

Often true


true FFQM

37 I can usually describe how I feel at the moment in considerable detail. (D)

1

2

3

4

5

FFQM38

I find myself doing things without paying attention. (AA-R)

5

4

3

2

1

FFQM39

I disapprove of myself when I have irrational ideas. (NJ-R)

5

4

3

2

1

Scoring: (Note: R = reverse-scored item) Subscale Directions Your Score TOTAL Your score item Avg. Observing: Sum items 1 + 6 + 11 + 15 + 20 + 26 + 31 + 36

Describing: Sum items 2 + 7 + 12R + 16R + 22R + 27 + 32 + 37.

Acting with Awareness: Sum items 5R + 8R + 13R + 18R + 23R + 28R + 34R + 38R.

Nonjudging of inner experience: Sum items 3R + 10R + 14R + 17R + 25R + 30R + 35R + 39R.

Nonreactivity to inner experience: Sum items 4 + 9 + 19 + 21 + 24 + 29 + 33.

TOTAL FFMQ (add subscale scores)

NOTE: Some researchers divide the total in each category by the number of items in that category to get an average category score. The Total FFMQ can be divided by 39 to get an average item score. Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13(1), 27-45.


Appendix F

Penn Alcohol Craving Scale (PACS) developed by Flannery, Volpicelli, and Pettinati, 1999.

Please read each item carefully and circle the number that best describes your craving during the past week.

1.) During the past week how often have you thought about drinking and/or using drugs, or about how good drinking/drugging would make you feel?

0 Never (1 times during the past week)

1 Rarely (1 to 2 times during the past week)

2 Occasionally (3 to 44 times during the past week)

3 Sometimes (5 to 10 times during the past week, or 1 to 2 times per day)

4 Often (11 to 20 times during the past week, or 2 to 3 times per day)

5 Most of the time (20 to 40 times during the past week, or 3 to 6 times per day)

6 Nearly all of the time (more than 40 times during the past week, or more than 6 times per day)

2.) At its most sever point, how strong was your craving during the past week?

0 None at all

1 Slight, that is a very mild urge

2 Mild urge

3 Moderate urge

4 Strong urge, but easily controlled

5 Strong urge and difficult to control

6 Strong urge and would have drunk alcohol or used drugs if it were available

3.) During the past week how difficult would it have been to resist taking a drink or drug if you had known it was in your house? 0 Not difficult at all

1 Very mildly difficult

2 Mildly difficult

3 Moderately difficult

4 Very difficult

5 Extremely difficult

6 Would not be able to resist

4.) Keeping in mind your responses to the previous questions, please rate your overall average alcohol craving for the past week.

0 Never thought about drinking or using drugs and never had the urge to drink or use

1 Rarely thought about drinking or using drugs and rarely had the urge to drink or use

2 Occasionally thought about drinking or using drugs and occasionally had the urge to drink or use

3 Sometimes thought about drinking or using drugs and sometimes had the urge to drink or use

4 Often thought about drinking or using drugs and often had the urge to drink or use

5 Thought about drinking or using drugs most of the time and had the urge to drink or use most of the time

6 Thought about drinking or using drugs nearly all of the time and had the urge to drink or use nearly all of the time


Appendix G

Art Interest Questionnaire (AIQ).

Please rate each of the following statements by circling the number that best describes your own opinion of what is generally true for you.

Never or very

rarely

Rarely true

Sometimes true

Often true

Always or very often true

I consider myself creative, and often think outside the box. 1 2 3 4 5

I do not particularly care about the arts. 1 2 3 4 5

I enjoy drawing. 1 2 3 4 5

I engage in art activities in my free time. 1 2 3 4 5

I consider myself artistic. 1 2 3 4 5

I find that doodling helps me concentrate. 1 2 3 4 5

I can express myself through art. 1 2 3 4 5

I have trouble expressing my emotions with words. 1 2 3 4 5

I do not believe I have any artistic talent. 1 2 3 4 5

I feel that the arts play an important role in my life. 1 2 3 4 5


Appendix H

Timeline Followback (TLFB) developed by Sobell et al., 1979.

colorful recovery: art therapy for substance abuse and...

Documents