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behavioral art therapy,” a brief overview of cognitive-behavioral theory and princi-ples is provided to describe and illustrate how these techniques can be used within the context of art therapy.
COGNITIVE-BEHAVIORAL THERAPY
Cognitive-behavioral therapy encompasses several different approaches, including rational-emotive behavior therapy (REBT; Ellis, 1993), cognitive-behavioral modifi-cation (Meichenbaum, 1977, 1985), and cognitive therapy (Beck, 1987; Ellis &
Grieger, 1996). The central notion in all these approaches is that it is not events per se but rather the person’s assumptions, expectations, and interpretations of events which are responsible for the production of negative emotions (Beck & Emery, 1985;
Clark, 1989). It is these negative emotions that cause people to feel depressed and anxious and can lead to full-blown emotional disorders. According to cognitively based theories psychological distress is largely a function of disturbances of cognitive processes and changing cognitions can produce desired changes in affect and behavior.
The basic goal of cognitive-behavioral therapy is to help the client identify the false and negative rules and assumptions governing actions and then find ways to re-place or restructure assumptions with more realistic and positive rules and expecta-tions. Beck’s techniques, Meichenbaum’s stress inoculation, and Ellis’s REBT deal primarily with the elimination of symptoms. A collaborative relationship between the client and therapist is at the foundation of this approach and treatment is gener-ally time-limited and psychoeducational in nature.
Cognitive frameworks for treatment recognize two levels of disturbed think-ing. First, dysfunctional assumptions and rules are those ideas and beliefs we hold about ourselves, how we live, and how we influence individuals and situations around us. For example, when a situation triggers these rules and expectations, a depressed or anxious person responds with repetitive negative thoughts. These are referred to as “automatic negative thoughts” or “negative self-talk,” because they are produced without effort or intention in response to a specific situations (Hawton, Salkovskis, Kirk, & Clark, 1989). Personal beliefs and expectations about situations are organized into “constellations” which are triggered when we are placed in a specific situation (for instance, public speaking, driving a car, or making a decision). Beck (1976) describes this constellation of rules and assump-tions as “schema.” A cognitive schema is a code by which people decipher and evaluate their experiences and behaviors and those of others. When a schema is or-ganized around a negative or unrealistic rule, all experiences are filtered through this punitive filter and individuals begin to see the world as unsafe and themselves as unworthy, untalented, and unlovable.
Meichenbaum (1977, 1985) defines cognitive-behavioral therapy through the lens of stress inoculation which not only includes the principles of self-talk and schema but also emphasizes the skills in developing “coping self-statements.” Such statements help the individual prepare to meet stress and include: “Don’t worry. You
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can meet this stress successfully”; “One step at a time; you can handle the situation”;
and “Relax. You are in control. Take a slow, deep breath.” The overall goal is to de-velop positive self-statements and internal images that reduce negativity and enhance successful performance.
Cognitive-behavioral therapy is a highly directive and structured approach that requires the clinician to play an active and educational role in the therapy. In most cases, the goal of treatment is to eliminate or drastically reduce symptoms in 6 to 20 sessions as well as give the client the tools to remain symptom-free. As mentioned earlier, the key components in cognitive-behavioral therapy are the identification, re-structuring, and/or elimination of negative thoughts, teaching the client to control the autonomic responses that usually attend feelings of anxiety and panic, and to use these skills to remain symptom free.
IMAGE MAKING AND COGNITIVE-BEHAVIORAL THERAPY
While art therapy is based on the use of imagery in treatment, cognitive-behavioral therapy is about language. Clients are taught to track, verbalize, and record negative thoughts in writing. Lists are made, charts are completed, and emotions ranked on scales to determine severity and monitor progress. It is a highly intellectual method, dealing with logic and cognition and questions and answers. So how does one use a nonverbal technique such as image making within such a structured therapeutic agenda?
The first barrier to using art in cognitive-behavioral therapy is the client’s as-sumptions and expectations about being “artistic”; therapists reading this chapter also may have to confront similar personal assumptions and expectations. “Art” is a loaded word and when asked to make a picture most people will experience the trig-gering of a universal responses: “I can’t draw.” “I have no talent.” “I will embarrass myself.” “I will fail.” The best way to avoid these responses is to jettison the use of the term “art” altogether. The term “image” is far less controversial and is actually a more accurate word for what will be produced in a cognitive-behavioral session. The client will be making concrete representations or images of negative schema, anxiety-producing cognitions, and negative self-talk. These images can be powerful represen-tations of the workings of the mind and the interior life of the person. Asking an in-dividual to make an image about his or her depression or anxiety makes the individ-ual feel less inadequate and paralyzed than asking him or her to make “art.” This is the one of the first acts of cognitive restructuring in treatment and it is used to illustrate how the client will be restructuring other negative schema and assumptions.
While much of cognitive-behavioral therapy has traditionally involved verbal and written exercises, there is a tradition of using mental imagery as a method of practicing new emotional patterns. Clients are asked to visually imagine themselves thinking, feeling, and behaving the way they would like to think, feel, and behave (Maultsby, 1984). Ellis (1993) observes that if we keep practicing such imagery sev-eral times a week for a few weeks, we reach a point where we are no longer upset by events that trigger negative feelings or self-talk. Meichenbaum’s (1985)
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behavioral modification techniques have also incorporated mental imagery to reduce stress and as a means of self-help.
Because cognitive-behavioral therapy is an approach that involves collaboration between client and therapist, it is well suited to the context of image making for sev-eral reasons. First, developing successful strategies for change in cognitive-behavioral therapy involves the input of the client in determining the course of the treatment. In an approach that includes image making, the client is offered the opportunity to col-laborate with the therapist in designing creative activities to support and enhance behavioral change. Also, cognitive-behavioral therapy is action oriented; that is, the client must be willing to put time and energy into treatment, both within the thera-peutic hour as well as through work outside the session. Image making as part of therapy requires the client to be an active participant in the process of change and re-covery and to commit oneself to “hands-on” strategies through drawing, collage, or other media.
INITIAL SESSIONS
When using a cognitive-behavioral approach to art therapy it is best to introduce the image making to the client as soon as possible, usually by the second session (assum-ing the first session is spent explain(assum-ing cognitive-behavioral treatment, establish(assum-ing goals, and gathering information). One way to do this is to replace a verbal directive with an imaginal one. For instance, rather than asking a client to list things that con-tribute to depression, the therapist might ask the client to make an image presenting a problem that contributes to depression. To be able to guide the client through an analysis of the image and the problem, it is helpful for the therapist to prepare a list of questions used in cognitive-behavioral work such as:
• What is the problem?
• What does the image tell the viewer about the problem?
• What thoughts came up during the making of the image?
• What thoughts are you having now?
Introducing image making within the early sessions allows clients to practice this form of expression before they attempt it outside the session. Visual strategies are involved in some forms of cognitive-behavioral therapy; for example, the use of a chalkboard to chart negative thoughts and track dysfunctional schema is a common practice (Emery 1989; McMullin, 2000). Seeing one’s negative thought in “black and white” can be a powerful experience and can bring home the personal tyranny of such cognition. How-ever, although it can be helpful to see negative aspects of oneself, viewing one’s negative self-thoughts as imagery can be overwhelming and some clients will hesitate to produce such imagery or not want to share it. By sensitive education about the process and help-ing the client to practichelp-ing the exercise in session at his or her own pace, the therapist can assist the person in demystifying negative self-thoughts, feelings, and behaviors and help the client to begin to identify and process reactions.
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A key to using image making in initial sessions of cognitive-behavioral therapy is to remain directive and structured with the use of images similarly to the way one would with cognitive aids such as charts and worksheets. It is also important to keep directives and materials as simple as possible to increase the likelihood that the client will succeed at the exercise. The worksheets and charts of cognitive work often seem daunting and must be sensitively introduced in order not to overwhelm the client; the same is true with the use of image making in cognitive work. It takes a substantial in-vestment of time and energy to do cognitive-behavioral exercises, and the client must comprehend the reason behind the directive and understand how it works and why it might be helpful.
Image making can also serve as a reinforcement of what is being learned, to help the person reframe or restructure experiences and behaviors (see section below) and to visually develop strategies for positive change. Integrating imagery making into to treatment might take the form of any or all of the following exercises:
• Make an image of a “stressor.” Identifying stressors which trigger negative feelings are key to understanding and developing strategies of how to cope. The ther-apist may direct the client to keep an imagery journal of events, situations, or people that initiate negative behaviors or self-talk.
• Making an image of “how I can prepare for a stressor.” For example, if being in a social setting is stressful, a client may be asked to create an image of “what I can do” or “how would I look if I were successfully meeting this challenge.”
• Make an image of “step-by-step management” of a problem. For some indi-viduals it is helpful to break down the problem or stressor into steps to a solution.
Making an image or series of images that illustrate how the problem can be divided into more manageable parts or components can visually assist some clients in learn-ing how to master difficult situations and any problem behaviors that result from these experiences.
• Making imagery for stress reduction. The very act of making images—whether drawing or constructing a collage—can be used as “time out” from negative experi-ences and may be useful in inducing a relaxation response (DeLue, 1998; Malchiodi, 1999). Meichenbaum’s (1985) stress inoculation theory emphasizes techniques such as relaxation training and similar skills that can be used to improve the quality of life. A therapist may also suggest to clients that they collect photo images that they find self-soothing from magazines or other sources and put these into a visual journal or keep them in a prominent place such as the office where they can regularly be seen.
HOMEWORK
In cognitive-behavioral therapy, the client and therapist work together to develop homework assignments that carry treatment beyond the sessions. These assignments may include creating lists of problems, listing beliefs, tracking negative self-talk, and recording internalized self-messages. For example, in REBT, a person may fill out
“self-help forms” to encourage them to challenge themselves outside therapy to
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gage in a risk-taking behavior, such as public speaking, and practice positive self-talk and beliefs.
In a cognitive-behavioral approach to art therapy, a client is also asked to com-plete homework assignments between sessions. Generally, these assignments involve using images to restructure beliefs and assumptions and to further record, through images, internalized self-messages. For example, the therapist may ask the client to purchase a three-ring binder which will serve an as image journal and workbook for homework purposes. As part of the assigned homework, the client may be asked to visually chart dysfunctional thoughts and feelings (a standard assignment) and also produce at least one image a day that represents the most pervasive thought the client experienced. To make it as easy as possible for the client to accomplish the assign-ment, the therapist may provide the client with some markers or oil pastels and some collage pictures and encourage the client to supplement these with additional materi-als. While markers are simple to use, for some clients collage is often the easiest method to record thoughts with imagery. It produces compelling results and helps some people to circumvent the anxiety of having to produce recognizable forms or pictures.
RESTRUCTURING NEGATIVE IMAGERY
Once clients have spent some time identifying and recording negative thoughts, ei-ther in session or through homework assignments, they can then start to distance from these cognitions and begin to recognize specific schema that control their per-ceptions and assumptions. Once these are recognized, the process of cognitive re-structuring can begin. This process usually involves analysis of faulty logic, hypothe-sis testing, generating alternative interpretations, enlarging perspective, and decatastrophizing (Ellis, 1993; Emery, 1989). Once the therapist has led a client through the process of analyzing thoughts and schema, the client may develop more positive assumptions by experimenting with physically altering a negative image through art expression.
CASE ILLUSTRATION
The following case illustrates the use of imagery within a framework of cognitive-behavioral therapy. The client, a women in her early 40s, presented with persistent feelings of low self-worth and depression which were affecting her daily life. The woman felt that “she really had no excuse or reason to feel this way” because she had a supportive husband, had planned her two pregnancies, and had ample finan-cial resources to obtain extra help at home. However, having two young children had made a serious impact on the time she spent making music, but she explained, “I knew this would be the case. I was prepared.” The client also described herself as
“ruthlessly positive” and “unflappable,” so finding herself in her current state repre-sented a failure to her. She was feeling depressed and also upset that she had encountered a situation she “couldn’t tackle.”
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The client was asked to make an initial record of her negative thoughts (List A) followed by an image of what she felt was a problem contributing to her depression.
See Figure 6.1.
List A: Initial Record of Negative Thoughts
“I’m overwhelmed.”
“I want someone else to take care of me for a change.”
“I want to get sick so I can stay in bed and let others handle things.”
“I am a hack.”
“I have no talent and am wasting my time.”
“I’m pretending to have a career to feel worthwhile.”
“My songs are rubbish and I might as well be putting recipes and dress patterns in with my CDs because I’m like the Betty Crocker of musicians!”
“I should be using my time to do something valuable, like being a full-time mom.”
Figure 6.1 is the image made in response to the thought record and one that the client felt represented a problem contributing to her depression. The primary figure of the desexualized yet perfect homemaker has dwarfed the image of the piano which
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FIGURE 6.1.Drawing of a problem contributing to depression.
represents the client’s identity as an artist. Not only is the piano in the background, but its surface is cluttered with the paraphernalia of homemaking which poses a threat to the condition of the instrument. The imagery depicted a less-than-flattering view of motherhood and one that threatened her core identity as an artist. The client returned to this image several times over the course of therapy because it so accu-rately reflected her issues. In subsequent sessions, she worked steadily to bring the pi-ano to the foreground as well as coming to terms with her new role as a mother. The therapist worked with the client to define core issues and identify the negative as-sumptions that were causing her to feel depressed. She was eventually able to chal-lenge the notion that mothering made her less of an artist and she was able to take a more realistic approach to time management. The use of the imagery kept the client focused on the work and kept the definition of her conflicts clear.
The client also wanted to work on her poor self-image which was contributing to her depression and affecting her happiness in her sexual relationship with her spouse. To address this issue, the therapist requested that she again make a record of her negative self-talk concerning her body (List B).
List B: Second Record of Negative Thoughts
“Whatever I try, it never works.”
“I just can’t make it work.”
“I will always feel this way.”
“I hate my breasts.”
“I am overweight and will never again be fit.”
“I have no control over my body.”
“My body is trashed and I am no longer attractive.”
She was again asked to make an image reflecting her negative self-talk. The drawing (Figure 6.2) was created in two stages: a female figure alone and then add-ing a male figure. The initial image made by the woman was the female figure alone, representing her overwhelming feelings of self-loathing concerning her physical ap-pearance. She felt the issue was not the weight itself but that she was not losing the weight due to having recently given birth; this feeling triggered a schema about accomplishing goals. Questioning about this image by the therapist along with the negative thought record indicated that it was her lack of progress that made her feel undesirable and unattractive. It also illuminated a schema which insisted that she be energetic, athletic, strong, and unconcerned with her weight.
Working on her own, the client picked one of the negative thoughts—“my body is trashed and I am no longer attractive”—and restructured the image. She chose to add the figure of her spouse, holding her in a protective and desirable way. Her spouse, in fact, did not share her feelings about her appearance and continued to ap-proach her sexually and his behavior actually disproved her belief that she was sexu-ally unattractive. Adding his image to the picture forced her to confront her dysfunc-tional cognitive schema, as well as providing her with some self-confidence.
The client frequently returned to this image as a way to counter her powerful
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convictions that she was unattractive. Despite clear evidence to the contrary (her hus-band’s supportive statements and physical attentions), her dysfunctional rules about her attractiveness continued to fuel persistent negative self-talk and depressed mood.
She was able to use her positive statements along with the images she created and she was able to use this final image (Figure 6.2) to reduce negative thoughts, reporting that the image became her “corrective mantra.”
CONCLUSION
Combining cognitive-behavioral therapy with image making interweaves linguistic and imaging techniques to help clients reduce or eliminate negative cognitions and self-talk. While cognitive-behavioral therapy has traditionally used verbal modalities as agents for change, image making actually complements cognitive-behavioral ap-proaches, providing therapists with an opportunity to capitalize on visual communi-cation to enhance therapy. The infusion of image making within treatment offers the client an opportunity to collaborate with the therapist on developing creative visual strategies to achieve change. The benefits of therapy continue after the session in the form of imagery-related homework and encourage the client to be an active
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FIGURE 6.2.Drawing reflecting negative self-talk.