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Expressive Arts & Cognitive Behavioral Expressive Arts & Cognitive Behavioral Therapy (CBT)Therapy (CBT)

Treating Adolescent AnxietyTreating Adolescent AnxietyDidactics & Case StudiesDidactics & Case Studies

Roger Luscombe, MS, DKATI, RCC.

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ResourcesResources

Approaches to Art Therapy, Theory & Technique Approaches to Art Therapy, Theory & Technique 22ndnd ed. Judith Aron Rubin, ed. ed. Judith Aron Rubin, ed.

Play Therapy, Theory & Practice, A Comparative Play Therapy, Theory & Practice, A Comparative Presentation, O’Connor & Braaverman, ed’s.Presentation, O’Connor & Braaverman, ed’s.

CBT Connections, Anxiety Disorders in Children & CBT Connections, Anxiety Disorders in Children & Adolescents: University of British Columbia Adolescents: University of British Columbia

Anxiety Disorder Association of British Columbia Anxiety Disorder Association of British Columbia (Anxiety B.C.)(Anxiety B.C.)

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Anxiety B.C.Anxiety B.C.five important elementsfive important elements

Anxiety is normal, everyone experiences it at timesAnxiety is normal, everyone experiences it at times

Anxiety is not dangerous, although anxiety feels Anxiety is not dangerous, although anxiety feels uncomfortable, it is temporary, and will eventually decreaseuncomfortable, it is temporary, and will eventually decrease

Most people cannot tell when you are anxiousMost people cannot tell when you are anxious

Anxiety is adaptive and helps us prepare for real danger or Anxiety is adaptive and helps us prepare for real danger or for performing at our best, it triggers our “fight-flight-for performing at our best, it triggers our “fight-flight-freeze” response preparing our body to reactfreeze” response preparing our body to react

Anxiety becomes a problem when our body reacts in Anxiety becomes a problem when our body reacts in absence of real dangerabsence of real danger

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Key Issues in AnxietyKey Issues in Anxiety

Anxiety is about fearAnxiety is about fear

Clinical Anxiety is IrrationalClinical Anxiety is Irrational

Clinical Anxiety is LearnedClinical Anxiety is Learned

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Anxiety Disorders: OverviewAnxiety Disorders: Overview

Most common mental health problemMost common mental health problem 12 – 20% of children affected12 – 20% of children affected Over 65,000 kids in B.C. with disorderOver 65,000 kids in B.C. with disorder Impact and morbidity not widely Impact and morbidity not widely

recognizedrecognized Girls often have more fears than boysGirls often have more fears than boys Number and types of fears across cultures Number and types of fears across cultures

are fairly consistentare fairly consistent

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Anxiety: Overview Anxiety: Overview ContinuedContinued

Presence of one anxiety disorder increases risk Presence of one anxiety disorder increases risk of developing additional anxiety disorderof developing additional anxiety disorder

Mom’s with any mental illness are 7 times more Mom’s with any mental illness are 7 times more likely to have a child with an anxiety disorderlikely to have a child with an anxiety disorder

Children and youth with anxiety disorders rarely Children and youth with anxiety disorders rarely receive appropriate or effective interventionsreceive appropriate or effective interventions

If left untreated there is a significant increase in If left untreated there is a significant increase in risk of depression & substance abuserisk of depression & substance abuse

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The Experience of AnxietyThe Experience of Anxiety

Body FearBody Fear

Mental FearMental Fear

Behavioral Indicators of FearBehavioral Indicators of Fear

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Components of the Anxiety Components of the Anxiety ResponseResponse

Behavioral AvoidanceBehavioral Avoidance

Distorted BeliefsDistorted Beliefs

Over Predictions of FearOver Predictions of Fear

Attentional BiasAttentional Bias

Physiological RespondingPhysiological Responding

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Causes and Maintenance of Causes and Maintenance of Anxiety DisordersAnxiety Disorders

GeneticsGenetics

TemperamentTemperament

ParentingParenting

Cognitive FactorsCognitive Factors

Avoidance BehaviorsAvoidance Behaviors

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Types of Anxiety DisordersTypes of Anxiety Disorders

Social anxiety disorder (separation Social anxiety disorder (separation anxiety disorder)anxiety disorder)

Obsessive compulsive disorderObsessive compulsive disorder Specific phobiasSpecific phobias Generalized anxiety disorderGeneralized anxiety disorder Panic disorder w/o AgoraphobiaPanic disorder w/o Agoraphobia Post traumatic Stress disorderPost traumatic Stress disorder

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anxietyanxiety

Regina Lafay

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Anxiety, Regina LafayAnxiety, Regina Lafaywww.survivorart.comwww.survivorart.com

"One of the first pieces I did to express an "One of the first pieces I did to express an emotion I had not yet had diagnosed – a feeling emotion I had not yet had diagnosed – a feeling that I had known since I was a teen, yet nobody that I had known since I was a teen, yet nobody was available to explain it to me or help me was available to explain it to me or help me through it. I have only recently been diagnosed through it. I have only recently been diagnosed with Generalized Anxiety Disorder, among others. with Generalized Anxiety Disorder, among others. Words fail me, as they often do, so I choose art to Words fail me, as they often do, so I choose art to tell my stories. This image helped a group of tell my stories. This image helped a group of troubled teenage girls recognize that they are not troubled teenage girls recognize that they are not alone. I continue to be moved by their counselor’s alone. I continue to be moved by their counselor’s letters, as she and I still keep in touch."letters, as she and I still keep in touch."

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Cognitive Behavioral Cognitive Behavioral TherapyTherapy

Psycho educationPsycho education Managing body symptomsManaging body symptoms Healthy thinkingHealthy thinking Building toleranceBuilding tolerance Relapse preventionRelapse prevention Evidence basedEvidence based

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Evolution of CBTEvolution of CBT

Behavioral TherapyBehavioral Therapy

Social Learning TheorySocial Learning Theory

Cognitive TherapyCognitive Therapy

Cognitive Behavioral TherapyCognitive Behavioral Therapy

Dialectical Behavioral TherapyDialectical Behavioral Therapy

Family Cognitive Behavioral TherapyFamily Cognitive Behavioral Therapy

Cognitive-Behavioral Art TherapyCognitive-Behavioral Art Therapy

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CBT & Art TherapyCBT & Art Therapy

CBT not widely been accepted in the art therapy fieldCBT not widely been accepted in the art therapy field There has been the misconception that CBT focuses There has been the misconception that CBT focuses

only on the thinking processonly on the thinking process In reality imagery, visual thinking and creativity are In reality imagery, visual thinking and creativity are

aspects of cognitionaspects of cognition Personal constructs are non verbal as well as verbal Personal constructs are non verbal as well as verbal

and creating art can enrich personal constructs'and creating art can enrich personal constructs' Emotional components, as illuminated in art therapy, Emotional components, as illuminated in art therapy,

are an integral part of understanding a person’s are an integral part of understanding a person’s cognitive processcognitive process

Approaches to Art Therapy, RubinApproaches to Art Therapy, Rubin

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Core CBT ComponentsCore CBT Components

Cognitive restructuringCognitive restructuring

Physical relaxationPhysical relaxation

Exposure, coping skillsExposure, coping skills

Social skills trainingSocial skills training

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Principals of CBTPrincipals of CBTTHOUGHTS

EMOTIONSBEHAVIOURS

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Myers – Briggs Type Myers – Briggs Type IndicatorIndicator

Carl Jung’s Carl Jung’s Psychological Psychological TypesTypes

Eg.Eg. ESTJ - Extraversion, - Extraversion,

Sensing, Thinking, Sensing, Thinking, JudgingJudging

INFP - Introversion, - Introversion, Intuition, Feeling, Intuition, Feeling, Perceiving Perceiving

Dichotomies

Extraversion Introversion

Sensing iNtuition

Thinking Feeling

Judging Perceiving

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Distorted ThinkingDistorted Thinking

All or nothing thinkingAll or nothing thinking Over generalizingOver generalizing Mental filteringMental filtering Disqualification of the positiveDisqualification of the positive Jumping to conclusionsJumping to conclusions Magnification (catastrophizing or minimizing)Magnification (catastrophizing or minimizing) Emotional reasoningEmotional reasoning ““Should” statementsShould” statements LabelingLabeling PersonalizationPersonalization

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Cognitive ApproachesCognitive Approaches

Identification of inner, private thoughtsIdentification of inner, private thoughts Use of positive self-talkUse of positive self-talk Techniques for challenging negative Techniques for challenging negative

self-talkself-talk Self-rewardSelf-reward Expectations of good things to happenExpectations of good things to happen Evaluation of own performance – Evaluation of own performance –

partial successespartial successes

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Physiological ApproachesPhysiological Approaches

Awareness of body cluesAwareness of body clues

Deep breathing exercisesDeep breathing exercises

Relaxation activitiesRelaxation activities

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Behavioral ApproachesBehavioral Approaches

Problem solving skillsProblem solving skills

Coping skillsCoping skills

Peer supportPeer support

Identification of pleasant eventsIdentification of pleasant events

ExposureExposure

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ExposureExposure

Interoceptive ExposureInteroceptive Exposure Deliberately bring on bodily symptoms Deliberately bring on bodily symptoms

of anxiety, e.g. spinning, breathingof anxiety, e.g. spinning, breathing In vivo ExposureIn vivo Exposure

Deliberately entering feared situations Deliberately entering feared situations e.g. movies, mallse.g. movies, malls

Naturalistic ExposureNaturalistic Exposure Deliberately engage in activities e.g. Deliberately engage in activities e.g.

exerciseexercise

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Role of Family & TeachersRole of Family & Teachers

Psycho education about anxiety and Psycho education about anxiety and treatments that worktreatments that work

Emphasize that well-intended intuitive Emphasize that well-intended intuitive responses may actually enable anxiety responses may actually enable anxiety problemsproblems

Consistency and firmness in follow through Consistency and firmness in follow through on planson plans

If family concurrent difficulties with If family concurrent difficulties with anxiety all members receive treatmentanxiety all members receive treatment

Assist with homeworkAssist with homework

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CBT ToolsCBT Tools

Thought and Mood ChartsThought and Mood Charts SUD’s Chart (subjective units of discomfort)SUD’s Chart (subjective units of discomfort) Fear Hierarchy ChartFear Hierarchy Chart Fear Monitoring FormFear Monitoring Form Grounding TipsGrounding Tips PTSD Impacts of Events ScalePTSD Impacts of Events Scale Brief Screening Instrument for Panic AttacksBrief Screening Instrument for Panic Attacks Relaxation Scripts Relaxation Scripts

Breathing, progressive muscle relaxationBreathing, progressive muscle relaxation

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Children’s CBT ResourcesChildren’s CBT Resources

Taming the Worry Dragons, Garland & Clark, B.C. Children's Hospital

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CBT Resources cont.CBT Resources cont.

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CBT Resources contCBT Resources cont

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CBT Case FormulationCBT Case Formulation

Brief demographicBrief demographic Problem identificationProblem identification Problem historyProblem history Family and social adjustmentFamily and social adjustment Main cognitive, physiological and Main cognitive, physiological and

behavioral components of major problemsbehavioral components of major problems Client’s perspectiveClient’s perspective Case formulationCase formulation

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CBT Treatment PlanCBT Treatment Plan

Prioritization of treatment targetsPrioritization of treatment targets Tracking of clients progressTracking of clients progress Methods of treatmentMethods of treatment Graduation from treatmentGraduation from treatment

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Case Study David Case Study David

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Case Formulation for DavidCase Formulation for David

Demographics:Demographics: Adolescent, rural isolation, single parented, Adolescent, rural isolation, single parented,

marijuana friendly community marijuana friendly community

Problem Identification:Problem Identification: Psychiatric Dx: Disthymic disorder with more severe Psychiatric Dx: Disthymic disorder with more severe

depression (double depression)depression (double depression) Academic, social and family stressorsAcademic, social and family stressors Substance misuseSubstance misuse General anxiety and social phobiaGeneral anxiety and social phobia

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Case Formulation cont.- 1Case Formulation cont.- 1

Problem History, Family & Social Problem History, Family & Social Adjustment:Adjustment: Unhappy as a babyUnhappy as a baby Ongoing depression last couple yearsOngoing depression last couple years History of family depression w/ History of family depression w/

hospitalizationhospitalization Poor relationship with bio dadPoor relationship with bio dad Daily use of marijuana for 5 yearsDaily use of marijuana for 5 years

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Case Formulation cont.- 2Case Formulation cont.- 2

Problem IdentificationProblem Identification CognitiveCognitive

Negative self image, self punishing, fears of Negative self image, self punishing, fears of future failure, downward spiraling thinkingfuture failure, downward spiraling thinking

PhysiologicalPhysiological Poor diet, lack of regular meals, lack of exercise, Poor diet, lack of regular meals, lack of exercise,

over sleeping, over sleeping, BehavioralBehavioral

School avoidance, social withdrawal, no School avoidance, social withdrawal, no employment, heavy marijuana use (self employment, heavy marijuana use (self identified)identified)

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Case Formulation cont.- 3Case Formulation cont.- 3

Client’s perspectiveClient’s perspective Depression, low self esteem, addiction Depression, low self esteem, addiction

acknowledgedacknowledged Sense that his personal history affects Sense that his personal history affects

his current statehis current state Goals include reducing fears, increase Goals include reducing fears, increase

self esteem, improve friendships, school self esteem, improve friendships, school graduation, and be drug free graduation, and be drug free

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Case Formulation cont.- 4Case Formulation cont.- 4

Case FormulationCase Formulation Psychiatrist had diagnosed depression and Psychiatrist had diagnosed depression and

recommended CBT treatmentrecommended CBT treatment CBT idea had hooked David, though CBT idea had hooked David, though

reluctantreluctant

some readiness present (Prochaska some readiness present (Prochaska stages)stages)

Positive male therapist transferencePositive male therapist transference Anxiety seen as possible core disturbanceAnxiety seen as possible core disturbance

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Stages of ChangeStages of Change

James Prochaska & Carlo DiclementeJames Prochaska & Carlo Diclemente Precontemplation StagePrecontemplation Stage Contemplation StageContemplation Stage Determination StageDetermination Stage Action StageAction Stage Maintenance StageMaintenance Stage RelapseRelapse

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CBT Treatment Plan for CBT Treatment Plan for DavidDavid

Psycho educationPsycho education Exploration of ABC triangleExploration of ABC triangle ReframingReframing Social exposureSocial exposure Expressive arts explorationExpressive arts exploration Stress reductionStress reduction Involve family in treatment Involve family in treatment Relapse preventionRelapse prevention Ten to Twelve independent sessionsTen to Twelve independent sessions

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Treatment Plan cont. - 1Treatment Plan cont. - 1

Tracking of client’s progressTracking of client’s progress Home work check-ins, reading assignmentsHome work check-ins, reading assignments Thought & mood recordsThought & mood records Sleeping pattern changesSleeping pattern changes Socialization changesSocialization changes School attendance recordSchool attendance record Drug and alcohol consumption Drug and alcohol consumption Changes in family timeChanges in family time Diet & exercise changesDiet & exercise changes

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CBT Tools UsedCBT Tools Used

ABC triangle presentedABC triangle presented Distorted thinking examinedDistorted thinking examined Reading homework on depression & Reading homework on depression &

CBTCBT Thought records, challenging Thought records, challenging

depressive thoughtsdepressive thoughts

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Expressive Arts ExplorationExpressive Arts Exploration

Icebreaking, rapport makingIcebreaking, rapport making Invites cognitive conversationInvites cognitive conversation Provide creative outletProvide creative outlet Self esteem through art making / Self esteem through art making /

productproduct Insight acquisitionInsight acquisition Co-art making positive transferenceCo-art making positive transference Provides visible record of changeProvides visible record of change

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David’s Art Making & David’s Art Making & GamingGaming

Clay piecesClay pieces Biofeedback GameBiofeedback Game Sandtray WorldSandtray World Roofing Paper Medicine WheelRoofing Paper Medicine Wheel

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Clay - David

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Sandtray - David

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Biofeedback Stress Biofeedback Stress ManagementManagement

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Clay - David

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Clay - David

4848Roofing Paper - David

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Summary: David Case StudySummary: David Case Study

CBT model intrigued youthCBT model intrigued youth Psycho education around thoughts, Psycho education around thoughts,

emotions, behaviors very beneficialemotions, behaviors very beneficial Art therapy engaged and gave youth Art therapy engaged and gave youth

insight & increased self esteeminsight & increased self esteem Positive transference enabled Positive transference enabled

personal transformation processpersonal transformation process

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TF-CBT for Aboriginal Child TF-CBT for Aboriginal Child Trauma VictimTrauma Victim

Honoring Children – Mending the CircleHonoring Children – Mending the Circle SpiritualSpiritual MentalMental PhysicalPhysical EmotionalEmotional RelationalRelational Mending the CircleMending the Circle University of Oklahoma

Health Sciences Center

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Case Study Sara Case Study Sara

Presenting Problem – General Presenting Problem – General Anxiety & Specific PhobiaAnxiety & Specific Phobia

Treatment ComponentsTreatment Components Play Therapy GenogramPlay Therapy Genogram Fears Assessment ToolFears Assessment Tool SUD’s Hierarchy ChartSUD’s Hierarchy Chart Fish Hook Diagram for anxiety attackFish Hook Diagram for anxiety attack

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Sara cont.Sara cont.

Play therapy family Play therapy family genogramgenogram

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Fears Assessment ToolFears Assessment Tool

Self Rating Questionnaire, 8 biggest Self Rating Questionnaire, 8 biggest fearsfears

FlyingFlying Punishment by motherPunishment by mother Criticized by parentsCriticized by parents Giving a recitalGiving a recital SnakesSnakes Mean dogsMean dogs Dead peopleDead people SpidersSpiders

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SUD’s Chart for Flying SUD’s Chart for Flying PhobiaPhobia

11 Looking at airplanesLooking at airplanes 22 Airplane play, sandtray, puzzlesAirplane play, sandtray, puzzles 33 Make airplane, clay, paper macheMake airplane, clay, paper mache 44 Going to local airportGoing to local airport 55 Going to Castelgar airportGoing to Castelgar airport 66 Getting near a planeGetting near a plane 77 Sitting in a planeSitting in a plane 88 Short flight on planeShort flight on plane 99 Long flight to HawaiiLong flight to Hawaii

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Panic Attack Fish Hook Model

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Summary of Cognitive Summary of Cognitive Behavioral - Art TherapyBehavioral - Art Therapy

CBT illustrates how thoughts & CBT illustrates how thoughts & emotions & behaviors co -influence emotions & behaviors co -influence each othereach other

CBT has particular treatment strategies CBT has particular treatment strategies to create healthy thinking, emotional to create healthy thinking, emotional awareness and positive actionsawareness and positive actions

Art Therapy accomplishes these same Art Therapy accomplishes these same goals and fits well with CBT treatment goals and fits well with CBT treatment strategies strategies

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In Memory OfIn Memory Of

Dr Peter Donald McLean,Dr Peter Donald McLean, CBT ConnectionsCBT Connections

Passed awayPassed away Nov 04, 2008Nov 04, 2008