constructing a personal visual vocabulary
TRANSCRIPT
Florida State University Libraries
Electronic Theses, Treatises and Dissertations The Graduate School
2014
Constructing a Personal Visual Vocabulary:An Art Therapy Intervention Study forAdolescents from Families with AlcoholUse DisordersAlexandria Wyeth Zettler
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FLORIDA STATE UNIVERSITY
COLLEGE OF VISUAL ARTS, THEATRE, & DANCE
CONSTRUCTING A PERSONAL VISUAL VOCABULARY:
AN ART THERAPY INTERVENTION STUDY FOR ADOLESCENTS FROM FAMILIES
WITH ALCOHOL USE DISORDERS
By
ALEXANDRIA WYETH ZETTLER
A Dissertation submitted to the
Department of Art Education
in partial fulfillment of the
requirements for the degree of
Doctor of Philosophy
Degree Awarded:
Spring Semester, 2014
ii
Alexandria Wyeth Zettler defended this dissertation on March 19, 2014.
The members of the supervisory committee were:
Marcia L. Rosal
Professor Directing Dissertation
Lisa Waxman
University Representative
David Gussak
Committee Member
Tom Anderson
Committee Member
The Graduate School has verified and approved the above-named committee members, and
certifies that the dissertation has been approved in accordance with university requirements.
iii
This study is dedicated to my daughters, Tessa Marie and Anna Louise; and my husband,
Christian Leonhardt, whom I simply could not be without.
iv
ACKNOWLEDGMENTS
I want to express my appreciation to the people who have assisted me in the development and
completion of this study:
Marcia Rosal, chairperson of this doctoral committee, whose logic, scholarly
reviews of this study, and expertise of cognitive processes and personal symbols
have been invaluable in guiding me to its completion;
Dave Gussak, committee member, for his passion for philosophy;
Tom Anderson, committee member, for his wealth of knowledge and critical eye;
Lisa Waxman, university representative, for her professionalism and kindness;
Peter Zettler, my father, who taught me to communicate through the language of
art;
Elizabeth Zettler, my mother, who modeled tenacity and excellence in teaching;
Katie, Nicole, Anthony, Brook, and CJ, my former high-school art students,
whose talents are boundless; and all the children and school personnel who made
this study a reality, especially Paige Thomas, for her extraordinary diligence and
support.
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TABLE OF CONTENTS
LIST OF TABLES ........................................................................................................................ vii
LIST OF FIQURES ..................................................................................................................... viii
ABSTRACT ................................................................................................................................... xi
CHAPTER ONE: CONSTRUCTING A PERSONAL VISUAL VOCABULARY .......................1
Philosophical Underpinnings of Therapeutic Methods ...........................................................2
Hegelian Dialectics ..................................................................................................................3
Chaos and Adverse Childhood Experiences ............................................................................5
Research Problem ....................................................................................................................6
A Brief Overview of the Study ..............................................................................................11
Summary ................................................................................................................................12
CHAPTER TWO: REVIEW OF THE LITERATURE .................................................................14
Children of Alcoholics ..........................................................................................................14
Theories of Alcohol-Related Disorders .................................................................................16
Family Systems Theory: Roles and Rules .............................................................................17
Interrelated Issues of Alcohol, Aggression, Violence, and Abuse ........................................18
Primary Prevention Models: Significant Components ..........................................................20
The Motivation for Change ...................................................................................................22
Cognitive Behavioral Therapy and Adolescents ...................................................................24
Art Therapy and Visual Language ........................................................................................25
Context and Visual Language ...............................................................................................26
Visual Dynamics and Personal Constructs ............................................................................28
Summary ................................................................................................................................31
CHAPTER THREE: METHODS ..................................................................................................32
Research Design ....................................................................................................................32
Sample ...................................................................................................................................33
Setting ....................................................................................................................................34
Procedures .............................................................................................................................34
Assessment Tools and Instruments .......................................................................................38
Data Collection and Evaluation Procedures ..........................................................................42
Summary ................................................................................................................................44
CHAPTER FOUR: RESULTS ......................................................................................................46
Description of the Sample .....................................................................................................47
Quantitative Results ...............................................................................................................48
Summary of Quantitative Results ..........................................................................................53
Qualitative Results .................................................................................................................56
Summary of Qualitative Results ............................................................................................66
CHAPTER FIVE: DISCUSSION AND CONCLUSION .............................................................67
Discussion ..............................................................................................................................67
Limitations .............................................................................................................................73
Clinical Implications and Suggestions for Further Research ................................................75
Conclusion .............................................................................................................................76
APPENDICES...........................................................................................................................................80
A: List Of Acronyms .............................................................................................................80
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B: Intake Form .......................................................................................................................81
C: Correlating Data for Tennessee Self Concept Scale, Second Edition (TSCS:2) and the
Piers-Harris Children's Self-Concept Scales, Second Edition (PH:2) ...............................82
D: Collected Demographics and Scores for All Participants ................................................86
E: Depression Scales From the FEATS .................................................................................88
F: Scoring Sheets for Qualified Sample's and Matched Sample's Artwork Using the
Depression Scales from the FEATS ..................................................................................91
G: Model and Explanation of the Expressive Therapies Continuum ....................................94
H: Analytical Art Criticism Model ........................................................................................95
I: End Of Study Objective/Criteria Assessment Questionnaire ............................................98
J: SASS Output of Paired T-Tests Scores for Qualified Sample...........................................99
K: TSCS:2/PH:2 Output, Self Statements, and Artwork .....................................................114
L: Florida State University Internal Review Board Approval and Consent Forms.............135
M: Copyright Permission Letters ........................................................................................141
REFERENCES ............................................................................................................................145
BIOGRAPHICAL SKETCH .......................................................................................................154
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LIST OF TABLES
Table 1. Randomized Pretest-Midtest-Posttest Experimental Study Design with One Control
Group. ........................................................................................................................................... 33
Table 2. Assessment Schedule with Total Collected Data/Scores for Three Group Participants,
Over All Three Observation Periods ............................................................................................ 35
Table 3. Art Therapy Study Directives for the Two Experimental Interventions, X1 And X
2 ...... 37
Table 4. Self-reported Data on Qualifying Status and Demographics. ....................................... 47
Table 5. TOT Scores, Means Percentage of Change after Each Intervention for the Qualified
Participants and the Control Group ............................................................................................. 50
Table 6: TOT Scores, Means, Standard Deviation, and Rate of Increase for all Participants ... 55
Table 7. Qualified Sample and Matched Sample’s Supplementary Scores Mean Increase ......... 60
Table 8: Mean Scores for Qualified Sample and Matched Sample's End of Study
Objective/Criteria Assessment Questionnaire .............................................................................. 65
Table 9. List of Frequently Used Acronyms ................................................................................. 80
Table 10. Correlation of the TSCS:2 Scores with the PH:2 from the TSCS:2 Manual ............... 82
Table 11. Correlation Table between the PH:2 And TSCS:2 from the PH:2 Manual ................. 83
Table 12. Corresponding Subtests and Correlations Used for TSCS:2 and PH:2 at O1 ............. 84
Table 13. Concatenate Table from PH:2 and TSCS:2 for TOT Scores at O1 .............................. 85
Table 14. Collected data from all participants ............................................................................ 86
Table 15. Scoring Sheets for the Qualified and Matched Samples' Artwork Using the Depression
Scales from the FEATS ................................................................................................................. 91
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LIST OF FIGURES
Figure 1. T-test statistics output for TOT of qualified sample from O1 to post-X
1. .................... 49
Figure 2. T-test statistics output for TOT of qualified sample from O1 to post-X
2. .................... 49
Figure 3. Distribution of difference for qualified sample from O1 to post-X
1. ............................ 49
Figure 4. Distribution of difference of qualified sample from O1 to post-X
2 .............................. 49
Figure 5. Paired profiles for qualified sample from O1 to post-X
1. ............................................. 49
Figure 6. Paired profiles of qualified sample from O1 to post-X
2. ............................................... 49
Figure 7. T-test results for the control group. .............................................................................. 51
Figure 8. Distribution of difference for the control group. .......................................................... 51
Figure 9. Line of projection for the control group. ...................................................................... 51
Figure 10. T-test statistics output for tot of experimental groups from O1 to post-X
1. ................ 54
Figure 11. T-test statistics output for tot of experimental groups from O1 to post-X
2. ................ 54
Figure 12. Distribution of difference for experimental groups from O1 to post-X
1..................... 54
Figure 13. Distribution of difference for experimental groups from O1 to post-X
2..................... 54
Figure 14. Paired profiles of qualified sample from O1 to post-X
1.............................................. 54
Figure 15. Paired profiles of qualified sample from O1 to post-X
2.............................................. 54
Figure 16. Comparison of group TOT score means at observations O1, O
2, and O
3. .................. 55
Figure 17. FEATS depression scale ratings at O2 and O
3. ........................................................... 57
Figure 18. Cluster of simple means for FEATS major depression score scales. ......................... 57
Figure 19. Comparison of sample means for a specific outlier scale score on the directive
entitled, The Element of Line. ...................................................................................................... 58
Figure 20. Artwork from the qualified sample and the matched sample showing little color and
level of completion. ...................................................................................................................... 59
Figure 21. Qualified sample’s percentage of change in TSCS:2 supplementary mean scores related to Beck’s theory of internal communication system. ........................................................ 60
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Figure 22. Sample of artwork completed by nonqualified participants from the experimental
groups. ........................................................................................................................................... 63
Figure 23. Qualified samples' self-report on the intervention rating scale. ................................. 65
Figure 24. Initial intake form used to determine qualification for the study and for calculating
demographics. ............................................................................................................................... 81
Figure 25. Depression Scales, a portion of the Formal Expressive Arts Therapies Scales by
Linda Gantt (1998). ....................................................................................................................... 88
Figure 26. Symbolic content and schematic representation of the Expressive Therapies
Continuum (ETC) by Vija Lusebrink (1990)................................................................................ 94
Figure 27. Analytic Art Criticism Method (formally known as Anderson's CritCard Method)
from Anderson and Milbrandt (2005). .......................................................................................... 95
Figure 28: Example of the end of study objective/criteria assessment questionnaire. ................ 98
Figure 29. Statistical output of paired t-test on INC score means for qualified sample. ............. 99
Figure 30. Statistical output of paired t-test on SC score means for qualified sample. ............. 100
Figure 31. Statistical output of paired t-test on FG score means for qualified sample. ............. 101
Figure 32. Statistical output of paired t-test on RD score means for qualified sample. ............ 102
Figure 33. Statistical output of paired t-test on TOT score means for qualified sample. .......... 103
Figure 34. Statistical output of paired t-test on CON score means for qualified sample. .......... 104
Figure 35. Statistical output of paired t-test on PHY score means for qualified sample. .......... 105
Figure 36. Statistical output of paired t-test on MOR score means for qualified sample. ......... 106
Figure 37. Statistical output of paired t-test on PER score means for qualified sample. ........... 107
Figure 38. Statistical output of paired t-test on FAM score means for qualified sample. ......... 108
Figure 39. Statistical output of paired t-test on SOC score means for qualified sample. .......... 109
Figure 40. Statistical output of paired t-test on ACA score means for qualified sample. .......... 110
Figure 41. Statistical output of paired t-test on IDN score means for qualified sample. ........... 111
Figure 42. Statistical output of paired t-test on SAT score means for qualified sample. .......... 112
x
Figure 43. Statistical output of paired t-test on BHV score means for qualified sample. .......... 113
Figure 44. Case O1 - Blue's individual SASS output, artwork, and self-statements from aesthetic
criticism....................................................................................................................................... 114
Figure 45. Case 03 - Nicht Werden's individual SASS output, artwork, and self-statements from
aesthetic criticism........................................................................................................................ 116
Figure 46. Case 09 - Ghost's individual SASS output, artwork, and self-statements from
aesthetic criticism........................................................................................................................ 120
Figure 47. Case 12 - Brody's individual SASS output, artwork, and self-statements from
aesthetic criticism........................................................................................................................ 123
Figure 48. Case 16 - Destructo's individual SASS output, artwork, and self-statements from
aesthetic criticism........................................................................................................................ 126
Figure 49. Case 04 - Vortex's individual SASS output, artwork, and self-statements from
aesthetic criticism........................................................................................................................ 129
Figure 50. Case 02 - Shirayuki's individual SASS output, artwork, and self-statements from
aesthetic criticism........................................................................................................................ 132
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ABSTRACT
There is a lack of research on intervention protocols for adolescent children of alcoholics who
are high-achieving and demonstrate a low probability of substance use disorders. Historically,
these children have high academic success and their familial issues often remain secret; thus,
school counselors or mental health professionals may overlook any psychosocial or emotional
issues. The primary problem this study addresses is how to identify and serve this specific
population as a mental health clinician.
The purpose of this study is to increase this population‘s positive self-concept—a
measurable and observable trait related to resiliency—using one or both of the following
experimental art therapy interventions: a) an art education-based intervention entitled,
Constructing a Personal Visual Vocabulary and b) Cognitive Behavioral Art Therapy based
directives, which include working toward a personal visual narrative, or trauma narrative. The
philosophical approach for this study is based on Hegelian dialectics.
This study used a randomized pretest–midtest–posttest experimental research design with
a control group. The double blind method was used to prevent research outcomes from being
'influenced' by observer bias. The participants’ qualifying criteria were determined following the
closing of the study.
Levels of self-concept were measured by statistical analysis of the Tennessee Self
Concept Scale, Second Edition (TSCS:2) and correlated with the Piers-Harris Children's Self-
Concept Scale, Second Edition (PH:2) to determine the total self-concept over three observation
periods. To provide additional information on the participants' clinical state, their clinical notes,
self-statements, and artwork were reviewed using the depression scales, a portion of the Formal
Elements Art Therapy Scale (FEATS), Beck's theory of internal communication system, and the
Expressive Therapies Continuum (ETC).
A paired-samples t-test using total scores (TOT) from the TSCS:2 was performed for the
qualified sample, all of the experimental participants, and the control group. The participants’
TOT scores, measuring the levels of self-concept, before and after each of the two interventions
were compared. The results indicated a significant difference in the TOT mean scores for all of
the experimental participants after both interventions, at Observation Three, t(18) = -4.71, p =
0.0002. The computed total self-concept scores from the qualified sample were too small to infer
xii
a significant effect value at observation three; t(4) = -1.52, p = 0.2034; thus, the percentage
changes for the mean total self-concept scores were calculated for each sample.
The qualified sample demonstrated a TOT mean score increase of 26.9% in positive self-
concept at Observation Two and maintained a TOT mean score increase of 16.5% at Observation
Three. Based on these results, the null hypothesis was rejected; it was inferred that sixteen
weeks of art therapy sessions increased the positive self-concept for high-achieving adolescent
children of alcoholics who demonstrated a low probability of substance-use disorders. Further
implications suggest that constructing a personal visual vocabulary increased positive self-
concept at a higher rate for the qualified sample than cognitive-behavioral therapy with a focus
on creating a personal visual narrative.
Keywords: art therapy, Cognitive Behavioral Art Therapy, visual language, visual
vocabulary, adolescent, children of alcoholics, alcohol use disorder, self-concept, resiliency,
Formal Elements Arts Therapy Scale (FEATS), Expressive Arts Therapy Continuum (ETC),
cognitive theory of internal communication, Anderson’s CritCard method, Hegelian dialectics
1
CHAPTER ONE
CONSTRUCTING A PERSONAL VISUAL VOCABULARY
Creating art is inherently a cognitive process. It is an active way to analyze, synthesize,
and create solutions for complex problems. Thus, one of the philosophical precepts for the
mental health field of art therapy is based on the belief that creating art is a healing and life-
enhancing experience. Art therapy provides tangible and active opportunities to examine,
problem solve, and reflect on these intricate processes.
This art therapy experimental research study specifically utilized Cognitive Behavior Art
Therapy (CBATx)1 techniques to assist children of alcoholics (CoA) with increasing their
positive self-concept through improved understanding and use of visual language. The focus
population was a sample of adolescent CoA who were high-achieving and demonstrated a low
probability of substance-abuse disorders (SUDs). The mental health community has historically
underserved this specific population.
CBATx techniques often facilitate the construction of alternative cognitions and
different ways for the clients to view their life and build a more holistic sense of self, or to
combine the physical, emotional, mental, and spiritual aspects of their personalities. The theory
is that an increased positive self-concept for this specific population corresponds to the concept
of resiliency, or the ability to overcome adverse childhood experiences (ACE). The hope is that,
if this population enhances its understanding and use of visual language, this ability would
facilitate the externalization of thoughts and feelings that are usually difficult for adolescents to
verbalize in therapy.
This process included constructing a personal visual vocabulary. A personal visual
vocabulary (PVV) is related to visual literacy (or, as it is colloquially known, visuacy), which is
the ability to interpret, negotiate, and make meaning from information presented as images.
Visual literacy is based on the idea that pictures can be read and that meaning can be
communicated through reading these pictures. For this study, a PVV is defined as a system of
symbols or icons to which the participant attaches personal meaning and uses consistently over
1 A list of acronyms frequently used in tare listed in Appendix A.
2
time in a variety of media and artwork. In her discussion on visual literacy, art therapist Judith
Rubin (2010) wrote:
We have abundant evidence—from such normal phenomena as dreams and such
abnormal ones as hallucinations—that much of what is encoded in the mind is in
the form of images. In fact, there is no question that a great deal of human
thought, at all levels of consciousness, is what psychologist Rudolf Arnheim
(1969) called “Visual Thinking.” (p. 86)
American photographer Minor Martin White (1963) wrote, “If we had no words, perhaps
we could understand one another better” (p. 18). White used formal art elements and design
principles to trigger specific emotional responses. He borrowed American photographer Alfred
Stieglitz’s theory of “equivalents” to describe this particular phenomenon. White (1963) wrote:
“If the individual viewer realizes that for him what he sees in a picture corresponds to something
within himself—that is, the photograph mirrors something in himself—then his experience is
some degree of Equivalence” (p. 18).
Perhaps White was a visual symbolizer, or a person whose primary cognitive process was
visual language. He used the play of light on mundane objects, such as walls, windows, and
doors, as the physical forms of concepts or signifiers. In the case of visual language, the formal
elements of art—such as line, shape, color, and value —may be compared to the vowels and
consonants of written language. Perhaps the rules of composition or the principles of design
could be considered the grammatical rules. Meaning is constructed when these parts are put
together or an idea becomes tangible reality. White‘s intention in his photographs was to use
these formal elements of art to facilitate the viewers’ understanding; he purposely used the
special quality of light and image sequencing to create personal narratives. When we, as the
viewer, "read" his narrative, we are experiencing the phenomenon of equivalence; for a moment,
we understand White‘s language.
Philosophical Underpinnings of Therapeutic Methods
This study was based on a fundamental principle of art therapy: art serves as a primary
language for communication. One of the ways in which many cognitive behavioral therapists
help clients with post-traumatic stress disorder is by using a directive entitled the trauma
narrative (Jongsma, Peterson, & McInnis, 2006). People who are exposed to traumatic events
have a profound need to make sense of them. Talking about a traumatic experience helps people
3
to organize their memories and feelings into a more manageable and understandable
psychological “package.” The paramount part of this process involves setting the traumatic
events securely in the past and seeing oneself as a survivor (Gantt & Tinnin, 2007).
Creating a visual narrative—a Cognitive Behavioral Art Therapy (CBATx)–based
intervention—meets this goal. Furthermore, the intervention of constructing a personal visual
vocabulary (PVV) was designed to alleviate issues involving alexithymia and verbally exposing
secrets from a closed-family system. This study provides data that emphasizes the validity of
learning and adapting the formal art elements of lines, shape, and color to aid in the treatment of
adolescent children of alcoholics (CoA).
The idea of constructing a PVV is based on Rhyne‘s (1979) work with mind-state
drawings, Jungian archetypal and symbol theory (Jung, 1986), and visual literacy (Avgerinou,
2005; Dake, 2007; Dondis, 1994). The structure for constructing the PVV utilizes elements of
art, specifically line, shape, color, value, and form. The second intervention used in this study is
based on Hegelian dialectics (Gaiger, 2002), Bandura (1986), Vygotsky (1930/1980), and Beck
(1955/1997)’s cognitive learning theories, and Rosal’s (2001) CBATx work with children and
teens. The final project for this intervention is based on Kelley (1955/1963)’s ideas about
personal constructs and narrative art therapy.
Hegelian Dialectics
In describing a threefold process for achieving telos—or the state of perfection—German
idealist Hegel used the verb aufheben or the noun Aufhebung for concepts that are difficult to
translate. For example, a concept first needs to be defined. Second, the concept requires
mediation or examination regarding what it is not, so that, third, one can determine what it truly
is and move beyond the original concept’s limitations (Papineau, 2004). However, the term
sublation is often used to describe how a concept may be both preserved and changed through a
dialectical interaction with another concept, Aufhebung. Often, this dialectical process is
described as thesis, antithesis, and synthesis, or when the contradiction of the thesis and the
tension between the two has been resolved. However, Hegel uses the terms abstract, negative,
and concrete. For example, in art-making, we might have an idea or a vision of something. When
we try to create that vision in the natural world, we discover all of the physical problems.
Perhaps our frustration results in a new representation of the problem, and perhaps the new art
4
object is even better than our original vision—or not. Still, we move on to a new vision, and the
cycle continues through time.
This threefold process is referred to as Hegelian dialectics or the logic of contradiction. In
other words, (a) everything gradually changes over time; (b) in a spiraling method as opposing
forces or contradictions rise above one another, which (c) results in significant holistic changes
(Cooper, 1995; Honderich, 2005). Hegel’s idea was that history is never static, always
teleological, and moving forward through the dialectal process. Theoretically, this implies that
all ideas and concepts—even the world itself—will eventually reach a final, ultimate state of
being. He termed the final state the Geist, which translates from German both as the spirit and as
the mind. Geist in Hegelian theory represents the absolute idea or truth (Hofstadter & Kuhns,
1976). Honderich (2005) wrote:
Because the German term covers both these meanings, Hegel is able to use it in a way that
suggests an overarching collective mind that is an active force throughout history, and of which
all individual minds—that is, all human beings, considered in their mental aspect—are a part. (p.
368)
Hegel’s approach to aesthetics developed out of his mature philosophical ideas and is
understood in terms of a meaningful succession of styles or expressions of the worldviews of
cultures or historical periods (Cooper, 1995; Gaiger, 2002). In his Lectures on Aesthetics (1820)
published posthumously,
[Hegel] emphasized the meaning and the content of works of art and takes those
works to be superior that have as their content the most concrete and fully
articulated ideas, but also express meaningfully the culmination of the historical
aspects of the culture in which it exists. (Cooper, 1995, p. 182)
When considering the purpose of making art in a therapeutic setting, at least three aspects
of Hegelian aesthetics theory applies to CBATx via theories of dialectical cognitive
constructivism: a) the ability of art to externalize internal processes for the purposes of
reflection, b) the dialectical process of initiating gradual change through the examination and
reframing of cognitions, and c) the emphasis on creating meaning through metacognition. In
order to create meaning, individuals form associations using subjective organizational structures
based on previous knowledge acquired via experiences in the external world, cognitive
abstraction, and the outcomes of mental contradictions.
5
For the purposes of therapy, it is also beneficial to view humans as being teleological or
having an innate drive to improve, although we may not agree on what constitutes
“improvement." Rather than subscribing to Hegel’s concept of attaining the Absolute Ideal
(Gaiger, 2002), it seems important to consider sociocultural and personal contexts, as the “ideal“
point of view implies a metanarrative or type of universal imperative for what self-realization
may look like. Therefore, as art therapists, it is important to help individuals discover and
emphasize what they find worthy within themselves. Explicitly, it seems imperative to suspend
value judgments on the aspect of aesthetics that deals with what is beautiful; instead, we ought to
provide materials, opportunities, and encouragement for individuals to participate in their own
dialectical process through metacognition.
According to Geiger (2002),
For Hegel, art takes its place alongside religion and philosophy as a form of self-
understanding through which human beings arrive at knowledge about themselves
and the world they inhabit.
Hegel suggests that one of the ways by which such knowledge [of self and
the world] is acquired is through a process of “externalization.” In working upon
and changing external things, we come to recognize ourselves in the changes we
have brought about. Works of art can thus be seen as the result of a highly
developed ability to articulate and make explicit the life of the mind. (p. 134)
By creating artwork (the thesis), individuals have an opportunity to reflect on the
psychological expression evidenced in their work and the experience of creating the work (the
antithesis), and therefore reframe or further the ideas found therein (synthesis). The hope is that
this approach will enable self-efficacy and self-regulation within the client‘s sociocultural and
personal context.
Chaos and Adverse Childhood Experiences
Family life for children whose primary caretaker(s) have alcohol-related disorders is
often characterized by chaos and unpredictability (Johnson, 2002; Nodar, 2012; Ross & Hill,
2001). As the family system breaks down, adults often cite the adolescent’s behavior as the root
cause of their substance issues (Kaufman & Yoshioka, 2005). As a result, children from these
maladaptive family systems often feel they have to present a false self to the public, to assure
their teachers, friends, employers, and even extended family members that all is “fine at home“
6
(Kaplan, Lui, & Kaplan, 2001; Straussner, 2011) . The consequence of keeping secrets within a
“closed” family system regarding alcohol-use disorders and other adverse childhood experiences
often causes issues, such as poor self-concept, depression, and eating disorders (Straussner,
2011).
Although coming from a family with alcohol use disorders is not always the primary
problem, rather, according to Anda (2006)'s report on the Adverse Childhood Experiences
(ACE) Study, issues may stem from concurrences of neglect or abuse. One of the possible
outcomes for people who have suffered severe ACEs is the development of a condition coined
by Sifneos in 1973 as alexithymia, or the inability to attach words to emotionally laden events. In
other words, some CoA decide not to tell the family secret and some CoA just cannot.
In general, there is a lack of research on intervention protocols for mental health
professionals serving adolescent children of alcoholics (CoA) who demonstrate a low probability
of having substance use disorders (SUDs), much less CoA who are high-achieving as well. Most
CoA who are treated have a wide range of health problems or presenting problems, such as
aggression, low school performance, or evidence of SUDs. However, because of this specific
population’s academic success, the psychosocial or emotional issues this specific population may
develop are often undetected by mental health professionals until later in their adult lives, when
perhaps their own family systems break down, (Eskin, Retaken, & Demir, 2008; Pilat & Jones,
1984/85). In other words, this particular population is often unobserved and therefore
underserved.
Research Problem
Statement of the Problem
The primary problem addressed in this study is how mental health clinicians can identify
and serve adolescent children of alcoholics who are high-achieving and demonstrate a low
probability of substance use disorders.
Purpose of the Study
The purpose of this art therapy study was to increase the positive self-concept of this
specific population using one or both experimental interventions. The specific interventions were
Cognitive Behavioral Art Therapy techniques and/or the construction of a personal visual
vocabulary.
7
Research Questions
The primary research question was whether the positive self-concept of all the
experimental participants and/or the qualified sample will increase after participating in
Cognitive Behavioral Art Therapy (CBATx) and/or constructing a personal visual vocabulary
(PVV), as measured by the Tennessee Self Concept Scale, Second Edition (TSCS:2) and the total
self-concept (TOT) scores from Piers-Harris Children‘s Self-Concept Scale, Second Edition
(PH:2).
Hypotheses
The implications for this study are reflected in the following hypotheses: First,
participation in one or both of the art therapy interventions will significantly increase the level of
positive self-concept, as measured by the correlated TOT scores for all of the experimental
participants or the qualified sample. This directional hypothesis describes a positive causal
relationship between participation in one or both of the interventions (independent variables) and
increased positive level of self-concept (dependent variable) for this population.
Null Hypothesis
The null hypothesis (H0: p-value > 0.05) is that there will be no statistically significant
increase in the level of positive self-concept, as measured by the TOT scores, for all of the
experimental participants or the qualified sample after participation in one or both art therapy
interventions.
Justification
According to Gantt and Tinnin (2007; 2009), one of the principal objectives for treating
trauma and abuse is to narrate the event or “tell the story“ in order to externalize the trauma and
set the events securely in the past.” Once the client sees himself or herself as a survivor, the
concepts of self-reliance, self-efficacy, and so on are reinforced. However, many clients are
reluctant to tell family secrets because of the concept of the “closed-family system” (Straussner,
2011), or they are unable to verbalize the abusive events due to issues involving alexithymia
(Lusebrink, 1990, Gantt & Tinnin, 2007, 2009; Sifneos, 1973). For these reasons, in addition to
specific CBATx directives, the experimental groups created a PVV for the visual expression of
secrets in an educational setting before working on a personal visual narrative.
According to psychologist Erik Erikson (1994)’s theory of the eight stages of
development, most adolescents are in the fifth stage of socialization, or learning identity versus
8
identity diffusion and the development of fidelity. At this stage, healthy development is
dependent on acquiring a sense of self-certainty, as opposed to self-consciousness and self-doubt.
In other words, the primary job of adolescence is individuation, or the process of developing an
individual identity. Accordingly, adolescence seems to be the primary stage in psychosocial
development during which an interruption of maladaptive familial patterns could occur (Gruber,
Celan, Golik-Gruber, Agius, & Murphy, 2007; Robertson, David, & Rao, 2003).
Typically, the specific population that this study focuses on is identified as well-adjusted
academically; therefore, a deliberate academic approach to cognitive–behavioral therapy (CBT)
may impart the feeling of a familiar or safe environment (Eskin, Ertekin, & Demir, 2008; Riley,
1999, Fenster, 2011). CBT methods enhance problem-solving skills and facilitate self-efficacy.
Often in CBT, the therapist is seen as a collaborator, rather than the expert. Consequently, CBT
techniques empower adolescent CoA to develop strategies and resolve feelings or behaviors
caused by the chaos and unpredictability of their maladaptive family systems (Riley, 1999a; de
Shazer, Dolan, Korman, Trepper, McCollum, & Berg, 2007). Specifically, Rosal (2001) wrote:
The portrayal of tough personal and social situations through drawings is a
technique used by several art therapists to increase problem-solving (Packard,
1977; Rosal, 1985, 1992, 1993, 1996). Having children depict complex life
moments can be followed by generating alternative solutions in pictures. This
technique can increase behavioral choice. (p. 215)
Most of the literature available on breaking the cycle of familial alcohol use disorders
agrees with the following statement from the Substance Abuse and Mental Health Services
Administration (SAMHSA, 2004):
The life skills CoA [need] can be gained through educational support groups and
healthy relationships with others, especially adults who show that they care about
children. By providing these children with experiences in which they have
opportunities to succeed, CoA can learn to respect themselves and cope with their
situations. (p. 15)
Although family therapy is often the primary intervention model for familial alcohol-related
disorders (Riley, 1999; 1999a) , a separate treatment program for children of alcoholics (CoA)
with an early positive intervention in a familiar environment with trusted adults who are not
family is recommended (Fenster, 2011; Kaufman & Yoshioka, 2005; Leichtling, Gabriel, Lewis,
9
& Vander Ley, 2006; Robertson, David, & Rao, 2003). Yalom (2005) advocated that a “therapy
group reincarnates the primary family” (p. 87). Additionally, peer therapy groups may quickly
provide the social support system necessary to develop group cohesion, catharsis, universality,
hope, altruism, guidance, interpersonal learning, and so on (Yalom, 2005). An advocate of
Yalom‘s principles when working with youth, Malchiodi (2008) wrote that “group work reduces
isolation, promotes corrective emotional experiences, and enhances interpersonal skills” (p. 252).
Walker and Lee (1998) suggested that the primary goals when working with CoA should be to
emphasize their individual strengths and develop their relational resilience outside their family of
origin, before working with the family as a whole. The hope is that the participants will work
together to summarize, question, contradict, and teleologically move towards a more holistic
sense of self.
Definition of Terms
Adolescence. Adolescence is indicated by chronological age (i.e., being 13–17 years
old).
Alcohol Use Disorder (AUD).This disorder is defined by a cluster of behavioral and
physical symptoms, which can include withdrawal, tolerance, and cravings. AUDs are specified
on a continuum from moderate to severe that includes various levels of remission. At present,
individuals with an alcoholic use disorder may continue to consume alcohol despite the
knowledge that continued consumption can pose significant physical, psychological, social, or
interpersonal problems within a 12-month period (American Psychiatric Association, 2013).
Alcoholism. The fifth edition of the Diagnostic and Statistical Manual of Mental
Disorders (2013) collapsed the medical distinction between problem drinking and alcoholism.
According to previous terminology, alcoholism was a chronic disease with genetic, psychosocial,
and environmental factors that influence its development and manifestations. The disease is often
progressive and fatal. It is characterized by continuous or periodically impaired control over
drinking, preoccupation with alcohol, use of alcohol despite adverse consequences, and
distortions in thinking, most notably denial (NCADD, 2013).
Alexithymia. Coined by Sifneos in 1973, the terms describes a dimensional personality
trait wherein the person is unable to experience or communicate feelings consciously or an
inability to recognize or describe their emotions.
10
Children of Alcoholics (CoA). Children of alcoholics are biological or non-biological
children and/or adolescents with at least one caregiver who qualifies as having an alcohol-related
disorder, as reported during the participant‘s initial intake interview.
Cognitive Behavioral Art Therapy (CBATx). Cognitive Behavioral Art Therapy is a
psychotherapeutic approach that incorporates the assessment of one’s higher cognitive processes
with the creative process of art making to 1) externalize internal processes, 2) facilitate self-
control, 3) increase problem-solving, and 4) improve one’s ability to cope with stress (Rosal,
2001).
Expression. Expression is defined as the act of expressing. In this study, expression is
the manifestation or publication of ideas in a tangible manner (i.e., by the human senses of sight,
sound, touch, taste, and/or smell).
High-achieving. High-achieving for this study was determined as educationally
mainstreamed students with a weighted GPA of 3.0 or above. This fits the initial eligibility
requirements for the State of Florida’s 2013 Bright Futures Florida Medallion Scholarship
award.
Substance Use Disorder (SUD). The substance use disorder combines the DSM-IV
categories of substance abuse and substance dependence into a single disorder that is measured
on a continuum from mild to severe. Each specific substance is addressed as a separate use
disorder, but nearly all substances are diagnosed based on the same overarching criteria (APA,
2013). The criterion of “demonstrating a low probability of SUDs” in this study has been
measured by the Substance Abuse Subtle Screening Inventory: Adolescent (Miller, 1985/1999).
Personal Constructs. Personal constructs are bipolar, or diametric, self-statements that
represent our most basic values and sense of self. The term is based on Kelly (1963/1999)’s idea
that people maintain their identities and existence by making assumptions about themselves
based on their experiences in the world and therefore behave in ways that support these
assumptions. According to Kelly, personal constructs are critical for the evolution and
organization of our larger construct system (e.g., “I am a good or bad person because…“).
Personal Visual Vocabulary (PVV). A personal visual vocabulary is a term that was
coined for this study and is defined as a system of symbols or icons that the participant attaches
personal meaning to and uses consistently over time in a variety of media and artwork. A PVV is
related to visual literacy (or, as it is colloquially known, visuacy), which can be described as the
11
ability to interpret, negotiate, and make meaning from information presented as an image
(Avgerinou, 2007; Braden, 1996; Brill, Kim, & Branch, 2007; Csillag, 2009; Dake, 2007;
Dondis, 1973; Moore & Dwyer, 1994). The concept of visual literacy is based on the idea that
pictures can be read and that meaning can be communicated through reading these pictures.
Qualified Sample. For this study, the qualified sample is a convenience sample of
adolescent CoA who were high-achieving and demonstrated low probability of SUDs.
Resiliency. Resiliency is the ability to cope, adapt, or recover from illness, depression,
adversity, trauma, and the like (Karatas and Cakar, 2011).
Secret. A secret is something that is not open or public and is kept private or not
revealed. A secret in this study is defined as a painful thought or idea that the participant reported
as not having previously expressed.
Self- concept. According to Kelly (1963/1999), self-concept is a person’s perspective of
himself or herself. This psychological construct includes the way a person sees, understands, and
defines him or herself in terms of beliefs and emotions. The degree of positive self-concept was
measured by using the TSCS:2 (Fitts & Warren, 2003) and the PH:2 (Piers & Harris, 2009).
A Brief Overview of the Study
This art therapy study investigates the efficacy of an intervention, or combination of
interventions, designed to increase the positive self-concept for high-achieving adolescent
children of alcoholics (CoA) who demonstrated a low probability of substance abuse disorders
(SUD). Since several standardized assessment tools for positive self-concept are available and
positive self-concept is one trait that supports one‘s ability to be resilient, positive self-concept
was chosen as the observable and measurable trait for this population. The levels of self-concept
were measured by statistical analyses of the Tennessee Self Concept Scale, Second Edition
(TSCS:2), correlated with the Piers-Harris Children‘s Self-Concept Scale, Second Edition’s
(PH:2) Total Self-Concept (TOT) score, over three observation periods. The TSCS:2 subtest
scores, self-reports, clinical notes, and client artwork provided additional supporting information.
The study used a randomized pretest-midtest-posttest experimental research design with a
control group. Data were analyzed from the qualifying sample to test and observe for significant
improvements in positive self-concept, as indicated by TSCS:2 and PH:2 TOT scores. To
elucidate the findings further, the art therapy discipline’s foundational theory, the Expressive
Therapies Continuum (ETC; Lusebrink, 1990); the depression scales; a portion of the Formal
12
Elements Art Therapy Scales (FEATS; Gantt and Tabone, 1998); and Anderson’s CritCard
method (Anderson and Milbrant, 2005) were used to evaluate the clinical notes, self-statements,
and the participants' artwork.
The convenience sample consisted of nine qualified adolescents out of 23 voluntary
participants from three small public schools in North Central Florida. All participants were
randomly assigned to one of two experimental groups or one control group. After completing the
study, the participants were qualified as having met the study criteria using information gleaned
from the original intake questionnaires/instruments. The qualifying participants had the
following attributes: they were 1) adolescent; 2) children of alcoholics or children from families
with alcohol use disorders; and 3) high-achieving; and 4) demonstrated a low probability of
substance-abuse disorders.
Participants were offered either a) eight 90-minute weekly sessions of art education–
based directives to construct a (PVV, followed by eight 90-minute weekly sessions based on
CBATx directives, while working towards a visual narrative or b) the opportunity to participate
in a control group. The study uses a randomized, three-interval test (O1, O
2, and/or O
3) design
with one control group and includes two interventions (X1 and X
2). The control group took a pre-
test (O1) and a post-test (O
2) after an approximate 18-week interval. The art education–based
intervention focused on the construction of a PVV using the art elements of line, shape, color,
value, and form. The CBATx interventions focused on feeling states, visual problem solving,
storytelling, and visual narrative development. In keeping with the tenets of art therapy, all of the
art directives were designed to move the participant around the ETC by providing opportunities
to work with a variety of materials.
Summary
Research indicates that a significant percentage of American children are growing up in
families that exhibit alcohol-use disorders. Some studies assert that parental alcohol abuse and
alcoholism cause ongoing maladaptive familial patterns of behavior that last for generations.
Furthermore, using functional magnetic resonance imaging (fMRI) technology, strong
correlations have been made between alcohol consumption and genetic factors and violent or
aggressive behavior, reduced impulse control, and an increased tendency for risk taking.
Additional studies have inferred through controlled multivariable research that the co-
occurrence of parental alcoholism and abuse are more likely to determine the long-term effects
13
on children born into these family systems than the use of alcohol per se. In other words,
children growing up in an alcoholic family system have an increased likelihood of having one or
more adverse childhood experiences, such as witnessing family violence, experiencing a
combination of physical, sexual, or emotional abuse, and being subjected to neglect and overall
poor parenting styles. Consequently, CoA are highly likely to develop alcohol use disorders and
continue maladaptive family patterns of internalized and externalized behavior, such as
aggression or depression. Evidence-based theories suggest that early intervention with trusted
adults and peers in a familiar environment is the most beneficial method of intervention for CoA.
The purpose of this study is to increase the positive self-concept of adolescent CoA who
were high-achieving and demonstrated a low probability of SUDs using one or both
experimental interventions—CBATx and/or the construction of a PVV. Specifically, the first
intervention utilized an educational approach to art therapy, and the second intervention focused
on established CBATx directives, including creating a visual narrative.
The philosophical approach for this study was based on Hegelian dialectics. The precept
was that an improved self-concept helps an individual overcome adverse childhood experiences
and disrupts the maladaptive familial pattern of issues surrounding alcohol-related disorders. The
hypothesis is that participation in one or both of the art therapy interventions will significantly
increase the CoA’s level of positive self-concept, as measured by the correlated TOT scores for
all of the experimental participants or the qualified sample. This directional hypothesis describes
a positive causal relationship between participation in one or both of the interventions
(independent variables) and increased positive level of self-concept (dependent variable).
Because several standardized assessment tools for positive self-concept (PH:2 and the TSCS:2)
are available and positive self-concept is one trait that supports one‘s ability to be resilient,
positive self-concept was chosen as the observable and measurable trait for this population.
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CHAPTER TWO
REVIEW OF THE LITERATURE
There is a lack of research on intervention protocols for adolescent children of alcoholics
(CoA) who are high-achieving and demonstrate a low probability of having substance use
disorders (SUDs). As discussed briefly, this population is difficult to identify due to their
academic achievement and the secrecy inherent in a maladaptive or dysfunctional family system.
For that reason, this literature review begins with a discussion on the specific term, the
meaning associated with, and the implications of being a CoA or being from a family system
with alcohol-use disorders, specifically the health and social impacts of growing up around
alcohol-use issues. Following is a discussion of the significant components for a successful
intervention and prevention programs and an overview of various cognitive theories. Finally,
there is a discussion of the efficacy of using art therapy and visual language to treat maladaptive
personal constructs for this population.
Children of Alcoholics
Studies reported by various national and government data-collecting groups indicate that
at least 17.6 million people, or one in every twelve adults, have an alcohol use disorder (AUD),
which can be further classified as either alcohol dependence or alcohol abuse2—both fall under
the larger category of SUDs. More than 28 million Americans are children from a family system
that is impacted by alcohol-related issues; nearly 11 million are under the age of 18 (Centers for
Disease Control, 2013; National Council on Alcoholism and Drug Dependence, 2013, National
Institute on Alcohol Abuse and Alcoholism, 2013).
Numerous empirical studies assert that parental alcohol-related disorders cause
multigenerational maladaptive patterns. CoA, or children from families with AUDs, are four to
six times more likely than their peers to develop a wide range of health problems, including
alcohol-related issues. (Anda, 2006; Gruber, Celan, Golik-Gruber, Agius, & Murphy, 2007;
Johnson, Cohen, Kasen, & Brook, 2008; Lejuez, Magidson, Mitchell, Sinha, Stevens, & De Wit,
2010). The presenting problems for CoA who seek treatment often include a variety of mental,
2 Using the DSM-V (American Psychological Association, 2013) terminology, “alcoholic” may be written as a
person with alcohol-related disorders or an alcohol-use disorder (AUD). Therefore, this study will use children of
alcoholics (CoA) and children from families with AUDs interchangeably.
15
physical, and emotional issues, such as difficulty talking about painful events, overachievement,
low self-esteem, external locus of control, anxiety, depression, and eating disorders (Anda, 2006;
Anda et al., 2002; Burnette et al., 2008; Dube et al., 2001; Elgán & Leifman, 2013; Kaufman &
Yoshioka, 2005; Straussner, 2011; Walker & Lee, 1998).
Additionally, CoA often have concurrent adverse childhood experiences (ACE), such as
witnessing family violence, experiencing a combination of physical, sexual, or emotional abuse,
and neglect, which may seriously affect their positive self-concept (Gantt & Tinnin, 2007).
Because of the poor parenting that is associated with ACEs, these children are highly likely to
continue maladaptive familial patterns of internalized and externalized behavior, such as
aggression and depression (Anda, 2006; Anda et al., 2002; Hall & Webster, 2007; Burnette,
Ilgen, Frayne, Lucas, Mayo, & Weitlaug, 2008; Dube, Anda, Felitti, Crogt, Edwards, & Giles,
2001; Johnson, 2002; Nicholas & Rasmussen, 2006; Mignone, Klostermann, & Chen, 2009). If
the family environment included significant trauma for the child, he or she may have developed a
condition called alexithymia. The operational definition of alexithymia is having a deficiency in
understanding, processing, or describing emotions (Lusebrink, 1990; Gantt & Tinnin, 2007;
2009; Sifneos, 1973).
Recently, researchers have focused on factors that contribute to resiliency, which is a
quality or process that seems to help interrupt the maladaptive family patterns associated with
ACEs or growing up in chaotic family environments (Kim & Lee, 2011; Mylant, Ide, Cuevas,
Meehan; 2002; Karatas & Caker, 2011). The internal characteristics associated with resilience
include positive self-concept, self-efficacy, perseverance, internal locus of control, and problem
solving, coping, and adaptation skills (Center for Substance Abuse Treatment, 2004; Hall &
Webster, 2007; Karatas & Cakar, 2011; Kim & Lee, 2011; Rekart, Mineka, Zinbarg, & Griffith,
2007; Mylant et al., 2002; Richards & Nelson, 2012; Walker & Lee, 1998).
The definition of children of alcoholics/children of substance abusers (CoA/CoSA) is
“any child whose parent (or parental caregiver) uses alcohol or other drugs in such a way that it
causes problems in the child’s life” (CoA/CoSA, 2013, para. 1). Does this label “children of
alcoholics” imply pathology? In their article Uncovering Strengths of Children of Alcoholic
Parents, Walker and Lee (1998) wrote, “CoA (Children of Alcoholics) are described as if CoA
were a diagnosis” (p. 521). The label CoA puts the focus on the child rather than the parent, as if
the child has the problem. Although the literature continues to use the label “CoA,” being a CoA
16
is not pathological. In the introduction of their book Children of Substance Abusing Parents:
Dynamics and Treatment, Straussner (2011) wrote:
Children of alcoholics and other drug-abusing parents, who will be referred to as
“children of substance-abusing parents,“ or CoSAPs, run the risk of a multitude of
short- and long-term problems and are likely to become the next generation of
individuals who are alcohol and/or drug dependent, thus perpetuating this cycle
into the future (Hissing et al., 2008). However, since CoSAPs exhibit not only
problematic behaviors but also strengths or resilience, careful individual
assessment of each family and each child is required. Help needs to be age- and
culturally appropriate and systemic and must take into account the needs of the
individual child and his or her family members. (p. 2)
In the literature on CoA, familial alcohol abuse, and the etiology of alcoholism, the
following questions were the most frequent: Why do CoA/CoSA often suffer from low self-
concept, anxiety, depression, aggression, locus-of-control issues, and substance-use disorders?
What specific factors lead to the high proclivity for continuing the cycle of behaviors modeled
by their maladaptive family systems? Is there a correlation between paternal substance-use
disorders, particularly of alcohol, and violence, abuse, and poverty?
Theories of Alcohol-Related Disorders
According to NIAAA (2003), “alcohol-use disorders are medical conditions that doctors
can diagnose when a patient’s drinking causes distress or harm…Like many other diseases,
alcoholism is typically considered chronic, meaning that it lasts a person‘s lifetime“ (para. 5).
If we accept, for the purposes of this study, that 1) alcoholism is a disease or that alcohol-use
disorder may cause a chronic disease if a person becomes addicted and 2) that the effects of
alcohol are subject to each individual‘s physiology, it behooves us to explore the etiologic
theories of addiction. Typically, these theories fall into the three main categories of a) biological,
b) psychological, and/or c) sociocultural issues. The combinations of these theories correspond to
the bio-psychosocial theory of use, abuse, and addiction (Keys, Hatzenbuehler, Grant, & Hasin,
2012).
Biological Theory
The biological theory for the use and abuse of alcohol and other drugs is based on years
of research in the area of alcohol-related issues. Biological or bio-psychosocial and genetic
17
theories suggest that some people are chemically predisposed to alcohol abuse; however, “no
specific genetic marker that predisposes a person towards alcoholism has ever been isolated”
(McNeece & DiNitto, 2005, p. 30). Nevertheless, there is sufficient evidence to suggest a
familial proclivity or genetic vulnerability for substance abuse. Specifically, recent studies that
include functional magnetic resonance imaging (fMRI) suggest a connection between alcohol-
use disorders and the tendency for impulsivity and/or risk-taking behaviors (Brody, Beach,
Philibert, Chen, & Murry, 2009; Lejuez et al., 2010; Newton, O‘Leary-Barrett, & Conrad, 2013;
Wai-Yuing, Zubieta, Weiland, Samudra, Zucker, & Heitzeg, 2012).
Psychological Theory
Psychological theories describe the cravings for alcohol as being based on cognitions and
emotions. For example, according to Keys et al. (2012), one explanation for alcohol use is as a
learned behavior, reinforced by the desire to reduce anxiety and stress, or that certain personality
traits are predictors for alcohol-related disorders. Specifically, the authors discuss how the
psychological and psychiatric effects of stress affect alcohol consumption and AUDs, such as
post-traumatic stress disorder caused by combat experiences and childhood maltreatment, as well
underdeveloped skills for coping with interpersonal issues, such as divorce and job loss.
Sociocultural Theory
Finally, sociocultural theories suggest that environmental factors are the primary cause
of alcoholism. According to the United Nations International Drug Control Programme
(UNDCP; 1995), poverty, unemployment, and marginalization are the some of the primary
contributing social factors for alcoholism and other SUDs. Other contributing factors may be
familial or cultural behavior modeling, a combination of risks taken during the process of
establishing one‘s individual and social identity, or the development of coping strategies (Ellis,
Zucker, & Fitzgerald, 1997; Hussong, Flora, Curran, Chassin, & Zucker, 2008; Hussong et al.,
2007).
Family Systems Theory: Roles and Rules
According to McNeece and DiNitto (2005), a maladaptive family is like a delicately
balanced mobile where the relationships among the members are interrelated and reciprocal. If
alcohol-use disorders are involved, alcohol is the central regulating theme. The mobile is a
“closed system" dependent upon itself. The entire system is organized by rules (strings) and roles
(the weights). In family systems theory (Gilbert, 2006), each member adjusts his or her behavior
18
(position) and plays a carefully developed role in order to maintain homeostasis (balance). In
other words, an alcoholic family has a circular rather than linear causality; the problem behavior
is a symptom of the larger context (McNeece & DiNitto, 2005).
Often, the focus of the alcoholic family may be on accommodating the alcoholic to keep
peace; thus, family members inadvertently inhibit the growth of the family or morphogenesis and
enable the alcoholic to escalate his or her dysfunctional behavior, rendering the entire system
dysfunctional (Hoshino, 2008; McNeece & DiNitto, 2005). Because of these behaviors, the
members become secretive and learn the rules: 1) “Don’t talk,” causing the members to possibly
live an elaborate lie; 2) “Don’t feel” causing the members to hide or discount their feelings
because expressing them only causes more trouble and upsets the homeostasis; and 3) “Don’t
trust,” causing the members to withdraw and become dependent on only themselves. Finally, all
of the members of the maladaptive system may develop a deep sense of shame, as each continues
to “fail” to meet the standards set forth by the system, i.e., perfectionism, blame, denial, and
control (McNeece & DiNitto, 2005; Straussner, 2011). Typical interpersonal familial
relationships do not occur, as positive authentic interactions that encourage this development are
severely inhibited. Any members of this family may display codependent tendencies and/or
perpetuate the cycle, which is dependent on their resiliency to the dysfunction (Fenster, 2011;
McNeece & DiNitto, 2005; Mylant et al., 2002; Nodar, 2012; Price & Emshoff, 1997).
Interrelated Issues of Alcohol, Aggression, Violence, and Abuse
As discussed in Chapter One, the result of growing up in a family with alcohol-use
disorder present often continues the maladaptive family patterns of internalized and externalized
behaviors, such as depression and aggression (Hussong et al., 2008; Hussong et al., 2007).
Nicholas and Rasmussen (2006) indicated, “childhood abusive and supportive experiences, inter-
parental violence, and parental alcohol use are a prediction of young adult depressive symptoms
and aggression” (p. 44). However, the authors go on to suggest that the connections among
alcoholism and violence and aggression are misleading. Specifically, when variables (i.e.,
alcoholism, abuse and aggression, parenting style, the sex of the parent, and the sex of the child)
are isolated, the findings indicated that, first, children of alcoholics are not necessarily adversely
affected and, second, of the three operationalized forms of abuse (i.e., emotional, physical, and
sexual), emotional abuse is the most frequent predictor for furthering maladaptive issues. In their
extensive literature review, the authors found a high incidence of child abuse in families with
19
AUD, but stated that “adult CoA have been compared to adult children from families judged to
be dysfunctional for reasons other than alcohol abuse and to adults from non-alcoholic,
functional families, [and that] adult CoA…did not differ from adult children of dysfunctional,
non-alcoholic families” (p. 44). After completing the study, the overall results demonstrated that
alcoholism, per se, did not predict depression. However, the combination of an abusive father, a
low-supportive mother, and witnessing family violence increased depression in women, whereas
low-supportive parenting from either parent increased depression in men. It seems important to
note, “There were few pathological outcomes due to growing up in an alcoholic family, per se”
(p. 44). Thus, the possibility that being a victim of child abuse, rather than growing up with
alcoholic parents, could account for the continued cycle of maladaptive patterns observed in CoA
(Burnette et al., 2008; Johnson, 2002; Nicholas & Rasmussen, 2006).
Nevertheless, in a report made to the National Adult Children of Alcoholics' board of
directors on his long-term study, co-investigator Anda (2006) reported that, out of the 17,337
predominately well-educated, middle-class participants, of which 54% were female and 46%
were male, with a mean age of 56 years, 27% reported growing up in dysfunctional homes with
SUDs. Of those children growing up around family members with AUDs, 81% reported at least
one other “adverse childhood experience” (ACE), specifically (a) emotional, sexual, or physical
abuse; (b) emotional and/or physical neglect; (c) household mental illness and/or parental
separation and divorce; and/or (d) crimes such as battery of the child’s mother. In the entire
study population, a mean of 87% of participants reported experiencing two or more ACEs. In
conclusion, Anda (2006) wrote:
One of the strongest relationships seen was between the ACE score and alcohol
use disorders and abuse. Given recent research indicating the negative impact of
alcohol use on the neurodevelopment of adolescents, the relationship of ACEs to
early initiation of alcohol use is particularly worrisome. The negative health and
social consequences of alcohol-related disorders constitute a major public health
problem—and ACEs have a particularly strong association with alcohol abuse. In
addition, it is notable that the perpetuation of the cycle of alcohol abuse appears to
be tightly interwoven with the number of ACEs, including marriage to an
alcoholic. (p. 9)
20
Although researchers have yet to find a genetic marker for alcoholism, neurobiological
imaging continues to provide significant information on addictions and the mesolimbic pathway,
or our neurobiological reward and impulse-control systems. In a meta-analysis conducted by Ito,
Miller, and Pollock in 1996, a strong correlation was made between alcohol consumption and
violent or aggressive behavior. In support of this, a plethora of recent studies have emerged
correlating the effects of family history, sex/gender, alcohol use, and impulse control using
functional magnetic resonance imaging (fMRI). Specifically, Lejuez et al.‘s (2010) recent review
of behavioral and biological research on AUDs and the brain found that alcohol use affects the
functioning of the central nervous system in very specific ways. Their findings included
increased impulsive behaviors, decreased awareness of social and environmental clues, and
decreased attention span. Claus, Kiehl, and Hutchison (2011) and Claus and Hutchison (2012)
used fMRI to investigate the neural basis of increased impulsivity among individuals with
alcohol-use disorders. According to their findings, people with AUDs demonstrated functional
irregularities in the brain regions involved in cognitive and emotional control. This resulted in
delayed responses, reduced ability for critical thinking, increased impulsivity, and increased risk-
taking behaviors.
Primary Prevention Models: Significant Components
Public information and educational primary prevention programs for adolescents have
traditionally been described as ineffectual, didactic shock-and-scare tactics (Beets et al., 2009;
McNeece & DiNitto, 2005; NIAAA, 2013). Currently, the most successful programs include
significant components that consider the biopsychosocial culture of the population through an
interactive, multi-component, and holistic approach. It seems that the significant components for
primary prevention programs are dependent on 1) the population and 2) the purpose. The best
prevention program that has integrated significant components may be ineffectual if it does not
address the etiology and include an attempt to stabilize the population.
Therefore, Price and Emshoff (1997) suggested that the significant components of a
primary prevention program for children from families with alcohol-use issues should include a
research-based model with stress-reduction techniques, educational components on a variety of
substances and their consequences, and coping and social-competence skills. Additionally, the
program should provide a social-support system, including peer-to-peer networking, a safe
environment, and a mode to express feelings, as well as healthy alternative activities. The
21
proposed setting should be within the school system to avoid humiliation, and the format should
be short term and small group. For example, three programs that employ all of the above
significant components are the Stress Management and Alcohol Awareness Program, Students
Together and Resourceful (STAR), and the Strengthening Families Program.
Other integrated research-based prevention models include (a) cognitive behavioral skills
training, which works to change dysfunctional thinking that affects behavior; (b) biopsychosocial
models that focus on education, values clarification, and skill-building techniques; (c) reducing-
harm models that teach normative beliefs, perceptions of harm, and refusal and decision-making
skills, as well as moderation and avoidance of developing alcohol-related issues; and (d) family-
based prevention models (Beets et al., 2009; Brody et al., 2009; NIAAA, 2007; Price & Emshoff,
1997; and Stephens et al., 2009). According to Morehouse (2011), “while all adolescent CoSAPs
can benefit from activities that increase awareness about the impact of parental substance abuse,
the adolescent’s individual need for services should be the primary determination of what
interventions are provided” (p. 215).
Thus, considering the current zeitgeist of short-term and high-efficacy treatment plans
and family therapies, peer-group treatment is the most commonly utilized form of therapy for
this population (Price & Emshoff, 1997). In fact, Fenster (2011) cited a study by Leichtling,
Gabriel, Lewis, and Vander Ley (2006) wherein 221 adolescents participated in treatment for
substance-related disorders. Fenster wrote, “At the 6-month data collection point, involvement in
family counseling was linked with increases in substance use among adolescents from
substance-involved families, an effect that was not observed among teens living with non-
substance-abusing parents” (p. 138). Based on Leichtling et al.'s study, Fenster (2011) stated,
“for parents and teens in earlier stages of recovery, individual and group treatment for
adolescents may be more effective than family treatment” (p. 138). In other words, small-group
therapy in a school setting imparts a feeling of a familiar or safe environment (Riley, 1999; Eskin
et al., 2008). Specifically, peer-group interventions can normalize the adolescent CoA’s
cognitions and emotions regarding the behaviors of their substance-abusing caregivers, as well as
provide pro-social modeling, problem solving, and empowerment, increase self-efficacy, reduce
social anxiety, and foster a feeling of acceptance (Fenster, 2011; Morehouse, 2011; Riley, 1999).
22
The Motivation for Change
Psychology is the science of behavior and mental processes. In this field, the four major
research perspectives are biological, cognitive, behavioral, and sociocultural (Griggs, 2006). The
biological perspective’s focus is on how physiological mechanisms affect human processes; the
cognitive perspective focuses on how memory, perception, problem solving, and so on affect
behavior; behavioral perspectives use external stimuli to condition observable behavior; and
sociocultural perspectives focus on the interactions between human processes and their cultural
context. These perspectives can be divided into two basic causal factors: internal and external.
The biological and cognitive perspectives emphasize internal factors, while the behavior and
sociocultural perspectives emphasize external factors (Griggs, 2006).
Because the traits and mechanisms that make up an individual’s personality tend to be
enduring (Larsen & Buss, 2009), the goal of therapy is usually to change maladaptive behaviors
to more adaptive behaviors (Nolen-Hoeksema, 2010). The following is an overview of cognitive
therapy from the perspective of discerning the best-possible (and most-practical) therapeutic
method to elicit behavioral change in adolescent clients.
Cognitive Theory
Cognitive theory includes many cumulative ideas but asserts that humans are thinking
creatures; therefore, examining cognitive processes, or metacognition, is central to understanding
human learning and maladaptive functioning. Cognitive theories include social-learning theories,
social–cognitive theories, and cognitive behavioral theories.
Social learning theory. While studying adolescent aggression and extinguishing
phobias, Canadian psychologist Alberta Bandura began to construct a transitional theory, or
bridge, between the conditioning theories posited by psychologists such as Pavlov, Skinner, and
Watson and cognitive learning theories. He originally referred to his idea as the social learning
theory (SLT; 1977) but later renamed the theory to the triadic reciprocal model of causality
(1986), stating that triangulation exists in interactions between people, the environment, and
observed behaviors (Griggs, 2006; Schunk, 2008). Bandura (1986) wrote that “most human
behavior is learned observationally through modeling: from observing others, one forms an idea
of how new behaviors are performed, and on later occasions this coded information serves as a
guide for action” (p. 22). In other words, primary learning is based on modeled behaviors,
environmental reinforcers for the practicing of that behavior, and the learner's emotional reaction
23
to the reinforcers. He noted that merely observing a behavior does not necessary result in a
behavior change; the learner must be motivated to repeat the modeled behavior (1986; 1997).The
motivation could be in the form of an emotional reinforce—“It feels good” or an environmental
reinforce—“Mom says, ‘good job” and so on.
To elucidate this idea further, Bandura (1986; 1997) suggested that the motivation for
learning is enabled through the interrelated concepts of self-efficacy and self-regulation,
operationalized as the belief in one’s abilities and the integrated process of personal motivation,
goal setting, and assessment. In other words, the type of response we receive from our
environment influences how we feel about others and ourselves and therefore may dictate our
behavior in any given situation. However, he noted that the action or behavior must be within the
learner‘s ability to achieve. An example could be that modeling the process of creating a contour
line drawing for a three-year-old might be an exercise in futility, whereas modeling how to use a
crayon to draw circular shapes is within a typical three-year-old’s fine motor skills and cognitive
ability.
Social cognitive theory. Although writing in the early 1900s, Russian psychologist Lev
Vygotsky proposed a similar theory entitled social cognitive theory (SCT), based on his work
with children and language acquisition. He posited that learning occurs in a complex interaction
between schematic memory, biological development or readiness, and concrete reinforcement of
the action (Van der Veer & Valsiner, 1994). In other words, “every aspect of [the learners’]
developing attitudes, values, motivations, aspirations, and, most important, their perceptions of
their own self-worth are influenced by their experiences within these varying and often
conflicting contexts of the community” (Thornburg, Hoffman, & Remieka, 1991, p. 200).
Vygotsky (1978) presented this idea of working within reach of an individual‘s ability level as
the zone of proximal development, which can be defined as “the difference between the
difficulty level of a problem a child can cope with independently and the level that can be
accomplished with help” (Bruning, Schraw, & Ronning, 2010, p. 218).
In addition to introducing an interrelated intrinsic–extrinsic model for experience-based
learning, both Vygotsky and Bandura suggested that humans are able to affect their environment
with both negative and positive consequences (Bandura, 1986, 1997; Vygotsky, 1978). They
asserted that humans internalize learning through the formation of cognitive maps based on
subjective ideas. They further maintained that the process of learning is enabled through self-
24
efficacy, belief in one’s abilities, and self-regulation, the integrated process of personal
motivation, goal setting, and assessment (Griggs, 2006; Schunk, 2008). Therefore, certain
assumptions must be made in applying both SLT and SCT theories: the learner must have the
capacity to (1) pay attention, (2) retain information, (3) reproduce the desired behavior, and (4)
be motivated to imitate the behavior. Once these criteria are met, some of the most powerful
tools a “teacher” can use are the ability to integrate and model desired behaviors in a social
environment and to provide positive feedback (Schunk, 2008).
Cognitive–behaviorism. As with SCT, proponents of cognitive behaviorism believe that
learners are actively engaged in a cyclical process of interpreting, reflecting, and imitating
modeled behaviors in their social and physical environments. The higher-order thinking process
associated with this activity has been termed metacognition, or the process of consciously
controlling cognitive activity (Brown, 1987; Flavell, 1985). In other words, cognitive–
behaviorism further conceptualizes the work of Bandura and Vygotsky but includes a model for
changing dysfunctional behaviors based on the learner’s ability to actively metacognate and, in
effect, be his or her own agent for change. American psychologist Aaron Beck (1955/1977)
posited that these internal changes are reflected via observable external behaviors, such as
positive self-statements and the use of coping skills.
Cognitive Behavioral Therapy and Adolescents
After examining his own anxiety-producing and self-critical thoughts, Beck suggested
that one‘s negative thoughts and feelings about oneself cause a downward-spiraling effect, which
he named the cognitive triad theory for depression (1955) but later renamed Beck‘s theory of
internal communication system (1997). Specifically, in determining a person‘s sense of self, he
suggested noting the 1) frequency of negative self-statements, i.e., statements that undermine a
person‘s self-efficacy; 2) arbitrary inference, i.e., erroneous cause-and-effect statements; and 3)
biased processing, i.e., interpreting situations subjectively (1997). In other words, the knowledge
of our own thoughts and the factors that influence thinking significantly increase learning
efficacy, motivation, problem solving, transfer, and concept attainment (Beck, 1955/97; Beck,
2011).
The cognitive behavioral model for therapy, or cognitive behavioral therapy (CBT),
suggests that, in order to initiate significant change in maladaptive behavior patterns, personal
beliefs and convictions must be examined to modify and create new mental constructs (Beck,
25
1955/97; Beck, 2011; Rosal, 2001). Using metacognition, the learner can (1) further his or her
quest for knowledge through self-efficacy, (2) find motivation for his or her own learning, and
(3) use reflection to assess and set goals or self-regulate (Brown, 1987; Beck, 1955/1997; Beck,
2011).
The CBT model includes developing healthy thinking patterns and solving current
problems, while behavioral techniques focus on developing healthy behavior. Specifically, CBT
facilitates identifying and challenging distorted thinking as well as reflecting on the risks and
benefits of choices (Beck, 2011). Thus, we can summarize the cognitive therapy model as an
interactive process of overcoming issues and working towards self-efficacy through the
examination of our thoughts, feelings, and behaviors in a social context. By working
collaboratively with the therapist and/or group members, individual clients have opportunities to
identify problematic emotional responses, behaviors, and arbitrary or erroneous inferences.
Metacognition, or the process of thinking about thinking, facilitates the modification of
behaviors in an emotionally safe environment and, subsequently, the generalization of these
newly learned and tested behaviors in their broader sociocultural context. In general, cognitive
theories encourage exploration, discovery, and the need for the learner to experience the world
directly (Schunk, 2008).
According to Fenster (2011), cognitive therapies have demonstrated efficacy in helping
adolescents presenting depression, anxiety, and disruptive behavior patterns as a result of
choosing constructive roles, positive role models, and developing affirmative relationships with
peers to raise their positive self-concept (Fenster, 2011). CBT may encourage adolescents to
examine how their cognitions influence maladaptive behaviors. As a benefit, CBT includes
important aspects of conditioning theory and social learning theory. Using problem-solving
techniques often results in an increased internal locus of control by utilizing the learner’s ability
to make choices and thereby motivating change.
Art Therapy and Visual Language
In Approaches to Art Therapy with Children, American art therapist Marcia Rosal (1996)
details the general principles of cognitive therapy and personal construct psychology, the role of
the art therapist, and evidence of efficacy in treatment, in terms of Cognitive Behavioral Art
Therapy, or CBATx. The author stated, “Recently, psychotherapists in the field are discovering
that mental processes, particularly mental images, are powerful tools for changing problem
26
behaviors—especially of self-control” (p. 48). Specifically, “mental imagery as a cognitive
process can be tapped and altered…concrete images can alter mental images, and mental images
can alter concrete images” (p. 70). In other words, the child or adolescent’s imagery is a direct
reflection of mental processes and therefore can be utilized as the means for change in
maladaptive behaviors and cognitions.
According to Rosal (2001), when we engage in artmaking, we use a full range of
cognitive processes, such as attention, memory, perception, decision-making, reasoning,
language, emotion, learning, problem solving, and so on. Therefore, CBATx combines the
internal control-building aspects of cognitive therapy with artmaking using techniques such as
(a) discovering, promoting, enhancing, and reconfiguring mental images; (b) comparing and
contrasting drawings; (c) choosing and portraying problem-specific situations and events; and (d)
creating pictorial metaphors of feelings and mind states. In discussing the efficacy of art in
therapy, Rosal (2001) wrote:
Art therapy is particularly suited to CBT, because art is an inherently cognitive
process. When creating a piece of art, the artist must be involved in uncovering
mental images and messages, recalling memories, making decisions, and
generating solutions. Whether drawing or sculpting, creating art involves instant
feedback systems and the ongoing reinforcement of satisfying behaviors. Each
brush stroke that appears on the paper can suggest or promote further action
(feedback) as well as delight (reinforce) the artist. Creating art means that there is
a concrete record of inner processes. (p. 217)
Additionally, the use of CBATx in a small-group setting may increase the efficacy of treating the
adolescent population, as art provides immediate opportunities for empathy, problem solving,
and goal setting with peers. If the goal of therapy is to change maladaptive cognitions and
behaviors to more-adaptive cognitions and behaviors, the cognitive learning theory model
facilitates this transformation, as evidenced by the artwork.
Context and Visual Language
It is important to note that, based on the idea that humans can be taught to see, the field of
visual literacy and visual language has grown exponentially diverse, from the field of art and
design to the construction of computer languages, thus further complicating an operational
definition (Avgerinou, 2007; Brill, Kim, & Branch, 2007). All one has to do is conduct a Google
27
search for “image as language” to find a plethora of explanations of how to learn to use visual
vocabulary to “tell your story” in images. Though there does not seem to be a universal visual
language, generally, a visual language is defined as a system of communication using visual
elements in a spatial context rather than in linear form (Dake, 2007; Marriott & Meyer, 1998).
One of the specific fields interested in developing a visual language is art and design.
Csillag (2009) wrote:
I have noticed that students, typical teenagers and young adults, would always
like to ‘break the rules’ of design and art, which I always supported. Yes,
supported for the sake of creativity, and I would tell them, “As long as you know
what you are doing and are aware of the nature of the eye!” (p. 127)
Despite Csillag’s (2009) extensive research and proposed operational model of visual perception,
the fact is that current understanding of the relationship among incoming sensory data, neural
activations, and the construction of meaning based on prior experiences remains elusive at best
(Dake, 2007). Perhaps part of the problem in devising a grammatical structure for visual
elements is that the meanings of these elements are usually culture-specific. Regarding the
cultural aspect of image making and constructing meaning, Anderson and Milbrandt (2005)
wrote:
Seeing is based on biology and framed by culture. We all have similar sensory
equipment, but at an early age the way in which we use our senses to construct
become increasingly social in nature. We have an innate desire to communicate;
our communication begins with imitation of other’s communications, but as we
learn to use the system, we become increasingly individuated. (p. 50)
The contextual aspect of the art elements was exemplified when a group of this
researcher’s adult clients described their feelings associated with a specific color, such as purple.
One participant in the group filled a circular shape with wild purple lines and explained:
Purple, for me, represents pain and confusion. Purple is how I felt about the
people in my life when I was growing up. I found that I could not trust any person
to be . . . to be good to me. Purple is a hard color. (Anonymous, 2010)
In the same group, another client swirled purple paint into her circle, explaining, “
28
Purple is pure happiness for me. It makes me feel like a princess. Everything around me
is purple, my rugs, my blankets, my curtains, my clothes, my jewelry. If I could, I would
dye my hair purple. Purple makes me happy.”
It seems obvious that, for both clients, though they were about the same age and race and had the
same socio-cultural background, the color signified completely different concepts. The color was
a clue about their personal constructs.
If we view visual language as evidence of personal construct, as in Cognitive Behavior
Art Therapy, we are no longer concerned with an operational definition of visual literacy or
visual language. Rubin (2010) wrote:
Those who emphasize the therapy [rather than the art] are less likely to be
concerned with quality and more likely to focus on the communities’ value of the
artistic product. They too are interested in the image but primarily for what it says
rather than how well it speaks. Rhyne (1995), who studies line drawings of
feelings-states based on Kelly’s “personal construct” theory, described such
creations as “visual language.” (p. 73)
Rhyne’s specific use of Arnheim’s (1969) concept of visual thinking and Kelly’s
(1963/1999) idea of personal constructs was the basis for her work in her doctoral dissertation,
“Drawings as Personal Constructs: A Study in Visual Dynamics” (1979).
Visual Dynamics and Personal Constructs
Rhyne (1979) stated that the primary concern for her work on visual dynamics and
personal constructs was to “explore empirically potential applications of theoretical tenets
toward better understanding of personally constructed cognitive content in drawings” (p. 6).
Rhyne listed three specific problem areas that she intended to address: (a) the problem of visual
literacy, (b) the problem of visual dynamics, and (c) the problem of visual form as content. In
terms of visual literacy, she wrote “visual languages, no matter how expressive, are difficult to
codify” and that “the various fields of humanities and the social sciences commonly relate
cultural variables to visual expression” (p. 10). However, she extended the premise that “the
effectiveness of visual communication is subject to principles of composition whose parameters
can be intelligently and systematically explored” (p. 10). In terms of visual dynamics, Rhyne
focused on the abstract qualities of the artwork rather than the representation of symbolic
content. Specifically, Rhyne used what Dondis called the “structural properties and elements in
29
drawings,” or “how form [as, the element of art] relationships convey meaning in their structural
dimensions of composition organization” (p. 12).
Finally, in terms of the problem of visual form as content, Rhyne wrote, “This study is
concerned with the testing of Gestalt psychology’s tenets that configurational characteristics in
visual form show traces of similar characteristics of those who created the drawings” (p. 13).
Specifically, referring to Arnheim’s idea of “artistic activity as a form of reasoning” (p. 23),
Rhyne “examines questions of how organizations of form in visual images are used to express
personal constructs of life experiences” (p. 13). She relied on cognitive psychologist Kelly’s
(1963/1999) work, and the subsequent use of repertory grids to devise a mathematical way of
exploring how a person’s assumptions, or how he makes sense of the world, affect his idea of
reality based on experience. Thus, in addition to limiting the study to the abstract structures and
elements of artistic expression, she emphasized that one of the objectives of the study was,
To obtain, organize, and present data consisting entirely of information gathered
from the subjects’ perceptions of their own drawings. Of prime importance in this
research is the insistence that questions of intended meaning in drawings are best
answered by their own creators. To maintain this objective, to classify
introspective reports in both visual and verbal media, this study has treated both
drawings and their perceived properties as personal constructs. (p. 17)
Rhyne’s (1979) study involved 50 participants either working or attending university in
the western United States and required each participant to (a) create 15 black line drawings on
white paper in response to 15 emotionally laden “concept words” and then (b) code his or her
mind-states on the Repertory Grids. By collecting the participants’ insights about their artwork,
problems associated with an operational definition of visual literacy and cultural bias or dictated
constructs were avoided. The results indicated that commonalities and interrelationships in
expressive structure exist within clusters of some mind states, but that “personal constructs of
mind-states have shown idiosyncrasies that can be comprehended only within the context of that
individual’s ideation system” (p. 250).
Rhyne’s work on visual dynamics and personal constructs supports the Cognitive
Behavior Art Therapy assumption that art activities are reflections of one’s cognitions or
personal constructs. The term “personal constructs“ was based on Kelly’s idea that people make
assumptions about themselves based on their experiences in the world and, therefore, behave in
30
ways that support these assumptions. Kelly went into detail about the varying types of constructs
found in the general population, but toward the end of the book, he laid out specific conditions
considered favorable and unfavorable for the formation of new constructs. Kelly (1963/1999)
wrote:
We pointed out that new constructs could be formed with less danger of
paralyzing effects if they are first approached in contexts that do not involve the
client’s self or members of his immediate family. . . . A person might first develop
a new hypothetical cast of characters and only later find that they were like the
people with whom he is living every day. (p. 161)
Rhyne’s (1979) study supports previously mentioned imperatives that therapists first
suspend aesthetic judgment and then seek meaning based not on preconceived ideas or
unconscious precepts but rather on the client’s personal perceptions. Additionally, the personal
construct approach is related to the cognitive therapy approach in that the knowledge of one’s
own thoughts and the factors that influence thinking significantly increase learning efficacy,
motivation, problem solving, transfer, and concept attainment. Once the learner understands
personal thought processes, strategies such as questioning, summarizing, elaborating, and
organizing may be learned. Additionally, the application of heuristics, or rules of thumb, for
further learning and problem solving may be used. In other words, using metacognition, the
learner can further the quest for knowledge through self-efficacy, find motivation for learning,
and use reflection to assess and set goals or self-regulate. The cognitive theory method, together
with art, promotes efficacy through immediate problem-solution techniques and the
externalization of internal processes or personal constructs.
As indicated previously, the primary intervention objectives for this study included the
construction of a PVV) and the application of the personal visual vocabulary to the CBATX
process and the creation of the visual narrative. The emphasis on the personal or individual
aspects of creating a visual vocabulary helped avoid problems associated with outlining an
operational definition of visual literacy and cultural bias or dictated constructs regarding the
underlying grammar associated with visual languages. The use of a PVV to produce visual
narratives inherently addresses each participant’s individual physical, emotional, mental, and
spiritual aspects through the interplay of internal cognitions and external socio-cultural contexts
or personal constructs
31
Summary
In general, there is a lack of research on intervention protocols for adolescent children of
alcoholics (CoA) who are high-achieving and demonstrate a low probability of substance abuse
disorders (SUDs). As a result, the literature review focused on the treatment protocols for
adolescents from maladaptive family systems who have suffered adverse childhood experiences,
including issues with familial alcohol use.
In treating adolescent CoA, it is important to avoid considering the label as pathology in
itself. Additionally, significant numbers of CoA find the support systems, necessary strengths,
and resiliency to cope with and interrupt maladaptive familial patterns. Thus, sensitivity to the
individuals’ attitudes regarding their family systems must be taken into account. However, the
literature reviewed suggested a high concordance rate between growing up in a family with
alcohol use disorder and traits of violence and abuse. These studies offer a possible explanation
for the circular causation of poor self-concept, anxiety, depression, aggression, locus of control
issues, and substance abuse disorders in CoA.
Of the plethora of intervention strategies recommended, family therapy is often
suggested for adolescents. However, for adolescent CoA whose family members are still actively
using, group therapy seems to provide a more appropriate therapeutic venue due to peer-to-peer
support, empathy, and empowerment, and may reduce risk of shame regarding the telling of the
family secret(s).
Specific to this study, Cognitive Behavior Art Therapy (CBATx) combined the internal
control-building aspects of cognitive therapy with art-making, using techniques such as:
discovering, promoting, enhancing, and reconfiguring mental images; comparing and contrasting
drawings; choosing and portraying problem-specific situations and events; and creating pictorial
metaphors of feelings and mind-states. Especially important to this study was the expression of
personal constructs, problem-solving, and exploring feeling states. Additionally, this study relied
on the client’s ability to develop a personal visual language and to interpret, negotiate, and make
meaning from visual information in order to apply that learning to a personal visual narrative, or
a visual trauma story.
32
CHAPTER THREE
METHODS
The Cognitive Behavioral Art Therapy (CBATx) model and double-blind method with a
focus of personalizing standard art education elements through the development of a personal
visual vocabulary (PVV) was designed to minimize the anxiety and stress resulting from being
identified as a child from a family with alcohol use disorders. The purpose of this study was to
increase this population’s positive self-concept, a measurable and observable trait related to
resiliency, using one or both experimental art therapy interventions. The specific interventions
were (a) an art education-based intervention, constructing a PVV and (b) CBATx based
intervention, which included working toward an image based personal narrative, or Trauma
Narrative. The philosophical approach for this study was based on Hegelian dialectics.
Following is specific information on the research design and methodology, including the
how the sample population was obtained, the setting for the study, and the procedures. The
validity and reliability for the assessment tools and instruments are given, followed by a
discussion of possible internal threats to validity. Finally, detailed information is stated regarding
data collection and evaluation procedures. The results for this study are given in Chapter Four.
Research Design
The study used a randomized pretest-midtest-posttest experimental research design with a
control group (see Table 1). Voluntary participants were randomly assigned to either one of two
experimental groups or a control group. This research study was intended to examine an inferred
causal relationship between positive self-concept (dependent variable) and participation in one or
both interventions, CBATx and/or constructing a PVV (independent variables). This design
implicitly controlled for the testing threat and maturation threat to internal validity as the Piers-
Harris Children’s Self-Concept Scale, Second Edition (PH:2) and the Tennessee Self Concept
Scale, Second Edition (TSCS:2) total self-concept (TOT) scores and relevant subscales scores
were highly correlated (Fitts & Warren, 2003; Piers & Harris, 2009). The control group did not
receive any interventions during the period of the study. To hold the variables of adolescent
children of alcoholics who were high-achieving and demonstrated a low probability of substance
use disorders constant, all participants completed an intake questionnaire and the Substance
Abuse Subtle Screening Inventory, Adolescent (SASSI-A2).
33
Table 1. Randomized pretest-midtest-posttest experimental study design with one control group.
Groups Intake SASSI-
A2
PH:2
(O1)
TSCS:2
(O1)
PVV
(X1)
TSCS:2
(O2)
CBATx
(X2)
TSCS:2
(O3)
Experimental Group
(Y1)
R O O
O
- X
- X O
Experimental Group
(Y2)
R O O
O
O
X
O
X O
Control Group (Y3) R O
O
O
O
C
- C O
Note. The following is a list of abbreviations used in this table:
Ex = experimental group (Y1 & Y
2)
C = control group (Y3)
R = randomly assigned
TSCS:2 = Tennessee Self Concept, Second Edition
PH:2 = Piers Harris Children's Self-concept Scale, Second Edition
PVV = Personal Visual Vocabulary
CBATx = Cognitive Behavioral Art Therapy
SASSI-A2 = Substance Abuse Subtle Screening Inventory, Adolescent
Sample
This art therapy study was approved and conducted in accordance with the Florida State
University Internal Review Board and Human Subjects Committee in 2012 and was revised and
renewed in February 2013 and February 2014. Involvement in this study was voluntary;
participants volunteered after seeing distributed flyers, posters, or hearing about the study by
word of mouth. The wording on the flier stated that the purpose of the study was to measure
levels of self-concept after using art materials in a small-group setting. Informed consent was
obtained from all of the participants and parents/guardians as required by the aforementioned
board and committee. During the initial intake interview, the parents/guardians of the adolescents
were informed of the purpose of the study, but the participants were not, in order to avoid the
Hawthorne Effect, according to which participants alter their behavior as a result of being part of
a study. Additionally, the parents/guardians and the participants were informed that the study
was “double- blind” in that neither the participants nor I would know who qualified as the
sample, as I did not access intake data until the study was complete.
After attrition, data was collected for 23 voluntary participants from three small public
schools in north Florida. Six participants from the experimental groups qualified as the sample
for the first intervention (n=6), five participants qualified as the sample for the second
34
intervention (n=5), and three participants qualified in control group (n=3). Participants’
qualifying criterion was determined following the closing of study.
Setting
All sessions were held in an after-school art therapy program. Confidentiality was held
constant as the designated classroom was isolated from other after-school programs but used
consistently for art-related purposes and/or tutoring services. Additionally, the door was locked
from the exterior, but not from the interior. Artwork was photographed and then stored in
individually made portfolios labeled with the client’s participation number and self-generated
pseudonym. Confidential documents were held in a secure locked cabinet and clinical notes were
composed on a computer independent of the school’s networking system. All school personnel
were informed regarding the necessary ethical responsibilities of the therapist and the rules of
confidentiality. As with all after-school programs offered, snacks were provided by parents, the
therapist, the school, and/or the participants themselves.
Procedures
After completing the initial intake questionnaire, all volunteer participants completed the
SASSI-A2 and PH:2, chose pseudonyms, and were randomly assigned to one of two
experimental groups or one control group. Once the volunteers were randomly assigned to either
the control or an experimental group, the observations were conducted over three meetings that
were not included in the weekly session count (see Table 2). These observations proceeded as
follows:
Prior to beginning the first intervention, random participants from the experimental
groups (R-Y1 and R-Y
2) and all participants from the control group (Y
3) completed the
TSCS:2 (O1).
After participating in the first intervention (X1), but before the second intervention,
random participants from the experimental groups (R-Y1 and R-Y
2) completed a second
administration of the TSCS:2 (O2).
All experimental subjects participated in a review based on the Analytical Art Criticism
Model (Anderson & Milbrandt, 2005).
After participation in the second intervention (X2), all participants from both the
experimental groups and control group (Y1, Y
2, and Y
3) completed a third administration
35
of the TSCS:2 (O3) and participated in an individual review based on the ETC and the art
therapy study’s therapeutic objectives and criterion.
The results from these instruments were not examined or scored until the completion of the
study. The data were summarized and reported using descriptive statistics. Clinical documents
and client artwork was examined and discussed using standardized art therapy assessment
protocols and qualitative analysis. The total testing and interview hours did not exceed two
contact hours for any individual.
Table 2. Assessment schedule with total collected data/scores for three group participants, over
all three observation period.
Group Intake SASSI PH:2 TSCS:2 PVV TSCS:2 CBATx TSCS:2
O1 O
1 O
1 O
1 X
1 O
2 X
2 O
3
Y1
Non-qualified
n=6 n=6 n=6 n=5 n=6 n=0 n=3 n=3
Y1
Qualified
n=4 n=4 n=4 n=4 n=4 n=4 n=4 n=4
Y1
Total Tuesday
n =10 n =10 n =10 n=9 n =10 n=4 n =7 n =7
Y2
Non-qualified
n =7 n =7 n =7 n=0 n =7 n=0 n =7 n =7
Y2
Qualified
n=2 n=2 n=2 n=0 n=2 n=0 n=2 n=2
Total Thursday n=9 n=9 n=9 n=0 n=9 n=0 n=9 n=9
Y3
Non-qualified
n=1 n=1 n=1 n=1 n=0 n=0 n=0 n=1
Y3
Qualified
n=3 n=3 n=3 n=3 n=0 n=0 n=0 n=3
Total Control n=4 n=4 n=4 n=4 n=0 n=0 n=0 n=4
Grand Total n=23 n=23 n=23 n=13 n=19 n=4 n=16 n=20
The presenting problem, goals, and long-term objectives for the experimental group
interventions were stated as:
Presenting problem: need for increased positive self-concept,
Group Goals: increase positive self -concept through familiarity with art materials, visual
symbol development, and autobiographical story telling; and
Long-Term Objective: development of a PVV for therapeutic storytelling.
36
The weekly directives for the experimental groups’ eight 90-minute art-education-based
sessions were as follows (see Table 3): Session 1 included establishment of group rules and
confidentiality and media exploration based on a power animal symbol from a set of Native
American Medicine cards. Session 2 focused on Rhyne’s (1979) work on mind-state drawing
directive and used I-Ching cards to create a line drawing. Sessions 3 and 4 involved discussions
on icons and symbols, the development of personal symbols associated with a “Love/Hate” or
“Adore/Loath” list in the form of a “T-chart,” followed by the creation of a construction paper
radial collage based on Matisse style shapes. Sessions 5 and 6 focused on exploring color
psychology to identifying an “inside” color and an “outside” color and using those colors to
create a value scale and central painting. Session 7 focused on identifying an archetypal or
personal symbol and creating that symbol three dimensionally using clay. Session 8 focused on
helping each individual identify his or her PVV using the Anderson CritCard method as a guide.
Random participants were given the TSCS:2 between the interventions.
The directives for the Cognitive Behavior Art Therapy groups’ eight 90-minute sessions
were as follows (see Table 3): Sessions 1, 2, and 3 included a review of confidentiality and group
rules, individual symbol exploration, art storytelling using past-present-future stories, and
instruction on Japanese accordion-fold book binding techniques. Session 4 focused on relaxation
techniques and anxiety issues using body-breath painting. Participants made single word
associations for each drawing and completed a “free” painting. Session 5 focused on cognitive
reframing through problem-solution collages and the choice of telling a fact or fiction problem
and solution. Session 6 involved identifying and documenting the four feeling states and the
choice of telling a fact or fiction feeling state story. Sessions 7 and 8 focused on completing the
personal visual narrative books and final critique using the End of Study Objective/Criteria
Assessment Questionnaire (see Appendix I). During the closing session (the final observation for
the end of the study), the group met to complete the TSCS:2 and create artist trading cards to
share. The total contact hours for the individuals involved amounted to 24 hours of group
participation and a maximum of two assessment hours for each client.
A snack was made available to the participants before the sessions started and every
session began with a review of confidentiality, group rules, and an opportunity to discuss any
unfinished business from the previous week. Every session ended with a discussion based on
what went well or what was unexpected using a “round-robin” method.
37
Table 3. Art Therapy Study Directives for the Two Experimental Interventions, X1 and X
2
Sessions Y1
(Tuesday) & Y2 (Thursday) Y
3
O1 Winter 2012
Intake, SASSI-A2, PH:2, TSCS:2,
Winter 2012
Intake, SASSI-A2, PH:2, TSCS:2,
X1 PVV
1 Establish Rules, Confidentiality, & Procedures
Media Exploration (Native American Animal Cards)
2 Elements of Art: Line
Painted Line Drawings (Rhyne & I-Ching Cards)
3 Elements of Art: Shape Adore/Loath List
(Jungian Personal Symbols)
4 Elements of Art: Shape
Radial Collage (Matisse)
5 Elements of Art: Color & Value
Inside/Outside Colors (Color Psych)
6 Elements of Art: Color & Value
Inside/Outside Mandala (Color Psych)
7 Elements of Art: Form
Three-dimensional Clay Symbols (Jungian Archetypes)
8 Critical Analysis
Anderson CritCard
(Jungian Archetypes and Personal Symbols)
O2 TSCS:2:
X2 CBATX &
Visual Narrative
1 Establish Rules, Confidentiality, & Procedures
Media & Symbol Exploration
(Art Cards & Japanese Tarot Cards)
2-3 Symbols & Past Present Future Stories
Book binding techniques
(Art Cards & Japanese Accordion Book)
4 Watercolor Body Breath Exercises
Image-Word Association
5 Problem-Solution Collage/
Fact or Fiction Reframe story
6 Feeling States/
Fact or Fiction Personal Narrative
7 Narrative Art
Japanese Accordion Book
8 Narrative Art & Individual Critiques
Japanese Accordion Book & Questionnaire
O3
Closing and TSCS:2
Artist Trading Cards
TSCS:2
38
Assessment Tools and Instruments
As previously discussed as the primary problem, identifying CoA who are high-achieving
and demonstrate a low probability of SUD is difficult, at best. Although this population often
conceals a variety of psychological, emotional, and physical issues caused by their parents’
SUDs, most of the participants were willing to disclose academic history and familial alcohol
issues on the intake questionnaire. Although the SASSI-A2 cannot guarantee that a sample is
substance-use free, it is one of the few clinically based screening instruments currently available
for this population. Other types of drug tests, specifically, technical examinations of urine, blood,
semen, sweat, and oral fluid samples, were deemed inappropriate for this study.
To avoid the possible effect of test-retest validity issues, the PH:2 was used to measure
the self-concept of all participants and correlated with the TSCS:2. According to the TSCS:2
manual, the correlation of the TSCS:2 subtest scores, including the TOT scores, have a
correlation value of .66 and above (Fitts & Warren, 2003; See Appendix C). It should be noted
that the questions on the PH:2 are overt, and participants may recognize the nature of the study
and answer accordingly. The primary dependent variable data was measured using the TSCS:2.
The intention of administering a pretest, midtest, and posttest assessments using the TSCS:2
were to elicit comparative data on the efficacy of the specific experimental tool, the construction
of a PVV and/or CBATx, in improving positive self-concept. To provide additional information
on the participants’ clinical state, the participants’ artwork was reviewed using the Depression
Scales, a portion of the FEATS, and the TSCS:2 summary scales that corresponded to Beck’s
theory of internal communication system and the Substance Abuse Subtle Screening
Inventory, Adolescent (SASSI-A2)
The SASSI-A2 is a brief screening tool designed to identify individuals’ probability of
having a substance-related disorder (Miller, 1999). The SASSI-A2 has proven effective even
with individuals who are unable or unwilling to acknowledge relevant behaviors; its decision
rules yield an overall accuracy of 94% (NIAAA, 2013). Since 1990, an adolescent version of the
SASSI has been available. The second version of the Substance Abuse Subtle Screening
Inventory, Adolescent, the SASSI-A2, has a 94% overall accuracy of identifying an adolescent
with a substance-dependence disorder, including both substance abuse and substance
dependence. The SASSI-A2 is designed to screen individuals who are 12 to 18 years old. The
39
accuracy of the SASSI-A2 is not affected by the respondent’s gender, age, ethnicity, education,
employment status, living situation, prior legal history, or general level of functioning.
Piers-Harris Children’s Self-Concept Scale, Second Edition (PH:2)
The second edition of the PH:2 provides a total score and six subscale scores in addition
to two validity scores based on the adolescent’s own perceptions of him- or herself (Piers, Harris,
& Herzberg, 2002). The scale assesses self-concept of individuals, ages seven to 18, and is
written at a second-grade reading level. The test requires approximately 10 to 15 minutes, and
the participant responds “yes” or “no” to a list of descriptive statements. Information retrieved on
the PH:2 was as follows:
Reliability. The PH:2 is comprised of nationally representative norms based on a sample
of nearly 1,400 students, ages 7 to 18, recruited from school districts throughout the United
States. The reported internal consistency scores were .91 for the total score and .69 for the two-
week test-retest score.
Validity. Interscale correlation analysis provides evidence that domain scales on the
PH:2 demonstrate moderate to high correlations with each other. The domain scales also
correlate strongly with the overall total score (Community University Partnership for the Study
of Children, Youth, and Families, 2011).
The Tennessee Self Concept Scale, Second Edition (TSCS:2)
The Tennessee Self Concept Scale, Second Edition is a self-report instrument that has
been normed on an age-stratified sample of more than 3,000 individuals from seven to 90 years
of age (Fitts & Warren, 2003). The TSCS:2 can be administered individually or in a group
setting in about 15 minutes and has been proven one of the most reliable self-concept tests
available; it is in concordance with the Minnesota Multiphasic Personality Inventory-2
(MMPI:2). Information retrieved on TSCS:2 was as follows:
Reliability. The reliability estimates for all TSCS:2 scales are retest coefficients based on
a sample of 60 college students over a two-week period and in general range from .60 to .90.
Validity. The manual presents correlations between the TSCS:2 scales and those of the
MMPI:2, the Edwards Personal Preference Schedule, and several other well-known measures. A
great many of these correlations are significant—so many, in fact, that where the MMPI is
concerned, it appears that the two inventories nearly overlap. Researchers have reviewed a
40
number of factor-analytic studies and concluded that none supports Fitts’ specific hypothesis of
15 dimensions of self-concept (Center for Psychological Studies, Nova, 2008).
Formal Elements Art Therapy Scale (FEATS)
The Formal Elements Art Therapy Scale is an art therapy assessment that was normed for
adults (Gantt & Tabone, 1998). The purpose of the FEATS, used in conjunction with the Person
Picking an Apple from a Tree (PPAT) assessment (standardized by Gantt, 1990/2000), is to
provide a method for understanding how adults draw, rather than what they draw, in order to
analyze possible graphics correlated to DSM-IV criteria for specific disorders. The FEATS is
comprised of 14 scales; these scales are labeled as, #1 prominence of color, #2 color fit, #3
implied energy, #4 space, #5 integration, #6 logic, #7 realism, #8 problem solving, #9
developmental level, #10 details, #11 line quality, #12 person, #13 rotation, and #14
perseveration. This study examined the participants’ artwork using the depression scales, which
include scales one, two, three, four, ten, eleven, and twelve.
Reliability. The authors used 37 raters across the different groups of raters to rate 30
drawing from their pilot sample. Interrater reliability was reported to be .90 or higher for eight of
the 14 scales. Of the remaining scales, the rotation and perseveration scales did achieve interrater
reliability, neither of which was used in this study. Reliability for use in this study may be in
question, as the FEATS has not been normed for children or adolescents.
Validity. Of the remaining twelve scales, the authors reported that 10 scales significantly
correlated to the DSM-IV diagnostic groups of major depression, bipolar disorder/mania,
schizophrenia, and delirium, dementia, amnesia, or other cognitive disorders. This study only
used scales associated with the diagnoses of major depression and validity may be question, as
the FEATS has not been normed for children or adolescents.
Internal Threats to Validity
Subjects’ characteristics may have been affected by the degree of parent(s)’ substance use
disorder issues, socioeconomic background, previous counseling, support circle (family, friends,
and community), and previous level of art education. This study was designed to address the
following internal threats to validity:
History. The treatment and control groups were tested at similar times and in similar
settings.
41
Maturation. Maturation issues were addressed by pre- and post-testing a control group
(without intervention) over a 24-session period.
Thus, the control group mean was compared to the experimental groups to ensure the increase in
self-concept did not naturally occur over time in the sample population.
Testing. The pretest may have alerted the participant to the self-concept issue. One
treatment group did not take the TSCS:2 as a pretest, and random treatment participants were
given the midtest. All participants took the PH:2 as a pretest and the TSCS:2 as a posttest, which
were highly correlated.
Instrumentation. Instrumentation may have threatened the internal validity if the
researcher/therapist’s characteristics were too varied. However, the same therapist(s) and
directives were used throughout the study. The TSCS:2 was used in all three observations, and
the PH:2 scores were then used to replace missing TSCS:2 pretest scores to validate the effect of
the independent variable. Additionally, the FEATS is normed for adults, although the use of the
depression scales with these participants was deemed appropriate and may contribute to further
studies to establish validity and reliability for use with children and adolescents.
Regression. The mean differences include the extreme scores for both the control and
treatment groups.
Selection. All volunteer participants were randomly assigned one of two treatment
groups or the control group.
Mortality. Because of the size of the study, mortality could have been an issue; however,
the researcher was prepared to form an additional set of groups and repeat the study if necessary.
As the treatment group’s dropout rate was higher than the control group’s rate, this remained an
issue; and because the sample size was so small, all inferences must be viewed with caution.
External Threats to Validity
Interaction of testing, selection, and “X.” Extraneous variables that may have affected
the hypothesis include (1) the degree of parent(s) alcohol-related disorder(s) and subsequent
behavior, (2) socioeconomic background, and (3) extent of emotional support (family, friends,
and community).
Reactive arrangements. The volunteers for both the treatment and control groups were
from small public schools and may not be representative of the sample population at large.
42
Data Collection and Evaluation Procedures
The data collected were both quantitative and qualitative in nature and included self-
reported information from the intake interview, SASSI-A2, PH:2, TSCS:2, and coding of
patterns observed in participants’ artwork and self-reports as recorded in the researcher’s clinical
notes. The SASSI-A2, PH:2, and TSCS:2 are norm referenced to older children and adolescents.
The FEATS is normed for adults, but was used appropriately in this study.
The intake and screening data were recorded electronically for each individual, which
facilitated comparison, grouping, and regrouping of data for statistical analysis (see Appendix
D). The quantitative outcome data of the TSCS:2 and the PH:2 were also recorded electronically
for each individual and used for comparative data analysis using IBM’s Statistical Analysis in
Social Science, previously known as by the acronym SPSS.
In order to establish a baseline for self-concept before participating in the study and avoid
the testing error for internal validity, all of the original participants took the PH:2. Randomly
selected experimental subjects, as well as all of the control group subjects, took the TSCS:2
before beginning the study. According to Fitts and Warren (2003), the correlation coefficient
between the two self-concept instruments ranged from 0.51 to 0.80, with the Total Self-concept
(TOT) scores correlation coefficient as 0.66. The TSCS:2 manual’s reported correlation
coefficient (r = 0.66) agrees with the PH:2 manual (Piers, Harris, & Herzberg, 2009), therefore
the correlation coefficient of 0.66 was used in the analysis of this study’s data (see Appendix C).
Specifically, using the correlation table between the PH:2 and TSCS:2, 15 separate paired
t-tests were performed on the subtest scores, including the TOT scores and the supplemental
scores for the domains of O1 to X
1 and O
1 to X,
for all the participants (see Appendix J). The
tests were performed again for the qualified sample group. The paired t-tests were used to
compare how the experimental and control groups performed before and after an intervention, as
well as over the course of both interventions. For the subtests, which had a significant change in
p-values (p < .05) or at least one p-value that was greater than (p > .05) and the set significance
value of 0.05 (sig = 0.05), it was necessary to look into the distribution of difference and the
pattern of change in the mean scores to identify the effects of X1 (PVV) and X
2 (CBATx).
The TSCS:2/PH:2 supplementary scores from the participants’ individual butterfly charts
were evaluated, as they appeared to correspond to Beck’s (1997) theories around internal
43
communication. Specifically, this refers to negative self-statements, arbitrary reference, and
biased processing. According to Fitts and Warren (2003):
The Supplementary scores are groups of TSCS:2 items from each Self-Concept
subscale that have historically been classified as expressing one of three primary
messages: (a) this is who I am, this is how I identify myself or Identity (IDN); (b)
this is how satisfied I am with myself, or Satisfaction (SAT); and (c) this is what I
do, this is how I behave, or Behavior (BHV). These are scores that have been
delineated on a theoretical basis only, and they are assumed to represent an
internal frame of reference within which the individual describes himself or
herself. (p. 25)
In order to elucidate these findings further, the qualitative criterion for each activity was
rated by using measurable objectives. Moreover, the qualified sample’s artwork was analyzed in
comparison to matched experimental subjects’ artwork. The measurable objectives were: The
participant utilized art materials to 1) identify, categorize, and create feeling states, 2) reduce
anxiety, associated with feeling states, 3) generate solutions to problems, 4) construct a PVV to
identify, categorize, and generate symbolic content in artwork, 5) apply the PVV to address the
participant’s familial issues in a visual narrative format, as evidenced by participant artwork,
clinical notes, or self-report, and 6) explore levels of the ETC by using a variety of media.
Further evaluation of the artwork was conducted by using Gantt and Tabone’s (1998)
Depression Scales, a portion of the FEATS (see Appendix F) and Lusebrink’s (1990) theory of
the ETC (see Appendix G). Specifically, Lusebrink’s ideas on formal elements, associated with
“masked depressive reactions,” alexithymia, and Jungian theory on symbol development were
recorded. A guided critical analysis and group discussion were completed using an adaptation of
Anderson and Milbrandt’s (2005) Analytical Art Criticism Model (see H). Finally, the
experimental participants were given the opportunity for a closing review, during which we
reviewed the therapeutic objectives and the study criteria, using an End of Study
Objective/Criteria Assessment questionnaire (see Appendix H). The subjects used a Likert scale
to rate themselves as No (1) = not meeting the objective/criterion; Sometimes (2) = meeting the
objective/criterion; or Yes (3) = met the objective/criterion.
44
Summary
This Art therapy study used a randomized pretest-midtest-posttest experimental research
design with a control group. The purpose of this study was designed to increase the positive self-
concept for high-achieving adolescent children of alcoholics, who demonstrated a low
probability of substance abuse disorders, using Cognitive Behavior Art Therapy (CBATx),
and/or the development of a personal visual vocabulary (PVV). The implication for this study
was reflected in the following hypothesis: Participation in one or both of the art therapy
intervention will significantly increase the level of positive self-concept, as measured by the
correlated total self-concept (TOT) scores for all of the experimental participants or the qualified
sample. The levels of self-concept were measured by statistical analysis of the Tennessee Self-
Concept Scale, Second Edition (TSCS:2), correlated with the Pier Harris Children’s Self Concept
Scale, Second Edition (PH:2) TOT scores during three observation periods.
The convenience sample consisted of nine qualified adolescents out of 23 voluntary
participants from three small public schools in north central Florida. All participants were
randomly assigned to one of two experimental groups or one control group. After completing the
study, the participants were qualified as having met the study criteria, using information from the
original intake questionnaires/instruments. The qualifying participants had the following
attributes: a) adolescent, b) children of alcoholics or children from families with alcohol-use
disorders (CoA), c) high-achieving, and d) demonstrating a low probability of substance abuse
disorders (SUDs).
Participants were offered eight 90-minute weekly sessions of art education-based
directives in constructing a PVV, followed by participating in eight 90-minute weekly sessions,
based on CBATx directives, while working towards a visual narrative, or the opportunity to
participate in a control group. The study used a randomized, three-interval test (O1, O
2, and/or
O3) design with one control group and included two interventions (X
1 and X
2). The control group
took a pre-test (O1) and a post- test (O
2) with an approximate 18-week interval. The art
education-based intervention focused on the construction of a PVV, using the art elements of
line, shape, color, value, and form. The CBATx interventions focused on feeling states, visual
problem-solving, storytelling, and visual narrative development. In keeping with the tenets of art
therapy, all art directives were designed to move the participant around the Expressive Therapies
Continuum (ETC) by providing opportunities to work with a variety of materials.
45
The quantitative outcome measurement instruments for this study were the TSCS:2 and
the PH:2, which were administered pre-interventions for one control group and one experimental
group; administered to a few experimental participants between interventions; and administered
to all the participants at the end of the study. There were post-interventions for all three groups.
Quantitative data were collected, coded, and organized electronically, so they could be
compared, grouped, and regrouped, according to intake information (see Figures 27 to 41). The
qualitative measurements included participants’ artwork, self-statements, and evaluation of pre-
established objectives (see Figures 42 to 48).
46
CHAPTER FOUR
RESULTS
The primary problem addressed in this study was, how to identify and serve adolescent
children of alcoholics (CoA) who were high-achieving and demonstrated a low probability of
substance-use disorders as a mental health clinician. The purpose was to increase this
population’s positive self-concept, a measurable and observable trait related to resiliency, using
one or both experimental art therapy interventions. The specific interventions were a) an art
education-based intervention, “constructing a personal visual vocabulary (PVV),” and b)
Cognitive Behavioral Art Therapy (CBATx) based directives, which included working toward an
image based personal narratives, or the trauma narrative.
As mentioned in Chapter Three, the design and methodology of this study used
techniques to reduce anxiety and stress associated with being identified as a child from a family
with substance abuse issues, or children of alcoholics (CoA). CBATx and art education based
directives were given in a peer-to-peer supportive educational environment in order to create a
sense of belonging, acceptance, and normalization. Furthermore, the focus on personalization of
symbolic content was designed to strengthen the population of interest's self-concept through
individuation while facilitating positive reframing and the non-verbal expression of difficult
thoughts and feelings and family secrets.
Following is a description of the experimental and control group's demographics, as well
as the presentation of both quantitative and qualitative results after attrition. The qualified
sample's artwork, self-statement, and Tennessee Self Concept Scale, second edition (TSCS:2)
supplementary scores were compared to that of the matched sample's corresponding data to
further triangulate the quantitative findings. The qualified sample was consisted of the
experimental groups' high-achieving adolescent CoA who demonstrated a low probability of
SUDs and the matched sample consisted of the experimental groups' non CoA adolescents
demonstrating a low probability of SUDs. These participants were matched in terms of age, sex,
and achievement level. The discussion, implications, and limitations for this study are given in
Chapter Five.
47
Description of the Sample
Qualifying demographic attributes were self-identified using a questionnaire, approved
by the Florida State University Internal Review Board and Human Subjects Committee (see
Appendix B). Participant demographics were self-reported (see Table 4 and Table 14). The mean
ages for the participants were as follows: 13 years in the experimental group, 14 years in the
qualified sample group, and 14.5 years in the control group. The experimental group’s age range
was from 10.2 to 15.2 years, with a mode of 14. The qualified sample group’s age range was
from 13 to 15.2 years with a mode of 14. The control group’s age range was from 13 to 16.9
years with a mode of 13. In the experimental group, 58% reported being children of alcoholics,
whereas 75% of the control group and 100% of the qualified sample indicated familial alcohol-
related issues. Success in school was assessed using the grade point average (GPA) needed to
earn a State of Florida’s Bright Future Scholarship and was self-reported based on current grade
point average. The mean GPA for the experimental group was 3.6, the qualified sample’s mean
GPA was 3.6, and the control group’s mean GPA was 3.8.
Table 4. Self-reported Data on Qualifying Status and Demographics.
All Experimental
Participants (n = 19)
Qualified Sample (n
= 6)
Control Group
(n=4)
Familial Alcohol Use
Disorder
CoA
Not
CoA
56%
44%
100% 75%
25%
Age Range
Mode
Mean
10.19-15.19
14
M: 13.01, SD 1.65
13-15.19
14
M: 14.22, SD .86
13-16.91
13
M: 14.6, SD 1.69
Grade Point Average
(GPA)
M=3.6; SD=0.47 M: 3.6, SD: 0.38 M: 3.78, SD: 0.26
Sex Female
Male
55%
45%
17%
83%
100%
Race/Ethnicity Other
Asian
Black
White
11%
0%
26%
63%
0%
0%
33%
67%
0%
0%
0%
100%
Note. The following is a list of abbreviations used in this table:
CoA = Children of Alcoholics
n = number of participants
M = mean
SD = standard deviation
48
For the purpose of this study, the terms ‘sex’ and ‘race’ were defined in the following
way: Sex was listed as male or female, and race was listed as white, black, Asian, or other.
Persons who identified as Hispanic, Native American, or any other race or ethnicity had the
option of choosing “black, white, Asian, and/or other” with a space for further delineation, as
desired by the participant. Although some of the participants discussed various options with me
at the intake, only one participant chose “other” but did not elaborate. Out of the experimental
participants, 47% reported their sex as female, 13% of the qualified participants reported their
sex as female, and 100% of the control group reported their sex as female. With the four
racial/ethnic groups listed—White, Black, Asian, and other—the participants were self-identified
as follows: the experimental group was 63% White, 26% Black, 0% Asian, and 11% other. The
sample was 67% White and 33% Black. The control group was 100% White.
Quantitative Results
Results for Qualified Sample
The qualified sample consisted of six participants (n=6) for the first intervention and five
participants (n= 5) for the second intervention. However, not all of the participants in the
qualified sample used the Tennessee Self Concept Scale, Second Edition (TSCS:2) during all
three observation periods. Therefore, the statistical results suggest that we proceed with caution
when calculating the effect size.
Nonetheless, initial results from the paired t-test indicated that there was no statistically
significant difference in the correlated TSCS:2 and the Piers-Harris Children’s Self-Concept
Scale, Second Edition (PH: 2) total self-concept score (TOT) score means for the qualified
sample, following the participation in one or both interventions (see Figures 1 and 2).
Specifically, using the correlation table between the PH:2 and TSCS:2, the TOT score means, for
the domains of O1 to O
2 and O
1 to O
3 for the qualified sample, indicate there was no significant
change in p-values after the first intervention (t = -2.16, p = 0.1630), or after both interventions(t
= -1.52, p = 0.2034). In other words, the p-values were greater than the set significance value of
0.05 (sig = 0.05); this indicates an acceptance of the null hypothesis for the qualified sample.
Moreover, it was necessary to examine the distribution of difference and the pattern of change in
the score means to identify the effects of X1
(PVV) and X2 (CBATx) on the qualified sample.
49
Figure 1. T-test statistics output for TOT of
qualified sample from O1 to post-X
1.
Figure 2. T-test statistics output for TOT of
qualified sample from O1 to post-X
2.
Figure 3. Distribution of difference for
qualified sample from O1 to post-X
1.
Figure 4. Distribution of difference of
qualified sample from O1 to post-X
2
Figure 5. Paired profiles for qualified sample
from O1 to post-X
1.
Figure 6. Paired profiles of qualified sample
from O1 to post-X
2.
50
Table 5. TOT Scores, Means Percentage of Change after Each Intervention for the Qualified
Participants and the Control Group
The distribution of difference for the qualified sample (see Figures 3 and 4) shows a normal
distribution of means after the first intervention (O2) but clearly demonstrates an outlier in the
final observation after both interventions (O3). Possible reasons for this skew will be commented
on in the discussion section of this text.
The results of the paired profiles for the qualified sample (see Figures 5 and 6) indicate
that the trend of scores increased significantly from observation one (O1) to observation two
(O2). The trend of scores continued to increase slightly over the course of the whole study, as
indicated at observation three (O3). Furthermore, in calculating the percentage of increase, the six
qualified subjects from the experimental groups (Y1 +Y
2), who were measured after the first
intervention (X1), demonstrated significant improvements in positive self-concept (O
2; +24%).
Additionally, the five qualified subjects (Y1 + Y
2), who participated in both interventions (X
1 +
X2), demonstrated a higher improvement in positive self-concept (O
3; +16.5%), in comparison to
the three qualified subjects (Y3) from the control group (O
3; +6.7%). As both groups’ TOT score
means increased over time, we may calculate the maturation error by simply subtracting the
percentage of TOT score means’ increase for the control group from the percentage of TOT
Ex Ex Ex Ex Ex Ex C C C Ex C
ID
Number
01 03 21 16 09 12 17 18 20
Group Y1 Y
1 Y
1 Y
1 Y
2 Y
2 Y
3 Y
3 Y3 Y
1 +Y
2 Y
3
n=6 n=3
TSCS:2/PH:2 TOT O1 36 56 52 54 41 41 52 59 68 M=46.7
SD=8.3
M = 59.66
SD = 6.58
PVV X1 1 1 1 1 1 1 0 0 0
TSCS:2
TOT
O2 57 59 62 54 - - M=58
SD=8.5
Percentage of
change
+24%
CBATx X2 1 1 0 1 1 1 0 0 0 n=5 n=3
TSCS:2
TOT
O3 35 56 - 59 50 72 61 62 68 M=54.4
SD=13.5
M = 63.67
SD = 3.10
Percentage of
change
+16.5% +6.7%
Total Percentage of Change for Qualified Sample +9.8%
51
score means’ increase for the experimental groups. Therefore, the statistic demonstrates a 9.8%
increase for the experimental group, after the group participated in both interventions (O3; see
Table 5).
Figure 7. T-test results for the control group.
Figure 8. Distribution of difference for the
control group.
Figure 9. Line of projection for the control
group.
Results for Control Group Sample
The control group consisted of four participants; three of the subjects qualified as high-
achieving, adolescent CoA, who demonstrated a low probability of SUDs. As with the qualified
sample, the corresponding results for the control group for the paired t-test indicate a p-value that
was greater than 0.05, (O3; t = -1.51, p = 0.2278; see Figure 7). Therefore, the probability of
52
significance is inconclusive. However, the distribution of difference plot indicates a normal
distribution (see Figure 8). In addition, the paired profile plot indicates a minimal positive
increase in self-concept (see Figure 9), which is also indicated with the difference in increase for
the control group's percentages of means (+ 6.7%; see Table 5). This information is useful for the
purpose of the control group; we may subtract the control group’s percentage of increase for the
score means from that of the qualified sample and that of the experimental group in order to
calculate the percentage of increase accurately.
Results for All of the Experimental Participants
The total number of participants from the experimental groups, both qualified and not
qualified, for the first intervention was 19. The total for the second intervention was 16. As with
previous results, not all of participants took the Tennessee Self Concept Scale, Second Edition
during all three observation periods Therefore, the statistical results suggest that we proceed with
caution when calculating the effect size.
Nonetheless, the initial results from the paired t-test indicated that there was a statistically
significant difference in the correlated TOT scores for all experimental participants, after the
participation in both interventions at observation three (O3), but not after the first intervention
(see Figures 10 and 11). Specifically, for the domains of O1 to X
1, the statistics were O
2, t = -
3.44. p = 0.0698, and for the domain of O1 to X
2, the statistics were O
3, t = -4.71, p = 0.0002).
In other words, after both interventions, the p-value was less than the set significance value of
0.05 (sig = 0.05), which indicates a rejection of the null hypothesis.
As with the qualified sample, to further elucidate the effects of X1 (PVV) and/or X
2
(CBATx), an examination of the output data provided important information. Specifically, this
refers to the distribution of difference (see Figures 12 and 13) and the plots of paired profiles
indicated (see Figures 14 and 15). The distribution of difference shows a normal distribution of
means after each intervention. Furthermore, the trend lines from the paired profile plots
demonstrate a significantly increase, after the PVV intervention, which continues over the course
of both interventions.
For the calculation of the percentage of increase, the participants from the experimental
groups, who participated in both interventions (X1 + X
2), demonstrated a higher improvement in
positive self-concept (O3; +14.4%), in comparison to the participants from the control group (Y
3;
O3; +6.3%). Because the TOT score means for both groups increased overtime, we can calculate
53
the maturation error by subtracting the percentage of TOT increase for the control group from
the percentage of TOT increase for the experimental groups. This statistic demonstrates an 8.1%
increase in TOT score means for the participants from experimental group at observation three
(O3). The TOT score means for each observation and the percentage of change for all the
participants are presented below in Table 6.
Summary of Quantitative Results
A paired t-test was used to calculate total self-concept (TOT) scores for the qualified
sample, all the experimental participants, and the control group. Levels of self-concept before
and after each of the two interventions were compared. The results indicated statistical
significance for all the experimental participants after both interventions using the set
significance value of p<0.05 (Y1+Y
2; O
3; t(18) = -4.71, p = 0.0002), or from Observation One
(O1; M = -10.5, SD = 7.6), to Observation Three (O
3; M = -14.4, SD = 13.3), based on the
correlated TSCS:2/PH:2 TOT scores. The number of computed TOT scores from the qualified
sample were too small to infer a significant effect value at Observation Two after the first
intervention (O2 ; t(2) = -2.16, p = 0.1630), or at observation three after the second intervention
(O3;
t(4) = -1.52, p = 0.2034); therefore, the percentages of change for the TOT score means
were calculated.
The qualified sample demonstrated a 24% increase in positive self-concept at
Observation Two (O2) and maintained a total increase of 16.5% at Observation Three (O
3). All
of the experimental participants demonstrated a 14.4% increase in positive self-concept over the
course of the study (O3). Moreover, the control group demonstrated a 6.7% increase of positive
self-concept (O3). In other words, according to the linear trend lines, the difference in mean TOT
score means indicated a positive increase for the qualified sample after the first intervention, and
the positive increase continued until the end of the study (O3).
According to the trend lines and
percentage of increase across both interventions and all three data collection points of the
TSCS:2/PH:2 TOT score means, the qualified sample, as well as all the participants in the
experimental groups, the qualified and nonqualified sample, (Y1 and Y
2), increased their
positive self-concepts by at least 8% (see Table 6).
Based on these results, we may infer that 16 weeks of art therapy sessions increased the
positive self-concept for high-achieving adolescent CoA, who demonstrated a low probability of
SUDs. Additionally, we may reject the null hypothesis, as the effect value was less than the set
54
significance value (p < .05) for all the participants, after they participated in both interventions.
Additionally, the results indicated that constructing a PVV increased positive self-concept at a
higher rate than both constructing a PVV and participating in CBATx with a focus on creating
visual narrative (see Table 6 and Figure 16).
Figure 10. T-test statistics output for tot of
experimental groups from O1 to post-X
1.
Figure 11. T-test statistics output for tot of
experimental groups from O1 to post-X
2.
Figure 12. Distribution of difference for
experimental groups from O1 to post-X
1.
Figure 13. Distribution of difference for
experimental groups from O1 to post-X
2.
Figure 14. Paired profiles of qualified sample
from O1 to post-X
1.
Figure 15. Paired profiles of qualified sample
from O1 to post-X
2.
55
Table 6: TOT Scores, Means, Standard Deviation, and Rate of Increase for all Participants
Figure 16. Comparison of group TOT score means at observations O
1, O
2, and O
3.
46.7 44.6
59.7 58 59.3 54.4
59.1 63.7
0
10
20
30
40
50
60
70
Qualified Sample Qualifed and
Nonqualified
Participants
Control Group
TO
T G
rou
p M
ea
ns
Groups
Comparison of Group TSCS:2/PH:2 TOT Score
Means
Pre-Interveions - O1
After PVV - O2
After PVV and CBATx - O3
Y1
+ Y2 Y
3
n=23 n=4
TSCS:2/PH:2 TOT O1 M = 44.6; SD = 10.05 M = 60.0; SD = 6.6
Intervention X1
n=4
TSCS:2 TOT O2 M = 59.25; SD = 2.06
Percentage of Change +14.65%
Intervention X2
n=19 n=4
TSCS:2 TOT O3 M = 59; SD = 10.9 M = 63.8; SD = 3.10
Percentage of Change +14.4% +6.3%
Y1
+ Y2 - Y
3 = ^8.1%
56
Qualitative Results
Sample and Matched Experimental Participants
The sample’s artwork was evaluated for symbolic content and graphic indicators. Then,
the artwork was compared to a sample of nonqualified experimental subjects’ artwork, the
matched sample (see Appendix K). Clinical notes were scanned for negative self-statements that
were made during the aesthetic criticism process or the final individual evaluation. Although I
noted several disruptive behaviors and a few negative self-statements, there were not enough
incidents to draw meaningful conclusions over time. Therefore, the individual supplementary
scores of the TSCS:2 that corresponded to Beck’s theory of internal communication system were
evaluated. Additionally the participants’ artwork and self-statements that were made during the
art criticism process provided interesting information that substantiates increased self-efficacy
and positive self-concept.
The FEATS major depression scales. According to Gantt and Tabone (1998), the
purpose of using the FEATS in drawing analysis is to focus on how the participants draw, rather
than what they draw; this is meant to provide objective information on the non-symbolic aspects
and structural characteristics of the art. The FEATS was developed primarily for use with adults
and for use in conjunction with the PPAT assessment. Therefore, the ratings may not be accurate.
The authors listed the following characteristics in the FEATS scales as graphic equivalent of
major depression symptoms; a) depressed mood, which includes scale #1-Color Prominence and
scale #2-Color Fit; b) loss of energy, which includes scale #3-Energy and #4-Space; and c)
diminished interest, which includes scale #7-Realism, scale #10-Details, and scale #12-Person.
The artwork by the qualified sample, who participated in both interventions, was
compared to the artwork by matched (age and sex) members from the experimental group. This
comparison was made by using the scales that Gantt and Tabone associated with the DSM-IV
criteria for Major Depression. The specific scales used were: Color Prominence, Color Fit,
Energy, Space, Realism, Details, and Person (See Appendix E).
The FEATS scales range from zero (no drawing) to five (meaning varied per scale), with
a three being more or less average. The mean for the qualified sample’s artwork, after the first
intervention, (O1 to O
2) was 3.1, as compared to the mean for the matched participants, which
was 3.4. The mean for the qualified sample’s artwork, after the second intervention (O1 to O
3),
was 3.4, as compared to the mean for the matched participants, which was 3.6 (see Figure 17).
57
Figure 17. FEATS depression scale ratings at O
2 and O
3.
Figure 18. Cluster of simple means for FEATS major depression score scales.
3.1
3.4 3.4
3.6
2.8
2.9
3
3.1
3.2
3.3
3.4
3.5
3.6
3.7
PVV CBATx
FE
AT
S s
cale
Ra
tin
g
Interventions
Comparison of Sample
Means for FEATS Major Depression Scale
Qualified Sample
Matched Sample
Linear (Qualified Sample)
Linear (Matched Sample)
0
1
2
3
4
5
6 1
2.5 2.5 2 3.5 2.5
3.25 3.75
3 4
3.6 3.6 3.6 3.6 2.7 3.6 2.8
2.4 4.2
4.2 3.3
3.8 3.4
3.5 1 1 2.8 4 3.4 3.6 4.6 2.5
2.5 2.5
3.25 4.75
2 3.75
3.75 3
3.5 2.75
3 4.25
5 3
4.5 3.75
3.5 2.5
4.5 3 5 5 5
Distribution of Sample Means for
FEATS Major Depression Scale
Scores
58
Figure 19. Comparison of sample means for a specific outlier scale score on the directive
entitled, The Element of Line.
On a scale from one to five, even a half-point increase seems significant. As indicated
previously, the linear trend lines demonstrate that the average graphic equivalents for depression
decreased during the course of both interventions. Furthermore, the scale score means for both
groups at both observations was equal to or above the average score means (<=3.0), as indicated
by the clustering of FEATS scale score means in Figure 18.
In the examination of specific paired outlying scores for specific directives, it was noted
that both the qualified and matched samples demonstrated similar means, as seen in Figure 19.
This indicates that there was a similar response from both the qualified sample and the matched
sample in creating the artwork for that specific directive. For example, both of the drawings in
Figure 20 demonstrated low-color prominence and low energy (unfinished work). As all outlying
scores demonstrated patterns that were similar to those shown in Appendix E it may be inferred
that graphic indicators for depression decreased significantly. It may be also inferred that none of
the participants demonstrated the graphic equivalents of major depression symptoms over the
course of the study.
1.8
2.3 2.5
3
2 2
0
0.5
1
1.5
2
2.5
3
3.5
Depressed Mood Loss of Energy Diminished Interest
Qualified Sample
Matched Sample
59
Qualified Participant's Artwork- Nicht Werden
Matched Participant's Artwork - Vortex
Figure 20. Artwork from the qualified sample and the matched sample showing little color and
level of completion.
Beck’s theory of internal communication system and the TSCS:2. Beck’s (1977)
theory of internal communication system, or his cognitive triad theory for depression, suggests
noting a person’s anxiety-producing and self-critical self-statements in order to determine that
person’s sense of self. Specifically, the concepts behind negative self-statements, arbitrary
reference, and biased processing were matched to three TSCS:2 supplementary scores, identity
(IDN), satisfaction (SAT), and behavior (BHV). Increases in these scores indicate a decrease in
negative self-statements. A score between 40 and 70 falls within the typical or average range.
The results indicated that the qualified sample demonstrated an increase of 37% for the
TSCS:2 supplementary mean score from Observation One to Observation Two (O1 to O
2), as
compared to the matched sample's increase of 59%. The qualified sample demonstrated a 24%
increase of The TSCS:2 supplementary mean scores from Observation One to Observation
Three (O1 to O
3). By comparison, the mean increase for the matched sample from O
1 to O
3 was
27%. Finally, the increase from O1 to O
3 for control group was 27% (see Table 7). As previously
60
noted, the rate of increase for both samples was higher after participating in the first intervention
than after participating in both interventions (see Figure 21).
Table 7. Qualified Sample and Matched Sample’s Supplementary Scores Mean Increase
Figure 21. Qualified sample’s percentage of change in TSCS:2 supplementary mean scores related to Beck’s theory of internal communication system.
41
56 51
41
65
52
0
10
20
30
40
50
60
70
O1 O2 O3
T
SC
S:2
Su
mm
ary
Sco
res
Percentage of Change
Qualified Sa ple’s TSCS:2 Scores related to Beck’s I ter al Co u itatio Syste
Qualified Sample
Matched Sample
Linear (Qualified Sample)
Linear (Matched Sample)
01 16 12 03 09 21 Mean 02 04 Mean
Blu
e
De
structo
Bro
dy
Nich
t
We
rde
n
Gh
ost
Ary
an
Sh
iray
uk
i
Vo
rtex
O1
IDN 35 43 37 49 33 47 244/6 40.6 45 33 78/2 39
SAT 29 58 29 58 29 50 253/6 42.1 57 23 80/2 40
BHV 34 35 34 56 39 48 246/6 41.0 46 35 81/2 41
Total Mean 124/3=41 120/3=41
O2
IDN 43 55 61 61/3 53.0 65 65/1 69
SAT 54 61 58 58/3 57.6 69 69/1 69
BHV 53 53 63 63/3 56.9 58 58/1 58
Total
Mean
168/3=56 196/3=65
% of increase +37% +59%
O3
IDN 28 43 61 52 43 227/5 45.4 43 52 95/2 46
SAT 40 66 72 56 46 280/5 56.0 63 61 124/2 62
BHV 31 63 70 52 47 263/5 52.6 48 48 96/2 48
Total Mean 154/3=51 156/3=52
% of increase +24% +27%
61
In examining the individual scores from the qualified sample’s butterfly charts
(see Figure 20), both Blue and Brody presented scores outside of the typical range. In general,
Blue’s low scores, in combination with its low TOT score, indicated a “self-view that is
particularly venerable to situational factors and to the reactions and opinions of others” (Fitts &
Warren, 2003, p. 25). Although Brody’s low scores at Observation One indicated some of the
same issues, regarding negative self-statements, Brody’s above-average cluster, in combination
with an above-average TOT score, indicated inflexibility and a resistance to change. In other
words, Brody may be experiencing biased internal cognitions, based on arbitrary referencing.
Moving around the Expressive Therapies Continuum (ETC). According to Lusebrink
(1990), “The intrinsic qualities of the media influence differentially the levels of information
process involved” (p. 243). The artwork of the qualified samples and matched participants was
analyzed and compared for themes of aggressive, violent, or self-damaging images; Lusebrink
(1990) suggested that these themes are associated with masked depressive reactions. Artwork
was also examined for a) an avoidance of emotional or symbolic content, b) a need for control
over imagery, and c) stereotypical images. Lusebrink (1990) associated all of these factors with
issues related to alexithymia. The goal of an art therapist is to help the client move easily from
“sensory/kinesthetic” interactions with the media to an “affective/perceptual” response during
the cognitive/symbolic processes. When this is achieved, the client is considered to be on the
creative level of the ETC. Achieving the creative level of the ETC suggests the client had begun
the teleological process, needed for self-efficacy and problem-solving
Using Anderson and Milbrandt’s (2005) Analytical Art Criticism Model as a guide, the
groups participated in an aesthetic criticism of their own work (see Appendix H and Appendix
K). In reviewing the qualified sample’s work, as well as the matched participants’ work, the
themes of aggression and violence, solitude, loneliness, and the unknown were noticed. When
examining Nicht Werden’s inside-outside color psychology/ color value painting and line
drawings (see Appendix K, Figure 43), the group asked questions such as, “Are you going into
the unknown? Would you like to have a companion?” Nicht Werden's and a member of the
matched sample, Shirayuki, both expressed anxiety over transitioning to high school; however,
Shirayuki work did not express such heavy thematic content around loneliness and isolation (see
Appendix K, Figure 49). She stated that "exploring the materials" was her focus rather than
62
trying to build a cohesive PVV. Both Nicht Werden and Shirayuki had stated early in the
sessions that they were not familiar with most art processes.
In speaking about his collection of work (see Appendix K, Figure 45), Destructo said,
“These figures have power over evil, mystical figures that have mastered the unknown, are all
seeing, over time and place." Similar in thematic content, a member of the matched sample,
Vortex commented on his line drawing and form pieces, “It looks like sorrow is coming. My
eyes are drawn to the swords." Vortex mentioned that his work seemed “bi-polar” and that
everything has opposites. He continued to state, “There is evil and destruction in the world but
also happiness. These are the opposites” (see see appendix K, Figure 48).
Finally, Blue, who worked on her inside-outside color psychology and color value
painting (see Appendix K, Figure 42) during most of the first intervention, stated the following
about her finished piece, “These are my ancestors. I want to stand out from my ancestors. I want
to leave; I want to be the light. But it looks like I am getting sucked into a tunnel. I am in the
center or a tornado. There is chaos and nothing."
Artwork from the qualified sample featured animals, such as the bat, bird, wolf, dog, and
meerkats; single figures; mountainous, barren, and open landscapes; elements of fire and water;
objects such as food, swords, castles; geometric shapes; and colors of blue, black, and red.
Although the artwork did not feature images of self-harm, the aesthetic criticism process
revealed themes of aggression and violence, as well as loneliness and helplessness. According to
Jungian theory, these free associations are indicators of buried thoughts and feelings about one’s
everyday world. Jung (1968) and Lusebrink (1990) suggested these theme of violence and
aggression, loneness and helplessness, suggest a masked depressive reaction. Although not
classified in the DSM-5 (American Psychology Association, 2013), the idea behind masked
depressive disorder is that these types of overt behaviors disguise the underlying affective
disorder, or depression. Lusebrink described a masked depressive reaction as one type of
response for people who experience trauma.
On the other hand, most of the nonqualified participants’ artwork featured warm colors,
flowers, sports, and other images. During critiques, the participants indicated themes of hope,
nature, and happiness (see Figure 21). A member in the group even stated, “The fire-breathing
dragon looks like it is protecting something good [the ball], rather than planning something
63
destructive. Another participant said about her work, “Everything is very pretty, colorful and
pink. Everything looks exciting.”
My Adore Shape Mandala
My Adore Shape Mandala
Inside Outside Color Psychology
Inside Outside Color Psychology:
Form Sculpture: The Queen of Rods
Form Sculpture: Star
Figure 22. Sample of artwork completed by nonqualified participants from the experimental
groups.
64
In the examination of the artwork, in terms of the ETC, only one of the qualified participants,
Brody, used resistive materials and depictions of real-world objects throughout the study, despite
being offered a variety of materials (see Appendix K, Figure 45). According to Lusebrink
(1990), “Constriction in the expression and experience of emotion as a psychological
manifestation has been defined by the term alexithymia” (p. 225). In other words, Brody
continued to use constrictive or resistive materials and draw representative or perceptual
drawings, rather than explore symbolic content. Although symbolic content may be “read” into
the artwork, Lusebrink (1990) wrote:
“Memories for alexithymic individuals consist predominately of recollection
imagery, whereby the images are simple reproductions of the objects and
situations without any emotional or personal elaborations. The recall imagery has
a stereotypical quality. The objective quality of the recall imagery increases in
traumatic situations (M'Uzan, 1974) ... This inability to form emotional imagery is
also manifested in the lack of dreaming or inability to remember dreams (Apfel &
Sifneos, 1979). Rigidity and stony expression (Krystal, 1979) also are
characteristic of alexithymia. These characteristics indicate a control of the
sensory-motor component as a means to control emotions... ” (p. 226).
As an illustration of these points, Brody’s final personal narrative book was a depiction
of his family’s trips across the country, using postcard-type colored pencil drawings.
Although Brody’s drawings suggest issues related to trauma-based alexithymia, when the
sculptural piece that he created after the first intervention is examined and compared to a
piece that he created after the second intervention, there is movement from a “constricted
form” to a more abstract and organic form. It may be assumed that Brody was
progressing through the ETC (see appendix K, Figure 45).
Evidence of issues related to alexithymia-masked depressive reactions were indicated by
the individuals’ artwork, based on the ETC and Jungian theory. Specific examples are: a)
Brody’s avoidance of the symbolic level, his need for control over the imagery, and the use of
stereotypical images; b) Destructo’s use of violent and aggressive images; and c) Nicht Werden
and Ghost’s minimal use of space and lone figures. Overall, the qualified sample had the highest
rate of incomplete artwork. In comparison to the matched sample’s finished visual narratives, the
qualified sample’s visual narrative, and artwork in general, was characterized by less color, more
65
empty space, constriction, disorganization, and less completeness and meaningfulness (see
Appendix K).
When participating in the final individual critiques, four out of five qualified participants
stated that they had met the therapeutic objectives and criteria for each project most of the time.
Additionally, three of the five felt that they had experimented with various types of media,
movement around the ETC; this implies increased information-processing, problem-solving, and
self-regulation (see Figure 23 and Table 8).
Figure 23. Qualified samples' self-report on the intervention rating scale.
Case Number 01 16 09 12 03 02 04
Pseudonym Blue Destructo Ghost Brody Nicht
Werden
Shirayuki
Vortex
PVV goals 6/3=2 3/3=1 3/3=1 5/3=1.7 6/3=2 9/3=3 6/3=2
CBATx goals 5/2=2.5 2/2=1 4/2=2 4/2=2 6/2=3 4/2=2 5/2=2.5
ETC 1/1=1 3/1=3 2/2=2 2/2=1 2/1=2 3/1=3 3/1=3
Total 2 1.5 2 2 2.3 2.7 2.3
Note. Self-assessment given to participants at the end of the study during individual processing. The
participants used a Likert Scale to rate their performance in meeting the groups' objectives. The scale
range was from one to three, with the following associations:
1 = no, 2 = sometimes, 3 = yes.
2
1 1
1.7 2
2.5
1
2 2
3
1
3
2
1
2 2
1.5
2 2 2.3
0
0.5
1
1.5
2
2.5
3
3.5
Blue Destructo Ghost Brody Nicht Werden
Lik
ert
Sca
le S
core
Me
an
s
Qualifed Participants
Summary of Self Report on Achieving
Goals and Objectives
PVV CBATx ETC Mean
Table 8: Mean Scores for Qualified Sample and Matched Sample's End of Study
Objective/Criteria Assessment Questionnaire
66
Summary of Qualitative Results
The analysis of the qualified sample and the matched sample’s artwork, using the
graphic indicators that were associated with the FEATS depression scales, indicated that none of
these participants suffered from major depression. Moreover, the mean scores for the scales
increased as well during the course of both interventions. When the comparison of individual
scores between the qualified sample and the matched participants indicated an issue, such as a
zero score for color prominence, it was found that the actual directive for the artwork was the
cause.
The TSCS:2 supplementary scores, which correspond to Beck’s theory of the internal
communication system, indicated an increase of means after the first intervention of at least 27%
for both the qualified and matched samples. In reviewing the clinical notes for possible reasons
of Blue and Brody’s outlying TSCS:2 TOT scores, it was found that Blue’s low score of self-
concept and Brody’s high scores, indicated different responses to high levels of personal trauma;
this is associated with the alcohol-related issues of the individuals’ parents.
After reviewing the artwork and self-statements made during the critical analysis
procedures, I agreed with the participants’ assessments of their final objective. I believed that all
the participants effectively developed functional self-symbols through power animals, lines,
shapes, colors, value, and form development. Extraordinary examples of self-symbols were the
participants’ power animals, painted line drawings, inside-outside color paintings, and clay
symbolic forms. Evidence that issues, related to alexithymia or masked depressive reaction, were
improved, as indicated by the individuals’ artwork. Specifically, a) participants were able use
words to describe images and tell stories to the group about their images and b) most of the
participants experimented with different materials and expressed themselves symbolically,
perceptually, and kinesthetically. In general, the qualitative data effectively elucidates and
supports the quantitative data in accepting the hypothesis of this art therapy study. In other
words, participation in CBATx and/or developing a PVV did significantly increase the level of
positive self-concept, among the qualified sample.
67
CHAPTER FIVE
DISCUSSION AND CONCLUSION
The primary purpose of this art therapy study was to increase the positive self-concept of
high-achieving children of alcoholics (CoA) who demonstrated a low probability of substance
abuse (SUD), which was the focus population, using one or both experimental interventions. The
specific interventions were Cognitive Behavior Art Therapy (CBATx) techniques and/or the
construction of a personal visual vocabulary (PVV). The results indicated higher efficacy for all
the experimental participants, including the focus population, after participating in the first
intervention, i.e., constructing a PVV. Additionally, results from the paired t-test using the
Tennessee Self Concept Scale, Second Edition (TSCS:2) correlated with the Piers Harris
Children's Self-concept Scales, Second Edition (PH:2). The total self-concept (TOT) scores
indicated the probability of both interventions having a statistically significant effect on the
positive self-concept on all of the experimental participants. These results from both the
quantitative and qualitative assessment tools and instruments are discussed in reference to the
literature as well as the efficacy of the methodology and research design. Additionally, the
limitations, clinical implications of this study, and suggestions for further research are given.
Discussion
Significant numbers of adolescents have experienced familial alcohol-related issues
(Centers for Disease Control, 2013; National Council on Alcoholism and Drug Dependence,
2013, National Institute on Alcohol Abuse and Alcoholism, 2013). In fact, more than 55% of the
experimental participants in this study were willing to disclose familial alcohol use disorders or
statuses as CoA. As was previously noted in this study’s introduction and literature review, this
population has a tendency to internalize rather than externalize their thoughts and feelings. In
other words, they "fly under the radar," making it difficult for school counselors and other mental
health clinicians to identify and meet this specific population's needs (Kaplan, Lui, & Kaplan,
2001; Straussner, 2011). Some of the behaviors identified within this study's focus population, or
qualified sample, were consistent with the broader literature findings. Specifically, the qualified
sample demonstrated a below-average self-concept, anxiety, evidence of masked depressive
disorder, and difficulty talking about painful events (Anda, 2006; Anda et al., 2002; Burnette et
68
al., 2008; Dube et al., 2001; Elgán & Leifman, 2013; Johnson, Cohen, Kaser, & Brook, 2008;
Lusebrink, 1990; Straussner, 2011; Walker & Lee, 1998).
The study design emulated research-based models on successful primary prevention
programs for children from families with alcohol-use issues as suggested by Eskin et al. (2008),
Fenster (2011), Price and Emshoff (1997), and Riley (1999). The after-school small group setting
provided a safe environment and social-support system that included peer-to-peer networking, a
mode to express feelings, and healthy alternative activities, specifically art making. The peer-
group interventions normalized cognitions and emotions regarding the behaviors of their
substance-abusing caregiver (Fenster, 2011; Price & Emshoff, 1997, Riley, 1999)
In keeping with Rosal's (2001) principles of CBATx, the methodology included using art
processes to facilitate development of problem solving and stress-reduction techniques, coping
and social-competence skills, expression of personal constructs, and the exploration of feeling
states. Additionally, the participants significantly increased their understanding of visual literacy,
dynamics, and visual form as content (Arnheim, 1969/2004; Dondis, 1994; Rhyne, 1979). The
group members practiced putting individual words to images, discussed how the elements of art
worked together to create meaning, and used the Analytical Art Criticism Model (Anderson &
Milbrant, 2005) to personalize symbolic content and discuss personal constructs as they built
their PVV.
This study's primary focus on the development of personal symbols supported a critical
‟job of adolescence,” e.g., the development of a strong Self or undergoing the process of
individuation (Jung, 1968; Erikson, 1950/1993). The secondary focus on the art process, rather
than the final product, gave group members the freedom of expression and opportunity to view
every mark as valuable and meaningful. Individual styles emerged through the reciprocal
exchange of ideas, art making, and peer-to-peer discussion. Additionally, the visual narrative and
storytelling directives supported Gantt and Tinnin's (2007) optimal process for working through
trauma, adverse childhood experiences, and issues of alexithymia.
Assessment Tools and Instrumentation
According to the results of the paired t-tests and review of the artwork, clinical notes, and
self-statements, the results indicated that participation in small-group art therapy interventions
over a course of 16 sessions significantly increased the mean total self-concept (TOT) scores for
all the experimental participants in the study. Multiple methods were used to infer an acceptance
69
of the hypothesis, which was stated as, participation in one or both of the art therapy
interventions will significantly increase the level of positive self-concept, as measured by the
correlated TSCS:2 and PH:2 TOT scores for all of the experimental participants or qualified
sample. The results also indicate an increase in positive self-concept for the focus population of
this study, CoA, who were high-achieving and demonstrated a low probability of SUDs. This
directional hypothesis described a positive causal relationship between the participation in one or
both of the interventions (independent variables) and increased positive levels of self-concept
(dependent variable) for this population. These methods included examining the TOT scores and
score means using paired t-test, linear trendlines, and the percent of change. Additional
information was examined to support the hypothesis, and this included evaluating TSCS:2
subtests, participant artwork, self-statements, and clinical notes. A discussion of the results for
the specific assessment interments and tools, the limitations, the implications, and suggestions
for further research follows.
Paired t-tests. Although the qualified sample was too small to infer a significant effect
value (p > .05) based on the TSCS:2/PH:2 TOT scores for the qualified sample, further analysis
of the subtest did demonstrate a significant positive change (p < .05) for some of the subtests.
The specific subtests were self-criticism (SC), conflict (Con), and academic/work self-concept
(ACA). Fitts and Warren (2003) indicated that an improvement in the SC scores suggest the
subject had a more realistic self-concept and decrease in defensiveness. An improved Con score
signifies s/he had a more balanced self-concept and self-acceptance. An improved ACA score
indicates s/he sees him or herself as more confident and has increased feelings of competency in
learning and work situations. The improved ACA score also indicates s/he was more willing to
approach new tasks. Nevertheless, given the small sample size, any findings from the paired t-
tests must be inferred with caution. Additionally, it seems important to note that of the
experimental group, 56% reported being CoA, whereas 75% of the control group and 100% of
the qualified sample indicated familial alcohol issues. In other words, subjects who did not meet
every criterion of the qualified sample self-reported familial alcohol issues. These participants
could not be included in the qualified sample because they did not meet all the criteria, e.g., they
were too young or their grade point average was below the set value of 3.0 or above.
Linear trends and the percent of change. The qualified sample demonstrated a
significant increase in positive self-concept after focusing on the construction of a PVV when
70
looking at the linear trend lines and calculating the percent of change. The sample also
demonstrated a limited degree of improved positive self-concept after the visual narrative portion
of CBATx. Possible explanations for these trends are discussed further in the Personal Visual
Vocabulary and the Adolescent portion of this discussion.
Formal Elements Art Therapy Scales (FEATS). As previously mentioned, the FEATS
is normed for adults, and although the depression scales were appropriate, valid for this study,
and helpful in triangulating of data, the inferences may not be valid for artwork produced by
adolescents. Specifically, the FEATS foci are on structural elements of art, which provide an
easy framework for comparing artwork across populations (Gantt, 2009). The raters in this study
included a practicing fine artist as well as the principal investigator, a certified art educator and
art therapist. The secondary purpose for applying the FEATS depression scales within this study
was to encourage more art therapists and mental health workers to systematically correlate art
therapy assessments alongside standardized assessment tools. In doing this, we strengthen the
field of art therapy and improve the validity and reliability of these assessments.
Beck’s theory of internal communication system and the TSCS:2 supplementary
scores. Several members’ unpleasant behaviors (e.g.), graphic descriptions of violent video
games and hoarding of art materials and food) significantly diminished over the course of the
study. Additionally, both experimental groups independently established, operationalized, and
enforced a version of the rule “be nice.” The groups agreed that this rule applied to self-
statements and talking about each other’s artwork. For example, Nicht Werden expressed
frustration that everyone thought he was a girl because of his long hair. Immediately another
group member said, “It doesn’t matter what people think, you have beautiful hair!” This verbal
pattern of exchange was so frequent so it was not possible to make a meaningful tally of negative
self-talk when scoring Beck’s theory of internal communication system. Therefore, it was
necessary to find the corresponding subtests means from the TSCS:2. The mean scores for each
individual qualified participant confirmed the previous findings by indicating an increase in
positive self-statements, which contributed to the overall TOT scores.
Foundational Philosophical Theories and Therapeutic Approach
The philosophical underpinnings of this study are rooted in Hegelian dialectics, or the
idea that change occurs when the tension caused by a contradiction has been resolved. As
evidenced by an examination of the art, both symbolically and formally, self-statements about
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creating the work, and the improved TSCS:2 scores, it may be inferred that the art criticism
process helped the participants discover and emphasize what they found worthy within
themselves and their artwork. The process of making art for these adolescents allowed them to:
a) externalize and reflect on internal processes, b) initiate gradual change toward more adaptive
or self-satisfactory mental processes, and c) create meaning through metacognition. In other
words, the participants demonstrated the beginning of an ongoing dialectical process, including
an interaction with cognitions, behavior, and environment (Bandura, 1976; Gaiger, 2002;
Vygotsky, 1930/1980).
These experiences will enable self-efficacy and self-regulation within the participant’s
sociocultural and personal context by suspending value judgments on the aspect of aesthetics that
deals with what is beautiful and instead providing materials, opportunity, and encouragement. In
other words, using the idea of Hegelian dialectics, the participants will continue to partake in a
tri-fold process where their self-concept will gradually change over time, creating a spiraling
effect as opposing forces or contradictions rise above one another (Gaiger, 2002). The
supposition is that this teleological effect will result in significant holistic change.
Small Group Cognitive Behavioral Art Therapy and the Trauma Narrative
The participants enthusiastically participated in the body-breath exercise painting,
problem-solution collage, and feeling state drawings directives (Rosal, 2001). The specific
CBATx intervention that proved most difficult for the qualified sample was perhaps the visual
narrative directive or the trauma narrative (Gantt and Tinnin, 2007). The final project involved
the application of their PVV to create visual narratives about their lives. Only two of the five
qualified participants completed this project. Destructo did not complete any part of his narrative
book. Brody created postcard-like drawings of his move from one side of the county to the other.
He did not include any people. Nicht Werden made a series of drawings of the earth from space
entitled The First Three Minutes after Death. Each drawing was the same. It seems these three
participants were reluctant to “expose” family secrets in such a short period (eight or so sessions)
and operated primarily in the cognitive and perceptive domains of the Expressive Therapies
Continuum (ETC; Lusebrink, 1990). One possible explanation for their reluctance might be that
these participants did not have the reflective distance or physical or temporal space to reflect yet
needed to tell their stories.
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Nevertheless, small group therapy provided an appropriate therapeutic venue, as
participants enjoyed peer-to-peer support and empathy and indicated individual feelings of
empowerment (Fenster, 2011, Price & Emshoff, 1997; Riley, 1999; 1999a). Over time,
participants demonstrated significantly reduced problem behaviors, such as negative cross
talking and negative self-comments, while in the group (Beck, 1955/97; Beck, 2011). According
to the clinical notes, it was determined that both experimental groups successfully monitored and
adjusted to the therapeutic factors (Yalom, 2005), or the mechanisms that effect change in group
therapy. Socialization, catharsis, interpersonal learning, altruism, and universality were
specifically noted. This was evidenced by the significant decrease in a few difficult behaviors
and negative comments. Evidence of peer-to-peer support was remarkable, especially when
difficult issues and participant history were discussed. Therefore, it seems CBATx externalized
internal processes in a tangible and lasting way for this population.
Personal Visual Vocabulary and the Adolescent
After completing the dynamic visual vocabulary directive (Rhyne, 1979) and attempting
to sort the “marks” into “alike” categories to represent emotionally laden words, the
experimental group participants reported similar conclusions to Rhyne. Specifically, participants
agreed that some of their marks had some similarities, but a universal line language could not be
made without a “dictator” or decider. This conclusion was foundational to the study, as the group
understood the goal to make a PVV. In other words, they agreed that symbolic language is
personal.
Although the participants spent a significant amount of time researching and interpreting
universal symbols using various resources, during Anderson and Milbrandt's (2005) aesthetic
criticism process, the group as a whole helped each member discover individual patterns and
themes that emerged in their artwork. This process was essential to the intervention. The
participants created art about themselves in an authentic way that helped them interpret and
negotiate their familial issues in the real world by becoming visually literate and constructing a
PVV. Foundational to the intervention based on art education directives in this study were ideas
regarding considering personal context when working with adolescents in the school setting:
I believed in the value of drawing upon personal history, of looking within
oneself as a point of reference. In other words, we should create art about what we
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know, about who we essentially are. We should address our own social, cultural,
political, and emotional points of view
That is what I expected of my students. I expected them to demonstrate
technical skills, such as an understanding of the elements of art and the principles
of design. Importantly, I expected them to use these skills to develop personal
visual vocabularies and to use them for unadulterated self-expression, critical
analysis, and problem solving. I expected every contour line drawing, every
Matisse-style shape collage, every mandala, illustration, portrait, landscape, or
photograph to communicate each individual student’s point-of-view. My final
evaluative question always was, “Did you communicate the idea you intended to?
Why or why not? And if not, did something better evolve?”
Through this process—the creation, publication, and critical analysis of
personal work—my hope was for my students to deconstruct their histories and to
reconstruct new meanings in their lives. My hope was for them to develop a
strong sense of self and to earn a place in the global community, based on their
own extrinsic and intrinsic analyses of their lives. This is authentic problem
solving, ... beyond stereotype, beyond merely extrinsic definitions based on race
or gender or economic status, reflecting the deeper and more genuine qualities of
their shared human lives. (Zettler, 2010, p. 147)
As indicated in the literature review, adolescents are in the fifth stage of development,
identified as learning identity (Erikson, 1950/1993). At this stage, a person is focused on him or
herself in relation to social situations. In other words, the primary objective is to develop a sense
of self and personal identity separate from their families, perhaps even from their friends. The
process of construction of a PVV supported this objective, specifically because the intervention
focused on increasing the sense of self through personal symbols or symbolic representations of
“who I am as an individual.”
Limitations
Results, Study Design, and Sample Size
The primary limitation of this study was the sample size. In the original proposal for this
study, the plan was to exclusively select qualified subjects to participate in the study. However,
as stated in the review of the literature, adolescents who meet all the criteria are underserved
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because they are difficult to identify. Additionally, in trying to recruit participants through
organizations such as Alcoholics Anonymous, Al-Anon/Alateen, and the National Association
for Children of Alcoholics, the indication was that family members recovering from alcohol-use
issues are generally focused on adult issues and rarely involved the children in therapy. Thus,
rather than using only qualified matched participants, any volunteer could participate in the study
with his/her guardian’s permission, and the “blind study” criterion was introduced.
Nevertheless, collecting voluntary participants continued to be a challenge, so study the
design had to be changed at its midpoint. Rather than using the randomized Solomon four-group
design with a control group, the study became a randomized pretest, midtest, and posttest
experimental research design with a control group. Although this test design was appropriate and
valid, the reduced sample size significantly diminished the study’s statistical power and the
magnitude of the effect (e.g., the outlying scores skewed the normative range).
Setting, Population, and Lurking Variables
The therapist/researcher was unaware of which experimental participants would be part
of the qualified sample. Additionally, the participants represented a unique selection of the
adolescent population as they were enrolled in either a rural public school or small public charter
schools. This specific population had strong parental advocates as public charter schools are part
of a CHOICE program. During the consent interview, all of the participants’ guardians expressed
a desire for their children to participate in the study due previous social/emotional issues. It was
interesting to note that most of the participants indicated an interest in being in art therapy,
primarily because they "felt they needed to get better at art." However, most of the participant's
intake TOT scores from the PH:2 and TSCS:2 indicated scores of below-average to average, or
average self-concept. Because the study was “double-blind,” it was assumed that there were
numerous external validity issues. Extraneous variables that may have affected the outcome
were: a) the degree of familial alcohol-related disorder(s) and subsequent behavior, b)
socioeconomic background, and c) extent of emotional support (family, friends, and
community).
In terms of self-reported demographics, the study participants did not reflect the 2010
U.S. Census Report. The qualified sample was 67% White and 33% Black. The report indicated
63.7% non-Hispanic White, 12.2% non-Hispanic Black, 4.7% non-Hispanic Asian, 16.4 %
Hispanic or Latino, and 3% other.
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Outliers, Absenteeism, and Problem Behaviors
Of particular interest in distribution of difference plots were the outliers, or the extreme
individual scores of two qualified participants from the experimental groups. These scores
caused two issues in terms statistical analysis: 1) a decreased positive trendline over the course
of the two interventions, and 2) a two-hump skewed distribution of mean for the TOT scores at
observation three (O3). However, a review of each client’s backstory indicated extreme external
threats to validity. For example, around the midpoint of the study, Blue’s biological sister, who
was her guardian, decided to turn her over to the custody of the state. Her absenteeism increased
and her affect alternated between somewhat flat to elevated. During the final session, she
demonstrated an elevated affect and ran out of the room before the group members could say
goodbye. Her final TSCS:2 subtest scores were as follows: the inconsistent responding (INC)
and Con scores were extremely high, and the faking good (FG) score was extremely low. Fitts
and Warren (2003) suggested this combination suggests ambivalence and a disturbed self-
concept.
Another issue was absenteeism, as many of the members were involved in other
extracurricular activities, specifically a musical theatre performance and chess club competitions.
There was a school-wide flu epidemic in the spring, toward the end of the study. The clients
upheld their agreement to come as often as possible. An interesting aside was that four of the
qualified sample had the highest attendance and participation rate.
Clinical Implications and Suggestions for Further Research
From these results, it was found that that 16 group sessions of CBATx and/or developing
a PVV does increase positive self-concept for the qualified sample and participation in both
interventions, and significantly increased positive self-concept for all the experimental
participants. Possible reasons for these results were developing a PVV that a) supports the
primary “job” of adolescence, to individuate, and b) supports adolescents’ foci on identity and
fidelity versus identity diffusion. Additionally, it may be easier to process difficult material
visually rather than having to “tell the secrets,” as art is a way to externalize internal processes.
The construction of a PVV followed by CBATx with a focus on feeling states, problem
solving, and creating a visual narrative was an appropriate and valid approach for increasing an
individual’s positive self-concept. As indicated previously, in treating adolescent CoA, it is
important to avoid considering the label of CoA as pathology in itself. Additionally, sensitivity to
76
the individual’s attitudes regarding the family system must be taken into account and care must
be taken not to rush the client into revealing the “family secret” before the participant is ready,
even using a PVV. Finally, it is important to spend extra time closing treatment with fragile
clients. Consider recommending another group or art therapist and follow-up as needed.
The possibilities for further research studies are considerable, however, in the interest of
this research, suggestions for further studies include:
Increased correlation studies using art therapy assessments and standardized mental
health instruments by art therapists and other mental health professionals alike.
Increased studies documenting the correlation between resiliency and positive self-
concept for adolescents from families with substance-use disorders.
Further exploration on how constructing a PVV affects the positive outcomes for
adolescents in small group CBATx.
Conclusion
Not only does constructing a personal visual vocabulary (PVV) support adolescents' need
to individuate but CBATx also helps externalize internal processes, providing opportunities for
concept mapping and reframing. Art naturally facilitates the use of created objects such as
houses, cars, and power animals to take on the role of self and facilitates the participants’
understanding of the interrelated nature of cognitive processes, behavior, and their assumptions
about the world as reflected in an improved positive self-concept.
The design of this art therapy study, a double-blind and randomized pretest-midtest-
posttest experimental research design with a control group, supported evidence based research
models that the participants were unaware of the qualifying criteria for the study and the
principal investigator was unaware of which participants would be part of the qualified sample.
The participants were randomly assigned to one of two experimental groups or one control
group. After attrition, data was collected for 23 voluntary participants from three small public
schools in north Florida. Six participants from the experimental groups qualified as the sample
for the first intervention (n=6), five participants qualified as the sample for the second
intervention (n=5), and three participants qualified in the control group (n=3). After completing
the study, the participants were qualified as having met the study criteria using information
gleaned from the original intake questionnaires. The qualifying sample had the following
attributes: a) adolescent, b) children of alcoholics or from families with alcohol-use disorders, c)
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high-achieving, according the criterion set forth by the state of Florida’s Bright Future’s
Scholarship, and d) demonstrated a low probability of substance-use disorders as evidenced by
the SASSI-A2.
Participants were offered eight 90-minute weekly sessions based on art education
directives, followed by eight 90-minute weekly sessions of CBATx based directives. Three
separate sessions were held for completion of the intake materials and assessment tools. The
observations were made via the TSCS:2 at three intervals before and after the two interventions.
The control group took a pretest and a posttest with an approximate 18-week interval to
eliminate the maturation error to internal validity. The educational approach focused on the
development of a PVV using the art elements of line, shape, color, value, and form. The
therapeutic approach was CBATx with an emphasis on feeling states, visual problem solving,
and visual narrative development.
Both quantitative and qualitative data were analyzed to test and observe for significant
improvement in TOT scores as evidenced by the TSCS:2 and the PH:2. The qualitative data
included rated participants’ artwork using the depression scales, a portion of the FEATS, and the
ETC. Visual themes, symbolic imagery, and self-statements were critically analyzed using
Anderson and Milbrandt’s (2005) analytical art criticism model, Beck’s theory of internal
communication, and the Tennessee Self Concept Scale: Second Edition summary scales.
Fifteen separate paired t-tests were performed on each subtest in the domains of to
Observation Two and Observation One to Observation Three using a correlation of the TSCS:2
and the PH::2 TOT scores for the qualified sample, all experimental participants, and control
group. Levels of self-concept before and after each of the two interventions were compared. The
results indicated a significant effect size on the TOT scores for all the experimental participants
after both interventions, t(18) =-4.71, p=0.0002), or from observation one (M=-10.5, SD=7.6) to
observation three (M=-14.4, SD=13.3). The percentages of change for the total self-concept
score means were calculated because the number of computed total self-concept scores from the
qualified sample was too small to infer a significant effect value at Observation Two after the
first intervention, t(2)=-2.16, p=0.1630, or at Observation Three after the second intervention,
t(4)=-1.52, p=0.2034.
The qualified sample demonstrated a 24% increase in positive self-concept at
Observation Two and maintained a total increase of 16.5% at Observation Three. All of the
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experimental participants demonstrated a 14.4% increase in positive self-concept over the course
of the study, and the control group demonstrated a 6.7% increase of positive self-concept. In
other words, according to the linear trendlines, the difference in mean total self-concept score
indicated a positive increase for the qualified sample after the first intervention, and continued to
increase at the end of the study. According to the trendlines and percentage of increase across
both interventions and all three data collection points of the TSCS:2 and the PH:2 TOT score
means, in the qualified sample and as well as all the experiment’s qualified and nonqualified
samples increased their positive self-concepts by at least 8.1%.
Based on these results, 16 weeks of art therapy sessions increased the positive self-
concept for high-achieving adolescent CoA who demonstrated a low probability of SUDs.
Therefore, we may reject the null hypothesis, as the effect value was less that the set significance
value (p<0.05) for all the experimental participants at the end of the study. Additionally, the
results indicated that constructing a PVV increased positive self-concept at a higher rate than
CBATx with a focus on creating a personal visual narrative.
It could be inferred that the average participant maintained higher levels of positive self-
concept over the course of the two interventions then the qualified sample by comparing the
difference of the TSCS:2 and the PH:2 TOT scores means between the qualified sample and all
the participants. This conclusion was reached regardless of age, sex, health, race, or parental
marital status. Even so, for the qualified sample and all experimental participants, further
analysis indicated a decrease in the FEATS associated with depression, an increase in the
creative level on the ETC, reduced negative self-statements, arbitrary associations, and biased
judgment according to the TSCS:2 supplementary scores.
The purpose of this study was to increase the positive self-concept of adolescent CoA
who were high-achieving and demonstrated a low probability of SUDs using one or both
experimental interventions: CBATx and/or the development of a PVV. A review of the literature
indicated that the level of a person’s positive self-concepts is interrelated to one’s resiliency and
the ability to interrupt teleological maladaptive family patterns, including alcohol-use disorders.
Therefore, this study used the observable and measurable personality characteristic described as
positive self-concept. As per the theory of Hegelian dialectics and methods behind group therapy
and the CBATx process, the making and critical analysis of the art was to provide immediate
opportunities for socialization, catharsis, universality, and so on in order to modify behaviors,
79
provide environmental reinforcement, and encourage more adaptive cognitions. As a result,
small group CBATx allowed the experimental population to focus on themselves in the “here
and now,” normalizing their experiences, thoughts, and feelings in a safe environment as
evidenced by the artwork, self-statements, and positive linear trends, which was seen through the
assessment instrument and tools. The philosophical underpinnings for the study were based on
Hegelian dialectics, or the idea that the threefold process referred to as the logic of contradiction.
In other words, everything gradually changes over time in a spiraling method as opposing forces
or contradictions rise above one another and result in significant holistic change.
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APPENDIX A
LIST OF ACRONYMS
Table 9. List of Frequently Used Acronyms ACE Adverse childhood experiences
AUD Alcohol use disorder
C or Con Control group
CBATx) Cognitive Behavioral Art Therapy
CBT Cognitive-behavioral Therapy
CLT Cognitive Learning Theory
CoA Children of Alcoholics
CoSA Children of Substance Abusers
ETC Expressive Therapies Continuum
Ex Experimental groups
FEATS Formal Elements Art Therapy Scales
fMRI Functional Magnetic Resonance Imaging
M Mean or average
n Value for data input
O Observation
PH:2 Pier Harris Children's Self Concept Scale
p-value Probability of significant effect size
SAM or QS Qualified Sample
SD Standard Deviation
sig Significance of Effect
SLT Social Learning Theory
SUD Substance abuse disorder
TOT Total Self-Concept
t-score Raw data score
TSCS:2 Tennessee Self-Concept Scale, Second Edition
X intervention
Y group
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APPENDIX B
INTAKE FORM
Figure 24. Initial intake form used to determine qualification for the study and for calculating
demographics.
82
APPENDIX C
CORRELATING DATA FOR TENNESSEE SELF CONCEPT SCALE, SECOND
EDITION (TSCS:2) AND THE PIERS-HARRIS CHILDREN'S SELF-CONCEPT
SCALES, SECOND EDITION (PH:2)
Table 10. Correlation of the TSCS:2 Scores with the PH:2 from the TSCS:2 Manual
83
Table 11. Correlation Table between the PH:2 And TSCS:2 from the PH:2 Manual
84
Table 12. Corresponding Subtests and Correlations Used for TSCS:2 and PH:2 at O1
TSCS:2 Subtests PH: 2 Subtests
INC = inconsistent response INC = inconsistent response
SC = self criticism
FG = faking good TOT = >66 = faking good
RD = response distribution RES = Response bias
TOT = total self concept score TOT = total self concept
CON = conflict
PHY = physical self concept PHY = physical appearance and attributes
MOR = moral self concept
PER = personal self concept HAP = happiness and satisfaction
FAM = family self concept
SOC = social self concept POP = popularity
ACA = academic/work self concept INT = intellectual and school status
IDN = identity FRE = freedom from anxiety
SAT = satisfaction HAP = happiness and satisfaction
BHV = Behavior BEH = behavioral adjustment
Note. According to Fitts and Warren (2003), the correlation coefficient between the two self-
concept instruments ranged from 0.51 to 0.80, with the Total Self-concept (TOT) scores correlation
coefficie t as 0.66. The TSCS:2 a ual’s reported correlatio coefficie t (r = 0.66) agrees with the
PH:2 manual (Piers, Harris, & Herzberg, 2009), therefore the correlation coefficient of 0.66 was
used i the a alysis of this study’s data.
85
Table 13. Concatenate Table from PH:2 and TSCS:2 for TOT Scores at O1
86
APPENDIX D
COLLECTED DEMOGRAPHICS AND SCORES FOR ALL PARTICIPANTS
Table 14. Collected data from all participants
87
Table 14 - continued
88
APPENDIX E
DEPRESSION SCALES FROM THE FEATS
Figure 25. Depression Scales, a portion of the Formal Expressive Arts Therapies Scales by
Linda Gantt (1998).
89
Figure 25 - continued
90
Figure 25 - continued
91
APPENDIX F
SCORING SHEETS FOR QUALIFIED SAMPLE'S AND MATCHED SAMPLE'S
ARTWORK USING THE DEPRESSION SCALES FROM THE FEATS
Table 15. Scoring Sheets for the Qualified and Matched Samples' Artwork Using the Depression
Scales from the FEATS
Case Number 01 16 09 12 16 Mean
Score
x Mean
Score
y
Pseudonym
Blu
e
De
structo
Gh
ost
Bro
dy
Nich
t
Sh
irayu
ki
Vo
rtex
PVV
ANIMAL - 3D 3D 3D 3D
#1 Color
Prominence
- - - 2 0 2/2 1 1 - 1/1 1
#2 Color Fit - - - 5 0 5/2 2.5 5 - 5/1 5
#3 Energy - - - 2 3 5/2 2.5 2 - 2/1 2
#4 Space - - - 1 1 2/2 2 2 - 2/1 2
#7 Realism - - - 4 3 7/2 3.5 2 - 2/1 2
#10 Details - - - 2 3 5/2 2.5 2 - 2/1 2
#12 Person - - - - -
Tally - - - 16/6 10/6 2.2 14/6 - 2.3
LINE
#1 Color
Prominence
- 3 5 5 0 13/4 3.25 2 5 7/2 3.5
#2 Color Fit - 5 5 5 0 15/4 3.75 1 5 6/2 3
#3 Energy - 4 3 3 2 12/4 3 2 3 5/2 5.5
#4 Space - 5 5 5 1 16/4 4 1 4 5/2 2.5
#7 Realism - 4 5 5 0 14/4 3.6 1 5 6/2 3
#10 Details - 4 5 5 0 14/4 3.6 1 5 6/2 3
#12 Person - - - - - - -
Tally 25/6 28/6 28/6 3/6 8/6 27/6
4.16 4.66 4.6 .5 3.5 1.3 4.5 9.3/2 2.9
SHAPE
#1 Color
Prominence
5 5 3 5 0 18/5 3.6 4 4 8/2 4
#2 Color Fit 3 5 5 5 0 18/5 3.6 4 3 7/2 3.5
92
Table 15 - continued
Case Number 01 16 09 12 16 Mean x Mean y
#3 Energy 3 4 2.5 4 0 13.5/5 2.7 3 3 6/2 3
#4 Space 5 5 3 5 0 18/5 3.6 5 4 9/2 4.5
#7 Realism 2 5 3 4 0 14/5 2.8 4 4 8/2 4
#10 Details 2 5 2 3 0 12/5 2.4 3 3 6/2 3
#12 Person - - - - - -
Tally 13 35 19.5 28 0 3.1 15 14 32.1/12 3.7
COLOR
#1 Color
Prominence
5 4 4 3 5 21/5 4.2 5 5 10/2 5
#2 Color Fit 5 5 4 2 5 21/5 4.2 5 5 10/2 5
#3 Energy 5 4 3 1.5 3 16.5/5 3.3 3 4 7/2 3.5
#4 Space 5 3 4 2 5 19/5 3.8 5 5 10/2 5
#7 Realism 3 3 3 3 5 17/5 3.4 3 5 8/2 4
#10 Details 5 3 2.5 2 5 17.5/5 3.5 4 5 9/2 4.5
#12 Person - - - - - - -
Tally 28 22 20.5 13.5 28 3.7 25 29 4.5
FREE
DRAWING
#1 Color
Prominence
- 0 0 5 0 5/5 1 0 0 0/2 0
#2 Color Fit - 0 0 5 0 5/5 1 0 0 0/2 0
#3 Energy - 3 3 4 4 14/5 2.8 1 3 4/2 2
#4 Space - 5 5 5 5 20/5 4 1 3 4/2 2
#7 Realism - 4 4 4 5 17/5 3.4 1 3 4/2 2
#10 Details - 3 5 5 5 18/5 3.6 1 4 5/2 2.5
#12 Person - 5 4 - 5 14/3 4.6 - 5 5/2 2.5
Tally - 20 21 28 24 3.4 4 18 1.7
BODY BREATH
#1 Color
Prominence
5 2 2 1 - 10/4 2.5 5 -- 5/1 5
#2 Color Fit 5 2 2 1 10/4 2.5 5 - 5/1 5
#3 Energy 3 4 2 4 13/4 3.25 3 - 5/1 5
#4 Space 5 5 4 5 19/4 4.75 5 - 5/1 5
#7 Realism 3 2 0 3 8/4 2 5 - 5/1 5
93
Table 15 - continued
Case Number 01 16 09 12 16 Mean x Mean
#10 Details 2 3 0 4 9/4 2.25 3 - 3/1 3
#12 Person - - - - - -
Tally 3 19 9 16 - 2.9 3 4.3
FEELING
STATES
#1 Color
Prominence
5 5 0 2 3 15/4 3.75 5 5 5/2 5.5
#2 Color Fit 3 5 0 3 4 15/4 3.75 5 5 5/2 2.5
#3 Energy 4 4 0 2 2 12/4 3 5 3 8/2 4
#4 Space 5 5 0 2 2 14/4 3.5 5 5 10/2 5
#7 Realism 3 4 00 2 2 11/4 2.75 3 3 6/2 3
#10 Details 3 3 0 2 4 12/4 3 5 4 9/2 4.5
#12 Person - - 0 - -
Tally 23 26 13 17 3.3 28 25 4.4
VISUAL
NARRATIVE
#1 Color
Prominence
5 - 5 5 2 12/4 4.25 5 5 10/2 5
#2 Color Fit 5 5 5 5 15/4 5 5 5 10/2 5
#3 Energy 3 2 4 3 9/4 3 4 4 8/2 4
#4 Space 5 5 5 3 13/4 4.5 4 5 9/2 4.5
#7 Realism 3 5 5 2 12/4 3.75 4 5 9/2 4.5
#10 Details 0 5 5 4 14/4 3.5 5 5 10/2 5
#12 Person - - 5 5 - 10/4 2.5 - -
Tally 21 - 32 34 19 4.1 27 29 4.7
ARTIST CARDS
#1 Color
Prominence
5 3 5 5 - 18/4 4.5 5 2 7/2 3.5
#2 Color Fit 5 3 5 5 18/4 4.5 5 4 9/2 4.5
#3 Energy 3 2 3 4 12/4 3 3 2 5/2 2.5
#4 Space 5 5 5 5 20/4 5 5 3 8/2 4
#7 Realism 5 5 5 5 20/4 5 4 2 6/2 3
#10 Details 5 5 5 5 20/4 5 4 3 7/2 3.5
#12 Person - - - -
Tally 28 23 28 29 4.5 26 16 3.5
94
APPENDIX G
MODEL AND EXPLANATION OF THE EXPRESSIVE THERAPIES CONTINUUM
Figure 26. Symbolic content and schematic representation of the Expressive Therapies
Continuum (ETC) by Vija Lusebrink (1990).
95
APPENDIX H
ANALYTICAL ART CRITICISM MODEL
Figure 27. Analytic Art Criticism Method (formally known as Anderson's CritCard Method)
from Anderson and Milbrandt (2005).
96
Figure 27 - continued
97
Figure 27 continued
98
APPENDIX I
END OF STUDY OBJECTIVE/CRITERIA ASSESSMENT QUESTIONNAIRE
Complete the following rating form with each client using the following scale:
1= No, 2 = Sometimes, 3 = Yes, or N/A
Did the participant...
CBATx: Identify, categorize, and create feeling states? ___
CBATX: Reduced anxiety associated with feeling states. ___
CBATX: Generated solutions to problems? ___
Score ______/ 3__
PVV: Identify, categorize, and generate symbolic content in artwork? ___
PVV: Applied the PVV to address his or her familial issues in a visual narrative
format as evidenced by participant artwork, clinical notes, and self-report? ___
Score _____/ 2 _
ETC: Explored levels of the ETC and various types of media? ___
Score ____/_1_
Figure 28: Example of the end of study objective/criteria assessment questionnaire.
99
APPENDIX J
SASS OUTPUT OF PAIRED T-TESTS SCORES FOR QUALIFIED SAMPLE
Figure 29. Statistical output of paired t-test on INC score means for qualified sample.
100
7
Figure 30. Statistical output of paired t-test on SC score means for qualified sample.
101
Figure 31. Statistical output of paired t-test on FG score means for qualified sample.
102
Figure 32. Statistical output of paired t-test on RD score means for qualified sample.
103
Figure 33. Statistical output of paired t-test on TOT score means for qualified sample.
104
Figure 34. Statistical output of paired t-test on CON score means for qualified sample.
105
Figure 35. Statistical output of paired t-test on PHY score means for qualified sample.
106
Figure 36. Statistical output of paired t-test on MOR score means for qualified sample.
107
Figure 37. Statistical output of paired t-test on PER score means for qualified sample.
108
Figure 38. Statistical output of paired t-test on FAM score means for qualified sample.
109
Figure 39. Statistical output of paired t-test on SOC score means for qualified sample.
110
Figure 40. Statistical output of paired t-test on ACA score means for qualified sample.
111
Figure 41. Statistical output of paired t-test on IDN score means for qualified sample.
112
Figure 42. Statistical output of paired t-test on SAT score means for qualified sample.
113
Figure 43. Statistical output of paired t-test on BHV score means for qualified sample.
114
APPENDIX K
TSCS:2/PH:2 OUTPUT, SELF STATEMENTS, AND ARTWORK
Qualified Sample
Case 01 - Blue
Data Output
Love/Hate List and Love Mandala
Value and Color Psychology Painting
Figure 44. Case O1 - Blue's individual SASS output, artwork, and self-statements from aesthetic
criticism.
115
Body Breath Exercised
Feeling States
Personal Narrative
BLUE: Aesthetic Criticism
General Reaction: Circles, happiness, feeling of going into a tunnel. Looks like a chess game.
Description: formal relationships seem to be contrasting between sad and happiness. Dark colors
inside surrounded by love and cheerfulness. The mood feels like confusion and sadness. Colors are
intense and there is black in the center. The colors seem in a way, over the top.
Context: Feelings about home and school.
Interpretation: When you look closely, there is either sadness or even evilness. The hopeful genesis
of light looks like a tunnel instead. I am covered by darkness. I am blue. I am surrounded by the joy
and my ancestors. Blue is my inside color; blue is the essence of color. The sky is blue, water is blue.
Blue is life. Turquoise is the lightest of this color and this is the color I surround myself with. It is my
outside. It is the light. I want to stand out from my ancestors. I want to leave. I want to be the light.
But it looks like I am getting sucked into a tunnel. I am in the center of a tornado. There is chaos and
nothing Judgment: I am in the center. I am getting sucked into the center, unwillingly.
Themes: Circles, black, blue, intensity. The Panther is my animal.
Figure 44 - continued
116
Case 03 - Nicht Werden
Output data
Material exploration
Line drawings
T-chart for Adore/Loath list
Value and Color Psychology Painting
Figure 45. Case 03 - Nicht Werden's individual SASS output, artwork, and self-statements from
aesthetic criticism.
117
Form Free
Drawing
Feeling States
Problem Solution Collage
Figure 25 - continued
118
Personal Narrative Book
Figure 25 - continued
119
NICHT WERDEN: Aesthetic Criticism
General Reaction: Circles, science, outer space.
Description: there are many circles, black, and celestial shapes. The darkness has a relationship with
the celestial shapes. There is contrast between known and unknown. The mood is quiet. There is
quiet in space. If colors were yellow, like the sky. It would feel happier with the green oceans.
Context: Thinking about quiet, life, graduating.
Interpretation: How I am on the outside is pretty much how I am on the inside. It is like, "Are you
going into the unknown? Would you like to have a companion?" I am not sure what my art is telling
me.
Judgment: "I am teal inside and out. My dog looks like an elephant, I am not good at painting, and I
mean I do not have much experience with painting. I like to draw with pencils."
Themes/symbols: unknown, space, earth shape
Figure 25 - continued
120
Case 09 - Ghost
Data Output
Material Exploration
Line Drawing
Adore/Loath List and Radial Adore Collage
Figure 46. Case 09 - Ghost's individual SASS output, artwork, and self-statements from
aesthetic criticism.
121
Value and Color Psycholtoy Painting
Form Sculpture
Free Drawing
Body-Breath Exercised
Figure 46 - continued
122
Feeling States
Problem Solution Collage
Personal Narrative Book
Artist Trading Cards
GHOST: Aesthetic Criticism
General Reaction: There are many blue and powerful details. The dragon looks like a Pokémon
character.
Description: Each picture has a solitary figure and there is not anything in the center of the
mandala. The mood is sad and lonely. There is a lot of white space and only really a few colors,
orange, blue, white, black, and red. Except the fox, he looks natural.
Context: Everything was done at school, but I was not thinking about anything. I just did things
that I like.
Interpretation: Everything except the figure drawing seems unfinished there is a journey into
the unknown. I could not really get excited about the "adore" mandala and I did not want to
think about the things I loathe. Except licorice.
Judgment: I like coming to the group and doing things. I do not know what I want to make next. I
think about food a lot.
Themes/symbols: single figures, fox, journey, food, blue, black, orange/red, loneliness
Figure 46 - continued
123
Case 12 - Brody
Data Outpu
Material Exploration and Power Animal
Line Drawing
Adore/Loath List and Adore Collage
Figure 47. Case 12 - Brody's individual SASS output, artwork, and self-statements from
aesthetic criticism
124
Value and Color Psychology Painting
Form Sculpture
Free Drawing
Feeling States
Body Breath Exercises and Free Painting
Figure 47 - continued
125
Personal Narrative Book
Free Form Sculpture
Artist Trading Cards
BRODY: Aesthetic Criticism
General Reaction: There is a sense of loneliness even with all the shapes and colors. The mandala makes me think
of a big black hole sucking up everything.
Description: Every color is used, but they are soft and light. Except the black and gray spheres floating in
white space. The eye is drawn to the red /yellow circle behind the scarecrow and the big black blob in the
middle of the mandala. I think we feel alone and nervous, surrounded by smoke.
Context: the context is just about what I wanted to draw now. The mandala is about the things that I love
about gaming, bacon, coke, and candy.
Interpretation: My colors are copper and purple, even though I was going to do silver and copper. I think
the house and the guardhouse are self-symbols. The guard tower is sitting and gathering moss, it is not on
fire because you can live and be on fire. If I came upon the abandoned house, I would walk away. The
windows and it is shabby. The scarecrow is protecting the wheat and doing a great job because the birds
are going away. I am the black shape in the middle of the mandala, and I am happy because I am going to
right into the coke bottles. The fox is on the hunt and I do not know about the tree picture.
Judgment: I have learned I really do not care for painting. I am more comfortable with colored pencils.
The clay was good.
Themes/symbols: loneliness, dilapidation, power/guard, orange, yellow (Fall Colors) and black.
Figure 47 - continued
126
Case 16 - Destructo
Data output
Media Exploration and Power Animal
Line Drawing
Love/Hate list and Love Collage
Figure 48. Case 16 - Destructo's individual SASS output, artwork, and self-statements from
aesthetic criticism.
127
Value and Color Psychology
Form Sculpture
Free Drawing
Body-breath Exercises and Free painting
Feeling States
Problem Solution Collage
Figure 48 - continued
128
DESTRUCTO: Aesthetic Criticism
General Reaction: Scary and Evil. Everything is like sorcery, with fire, dragons, and enchantment.
Description: the images are thin, red, and wispy. The black and red colors are intense and stand out
from all the white spaces. The bat is white too. His inside is amber. The mood is intense and we are
meant to feel in awe.
Context: In my head. The things I like to read about.
Interpretation: I am purple and red. The colors of passion and royalty. I am rare and intense. Like the
bat, I have ancient wisdom carried within my soul. I am alone in my quest with the help of
knowledge, the eagle." In the center, I am the all-knowing eye, like the eye of Sauron. These figures
have power over evil. Mystical figures that have mastered the unknown, are all seeing, over time
and place.
Judgment: The intention was communicated, but I'm frustrated because I see the pictures better in
my head.
Themes: Mythology, ancient wisdom, swords, red, black, and purple.
Figure 48 - continued
129
Matched Sample
Case 04- Vortex
Data Output
Line drawing
Love/loath List and Love collage
Figure 49. Case 04 - Vortex's individual SASS output, artwork, and self-statements from
aesthetic criticism.
130
Value and Color Psychology
Form Sculpture
Free Drawing
Feeling States
Figure 49 - continued
131
Personal Narrative Book
VORTEX: Aesthetic Criticism
General Reaction: It looks like sorrow is coming. My eyes are drawn to all the swords.
Description: The yellow sphere is popping of the page in the field of blue. I am yellow on the
inside and blue on the outside. I like dark blue. There is an overall mood of being bi-polar,
because blue is the opposite of yellow on the color wheel. There is a mood of injustice and
oppression.
Context: My imagination
Interpretation: There is evil and destruction in the world, but also light and happiness. These are
opposites.
Judgment: Never feel like I have enough time to finish. Hard to "play" with materials. The shape
collage was not worth doing, but the rest was important to me.
Themes: swords, solitary figures, lynx, and balance
Figure 49 - continued
132
Case 02 - Shirayuki
Data Output
Power animal and material Exploration
Line Drawing
Adore/Loath List and Love collage
Figure 50. Case 02 - Shirayuki's individual SASS output, artwork, and self-statements from
aesthetic criticism
133
Value Painting and Color Psychology
Form Sculpture
Free Drawing
Feeling States
Body Breath Exercises
Problem Solution collage
Figure 50 - continued
134
Personal Narrative Book
SHIRAYUKI: Aesthetic criticism
General Reaction: Asian feel. The figures are all on their own in each picture.
Description: I see a tiger, and a starving wolf. The shapes are simple and are like a shrine.
Then there is a "Ka-Bam" repeated shape. Orange is repeated in all the art cards I chose to
work with, the sunset, the tiger, my inside and outside color. Both are inside and outside
colors. I like to read and I like nature.
Context: Graduating from the 8th grade in a small school and going into a big high school.
Interpretation: I like the blue/orange because of the balance. I feel like I am at a beginning,
going up into the unknown but I need shelter. I am uncertain but also know that I am
trustworthy with secrets and meditative. That is the shrine. The blue is meditative.
Judgment: I like to get things puurrrfect. I didn't finish the work but I learned about the
materials.
Themes: Balance between two opposites. Aggressive vs. Meditation. Tiger and Water.
Figure 50 - continued
135
APPENDIX L
FLORIDA STATE UNIVERSITY INTERNAL REVIEW BOARD APPROVAL AND
CONSENT FORMS
136
137
138
139
140
141
APPENDIX M
COPYRIGHT PERMISSION LETTERS
142
APPENDIX M continued
143
144
145
REFERENCES
Addictioninthefamily.com (2010). Children of Alcoholics/Children of Substance Abusers.
Retrieved from Addiction in the Family website:
http://addictioninfamily.com/addiction_types/children-of-substance-abusers/
American Psychiatric Association (APA). (2013). Diagnostic and Statistical Manual of Mental
Disorders (5th Ed.). Washington, DC: Author.
Anda, R. F, Whitfield, C. L., Felitti, V. J., Chapman, D., Edwards, V. J., Dube, S. R., &
Williamson, D. F. (2002). Adverse childhood experiences, alcoholic parents, and later
risk of alcoholism and depression. Psychiatric Services, 53(8), 1001-1009.
Anda, R. F. (2006). The health and social impact of growing up with adverse childhood
experiences: The human and economic costs of the status quo. Retrieved from
http://www.acestudy.org/files/Review_of_ACE_Study_with_references_summary_table_
2_.pdf
Anderson, T. & Milbrandt, M. K. (2005). Art for Life: Authentic instruction in art. NY: McGraw.
Arnheim, R. (1969/2004). Visual Thinking. Berkeley, CA: University of California Press.
Atkinson, R. C. & Shiffrin, R. M. (1968). Human memory: A proposed system and its control
processes. In K. Spence & J. Spence (Eds.). The psychology of learning and motivation:
Advances in research and theory, Vol. 2 (pp. 189-195). NY: Academic Press.
Avgerinou, M. (2007). Towards a visual literacy index. Journal of Visual Literacy, 27(1), 29-44.
Bandura, A. (1997). Self-efficacy: The exercise of control. NY: W. H. Freeman.
Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory.
Englewood Cliffs, NJ: Prentice Hall.
Bandura, A. (1976). Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall.
Beck, A. T. (1955/1997). The past and the future of cognitive therapy. Journal of Psychotherapy
Practice and Research, 6(4), 276–284.
Beck, J. S. (2011). Cognitive Therapy: Basics and Beyond. New York: Guilford.
Beets, M. W., Flay, B. R., Vuchinich, S., Snyder, F. J., Acock, A., Li, K.-K., Burns, K.,
Washburn, I. J., and Durlak, J. A. (2009). Use of a social and character development
program to prevent substance use, violent behaviors, and sexual activity among
elementary students in Hawai’i. American Journal of Public Health, 99(8), 1438-1445.
Berg, I. K. (1994). Family-based services: A solution-focused approach. NY: Norton.
146
Bledsoe, E. (Ed.). (1999). Getting naked with Harry Crews. Gainesville, FL: University of
Florida Press.
Braden, R. (1996). Visual literacy. Journal of Visual Literacy, 16(2), 9-81.
Bratter, T. E & Forrest, G. G. (1985). Alcoholism and substance abuse: Strategies for clinical
intervention. New York: Simon and Schuster.
Brill, J. M., Kim, D., & Branch, R. M. (2007). Visual literacy defined—the results of a Delphi
study: Can IVLA (operationally) define visual literacy? Journal of Visual Literacy, 27(1),
47-60. .....................................................................................................................................
Brody, G. H., Beach, S. R. H., Philibert, R. A., Chen, Y. F., & Murry, V. M. M. (2009).
Prevention effects moderate the association of 5-httlpr and youth risk behavior initiation:
gene environment hypotheses tested via a randomized prevention design. Child
Development, 80(3), 645–66.
Brown, A. L. (1987). Metacognition, executive control, self regulation and other more
mysterious mechanisms. In F. E. Weinert & R. H. Kluwe (Eds), Metacognition,
motivation and understanding (pp. 65-116). Hillsdale, N.J.: Lawrence Erlbaum.
Bruning, R. H., Schraw, G. J., & Ronning, R. R. (2010). Cognitive psychology and instruction
(5th ed.). Upper Saddle River, NJ: Prentice-Hall.
Burnette, M. L., Ilgen, M., Frayne, S. M., Lucas, E., Mayo, J., & Weitlauf, J. C. (2008). Violence
perpetration and childhood abuse among men and women in substance abuse treatment.
Journal of Substance Abuse Treatment, 35, 217–222.
Calcott, W. (1758). Thoughts moral and divine [electronic resource]; collected and intended for
the better instruction and conduct of life. The second edition with improvements:
Dedicated by permission to the Right Honourable the Earl of Powis, by Wellins Calcott,
Gent. Birmingham, England: T. Warren. Retrieved from
https://library.villanova.edu/Find/Record/881790/Details
Center for Substance Abuse Treatment (CSAT). (2004). Substance abuse treatment and family
therapy treatment improvement protocol (TIP): Series, no. 39. (DHHS Publication No. 5-
4006). Retrieved from Substance Abuse and Mental Health Services Administration
(SAMHSA) website: http://adaiclearinghouse.org/downloads/TIP-39-Substance-Abuse-
Treatment-and-Family-Therapy-55.pdf
Centers for Disease Control and Prevention (CDC). (2013). National center for health statistics,
health behaviors of adults: United States (DHHS publication No. 2013–1585.2008-2010).
Retrieved from US Department of Health and Human Services (DHHS) website:
http://www.cdc.gov/nchs/data/series/sr_10/sr10_257.pdf
147
Claus, E. D. & Hutchison, K. E. (2012). Neural mechanisms of risk taking and relationships with
hazardous drinking. Alcoholism: Clinical and Experimental Research, 36, 932–940.
Claus, E. D., Kiehl, K. A., & Hutchison, K. E. (2011). Neural and behavioral mechanisms of
impulsive choice in alcohol use disorder. Alcoholism: Clinical and Experimental
Research, 35, 1209–1219.
Community University Partnership for the Study of Children, Youth, and Families. (2011).
Review of the Piers-Harris children’s self-concept scale, 2nd edition (Piers-Harris:2)
Edmonton, Alberta, Canada. Retrieved from http://www.cup.ualberta.ca/wp-
content/uploads/2012/06/FINAL_Piers-Harris-2_May-2012.pdf.
Csillag, P. (2009). A model of visual perception useful for designers and artists. Journal of
Visual Literacy, 28(2), 127–144.
Dake, D. M. (2007). A natural visual mind: The art and science of visual literacy. Journal of
Visual Literacy, 27(1), 7-28.
de Shazer, S., Dolan, Y. M., Korman, H., Trepper, T. S., McCollum, E. E., & Berg, I. K. (2007).
More than miracles: The state of the art of solution focused therapy. New York: Haworth
Press.
Dondis, D. A. (1994). A primer of visual literacy. Cambridge, MA: MIT Press.
Dube, S. R., Anda, R. F., Felitti, V. J., Croft, J. B., Edwards, V. J., & Giles, W. H. (2001).
Growing up with parental alcohol abuse: Exposure to childhood abuse, neglect, and
household dysfunction. Child Abuse and Neglect, 25(12), 1627-1640.
Elgán, T. H. & Leifman, H. (2013). Prevalence of adolescents who perceive their parents to have
alcohol problems: a Swedish national survey using a web panel. Scandinavian Journal of
Public Health, 41(7), 680-683.
Ellis, D. A, Zucker, R. D. & Fitzgerald, H. E. (1997). The role of family influences in
development and risk. Alcohol Health & Research World, 21(3), 218-226. .........................
Erikson, E. H. (1950/1993). Identity and the life cycle. New York: W.W. Norton & Company.
Eskin, M., Ertekin, K., & Demir, H. (2008). Efficacy of a problem-solving therapy for
depression and suicide potential in adolescents and young adults. Cognitive Therapy and
Research, 32(2), 227-245.
Fenster, J. (2011). Treatment issues and interventions with adolescents from substance abusing
families. In S. L. A. Straussner & C. H. Fewell (Eds.), Children of substance abusing
parents: Dynamics and treatment (pp. 127–151). New York: Springer Publishing
Company.
148
Fitts, W. H. & Warren, W. L. (2003). Tennessee self-concept scale: Second edition (TSCS:2).
Los Angeles, CA: Western Psychological Service.
Gaiger, J. (2002). The aesthetics of Kant and Hegel. In P. Smith and C. Wilde (Eds.), A
companion to art theory (pp. 137–138). Maldon, MA: Blackwell Publishing Ltd.
Gantt, L. & Tinnin, L. W. (2009). Support for a neurobiological view of trauma with
implications for art therapy. The Arts in Psychotherapy, 36(3), 148-153.
Gantt, L. & Tinnin, L. W. (2007). Intensive trauma therapy of PTSD and dissociation: An
outcome study. The Arts in Psychotherapy, 34, 69-80.
Gantt, L. & Tabone, C. (1998). The formal elements art therapy scale: The rating manual.
Morgantown, WV: Gargoyle Press.
Gilbert, R. M. (2006). The eight concepts of Bowen theory. Falls Church, VA: Leading Systems
Press.
Griggs, R. (2006). Psychology: A concise introduction (1st ed.). New York: Worth Publishers.
Gruber, E. N., Celan, J., Golik-Gruber, V., Agius, M., & Murphy, S. (2007). The relationship
between having smoking or drinking parents and the occurrence of smoking or drinking
in their adolescent children. Alcoholism: Journal on Alcoholism and Related Addictions,
43, 25-35.
Hall, C. W. & Webster, R. E. (2007). Risk factors among adult children of alcoholics. The
International Journal of Behavioral Consultation and Therapy, 3, 494-511.
Hoshino, J. (2008). The development of family therapy and family art therapy. In C. Kerr and J.
Hoshino (Eds.) Family art therapy: Foundations of theory and practice (pp. 25–63). New
York: Routledge.
Hussong, A. M., Flora, D. B., Curran, P. J., Chassin, L. A., & Zucker, R. A. (2008). Defining
risk heterogeneity for internalizing symptoms among children of alcoholic parents.
Development and Psychopathology, 20(1), 165–19.
Hussong, A. M., Wirth, R. J., Edwards, M. C., Curran, P. J., Chassin, L. A., & Zucker, R. A.
(2007). Externalizing symptoms among children of alcoholic parents: Entry points for an
antisocial pathway to alcoholism. Journal of Abnormal Psychology, 116(3), 529–542.
Ito, A. T., Miller, N., & Pollock, V. E. (1996). Alcohol and aggression: A meta-analysis on the
moderating effects of inhibitory cues, triggering events, and self-focused attention
Psychological Bulletin, 120(1), 60-82.
149
Johnson, J. G., Cohen, P., Kasen, S., & Brook, J. S. (2008). Parental concordance and offspring
risk for anxiety, conduct, depressive, and substance use disorders. Psychopathology,
41(2), 124-128.
Johnson, P. (2002). Predictors of family functioning within alcoholic families. Contemporary
Family Therapy, 24, 371–384.
Jongsma, A. E., Peterson, L. M., & McInnis, W. P. (2006). The adolescent psychotherapy
treatment planner (4th ed). Hobokem, New Jersey: Wiley & Sons, Inc.
Jung, C. (1968). Approaching the unconscious. In C. G. Jung (Ed), Man and his symbols (pp. 1-
94). London: Aldus books.
Keyes, K. M., Hatzenbuehler, M. L., Grant, B. F., & Hasin, D. S. (2012). Stress and alcohol:
Epidemiologic evidence. Alcohol Research 34(4), 391-400.
Kaplan, D. S., Liu, X., & Kaplan, H. B. (2001). Influence of parents' self-feelings and
expectations on children's academic performance. Journal of Educational Research, 94,
360-370.
Karatas, Z & Cakar, F. S. (2011). Self-esteem and hopelessness, and resiliency: an exploratory
study of adolescents in Turkey. International Education Studies, 4(4), 84-9.
Kaufman, E. & Yoshioka, M. R. M. (2004/2005). Treatment improvement protocol (TIP) series,
(No. 39. DHHS Publication No. 05-4006). Retrieved from Substance Abuse and Mental
Health Services Administration (SAMHSA) website:
http://adaiclearinghouse.org/downloads/TIP-39-Substance-Abuse-Treatment-and-Family-
Therapy-55.pdf
Kelly, G. A. (1963/1999). A theory of personality: The psychology of personal constructs. New
York: W. W. Norton & Company.
Kim, H. K. & Lee, M. H. (2011). Factors influencing resilience of adult children of alcoholics
among college students. Journal Korean Academy of Nursing, 41(5), 642-651.
Larsen, R. J. & Buss, D. M. (2009). Personality psychology: Domains of knowledge about
human nature (3rd ed.). New York: McGraw-Hill.
Leichtkubg, G., Gabriel, R. M., Lewis, C. K., & Vander Ley, K. J. (2006). Adolescents in
treatment: Effects of parental substance abuse on treatment entry characteristics and
outcomes. Journal of Social Work Practice in Addictions, 6(1), 155-174
Lejuez, C. W., Magidson, J. F., Mitchell, S. H., Sinha, R., Stevens, M. C., & De Wit, H. (2010).
Behavioral and biological indicators of impulsivity in the development of alcohol use,
problems, and disorders. Alcoholism: Clinical and Experimental Research, 34, 1334-
1345.
150
Lusebrink, V. B. (1990). Imagery and visual expression in therapy. NY: Plenum Press.
Malchiodi, C. A. (Ed.). (2008). Creative interventions with traumatized children. NY: Guilford
Press.
Marriott, K. & Meyer, B. (1998). Introduction. In K. Marriott & B. Meyer (Eds.), Visual
language theory (pp. 1–4). New York: Springer.
McNeece, C. & DiNitto, D. (2005). Chemical dependency: A systems approach (4th ed.). NY:
Pearson.
Mignone, T., Klostermann, K., & Chen, R. (2009). The relationship between relapse to alcohol
and relapse to violence. Journal of Family Violence, 24, 497–505.
Miller, G. A. (1985/1999). The substance abuse subtle screening inventory (SASSI) manual (2nd
ed.). Springville, IN: The SASSI Institute.
Moore, D. M. & Dwyer, F. M. (Eds.). (1994). Visual literacy: Spectrum of visual learning.
Englewood Cliffs, NJ: Educational Technology.
Morehouse, E. R. (2011). Programs for adolescent children of substance-abusing parents in
school and residential settings. In S. L. A. Straussner & C. H. Fewell (Eds.), Children of
substance abusing parents: Dynamics and treatment (pp. 207-222). NY: Springer
Publishing Company.
Mylant, M., Idle, B., Cuevas, E., & Meehan, M. (2002). Adolescent children of alcoholics:
Vulnerable or resilient? Journal of the American Psychiatric Nurses Association, 8(2),
57-64.
National Aeronautics and Space Administration (NASA). (2008). Employee’s guide to security responsibilities. Retrieved from
http://www.hq.nasa.gov/office/ospp/securityguide/Eap/Drugs.htm
National Council on Alcoholism and Drug Dependence (NCADD). (2013). Alcoholism.
Retrieved from NCADD website: http://www.ncadd.org/facts/defalc.html
National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2013). Alcohol use disorders.
Understanding the impact of alcohol on human health and well-being. Retrieved from
NIAAA website: http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-
consumption/alcohol-use-disorders
Newton, N. C., O’Leary-Barrett, M., & Conrad, P. J. (2013). Adolescent substance misuse:
neurobiology and evidence-based interventions. Behavioral Neurobiology of Alcohol
Addiction, 13, 685-708.
151
Nicholas, K. B. & Bibber, S. L., (1997). Assessment of perceived parenting behaviors: The
exposure to abusive and supportive environments parenting inventory (EASE-PI).
Journal of Family Violence, 12(3), 275–291.
Nicholas, K. B. & Rasmussen, E. H. (2006). Childhood abusive and supportive experiences,
inter-parental violence, and parental alcohol use: Prediction of young adult depressive
symptoms and aggression. Journal of Family Violence, 2(1), 43-61.
Nodar, M. (2012). Chaotic environments and adult children of alcoholics. The Professional
Counselor (TPC), 2(1), 43-47.
Nolen-Hoeksema, S. (2010). Abnormal Psychology (4th Ed.). Boston: McGraw-Hill Higher
Education.
Piaget, J. (1962). Play, dreams, and imitation in childhood. NY: W.W. Norton & Company.
Piers, E. V. & Harris, S. H. (2009). Piers-Harris children's self-concept scales (2nd ed). Los
Angeles: CA: Western Psychological Services.
Pilat, J. M. & Jones, J. W. (1984/85). Identification of children of alcoholics: Two empirical
studies. Alcohol Health Research World, 9(2), 27–33, 36.
Price, A. & Emshoff, J. (1997). Breaking the cycle of addiction: Prevention and intervention
with children of alcoholics. Alcohol Health and Research World, 21(3), 242–246.
Rekart, K. N., Mineka, S., Zinbarg, R. E., & Griffith, J. W. (2007). Perceived family
environment and symptoms of emotional disorders: The role of perceived control,
attributional style, and attachment. Cognitive Therapy and Research, 31(4), 419–436.
Rhyne, J. (1979). Drawings as personal constructs: A study in visual dynamics (Unpublished
doctoral dissertation). University of California, Santa Cruz, CA.
Richards, S. T. & Nelson, C. L. (2012). Problematic parental drinking and health: Investigating
differences in adult children of alcoholics' status, health locus of control, and health self-
efficacy. Journal of Communication in Healthcare, 5(2), 84-90.
Riley, S. (2001). Commentary on systemic approaches. In J. A. Rubin (Ed.), Approaches to art
therapy (pp. 281-284). London: Brunner Routledge.
Riley, S. (1999). Brief therapy: An adolescent intervention. Art Therapy, 16(2), 83-86.
Riley, S. (1999a). Contemporary art therapy with adolescents. London: Jessica Kingsley.
Robertson, E. B., David, S. L., & Rao, S.A. (Eds). (2003). Preventing drug use among children
and adolescents: A research based guide for parents, educators, and community leaders
152
Substance Use & Misuse, 36 (2nd ed). Retrieved from DHHS website:
http://www.drugabuse.gov/sites/default/files/preventingdruguse.pdf
Rosal, M. (2001). Cognitive-behavioral art therapy. In J. Rubin (Ed.), Approaches to art therapy:
Theory & technique (2nd ed.) (pp. 210–225). NY: Brunner-Routledge.
Rosal, M. (1996). Approaches to art therapy with children [Monograph]. Burlingame, CA:
Abbeygate Press.
Ross, L. T. & Hill, E. H. (2001). Drinking and parental unpredictability among adult children of
alcoholics: A pilot study. (5), 609-638.
Rubin, J. A. (2010). Introduction to art therapy: Sources and resource. NY: Routledge.
Russell, R., Shirk, S., & Jungbluth, N. (2008). First session pathways to the working alliance in
cognitive-behavioral therapy for adolescent depression. Psychotherapy Research, 18(1),
15-27.
Schunk, D. H. (2008). Learning theories: An educational perspective (5th ed.). Upper Saddle
River, NJ: Pearson.
Sifneos, P. E. (1973). The prevalence of "alexithymic" characteristics in psychosomatic patients.
Psychotherapy and Psychosomatics, 22, 255-262.
Stephens, P., Sloboda, Z., Stephens, R., Teasdale, B., Grey, S., Hawthorne, R., & William, J.
(2009). Universal school-based substance abuse prevention programs: Modeling targeted
mediators and outcomes for adolescent cigarette, alcohol, and marijuana use. Drug and
Alcohol Dependence, 102, 19–29.
Straus, M. A. (1979). Measuring intrafamily conflict and violence: The conflict tactics (CT)
scales. Journal of Marriage and Family, 41, 75–88.
Straussner, S. L. A. (2011). Children of substance abusing parents: an overview. In S. L. A.
Straussner & C. H. Fewell (Eds.), Children of substance abusing parents: Dynamics and
treatment (pp. 1–27). NY: Springer Publishing Company.
The Substance Abuse and Mental Health Services Administration (SAMHSA). (2004). Children
of alcoholics: A guide to community action [Kit] (US Department of Health and Human
Services. Pub ID MS939). Retrieved from SAMHSA website:
http://store.samhsa.gov/product/Children-of-Alcoholics-A-Guide-to-Community-
Action/MS939
Thornburg, K. R., Hoffman, S., & Remieka, C. (1991). Youth at risk: Society at risk. Elementary
School Journal, 91(3), 199–208.
153
United Nations International Drug Control Programme (UNDCP). (March 1995). The social
impact of drug abuse. Paper presented at the World Summit for Social Development,
Copenhagen. Retrieved from United Nations Office on Drugs and Crime website:
http://www.unodc.org/pdf/technical_series_1995-03-01_1.pdf
Vygotsky, L. S. (1930/1980). Mind in Society: The development of higher psychological
processes, (M. Cole, V. John-Steiner, S. Scribner, & E. Souberman, (Eds). Cambridge,
MA: Harvard University Press.
Wai-Yuing, W. Y., Zubieta, J., Weiland, B. J., Samudra, P. G., Zucker, R. A., & Heitzeg, M. M.
(2012). Nucleus accumbens response to incentive stimuli anticipation in children of
alcoholics: relationships with precursive behavioral risk and lifetime alcohol use. The
Journal of Neuroscience, 32(7), 2544-51.
Walker, J. P. & Lee, R. E. (1998). Uncovering strengths of children of alcoholic parents.
Contemporary Family Therapy, 20, 521–538.
White, M. M. (1963). Equivalence: The perennial trend. Photographic Society of America (PSA)
Journal, 29, 17-21.
Windle, M. (1997). Concepts and issues in COA research. Alcohol Heath & Research World,
21(3), 185-191.
Yalom, I. D. (2005). The theory and practice of group psychotherapy, 5th ed. NY: Basic Books.
Zettler, A. W. (2010). Considering personal context for authentic problem solving. In T.
Anderson, D. Gussak, K.K. Hallmark, & A. Paul (Eds.), Art education for social justice,
(pp. 140- 14)7. Reston, VA: National Art Education Association
154
BIOGRAPHICAL SKETCH
Alexandria Zettler's passion is working with adolescents and transitioning adults
in rural communities, both educationally and therapeutically. Zettler earned a Doctor of
Philosophy: Art Education (2014) and Master in Science: Art Therapy (2010) from
Florida State University, Master in Teaching: Elementary Education (1996) from City
University, and a Bachelor of Art: Studio Art (1983) from Oberlin College. She has
taught in a range of positions from PreK to 12th grade, including exceptional, elementary,
technology, and visual arts education. Additionally, Alexandria has traveled, lived, and/or
worked throughout North and South America, from Brazil to the coastal waters of
Alaska. Zettler and her husband are committed to further developing their limited liability
corporation, Studio1, and providing eructation and therapeutic services to their local
community.
Education
2014 Florida State University Tallahassee, FL
Doctorate of Philosophy: Art Education with a specialty in Art Therapy
Dissertation: Constructing a Personal Visual Vocabulary: An Art Therapy
Intervention Project for Adolescents from Families with Substance Abuse
Disorders
2010 Florida State University Tallahassee, FL
Master in Science: Art Education/Art Therapy
Master Project: Experiencing Control of the Self: A Mandala Action Research
Project with Children
1996 City University Renton, WA
Master in Teaching: Elementary Education
Thesis: On-task Behavior for the Student with an External Locus of Control
1983 Oberlin College Oberlin, OH
Bachelor of Arts: Studio Art in Photography & Drawing
Individual Senior Art Exhibit: “Phantasmagoria”
Presentations
March, 2014 Cedar Key Library-Friends of the Library Cedar Key, FL
Presenter: Constructing a Visual Vocabulary: An Art Therapy Intervention Study for
Adolescents from Families with Alcohol Use Disorders
January, 2012 Art & Social Justice Symposium Tallahassee, FL
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Presenter: Action Research Project: Control of the Self
July, 2011 American Art Therapy Assoc. Conference Washington, DC
Workshop Co- Presenter: Containing the Anger Monster
January 2011 Art & Social Justice Symposium Tallahassee, FL
Poster-board Presenter: Laylah Ali, Symbols of Power and Repression
August, 2010 Play Therapist Association Jacksonville, FL
Co-presenter: The Therapeutic Use of Art in Treating Anxiety
August, 2010 Florida State University Tallahassee, FL
Presenter: Master in Science Research Project: Experiencing Control of the Self: Action
Research Project with Children
Publications
Zettler, A. (2010). Considering personal context for authentic problem solving. In
Anderson, T., Gussak, D., Hallmark, K., & Paul, A. (Eds.). Art education for
social justice (pp. 140-147). Reston, VA: NAEA.
Coordinated middle school student group for illustration of:
Bagert, B. (2006). Hormone jungle: Coming of age in middle school, Gainesville, FL:
Maupin House Quiet Space