DIALECTICAL BEHAVIOR THERAPY-BASED ART THERAPY

A Thesis

Submitted by

DIEDRÉ M. BLAKE

For the degree of

Master of Arts in Expressive Therapies

LESLEY UNIVERSITY
GRADUATE SCHOOL OF ARTS & SCIENCES
May
2006
 THESIS ABSTRACT

Diedré M. Blake

May, 2006

Dialectical Behavior Therapy-Based Art Therapy

The purpose of this research was the creation and exploration of a method that

integrates dialectical behavior therapy skills technique of core mindfulness into the

structure of the individual art therapy setting. The research reviewed the study of Helen,

a young woman diagnosed with an eating disorder, and her use of a mindfulness art

journaling technique over the course of six weeks. The research also tracked the artistic

development of Helen by examining her relationship to the art-making process over the

entirety of her seven individual art therapy sessions. The analysis of interviews with

clinicians specializing in dialectical behavior therapy, cognitive behavior therapy and

expressive therapy were used to inform this thesis. The culmination of the research was

the presentation of a dialectical behavior therapy-based individual art therapy protocol

and a review and analysis of its clinical implementation with a further look at

implications for group art therapy.

 ACKNOWLEDGEMENTS

This thesis stands as a result of the enormous efforts made by a number of people,

to whom I am eternally grateful. I would like to thank Dr. Robyn Cruz, my First Reader,

for her patience and guidance throughout this process and for having faith in my ability.

I would also like to thank Dr. David Ortega, my Second Reader, who with each draft

pushed me to surpass my own expectations. His knowledge of and sensitivity to the

subject matter was vital in helping me to conceptualize the data.

I would also like to thank the participants of the study, without whom this thesis

would not have been possible. Thank you for sharing yourselves and knowledge with

me. The many conversations have only served to enrich my experiences and reinforce

my beliefs in the power of art.

There were many times during this process when I needed support of all types,

and I received it from friends. I would like to thank Dialma, Marcie, Natasha, and Holly

for believing in me, and putting up with many conversations about this project. I would

like to also give special thanks to Steph Taylor, who was an artistic guide through the last

two months and helped me to get the words out.

Finally, I could not have gotten this far without the support of my family, who

have journeyed with me through my academic highs and lows. I give my many thanks to

you for keeping me afloat throughout the years. I am eternally grateful.

 TABLE OF CONTENTS

LIST OF TABLES………………………………..............................................4

LIST OF FIGURES………………………………............................................5

1. INTRODUCTION………………………………..........................................8

Art Therapy …………………................................................................8

Introduction to Dialectical Behavior Therapy…………………...........11

DBT Treatment Program…………………...........................................13

Core Mindfulness…………………......................................................16

Mindfulness Art Journal…………………...........................................18

2. LITERATURE REVIEW.……………………………................................21

Female Adolescent Identity Development……………………………21

Female Adolescents and Eating Disorders…………………………...27

Adolescents and Art Therapy.….………….…………........................32

Art Therapy and Eating Disorders……….……………………...........33

Dialectical Behavior Therapy and Eating Disorders…………………35

3. METHOD…….………………………........................................................39

Participants……………………….……..............................................39

Setting………….….……………........................................................40

Procedure……………………………….............................................41

Data Analysis…………………..........................................................45

4. RESULTS……….…….…….……............................................................48

Interviews…………………...............................................................48
 Sessions………………….....................................................................50

Mindfulness Art Journal…………………............................................55

Completion Dates…………………......................................................57

5. DISCUSSION.……………………………..................................................62

APPENDIX A:

APPENDIX B:

REFERENCES……………….….……….......................................................97
 LIST OF TABLES

TABLE 1, Aspects of DBT

TABLE 2, Examples of Psychosocial Factors in the Development of Eating Disorders

TABLE 3, Examples of themes that emerge in the treatment of adolescents diagnosed

with eating disorders

TABLE 4, Frequency of theme-related artwork depicted in sessions and mindfulness art

journals.

TABLE 5, DBT-based art therapy 8-week structure.

 LIST OF ILLUSTRATIONS

Figure

1. Helen‟s emotion regulation drawing

2. Helen‟s first drawing in the final assessment

3. Helen‟s second drawing in the final assessment

4. Helen‟s third and final drawing in the final assessment.

5. Helen‟s last journal entry for the first week.

6. The process of artistic skill and emotional awareness through the use of the

mindfulness art journal

A1. Helen‟s first drawing of the first assessment.

A2. Helen‟s second drawing of the first assessment.

A3. Helen‟s third drawing of the first assessment.

A4. Helen‟s mindfulness drawing.

A5. Helen‟s drawing of her primary emotional state.

A6. Helen‟s drawing of her opposite emotion

A7. Helen‟s self-portrait

B1. First journal entry of week one

B2. Third journal entry of week one

B3. Fifth journal entry of week one

B4. Last journal entry of week one

B5. First journal entry of week two

B6. Second journal entry of week two

B7. Fourth journal entry of week two

B8. Sixth journal entry of week two

B9. First journal entry of week three

B10. Third journal entry of week three

B11. Fourth journal entry of week three

B12. Last journal entry of week three

B13. First journal entry of week four

B14. Third journal entry of week four

B15. Fourth journal entry of week four

B16. Fifth journal entry of week four

B17. Sixth journal entry of week four

B18. Last journal entry of week four

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CHAPTER 1

INTRODUCTION

The focus of this thesis is an examination of both art therapy and dialectical

behavior therapy (DBT), and their uses in the treatment of eating disorders with a female

adolescent population. Specifically, the thesis concentrates on how core mindfulness,

one of the four dialectical behavior therapy skills training techniques, created by Marsha

Linehan (1993), which also includes interpersonal effectiveness skills, emotion

modulation skills, and distress tolerance skills, can be integrated into the structure of

individual art therapy. The thesis will address the following question: Is the core

mindfulness skills training technique of dialectical behavior therapy better understood

through the use of art when working with an adolescent population?

In order to answer the above question, the thesis examines the individual art

therapy sessions of Helen, a young woman diagnosed with an eating disorder, over the

total course of her seven individual art therapy sessions, spanning six weeks. Moreover,

interviews with therapists within the fields of cognitive-behavioral therapy, dialectical

behavior therapy and expressive therapy who have experiences working with individuals

with eating disorders or adolescents were used to triangulate the case study data.

This thesis manifests from a long-standing interest in the treatment of eating

disorders that developed from an overall interest in self-injurious behaviors. The

American Psychiatric Association (2000) defines eating disorders as being “characterized

by severe disturbances in eating behavior, ” and have three diagnoses included in the

current Diagnostic and Statistical Manual for Mental Disorders: Anorexia Nervosa,

Bulimia Nervosa, and Eating Disorder Not Otherwise Specified (p. 583).
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A diagnosis of anorexia nervosa reflects some or all of the following criteria: a

persistent refusal to maintain normal body weight typical for the individual‟s age and

height, having a fear of weight gain regardless of actual weight, body image distortions,

and amenorrhea (American Psychiatric Association, 2000). Bulimia nervosa addresses

individuals who consume large quantities of food over a specific period of time and feel

out-of-control during that period; have use unhealthy methods to prevent weight gain,

such as vomiting, using laxatives, or over exercise; who base their self-regard upon their

weight and body; and who persistently engage the in the previously mentioned behaviors

at least twice weekly over a period of 3 months (American Psychiatric Association,

2000). For individuals who do not meet the all of the criteria for either anorexia nervosa

or bulimia nervosa, the diagnosis of Eating Disorder, Not Otherwise Specified is given

(American Psychiatric Association, 2000). McAniff Zila and Kiselica (2001) note in

their article on female adolescents and self-injury that a relationship between self-injury

and eating disorders exists due to the distortion of “body image, self-directed aggression,

and indirect self-destructive behavior” (p. 48). They further state that this relationship is

“not cause and effect,” but rather “separate choices for coping with similar situations”

(p.49). Following this self-injury can be seen as having a more encompassing

connotation and therefore could be perceived as more inclusive of eating disorders than

exclusive.

The expression of the internal struggle of a person is revealed in a direct but

hidden manner in both manifestations, whether it is in the form of restricting or gorging

food, or cutting one‟s self. It can be concluded that an internal expression of pain is

externalized but contained within the self. The field of art therapy is a means of helping
 3

others find alternate ways of expressing that pain, that is, instead of marking or harming

the body; using canvas, wood, paper, graphite, and paint.

Having gained the chance to work with female adolescents diagnosed with eating

disorders over the course of a year provided the opportunity to examine the use of art

therapy with this population. These female adolescents were between the ages 13 to 23,

and diagnosed primarily with anorexia nervosa and bulimia nervosa and were engaged in

intensive group therapy treatment. These groups focused on nutrition, body image, and

cognitive-behavioral changes. The main group therapy approach stemmed from

cognitive-behavioral therapy, and included in this was DBT. The expressive therapies

were also an integral part of the program structure, and there were typically five to seven

expressive therapy groups offered on a weekly basis at the site.

The results of the experiences led to the conclusion that the cognitive-behavioral

concepts used in most groups had not been integrated into the structure of the expressive

therapy groups. Moreover, it appeared that some of the young women were not able to

grasp the DBT skills training concepts in a verbally-based structure. This led to an

interest in understanding whether an arts-based structure incorporating the DBT concepts

could work to aid these young women in their understanding. Finding a means of

integrating a DBT approach into both individual and group art therapy became a

challenging interest. This integration would serve not only as an alternate means of

understanding key DBT concepts, but it would also aid in further development of clinical

art therapy skills, expanding upon a primarily existential and psychoanalytic background.
 4

Art Therapy

Art therapy as a field developed initially with an orientation to Freud‟s

psychoanalytic theory, in which art was seen as a manifestation of the unconscious as

illustrated by the work of Margaret Naumburg (1973; 2001). Both Margaret Naumburg

and Edith Kramer are considered the founders of art therapy. From these two art

therapists, there developed two distinct branches within the art therapy field: 1)

Naumburg‟s art psychotherapy or “dynamically oriented art therapy,” and 2) Kramer‟s art

as therapy (Malchiodi, 2003; Rubin, 2001). In response to this division, another art

therapist, Elinor Ulman (1992), developed her own neo-Freudian approach that integrated

both branches. She described it as an “attempt to define art therapy so as to encompass

both art psychotherapy and art as therapy” (Rubin, 2001, p. 292). Although divided both

approaches share some of the fundamental principles of the Freudian psychoanalytic

school of thought. These principles are 1) free association, 2) sublimation and catharsis,

and 3) transference and countertransference, all as means to resolve inner unconscious

conflict that is psychologically inherent.

Margaret Naumburg saw symbolic expression as a means to reveal the

unconscious conflict. Rubin (1999) states “Naumburg emphasized [art therapy as

creating] insight, [which uncovered] unconscious forces through images and associations

with them” (p. 158). Naumburg believed that “art therapy recognizes that the

unconscious as expressed in a patient‟s phantasies, daydreams, and fears can be projected

more immediately in pictures than words” (as cited in Malchiodi, 2003, p. 43).

Corresponding to this philosophy, Naumburg‟s approach focused on the concepts of free

association and transference.

 5

Introduction to Dialectical Behavior Therapy

Whereas existential psychoanalytic theory comes from a place of internal

disruption caused by internal realization of external factors seen as a positive step to self-

discovery (Corsini & Wedding, 2000; May, 1958), DBT, developed by Marsha Linehan

(1993), looks at internal disruption caused by internal and external factors and is seen as

detrimental to an individual‟s development of self. Developed for the treatment of

individuals who meet the criteria for borderline personality disorder, DBT states that

individuals with borderline personality disorder operate from a point of emotion

dyregulation that stems from a combination of biological and environmental factors and

their interrelationship. In stating that these individuals suffer from emotion

dysregulation, Linehan refers to their vulnerability and inability to regulate their

emotional states. Often this develops when a child is faced with what Linehan terms an

“invalidating environment.” In this environment the individual learns that what she or he

thinks or feels is not correct and acquires maladaptive behaviors as coping skills to deal

with intolerable circumstances. Thus, these individuals may operate at the extremes in

order to gain responses from external sources. Specifically, Linehan believes that the

invalidating environment does not teach the following skills: a) how to accurately label

emotions, b) how to modulate emotions, c) how to tolerate stress or distress, and d) how

to trust himself or herself and experiences. This causes the individual to invalidate the

self, referring to others on how to respond to situations. Furthermore, Linehan points out

that “impulsive behaviors and especially parasuicide can be maladaptive but highly

effective emotion regulation strategies… [and although] the mechanism by which self-
 6

mutilation exerts affect regulating properties is not clear, it is very common for borderline

individuals to report substantial relief from anxiety and other intense, negative emotional

states following such acts” (p. 4).

DBT Treatment Program

Understanding the dichotomous nature of the environment in which many

individuals diagnosed with borderline personality disorder have experienced as well as

the possible self-injurious nature of the disorder, Linehan (1993) designed a program that

caters to the core features of the disorder. DBT takes a cognitive-behavioral approach,

stressing “ongoing assessment and data collection on current behaviors; clear and precise

definition of treatment targets; and a collaborative working relationship between therapist

and patient, including attention to orienting the patient to the therapy program, and

mutual commitment to treatment goals” (p. 5). The cognitive-behavioral model,

however, stresses a change in behavior and focuses on the changing the cognitive thought

processes (Gilland & James, 1998; Linehan, 1993). For example, a cognitive-behavioral

approach with eating disorders may focus on the patient‟s ideals or beliefs about body

image and how that manifests in behavior, that is through eating disordered behavior

(Wiser & Telch, 1999). The focus of the therapy may be then to change the behavior by

regulating food intake, exposing the patient to challenging foods, for example of high

caloric value, and changing cognitive distortions and dichotomous thinking around body

image and food.

DBT differs from cognitive-behavioral therapy in its a) emphasis on acceptance

of the present emotion regulating behavior that the patient exhibits, b) balance between

change and acceptance, c) a more psychodynamic approach attention paid to the

 7

interpersonal relationship between patient and therapist, and d) a focus on dialectical

processes. By focusing on acceptance, DBT attempts to foster within the patient an

acceptance of self and his or her experience of the world that is not focused on change.

While acceptance is a key strategy of DBT, it is balanced with adaptive learning that is

while accepting the patient‟s present maladaptive strategies the therapist is actively

helping the patient to learn more adaptive skills. By looking at the relationship between

the patient and therapist, DBT attempts to avoid therapy-interfering behavior by both

patient and therapist. This is similar to psychodynamic concepts of transference and

countertransference (Freud, 1961; Gilland & James, 1998; Linehan, 1993; Strachey,

1977). In the treatment of eating disorders, for example, DBT views the maladaptive

behavior as a method of emotion regulation, stemming from an intolerable emotional

experience. The exposure to such an experience creates an upswing of an undesired

emotion, for example anger or fear, the maladaptive behavior aids in returning the patient

back to a neutral point, where she or feels emotionally safe (Wiser & Telch, 1999).
 8

Table 1.

Aspects of DBT

Unconventional attitude toward dysfunctional and parasuicidal behaviors exhibited by the

patient, but done in an empathic manner.

Helps patient to “reframe” thinking around self-harming behaviors.

Helps patient learn skills that can help in problem-solving by providing a validating

environment that addresses patient‟s emotional states and behaviors as is.

Helps patient implement skills learned in real life.

Helps patient remain in therapy and respect therapeutic relationship

Helps therapist maintain therapeutic relationship by requiring the therapist to attend his or

her own dialectical behavior therapy group with peers.

Note. Based on information gathered from Skills Training Manual for Treating Borderline Personality Disorder by M. Linehan, The

Guilford Press, 1993.

The adaptive skills that are taught in both individual and group DBT are known as

the core skills training. The skills are a) core mindfulness, b) interpersonal effectiveness,

c) emotion regulation, and d) distress tolerance (Linehan, 1993). Core mindfulness,

which was the focal skill of this thesis, involves learning how to observe, describe, and

experience emotions, thoughts and physiological responses to an experience, while

remaining nonjudgmental, focused on the present (the experiences), and planning an

effective response to the experience that is based on the reality of the situation. This skill

helps the individual learn how to tolerably experience his or emotions. Interpersonal

effectiveness teaches assertiveness, empowering the individual to state what she or he

means to others in a manner that is effective. Emotion regulation is aimed at helping the
 9

individual understand the function of emotions, identify the different aspects to emotional

responses, increase positive emotional experiences, shift emotional states, and decrease

the experience of vulnerability to challenging emotions. Distress tolerance involves

learning techniques, such as relaxation and distraction that help to reduce the intensity of

challenging emotions. All of these skills are practiced by the individual in individual

therapy, group therapy, and through the use of homework practice sheets developed by

Linehan. Core mindfulness, however, is the only skill that does not have a homework

sheet developed and the individual is expected to “practice the skills learned so far during

every week… [and] circle [on their diary card] each skill each day that they make any

attempt to practice their skills” (p. 65). These diary cards are to be reviewed with the

therapist during sessions.

Overall Linehan (1993) structured dialectical behavior therapy to help individuals

diagnosed with borderline personality disorder learn to recognize and modulate their

emotions, gain a healthy perspective of self, decrease episodes of self-harming behaviors,

express their wants and desire in an effective and meaningful way, learn to focus on

experiences, learn to be present in their bodies, learn to accept others where they are, and

maintain a therapeutic relationship. This is achieved by the therapist maintaining a

validating, empathetic, and structured environment, which remains flexible and open to

the patient‟s experiences and behaviors.

Core Mindfulness

Linehan (1993) included the concept of mindfulness into the structure of DBT

because of her belief in the behavioral and psychological effectiveness of meditation

 10

practices used in Eastern spirituality practices. She based mindfulness primarily on the

practice of Zen. Emotion regulation is the primary aim of DBT and mindfulness is seen

as a method of creating within the individual emotional awareness. As mentioned above

a emotionally dysregulated individual may use maladaptive behaviors to regulate his or

her emotional state. In effect the behavior helps the individual to avoid the experience of

the emotion. Linehan states that emotional regulation can be found through increased

awareness of the individual‟s experience of themselves and their environments.

Mindfulness involves becoming a) more aware, b) more intentional, c) more

participatory, and d) more present in ones experiences in life. Linehan sees as a function

of understanding the three mind states from which individuals operate. These mind states

are “reasonable mind,” “emotion mind,” and “wise mind.” Individuals who operate

primarily from “reasonable mind” act primarily on logic and do use emotional

intuitiveness to inform them in their decision-making process. Individuals who operate

primarily from “emotion mind” rely upon their emotions to inform them in their decision-

making process. Linehan have termed these are “cool” and “hot” respectively. “Wise

mind” individuals integrate both aspects of “emotion mind” and “reasonable mind” and

use both sets of information to inform their decision-making process. The skills learned

in core mindfulness are aimed at helping the individual achieve the preferred “wise

mind,” which is a crucial component of emotion regulation because it means awareness

of both thought and feeling for the individual. For this reason, core mindfulness skills are

seen as central to DBT and are the first skills taught.

Core mindfulness is comprised of two skills sets, “what” and “how” skills

(Linehan, 1993). Both the “what” and “how” skills have three parts. The individual
 11

learns how to observe, describe, and participate in an experience through practicing the

“what” skills. In the “how” skills, the individual learns how to participate in an

experience nonjudgmentally, one-mindfully, and effectively. Observing involves

becoming aware of the emotions, thoughts, and bodily sensations (focusing on the five

senses). Describing involves being able to put words to the observed emotions, thoughts,

and sensations. Participating involves being present in the experience, focusing on the

here-and-now without being self-conscious or obsessive. Nonjudgmentally refers to the

individual taking a nonjudgmental approach to the experience, choosing actively to not

label the experience as either positive or negative. Like observing, it is involves being

factual, seeing what is there and accepting it for what it is. One-mindfully corresponds to

participating by demanding of the individual to stay present and focused on the

experience at hand. It asks that the individual focus on one thing at a time, for example if

writing, then write without splitting focus. Effectively involves having goals in an

experience and plan on how to execute and achieve them that is based on the present

reality rather than what might, could, or should happen in the experience.

Mindfulness Art Journal

The mindfulness art journal was one of the key components of the individual art

therapy sessions with Helen. The development of the mindfulness art journal stemmed

from the absence of a homework practice sheet for core mindfulness as mentioned earlier

(Linehan, 1993). The practice of mindfulness can be seen as rather internalized abstract

process that is difficult to translate into concrete form. How does an individual

concretize the “what” skills of observing, describing, and participating? Or how does an
 12

individual concretize the “how” skills of nonjudgmentally, one-mindfully, and

effectively? The homework practice sheets of the other core skills are checklists and

written responses based on specific events, emotions, or practices (Linehan, 1993). Core

mindfulness is an ongoing process that is not a response to specificity rather it is a state

of being, showing evidence of a particular mindset. What type of homework practice

sheet would be needed to track the progress made with in practicing core mindfulness?

Linehan (1993) has found that having individuals circle the mindfulness skills practiced,

listed on the back of the DBT diary cards, to be the best approach. This thesis examined

how an arts-based approach to practicing core mindfulness might better aid the process of

practice as well as the development of awareness. This arts-based approached was the

three-part mindfulness art journal technique.

The mindfulness art journal technique was structured to enable the individual to

develop mindfulness and artistic skills as mentioned above. The three parts of the

technique involved the following: focus on experience of self and environment; execution

of artwork related to present moment; written documentation related to artwork created.

The individual is provided with a small drawing pad (5”X8”) and is asked to stop at one

moment in the day and simply focus on the experience that she or he is having in that

moment, while drawing. At a later point in the day, the individual is to go back and write

a reflective response to the artwork created. This process is done over the course of a

week and is reviewed by the therapist with the individual. The implementation and

results of this technique is further discussed in the Methods section of the thesis.
 13

Conclusion

Both art therapy and DBT have been shown to be effective in the treatment of

adolescents diagnosed with an eating disorder (Kerr-Price & Fowler, 2003). Although

typically viewed as an adjunctive therapy, art therapy is valued for its particular ability to

give voice to “patients whose capacity for verbal expression is limited or who are

struggling with excessive body image problems” (p. 30). Further art produced within the

art therapy session serves as concrete documentation of the emotional experiences of the

patient in treatment (Rehavia-Hanauer, 2003). Although Kerr-Price and Fowler (2003)

noted DBT as one of the approaches that would work well in the treatment of children

and adolescents diagnosed with eating disorders, the more recent available research

literature on the use of DBT in the treatment of eating disorders is directed towards its

use with an adult female population (McCabe & Marcus, 2002; Palmer, Birchall,

Damani, Gatward, McGrain & Parker, 2003; Safer, Telch & Argras, 2001; Safer, Lively,

Telch & Argas, 2002; Swenson, Torrey & Koerner, 2002). In these studies conducted,

the use of DBT was found to be effective, particularly in the treatment of bulimia

nervosa, in decreasing eating disordered behaviors.

Creating a DBT-based art therapy approach to the treatment of adolescent females

with an eating disorder diagnoses was one of the goals of the thesis. The development of

the approach was based upon examination of the strengths and weakness of both art

therapy and DBT as individual therapies in working with the focus population. This

thesis approached these assessments through the use of literature review of available

information about the focus population and its treatment within the respective fields,

analysis of a case study with an adolescent diagnosed with an eating disorder, and
 14

interviews with experts experienced in the focus fields and population. The conclusions

reached in this thesis highlight the known strengths of both art therapy and DBT and their

uses in the treatment of eating disorders. More importantly, however, the conclusions

emphasized the effectiveness of using a DBT-based art therapy approach specific to the

case study discussed. The results presented offer a basis for continued exploration in this

approach, looking perhaps at how to fully integrate all of the skills training techniques,

outside of core mindfulness, into an art therapy structure. Moreover, the results have led

to possible implications for the structure of and implementation of both individual and

group art therapy approaches.

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CHAPTER 2

LITERATURE REVIEW

The separate topics of adolescent therapy, eating disorders, art therapy, and

dialectical behavior therapy have a wealth of available research information.

Researching these topics as a combined unit, however, posed an initial but interesting

challenge. The search for articles and books related to an integrative approach to art

therapy and dialectical behavior therapy (DBT) in the treatment of female adolescents

with eating disorder diagnoses fell short. The literature available, however, presented

various combinations of the five above-mentioned topics. These areas presented are a)

female adolescent identity development, b) adolescents and eating disorders, c)

adolescents and art therapy, d) art therapy and eating disorders, and e) dialectical

behavior therapy and eating disorders.

Female Adolescent Identity Development

Adolescence

Theorists have described adolescence as a time of chaos, although it has been

shown that most adolescents appear to transition through this time period with relative

ease (Cole & Putnam, 1992). Why then has adolescence gained this reputation? The

answer reflects the very nature of this stage in development. It is a time of great physical

and cognitive change. These changes, in themselves, need not be described as the

bringers of „storm and stress,‟ but within the context of the adolescent‟s ethnic

background and culture, they may be experienced with some difficulty (Berk, 2000;

Weisz & Hawley, 2002). Based upon the socioeconomic and ethnic background,

different adolescents may experience the same life stressors with varying degree. Issues
 16

such as poverty and minority statuses play a major role in how the adolescent experiences

himself or herself in society (Riley, 1999). Belonging and conforming to a more socially

accepted or popular peer group also present a special challenge to adolescent, who in this

developmental stage views peer relationships with increased importance (Feldman, 2005;

Weisz & Hawley, 2002). If the desired peer group differs radically from the adolescent;

for example in socioeconomic status, ethnicity, race, or sexual orientation; the adolescent

may be left feeling ostracized or experience difficulty adjusting to his or her social

environment. These factors among others can make this period more challenging for the

adolescent. Johnson, Cohen, Kotler, Kasen and Brook (2002) discuss multiple factors

that contribute to the development of eating disorders during adolescence, identifying

depressive disorders as prevalent and co-morbid with eating disorder diagnoses. They

further state that the depressive symptoms experienced by the adolescent may result from

“a stressful array of physical and psychosocial challenges” (p. 1120).

For the most part, these changes are positive developments for the adolescent,

who during adolescence is reaching sexual maturation, experiencing physical growth,

capable of advanced thinking and reasoning, and becoming recognized as a member of

society. It may be reasonable to conclude that the adolescent is faced with many

challenges. The most crucial of these is cognitive development that allows the adolescent

to be capable of abstract thinking and introspection as indicated in Jean Piaget‟s

cognitive-developmental theory (Crain, 2000). Because of this development, the

adolescent becomes more self-aware and aware of how she or he impacts others. With all

that occurs during this stage of development, it is no wonder that the adolescent appears

very egocentric. Piaget‟s cognitive-developmental theory is divided into four periods:

 17

sensori-motor intelligence (birth to 2 years), preoperational thought (2 to 7 years),

concrete operations (7 to 11 years), and formal operations (11 to adulthood) (Crain,

2000). The concept of egocentrism begins in the preoperational thought period, and is

defined as the inability to take into consideration the experiences or perspectives of

others Berk, 2000). Children in the preoperational thought period exhibit this in multiple

ways, whether it is conducting an ongoing monologue in the presence of others, or simply

ignoring what is being stated by others (Feldman, 2005). This egocentrism can be found

in adolescence, but takes on different tone. It is marked by a rejection or criticism of

authority figures, for example parents and teachers, and their viewpoints. Feldman

(2005) notes that this egocentrism can isolate the adolescent from being able to relate his

or her experiences with those of adults, leading to the belief that his or her experiences

are wholly unique. This belief in his or her uniqueness creates the foundation for the

adolescent to perceive of himself or herself as „standing out‟ or being markedly observed

by others, creating the notion of the “imaginary audience, fictitious observers who pay as

much attention to the adolescents‟ behavior as adolescents do themselves” (p. 397).

Because the adolescent‟s experiences have not been shared by adults, the adolescent

looks to other adolescents who may not have had his or her unique experiences, but can

at least relate to having unique experiences in general. This way of relating to the world

defines the paradox of the social interaction of the adolescent.

The egocentrism of adolescence creates a central theme for this stage, that of

identity. Who am I? What are my beliefs? Why am I different? These types of

questions are typical for the adolescent, who is on a journey of self-discovery that is

being prompted by the adolescent‟s newfound sense of self-awareness. This search can
 18

be summarized by the developmental theory of Erik Erikson (1994), whose fifth stage of

development describes the period of adolescence called identity versus role confusion.

Erikson saw the “the adolescent‟s primary task… [as] establishing a new sense of ego

identity- a feeling for who one is and one‟s place in the larger social order” (Crain, 2000,

p. 281). This search, however, becomes a source of tension for the adolescent, who feels

both like child and adult (Feldman, 2005). Thus, the emotional drama of adolescence

looks very similar to that of Margaret Mahler‟s separation-individuation stage of

rapprochement that toddler‟s experience (Berk, 2000; Crain, 2000).

Mahler‟s theory states that toddlers, around 15-24 months, attempt to seek

independence, but realize that that cannot be achieved, because of their dependence on

adults (Crain, 2000). The adolescent, too, experiences this extreme conflict between

assertion and dependence. Whereas the toddler may simply say „no‟ repeatedly and

throw a tantrum as a way to express his or her need for independence, the adolescent

shifts towards rebelliousness that can occur on many levels, from moderate to severe.

For example, the adolescent may simply dress like a member of an undesired subculture

(moderate), or begin partaking in harmful activities such as illicit drug use (severe) (Berk,

2000). Otherwise the changes that the adolescent experiences as well as the behaviors

that she or he may display serve the purpose of personal growth that will help the

adolescent achieve a better understanding who she or he is.

Identity. The formation of one identity is informed by the individual‟s experience

in relation to his or her environment (Gardiner & Kosmitzki, 2002). As one grows older,

this formation becomes more and more influenced by a growing number of internal and

external factors, such as temperament, physical and cognitive development, gender,

 19

sexual orientation, culture, ethnicity, and socioeconomic background. The actual

realization of one‟s identity, however, does not become a prominent issue until one

reaches adolescence in many cultures (Gardiner & Kosmitzki, 2002; Kroger, 2002). For

some theorists, such as Erikson (1994), it is at this point in one‟s development that one

experiences an identity crisis (Feldman, 2005). Erikson (1994) called this stage in his

developmental theory identity versus role confusion, where the adolescent‟s task is to

establish a concrete psychological sense of self. During this time, adolescents „try on‟

different roles and may present emotionally and physically in varied ways to others. The

pressure to establish an identity can be an overwhelming process for some adolescents,

who may choose to enter a psychosocial moratorium, a period spent finding one‟s self; or

may choose identity foreclosure, prematurely taking on an accepted social role. Erikson

believed that if an adolescent is not able to achieve a positive and committed

understanding of himself or herself, then she or he will not be able to establish an identity

but will instead enter into role confusion, which understood as the inability to identify

appropriate roles in life.

The journey to identity realization is not always clear, and in reality it is a lifelong

process. It may appear to one adolescent as a straight road with no divergence, while

another it may be forked causing the adolescent to have to try its different roads. Each

adolescent can be found on his or her journey towards achieving identity at four points.

These points, called identity statuses by James Marcia, are a) identity achievement, b)

moratorium, c) identity foreclosure, and d) identity confusion. The adolescent is able to

achieve identity by moving through each status (Crain, 2000; Feldman, 2005; Gardiner &

Kosmitzki, 2002; Kroger, 2002). Laura E. Berk (2000) states that the first two statuses,
 20

identity achievement and moratorium, are seen as positive points for the adolescent,

because they positively impact the adolescent in terms of overall self-regard and

reasoning. The latter two are more negative for the adolescent and result in a higher level

of intolerance, fear of rejection, immaturity, passivity, and apathy (Kroger, 2002).

Female Adolescent Identity. For the female adolescent, the aforementioned

changes can be both positive and negative experiences. Puberty brings obvious external

changes that can shift not only her attention to her body but others as well. The

presentation of her body becomes an important factor, and dependent upon culture, can

have a greater impact on her self-regard. In the United States, for example, eating

disorders are becoming more and more prevalent among female adolescents across racial,

ethnic and socioeconomic lines (Shaw, Ramirez, Trost, Randall & Stice, 2004). The

increase could be said to be reflective of that society‟s emphasis on thinness as being the

ideal standard for feminine beauty (Johnson, Cohen, Kotler, Kasen & Brook, 2002).

In addition to the belief that she needs to conform to cultural expectations of

femininity, the female adolescent also has the added challenge of being seen as a

potential sexual partner for males, even if she is not cognitively ready. Girls, who

experience early physical maturation, are more susceptible than others to external

pressures to engage in sexual activity because of the external attributes that announce the

start of their sexual maturation to others (Feldman, 2005). In response to this pressure,

these girls may make attempts to delay their physical development through controlling

their weight. This can lead to excessive dieting and exercise, which in turn leads to the

development of eating disorders (Mallinckrodt, McCreary & Robertson, 1995).

 21

Identity is influenced by multiple factors. When the female adolescent embarks

on the discovery of herself, she has already been acculturated into the expectation of

society for her gender. Therefore, in some ways, the female adolescent could perceive

her identity as already formed without her input. For many years, researchers within the

field of psychology believed that “adolescent girls postponed the task of establishing an

identity and instead focused their energies on Erikson‟s next stage, intimacy

development” (Berk, 2000, p. 457). It is now understood that female adolescents tend to

be more relational and are more advanced than their male counterparts in the intimacy-

related areas of identity (Gilligan, 1992; Josselson, 1992; Sampson, 1993). Because of

the female adolescent‟s natural tendency towards a relational existence, the reliance on

input from external sources plays a greater role in the development of her identity.

Female Adolescents and Eating Disorders

Overview

Adolescence has been identified as the typical onset period for eating disorders,

with females being diagnosed with anorexia nervosa and bulimia nervosa more often than

males with an approximate ratio of 10:1 (American Psychiatric Association, 2000).

Moreover, there is a higher occurrence of bulimia nervosa (1%-3%) than anorexia

nervosa (.48%) in older female adolescents (Manley & Leichner, 2003; Safer, Telch &

Agras, 2000; Weisz & Hawley, 2002). As the primary diagnoses of eating disorders,

anorexia nervosa and bulimia nervosa are more often the focus of many treatment

facilities. Anorexia nervosa is described as “a refusal to maintain a minimally normal

body weight,” and bulimia nervosa as “repeated episodes of binge eating followed by
 22

inappropriate compensatory behaviors such as self-induced vomiting” (American

Psychiatric Association, 2000, p. 583).

There are many factors that can be attributed to the development of eating

disorders, including the aforementioned developmental factors. There is, however, no

one reason why an individual develops an eating disorder. Here, however, is a list of

some of the more prominent psychosocial factors:

Table 2.

Examples of Psychosocial Factors in the Development of Eating Disorders

Low self-esteem

Cultural or familial expectations to be thin

Reaction to negative emotions, i.e., using food as a coping skill

Dichotomous thinking, e.g. “thin is beautiful” and “fat is ugly”

Sexual abuse

Perfectionism

Power and control

Note. Based on information gathered from Lives Across Culture: Cross-Cultural Human Development by H. W. Gardiner and C.

Kosmitzki, Allyn and Bacon, 2002.

Self-Injury. Eating disorder can be life threatening. This is not only because of

the devastating effects of starvation or regurgitation upon the body, but also because of

the high risk of suicide and self-injurious behaviors, for example cutting, burning,

scratching, etc., associated particularly within the adolescent population (Manley &

Leichner, 2003). MacAniff Zila and Kiselica (2001) in their article on self-injury found

that a relationship existed between self-injury and eating disorders, finding that a

majority of women (in one study over 50%) who identify as having self-injured were also
 23

found to have an eating disorder, or to have had in the past. The relationship suggested,

however, is not cause-and-effect, that is that having an eating disorder automatically

leads to self-injury or vice versa. Rather, both are maladaptive strategies employed by

the individual to deal with an intolerable circumstance. Adolescents who have been

diagnosed with eating disorders have a 10% higher risk of achieved suicide than

adolescents without (Yager & Stein, 2001). It is believed that suicidal ideation and self-

injurious behaviors might develop out of feelings of worthlessness; as an attempt to feel;

or as an attempt emotion regulation as discussed in the Introduction (Linehan, 1993;

Manley & Leichner, 2003; Weisz & Hawley, 2002; Wiser & Telch, 1999).

Themes Within Therapy. Eating disorders can be seen as a response to the anxiety

created by an ultimate concern. In the case of female adolescents, the ultimate concern

could be death, isolation, or meaninglessness. Themes of isolation, emptiness, and

meaninglessness often emerge in the treatment of eating disorders, and are significant for

adolescents, who are in the developmental stage of forging an identity through peer

relations (Acharya, Wood & Robinson, 1995; Craig, 2004; Crain, 2000; Kerr-Price &

Fowler, 2003; Manley & Leichner, 2003; Wolf, Wilmuth, Gazda & Watkins, 1984). The

eating disorder then can be seen as creating a feeling of specialness for the individual by

creating a paradox of survival through defiance of actual bodily needs, that is, “I exist

although I destroy myself.” Meanwhile the disorder takes on the equally paradoxical role

of the ultimate rescuer, protecting or saving the individual from feelings of normalcy or

intolerable feelings of his/her life, but who also brings the individual to „edge.‟

In treating female adolescents diagnosed with eating disorders there are certain

themes that often emerge within the therapeutic setting and could act as obstacles to
 24

advancement in treatment and recovery. Manley and Leichner (2003) have identified

such obstacles as feelings of anguish and despair, feelings of hopeless and helplessness,

inability to recognize, distinguish, and express feelings, and ambivalence and mistrust as

major themes that can negatively impact treatment of female adolescents within the

therapeutic relationship on an ongoing basis. Manley and Leichner see the theme of

anguish and despair as stemming from feelings of being undeserving of receiving the

help of others. It is in essence a conflict of shame and control, where the individual sees

receiving or asking for help as giving up control, or being out-of-control, which in turn

produces feelings of shame. This creates a challenging situation for female adolescents

diagnosed with an eating disorders, who are often markedly high-achieving and

perfectionist. The feelings of hopeless and helplessness refers to the state in which the

individual has experienced several losses; for example, inability to socialize with friends,

participate in school, or even to physically move, as a result of the eating disorder. The

individual may then feel as though there is no point to recovery because she is too far

gone. The individual‟s though process may be distorted to the extreme of believing that

she may be punished by the eating disorder if she tries to become healthy. The inability

to recognize and express emotions, Manley and Leichner believe, may stem from explicit

or implicit messages received by the individual that her acknowledgment or verbalization

of her emotional experiences outside of her eating disordered behaviors were

discouraged. Over the course time, the individual may then begin to distrust or avoid her

emotions, seeing them as irrelevant and relying on eating disordered behaviors as

methods of coping. Ambivalence towards treatment and mistrust of treatment providers

reflect the individual‟s need to maintain her eating disordered behaviors, which have
 25

become a primary source of coping. The individual may see treatment and treatment

providers as attempting to take away this primary coping skill. Furthermore, the

individual may see treatment and treatment providers as trying to control her by

controlling her body.

There are other significant themes that emerge as well in treatment such as

perfectionism and power and control (Pratt, Telch, Labouvie, Wilson, & Agras, 2001;

Sallas, 1985). The issue of power and control is especially significant given the female

adolescent‟s strife to discover identity relationally separate from her parental/authority

figures, and in treatment the therapist might be placed in a parental and authority role by

the patient. Thus, she is placed in the paradox of wanting to please and at the same time

rebel against those in a power of position. Although the aforementioned themes may

pose challenges to therapy, if appropriately addressed throughout treatment, they may

serve to aid in a more complete recovery for the female adolescent, and also help her

firmly establish her identity.

 26

Table 3.

Examples of themes that emerge in the treatment of adolescents diagnosed with eating

disorders

Anguish and despair

Helplessness and hopelessness

Inability to recognize, distinguish, and express feelings

Ambivalence and mistrust

Power and control

Cognitive distortions around notions of fatness, thinness, and ideal body image

Note. Based on information gathered from “Anguish and Despair in Adolescents with Eating Disorders: Helping to Manage Suicidal

Ideation and Impulses” by R. S. Manley and P. Leichner, 2003, Crisis, 24(1), 32-36; and “Psychiatric Disorders Associated With Risk

for the Development of Eating Disorders During Adolescence and Early Adulthood” by J. G. Johnson, P. Cohen, L. Kotler, S. Kasen,

& J. S. Brook, 2002, Journal of Counseling and Clinical Psychology, 70(5), 1119-1128.

Adolescents and Art Therapy

“Making art is first and foremost a natural way to experience self-exploration,

self-expression and self-revelation” (Moon, 1998, p. 14).

Given that adolescence marks the official start of the search for and development

of one‟s identity, it would seem fitting that the adolescent may view and use the arts as

means of expressing who she or he is at each step of his or her journey towards

establishing an identity (Moon, 1998). It is no wonder that adolescence is seen as one of

the most creative stages of human development (Riley, 1999). It is through this burst of

creativity that we see the art of adolescents emerge, serving not only as a means of self-
 27

expression but also as self-reflection. The final art product can serve then to open up

both internal and external dialogues, that is, the adolescent with himself or herself and the

adolescent with others in his or her environment.

To understand the art of adolescents is to understand metaphor, and art is

inherently a form of metaphorical communication (Moon, 1998; Riley, 1999). With the

focus on separating and individuating through the development of identity, adolescents

seek to create a world with a language of their own making. One needs only partake in a

conversation with a group of adolescents to understand they have their own unique ways

of using language that makes it new and cryptic. It can seem, at times, totally

indecipherable. The same, however, can be said about the art created by adolescents.

Thus, it is only through asking questions of the adolescent about his or her art that insight

can be gained. Riley (1999) states that “by validating the image, staying with the

imagery, rather than assuming knowledge of the meaning” a connection can be made

with adolescents, who find it easier to talk through metaphor or their art (p. 44).

Art Therapy and Eating Disorders

Art can play a significant role in the life of the adolescent, who is enjoying a high

level of creativity due in part to his or her developmental stage (Riley, 1999). Art can

also play a role in the role of therapy with adolescents, and can help them to learn to

effectively express their many states of being and experiences. Given this the role of art

therapy in the treatment of adolescents has gained importance over the past two decades

and is often used as a part of the group therapy curriculum of treatment facilities (Kerr-

Price & Fowler, 2003). Art therapy‟s ability to not only tap into underlying factors
 28

affecting adolescents but to facilitate insightful dialogues about those factors continues to

contribute to its growing relevance in the overall field of adolescent therapy.

Based upon the literature, art therapy has been used in a variety of ways to aid in

the treatment of eating disorders. Although the focus of the literature tends to be on an

adult population, it is still relevant in the treatment of adolescents. Morenoff and Sobol

(1989) state that art can be used in two distinct ways in regards to group therapy with

individuals diagnosed with eating disorders. It can be used as an adjunctive therapy to

facilitate discussion and as a primary therapy, in which the art-making process becomes

more about the personal experience. Beyond this basic premise, art can be used with this

population to increase overall self-awareness and decrease symptoms (Hornyak & Baker,

1989). Following in the footsteps of pioneer Margaret Naumburg, Levens (1995) states

that the role of the art in therapy is that of the „transitional object‟ on which internal

conflicts are projected, taking over the position in which the therapist typically finds

himself or herself. In being the transitional object, the individual is free to accept the

insight that art has to offer without worry of a power and control dynamic as the art is

something that the individual has created and is thus an extension of self (Acharya,

Wood, & Robinson, 1995; Levens, 1995; Rabin, 2003). Moreover, the art creates a

permanent language, a type of story, for a population who may lack the ability to verbally

express (Manley & Leichner, 2003). The art is concrete, tangible, and symbolic of what

the individual is thinking or feeling at the moment of creation. The art is also safe as it

contains these feelings or thoughts in whatever medium has been used, providing

boundaries for individuals who do not often have boundaries, or who have had their

boundaries violated (Milia, 1996; Rabin, 2003). The art also gives individuals diagnosed
 29

with eating disorders a feeling of power because they can reveal as much or as little as

they choose to through the art (Rabin, 2003; Wolf, Willmuth, Gazda, & Watkins, 1984).

Art therapy like verbal therapy can focus on cognitive and behavioral themes that

may emerge in therapy with this population (Fleming, 1989; Levens, 1995; Morenoff &

Sobol, 1989). The six themes, mentioned in the section Female Adolescents and Eating

Disorders, can be addressed in many ways in therapy. Based upon the theoretical

approach of the art therapist, the art task given to address these themes may appear

radically different.

Dialectical Behavior Therapy and Eating Disorders

Outside of the treatment of borderline personality disorder, dialectical behavior

therapy is being used to treat a variety of populations (Swenson, Torrey & Koerner,

2000), including complex posttraumatic stress disorder (Black Becker & Zayfat, 2001;

Spoont, Sayer, Thuras, Erbes & Winston, 2003), substance abuse, and eating disorders

(Palmer, Birchell, Damani, Gatward, McGrain & Parker, 2003; Safer & Telch, 2001;

Safer, Lively, Telch & Argas, 2002; Telch, 1997; Wiser & Telch, 1999). In regards to

the treatment of eating disorders dialectical behavior therapy has been found successful,

in terms of decreasing maladaptive behaviors such as purging and increasing continued

participation in treatment, especially in the treatment of binge eating disorder and bulimia

nervosa (Palmer, Birchall, Damani, Gatward, McGrain & Parker, 2003). There is also an

indication to its success, specific to providing a therapeutic context for the acquisition of

skills, in treating anorexia nervosa (McCabe & Marcus, 2002).

 30

The appeal of dialectical behavior therapy has been far-reaching given its success

with „difficult‟ populations. Swenson, Torrey and Koerner (2002) discussed the appeal

of dialectical behavior therapy as being based upon its structure that is “simple and

coherent enough to be understood by new practitioners and sophisticated and complex

enough to appeal to experienced therapists” (p. 173). It is also simple enough for the

layperson as indicated by available self-help books (Spradlin, 2003). Dialectical

behavior therapy takes into consideration multiple approaches, including aspects of

spirituality and behaviorism. Moreover, it emphasizes the need for validation, skill

acquisition, self-care and support for both the patient and therapist (Linehan, 1993). As

mentioned in the Introduction, one of the core dialectic in DBT is acceptance versus

change. DBT stresses the importance of accepting who the patient is and his or her

attempt to regulate emotions that may be maladaptive. At the same time, the therapist

helps the patient learn new adaptive skills to regulate his or her emotions, enabling

change.

Following the framework of dialectical behavior therapy, eating disorders are

seen as maladaptive behaviors that are used as attempts to regulate emotions. It focuses

its attention on validating the patient at his or her attempt to regulate emotions through

the eating disorder while simultaneously providing the individual with a new skill set to

replace the maladaptive ones, that is, eating disorder behaviors. There are many ways in

which dialectical behavior therapy helps to contain individuals with diagnoses of eating

disorders, creating for them a sense of safety, in which there is room for error and

growth.
 31

Conclusion

The literature reviewed in this thesis examined the following areas: female

adolescent identity development, adolescents and eating disorders, adolescents and art

therapy, art therapy and eating disorders, and dialectical behavior therapy and eating

disorders. The biopsychosocial changes experienced by the female adolescent aid in the

formation of identity. These same factors also set the stage for psychiatric disorders such

as eating disorders sometimes caused by the intense internalized and perceived

externalized focus (imaginary audience) on changes occurring within the self. An eating

disorder can have many functions for the female adolescent. For example, it can be a

way to a) feel in-control over the self in the environment, especially if the adolescent has

experienced a violation like sexual abuse, b) delay sexual development, c) conform to

societal, cultural, or familial expectations, or d) understand her existence (existentialism).

On the whole there is no one specific reason why a female adolescent develops an eating

disorder, rather there are multiple factors involved in its formation. Artistic expression

becomes more developed during adolescence (Malchiodi; Riley, 1999; Spaniol, 2004).

With this increase in the ability for artistic expression, art can serve to aid the female

adolescent develop her own language, fostering a more concrete sense of identity. Art

therapy has worked well in the treatment of eating disorders. The female adolescent can

use art as a means of conceptualizing the function of the eating disorder in her life. Art

therapy can also aid the female adolescent in improving self-esteem and creating overall

positive self-regard through providing adaptive coping skills and artistic technique

through the use of the art-making process. The use of DBT in the treatment of eating

disorders has increased over the last several years. In terms of eating disorders, the
 32

current research on DBT has paid particular attention to bulimia nervosa and binge-eating

rather than anorexia nervosa. This stems from the impulsivity associated with bulimia

nervosa and binge-eating and which DBT targets and improves. Eating disorders are

seen as maladaptive methods of emotion regulation in DBT. Thus one of the goals of

treatment would be to provide the female adolescent with alternate means to regulate her

emotions. DBT helps the female adolescent understand her existence in a more dialectic

rather dichotomous manner. For example, the female adolescent in DBT is asked to

accept herself and her attempts at emotion regulation (eating disordered behavior) while

at the same time learn new adaptive skills to enable a change in this behavior.
 33

CHAPTER 3

METHODS

Participants

Case Study

Helen was a 20-year-old Jewish American bisexual female being treated for

anorexia nervosa, binge-eating/purging type at an eating disorder residential program.

Prior to admission Helen had been a full-time student and worked part-time to support

herself through college. During the course of the last semester, she began to severely

restrict and purge due to multiple stressors. Helen had a six-year history of anorexia

nervosa, binge-eating/purging type from the age of 14 to present. Alongside this, Helen

experienced depression, sexual trauma, hypomania, self-injury (cutting and burning), and

a suicide attempt. Helen began therapy at age six due to the divorce of her parents and

subsequently for her eating disorder symptoms, and she was also hospitalized several

times over the course of the last five years.

Helen was a participant in the weekly expressive therapy groups at the program

led by the author. After three weeks in the program, Helen asked to begin individual art

therapy to learn to “draw better” and for self-exploration. Helen identified her artistic

strength in the area of musical performance and she discussed having been proficient in

playing the cello during high school. Further, Helen‟s individual therapist was concerned

by her inability to identify her emotions and label her experiences. Helen gave informed

consent to participate in the study and to have her case material used for academic

purposes.
 34

Interviewees. Two dialectical behavior therapists, one cognitive-behavioral

therapist, and one expressive therapist were interviewed for this thesis. These

interviewees were recruited from the program setting. With the exception of the

expressive therapist, they were chosen for their experiences working with an adolescent

population or eating disorder. The expressive therapist was chosen for her use of DBT‟s

mindfulness skill in her work with adult women diagnosed with dissociative disorders. In

total the interviewees included two women and two men. Three of the interviewees

identified as Caucasian and one identified as Asian-American. The educational level of

all the interviewees was at a graduate level or above.

Three of the four interviews were documented through note-taking and one was

tape recorded. The purpose of conducting these interviews was to triangulate the

research and to gain a better understanding of how the use of an art-based dialectical

behavior therapy-based art therapy approach could be beneficial to the target population.

A further goal was to understand the potential structural difficulties that could arise in

creating and implementing such an approach.

Setting

During the course of the study, Helen was both a resident and partial patient of the

program. The program required that all patients entered at a residential level of care to

help in the assessment and stabilization of their nutritional and psychological needs. The

program operated on a weight-based level system, and as patients stabilize in their weight

range they were allowed to move on to a partial level of care. The average length of stay

was 2-3 months.

 35

Procedure

Treatment

Treatment involved seven sessions of weekly 50-minute individual art therapy

over the course of six weeks aimed at teaching mindfulness skills to aid in the

observation, identification, and experiencing of emotions from a nonjudgmental stance.

As a part of the treatment four weekly mindfulness art journals were completed to

practice the mindfulness techniques taught and to monitor artistic development. These

journals were reviewed weekly in the individual sessions. The mindfulness art journal

was developed from DBT mindfulness skills and implicitly addressed the three mind

states of “reasonable mind,” “emotion mind, ” and “wise mind.” Mindfulness is the only

core skill that does not have a homework sheet associated with it and patients are simply

expected to practice the skills as learned (Linehan, 1993). The journal provided a

concrete way to practice mindfulness skills.

Session 1. An orientation to individual art therapy was given, including

discussions on treatment goals, commitment to therapy, ground rules involving respecting

the expressive therapy studio, and openness to artistic exploration. An initial art therapy

assessment was conducted to assess target behaviors and artistic skill development. An

introduction to the concept that emotional awareness can be facilitated through the use of

art-making was given, followed by music-based art directive to demonstrate the concept.

The mindfulness art journal technique was explained and discussed as a possibility for

treatment. An artistic skill-building assignment was given to be completed for the

following week. Patient was asked to bring in music of her choice to the next session to

be used in music-based art directive.

 36

Session 2. A review of the last week‟s session was completed at the beginning to

discuss any concerns and address any possible changes desired. The skill-building

assignment was reviewed. A second assessment was completed to monitor any changes

in target behaviors and artistic skill development. A skill-building lesson in the use of

materials (oil pastel, chalk pastel, and charcoal) was given. The music-based art directive

was completed using music brought in by patient followed by a discussion on

maintaining a nonjudgmental stance while experiencing an emotionally discomforting

situation. The mindfulness art journal was given to be completed for the following week.

Session 3. This session was used as a review of all artwork completed over the

course of treatment. At the start of the session, an “emotion mind” drawing was

completed. Thereafter, the completed mindfulness art journal and accompanying journal

were reviewed and discussed, highlighting themes and focusing on the process of the

mindfulness “what” skills of observing, describing and participating. The patient was

asked to review all artwork, locating themes within the art and relating them to her

present experiences. A discussion on how awareness can help to create effectiveness was

introduced. The second mindfulness art journal assignment was given to be completed

for the following week. A painting assignment (“Where I am now”) was given, which

was begun in session and patient was expected to complete by the next session.

Session 4. The second mindfulness art journal was reviewed along with its

accompanying writings. The completed painting was reviewed and compared to „life

map‟ drawings the patient brought in with her to the first session. The focus of this

session was a review of all artwork completed since the start of individual art therapy.

The patient was asked to discuss themes, emotional content, and artistic development.
 37

The patient was not explicitly directed to complete the mindfulness art journal, but was

provided with the materials. The patient was given an open art assignment to complete,

which took into consideration her experience of herself outside of treatment.

Session 5. The focus of the session was understanding the necessity of being both

emotionally and intellectually aware in emotionally charged situations. A review of the

mindfulness art journal and writings was done, highlighting themes and discussing

artistic development. Patient was also asked to discuss why she chose to complete

journal processing although not explicitly asked to do so. The final mindfulness art

journal assignment and a painting assignment were given. Termination was discussed

with the patient at the end of the session.

Session 6. This session was used to review all artwork completed and to discuss

termination. A third art assessment was completed to monitor target behaviors and

artistic skill development, followed by a music-based art directive. The patient was given

the opportunity to address any other concerns and discuss her experience of the

therapeutic relationship. The patient asked for and was given another canvas to complete

a final painting for the final session.

Session 7. Termination session that focused on the therapeutic relationship,

review of treatment goals, planning for the future and a discussion on final painting. A

review of the final mindfulness art journal and writings as well as final painting. The

patient was asked to discuss how she understood her experiences of her emotions in

emotionally triggering situations. Moreover, patient was asked to identify therapeutic

themes that emerged in her work that could help to focus her future therapy goals. The
 38

patient was asked to self-assess her artistic development. A joint art directive was

completed with the patient and given to the patient at the end of the session.

Interview Questions. The structure of the interviews was based on a set of six

questions. The focus of the six questions was specific to the orientation of the individual

therapists. Below are the guideline questions.

Guideline Interview Questions For Expressive Therapists

1. From your experience, have you observed any common themes that have

emerged in the artwork of this population? If so, what are the themes? How

have they related to the stage of treatment?

2. As an expressive therapist working within a short-term setting, what do you

believe can be achieved in treatment?

3. What are some of the problems you have encountered while working with this

population as an expressive therapist? How have you dealt with resistance?

4. What are some of your favorite art interventions to use with this population?

What materials do you find to be the most effective in working with this

population and within a short-term setting? Why? What do you find to be

least effective? Why?

5. What is your theoretical framework used in working with this population?

Why have you chosen this framework?

6. What has been the most difficult aspect of implementing this type of therapy

with this population for you? Could you discuss your development as a

therapist and how your experiences over the years have informed your choice

in this approach?
 39

Guideline Questions for cognitive-behavioral Therapists

1. Have you observed any behavioral changes in a patient when she or he first

begins working with the dialectical behavior therapy framework? If so, what

were the significant changes?

2. What are some of the problems you have encountered while working with this

population and the dialectical behavior therapy framework? How have you

dealt with resistance?

3. Is cognitive-behavioral therapy your main theoretical framework? If not, then

what are others?

4. Do you find that dialectical behavior therapy is effective in a short-term

setting? What are some of the challenges you have encountered in

implementing this approach? Are the challenges specific to this population?

What do you find to be successful in this approach? How/What would you

change in this approach?

5. Which of the core skills have you found to be the most problematic for this

population? Which is the least?

6. What has been the most difficult aspect of implementing this type of therapy

with this population for you? Could you discuss your development as a

therapist and how your experiences over the years have informed your choice

in this approach?
 40

Data Analysis

The study was based upon a phenomenological approach, looking at the

experiences of the subjects involved to gain an understanding how the use of art can be

beneficial in creating mindfulness. There were three sets of data analyzed: the individual

art therapy sessions, the interviews, and the artwork and writings of the case subject.

Each individual art therapy session was documented, including descriptions of materials,

directives and homework assignments, patient observations and responses, and therapist

observation. Interviews were recorded and analyzed to find recurrent themes that would

aid in informing the study question. Session and homework artwork and writings were

evaluated to understand, chart, and define artistic development and themes of

mindfulness.

Individual Art Therapy Treatment

The mindfulness art journal was a central component of the study. It was

introduced to the subject in the first session as a method of aiding in creating emotional

awareness or mindfulness. In total there were four mindfulness art journals completed

during the course of the study. All of the images of the journal were analyzed alongside

other homework materials by the following areas: date of completion, titles given, use of

materials, color choice, percentage of paper use, style of execution (compartmentalized,

integrated, integrated/compartmentalized), use of color, presence of schema types,

presence of blending, idiosyncratic mark-making, and diagnoses and treatment goal

themes. The session artwork and writings were analyzed by the following areas: titles

given, use of materials, color choice, percentage of paper use, style of execution
 41

(compartmentalized or integrated), use of color, presence of schema types, presence of

blending, idiosyncratic mark-making, and diagnoses and treatment goal themes.

The use of the terms integrated, compartmentalized, blending, and idiosyncratic

mark-making have the following meanings. Integrated refers to a well-formed image, in

which elements relate to one another and there is consistency in style and form.

Compartmentalization refers to a disjointed image, featuring multiple aspects that do not

relate to each other. This type of drawing may also be complete and feature form and

style inconsistency. Blending refers to the manipulation of the art medium to create a

smooth appearance and the mixing of colors. Idiosyncratic mark-making refers to motifs

that are recurrent and unique to the artwork.

 42

CHAPTER 4

RESULTS

Overview

The primary task of the study was to gain an understanding of the development of

mindfulness through the use of art using a combination of in-session art directives and the

mindfulness art journal homework assignment. Furthermore, the study looked at artistic

development over the duration of the study. The patient was asked in each individual

session to review the mindfulness art journal completed over the course of the last week

and to discuss her experience of practicing mindfulness using this technique. Although

explicit discussion of the patient‟s eating disorder was not a focus, the eating disorder

related themes were monitored in the patient‟s artwork in order to observe any changes in

the way in which the patient related to her diagnosis. Over the course of the seven

sessions, the patient made significant progress in her ability to engage in mindfulness and

in her artistic skill development.

The following results have been divided into five sections: interviews, sessions,

mindfulness art journal, completion dates, and themes. The sessions and mindfulness art

journal sections have included data more aimed at addressing the patient‟s artistic

development over the course of treatment. The sections on completion dates and themes

have included data on the development of mindfulness by the patient.

Interviews. Three themes were identified from the interviews conducted for the

study. These themes are simplicity, impulsivity, and consistency.

 43

Simplicity. All interviewees agreed that the structure of DBT needs to be

simplified for adolescents who may not be developmentally ready for the abstract

thinking that DBT demands.

Interviewee 1 stated, “Good skills are concrete, real world, and easy to explain…

DBT language and concepts need to be deconstructed into teen speak.”

Interviewee 2 stated, “For adolescents the concept of mindfulness is too abstract

and needs to be simplified and made more behavior-based.”

Interviewee 3 stated, “For adults its easier to explore [cognitive behavior therapy].

Adolescents are more likely to dismiss it [because of] development. One of the biggest

problems with DBT is that it is very intellectual.”

Interviewee 4 stated, “It is difficult to teach mindfulness… That is why I use art in

my DBT groups.”

Impulsivity. DBT specializes in dealing with impulsive behaviors. Three

out of the four therapists, who work with patients diagnosed with eating disorders, agreed

that DBT may not work well with patients diagnosed with anorexia nervosa, restricting

type.

Interviewee 1: “DBT doesn‟t help with anorectics, who are over controlled. It

works with impulsivity.”

Interviewee 2: “DBT is meant to conceptualize certain behaviors like parasuicide,

or for example, binge-eating. [It is] not so easy with restricting.”

Interviewee 3: “I have found that some of the girls do not have great meta-

cognition [and are] impulsive.”

 44

Consistency. All interviewees agreed that adolescents needed

consistency; that is, maintaining a regular therapeutic format that is easily understood by

the patients; in both group and individual therapy. Consistency was seen helping to

create boundaries, a sense of safety, and trust between therapist and patient.

Interviewee 1: “[Patients] prefer a more clear and directive approach and want to

work more with them.

Interviewee 2: “It is important to remain consistent with [the patient]… and

[employ] the stylistic strategies of validation and irreverent communication, [for

example] humor and confrontation, to foster the relationship.”

Interviewee 3: “In groups you should try to maintain a consistent message.”

Interviewee 4: “I have used the same basic structure for my groups, so that the

group members know what to expect.”

Sessions. In the initial session, the patient presented two pencil drawings

completed earlier in the week for group art therapy. These drawings were filled with

schematic images representing people, places, and objects. Based upon these drawings,

the patient could be placed in the schematic stage of artistic development, which features

repetitive form concepts, schematic imagery, and two-dimensionality (Spaniol, 2004).

Although the patient stated in the first session that she was “only comfortable using

pencil, because [she could] erase mistakes,” she was able to complete the assessment

given, which required her to use four media, charcoal, oil pastels, and markers (sharpies).

The patient was able to date and title drawings. The patient used all four media provided

although limitedly, and only combined two different media (oil pastel and charcoal) on

one drawing. She was able to cover on average approximately 88% of the drawing
 45

papers. The patient‟s work was integrated and she showed a preference for the primary

colors blue and red and the secondary color green. There were no schematic

representations, that is, pre-designed images such as drawing a stick figure to represent

human form. The patient was able to execute blending in only one out of three of the

drawings completed in the assessment. A primary idiosyncratic mark, best described as a

spiral-like shape, emerged in two out of three of the drawings completed in the

assessments. Two out of the three drawings were abstract. One drawing was

representational and of a naturalistic tree, which revealed the patient‟s ability for

subjective interpretation and control of material to create purposeful expression. This

exhibited the patient‟s potential to achieve the adolescent art stage of artistic development

(Spaniol, 2004).

In sessions two and three, the patient continued to exhibit a willingness to engage

in the creative process. In session two she was given the art therapy assessment again

and completed it. The results from the assessment are similar to the first with the

exception of an increase in the combination of media used. In two out of three drawings,

the patient combined two to three different media (pencil, chalk pastel, and oil pastel).

There was also a shift in the percentage of paper used, which increased from 88% to

100%. Two out of three of the drawings were integrated, one was coded as

integrated/compartmentalized. The patient continued to show a preference for the colors

blue, red, and green. She also began to show a preference for using purple. Patient

included schematic representation in one of the drawings. The patient used blending in

all three drawings and incorporated idiosyncratic spiral mark.

 46

At the start of session three, the patient was in apparent distress and experiencing

difficulty with emotion regulation. The patient was made to complete an art-based

mindfulness exercise that focused on aiding her to practice transitioning from “emotion

mind” to “wise mind.” The patient stated that the process helped her to safely experience

and describe her emotion, and at the same time become present for the session. The

patient stated that she felt “better now and [could] focus.” This drawing, aptly titled

“Trapped,” was completed in chalk pastels, covered 100% of the paper, integrated,

featured a predominant use of the color blue, blending and did not contain any schematic

imagery or idiosyncratic marks (see Figure 1).

Figure 1. Helen‟s emotion regulation drawing, on 9”X12” paper, and completed in chalk

pastels. Title is “Trapped”

The patient explained that the drawing represented a spider in its web. The

patient‟s representation of the spider exhibited again her use of subjective interpretation

and purposeful use of material and expression. An introduction to painting was the

artistic skill development focus of session three. The patient experienced difficulty in

blending colors and was unable in the session to decide what she wanted to paint. The

difficulty stemmed from the patient‟s fear of “making a mistake” she could not easily fix
 47

because “there‟s no way to fix [paintings].” The patient chose to use acrylic paints and

was able to cover 100% of the canvas but it was compartmentalized. Various shades of

blue were used in the painting.

In the fourth session a review of the completed painting from session three was

done. The patient made self-deprecating remarks in reference to her artistic skill ability,

and pointed out that it looked “childish” and that she was “no good at art.” The painting

focused on the theme “Where I am now” and the patient did not date and title the

painting. As mentioned above, patient used acrylic paint and 100% of the canvas was

covered. The style was compartmentalized, featuring a predominant use of the colors

blue, red, and green. Schematic imagery, blending, and idiosyncratic spiral marks were

present.

In session five the patient reviewed her second painting. The painting was dated,

titled and completed using acrylic paint. She painted 100% of the canvas and the image

was integrated. The patient used the preferred colors of blue and green as well as black,

yellow and white. Schematic imagery and blending were present. There was no

evidence of idiosyncratic mark-making.

The patient completed a third and final art assessment in session six (see Figure,

2, Figure 3, Figure 4). The patient was able to date and title artwork. She was able to use

all media in drawings and covered approximately 95% of the papers. Two out of the

three drawings were integrated, one was compartmentalized. Although patient used

preferred colors of blue, red, and green, she also increased her use of yellow and black.

There were schematic images present in one of the drawings. One drawing showed

evidence of blending and two drawings showed idiosyncratic mark-making.

 48

Figure 2. Helen‟s first drawing in the final assessment. Completed on 5”X8” paper with

chalk and oil pastels and Sharpies. Title is “Someone‟s Watching.”

Figure 3. Helen‟s second drawing in the final assessment. Completed on 9”X12” paper

with chalk and oil pastels. Title is “Dust in the Wind.”

 49

Figure 4. Helen‟s third and final drawing in the final assessment. Completed on 16”X20”

paper with charcoal and oil pastels. Title is “Despair.”

The final painting produced by the patient is marked departure from what she had

been doing. This third and final painting was dated and titled. The patient used the

following materials to complete the painting: acrylic paint, a tape measure, a pair of

scissors, a used packed of birth control, a crystal heart, a sticker, and leggings. She

covered 100% of the canvas and created an integrated/compartmentalized piece. She did

maintain use of her preferred colors blue, green, and red and included black, yellow, and

white. There were no schematic representations, evidence of blending or inclusion of

idiosyncratic mark-making. The patient introduced new elements to her art-making

process: physical objects (stockings, tape measure, sticker, crystal, birth control, and

scissors. The patient also used her own handprint on this painting as well.

Mindfulness Art Journal. The patient began using the mindfulness art journal

between sessions two and three. From the first week of journal entries, the following

generalizations could be made. The patient was able to date and title seven out of eight

entries (87.5%). The eighth and final entry was left untitled, but the time of creation was

noted by the patient. The patient stated that she “didn‟t know what to title it.” When
 50

asked what the image conjured for her, the patient replied that the drawing reminded her

of “flesh” and of times when she “used to cut” (see Figure 5). The materials used for

these drawings were oil pastel and chalk pastel. She covered on average approximately

98% of the paper for each drawing. Fifty percent of her drawings were integrated, 37.5%

were coded as integrated/compartmentalized, and 12.5% were compartmentalized.

Patient preferred colors were red, blue, and green with some preference shown for brown

and black. Fifty percent of the drawings showed schematic representations and evidence

of blending. The idiosyncratic mark-making was evident in 37.5% of drawings, in which

the patient incorporated a spiral-like motif.

Figure 5. Helen‟s last journal entry for the first week. Completed on 5”X8” paper with

chalk pastels. Title is “Untitled: 9:30AM.”

All drawings in the second journal were dated, but only nine out ten (90%) were

given titles. Patient used the following media to complete the drawings: chalk pastel, oil

pastel, markers, pencil, and watercolor. Patient covered on average 80% of the paper for

each drawing. Fifty percent of the drawings were integrated, 30% were

integrated/compartmentalized, and 20% were compartmentalized. Fifty percent of the

 51

drawings showed schematic representation and 70% showed evidence of blending.

Thirty percent of the drawings contained idiosyncratic mark-making.

Six drawings were completed for the third journal. Each of these drawings was

dated and titled. The patient used only chalk pastel and oil pastel to complete these

drawings. Patient was able to cover on average approximately 76% of the paper for each

drawing. Five out of six of the drawings (83%) received the style code integrated, while

on received the code integrated/compartmentalized. Although the patient continued to

show preference for the colors blue, green, and red, there was a dramatic increase in the

use of the colors purple, yellow, and black. Purple surpassed green and red in frequency

of use. In terms of schematic representation, approximately 67% of drawings showed

evidence of this and 83% of the drawings showed evidence of blending. Only two out of

the six drawings (33%) showed evidence of idiosyncratic mark-making.

The fourth and final journal was comprised of nine drawings. All the drawings

were dated and eight of nine (89%) were given titles. The patient used a wider range of

media in this journal, including pencil, chalk pastel, oil pastel, colored pencils, markers,

and pen. The patient was able to cover on average approximately 76% of the paper for

each drawing. Drawings received an equal percentage for (44%) for integrated and

integrated/compartmentalized and 12% received compartmentalized. The patient showed

an equal preference for the following two sets of color combinations: blue, red, green;

and purple, yellow and black. Approximately 78% of the drawings contained schematic

imagery and approximately 56% showed evidence of blending. Thirty-three percent of

the drawings showed evidence of idiosyncratic mark-making.

 52

Completion Dates. The patient completed the first mindfulness art journal as

directed, completing one drawing for each day. The subject of each drawing was Helen‟s

experiences of being present within an isolated moment. The patient began these

drawings the day after receiving the assignment and completed eight drawings (she

completed two drawings on the last day). She stated that she did this because she felt

“frustrated with [the other residents and treatment]” and found that drawing helped her to

feel more “calm.”

The second mindfulness art journal contained ten drawings of which the first three

were completed sequentially. The patient missed the fourth day‟s drawing, and

completed three drawings on the fifth day. She completed one drawing on the sixth day,

followed by three on the seventh day. When asked why there was a drawing missing as

well as an increase in the number of drawings on certain days, the patient responded that

she “didn‟t have time” to complete the drawing on the missing day, and that she had

chosen to increase the number of drawings at times when she was feeling “worried” and

“anxious.”

There was also an evident increase in the number of drawings produced on one

day in the third mindfulness art journal. This journal contained six drawings. Of the six,

five were completed on the same day. The patient explained that she had been feeling

“nostalgic” and had been thinking about a past experience in treatment. Patient stated

that she had been “too busy” preparing for discharge to complete the drawings on the

missing five days. This mindfulness art journal was also not completed in the 5”x8”

drawing pads provided, but were completed on 9”x12” drawing paper from the patient‟s
 53

own drawing pad. Patient explained that the drawing pad was not accessible at that time

of the drawings due to her being outside of the program at the time.

The fourth mindfulness art journal also contained one day in which the patient

completed several drawings. This journal, however, was more sequential in its execution

with only two missing days. The patient completed six drawings on the last day of the

journal entry. The patient stated that she had been feeling “angry” and “anxious” on

that particular day and found that drawing helped her to tolerate those emotions.

Cross-referencing the days on which the patient had an increased number of

drawings with her session notes revealed that on those dates the patient had been

experiencing difficulty with her relationships with her peers at the program, her

boyfriend, and her father.

Themes. The Literature Review examined six themes that emerge in the treatment

of eating disorders. The themes were anguish and despair; helplessness and

hopelessness; inability to recognize, distinguish, and express feelings; ambivalence and

mistrust; and power and control (Manley & Leichner, 2003). The artwork of the patient

reflected these themes and informed new themes of empowerment and emotional

awareness. In the last mindfulness art journal, the patient made explicit reference to

eating disorder themes. These themes were coded under the theme of helplessness and

hopelessness. Themes were identified based upon the title given, imagery depicted, and

verbal input of the patient. Some drawings referenced more than one theme and were

counted in both.

Anguish and Despair. Two drawings produced within the sessions

(session four) were identified as being related to the theme of anguish and despair. From
 54

the mindfulness art journals (journals 1, 2, 3, and 4), nine drawings were identified as

relating to this theme.

Helplessness and Hopelessness. Three drawings produced within the

sessions (sessions 3 and 4) were identified as being related to the theme of helplessness

and hopelessness. From the mindfulness art journals (journals 1, 2, and 4), six drawings

were identified as relating to this theme. Of the six drawings, two had eating disorder-

related themes.

Inability to Recognize, Distinguish, and Express Feelings. Two drawings

completed in session (sessions 1 and 2) were identified as relating to this theme. Four

drawings from the mindfulness art journals (journals 1, 2, 3, and 4) were identified as

relating to this theme.

Ambivalence and Mistrust. One drawing completed in session four was

identified as relating to this theme. Three drawings from the mindfulness art journals

(journals 2, 3, and 4) were identified as relating to this theme.

Power and Control. Three drawings completed in session (sessions 1 and

2) were identified as relating to this theme. Two drawings from the mindfulness art

journals (journal 1) were identified as relating to this theme.

Empowerment. Four drawings completed in session (sessions 1, 2, and 3)

were reflective of this theme. Four drawings from the mindfulness art journals (journals

2 and 3) were identified as relating to this theme.

Emotional Awareness. Four drawings completed in session (sessions 2, 3,

and 4) were reflective of this theme. Twenty-five drawings from the mindfulness art

journals (journals 1, 2, 3, and 4) were identified as relating to this theme.

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Table 4.

Frequency of theme-related artwork depicted in sessions and mindfulness art journals.

Theme In-Session Mindfulness Art Journal

Anguish and Despair 2 9

Helplessness and Hopelessness 3 6

Inability to Recognize Feelings 2 4

Ambivalence and Mistrust 1 3

Empowerment 4 4

Emotional Awareness 4 25

Note. The values represent the number of times each theme occurred in the artwork created in session and in the mindfulness art

journals.
 56

APPENDIX A

ART TASKS

Art Task 1: Three-Drawings Assessment

Complete three drawings within a 6-minute timeframe. Each drawing is allotted 2

minutes. Patient is instructed to use a combination of two or more of the four drawing

media on each paper. The patient is requested to completely covering each paper as

much as s/he can. Patient is asked to date, initial and title the art created. Purpose: Assess

abilities to use materials provided, assess expressive and creative ability, restrictive and

obsessive-compulsive tendencies, and to assess perfectionism.

Population Appropriateness: Gives structure in terms of materials available for

use, time management, and goal. Gives independence in choice of combining materials

to use, and subject/theme to be drawn.

Materials:

5X8, 9X12, and 16X20 drawing paper

Chalk Pastels, Craypas (Oil Pastels), Charcoal, Sharpies (markers)**

** I prefer to use Sharpies because they are more controlled than markers, but less

controlled than pencils.

What I look for in this process:

1 Can the Patient complete the task as instructed?

2 How does the Patient tolerate „getting dirty‟?

3 How „dirty‟ does the Patient get during this process?

4 How does the Patient organize the materials?

 57

5 What medium does s/he start with? What paper size?

6 Does Patient need to be asked to move on to the next drawing?

7 Does Patient ask for the time or other types of materials to use instead?

8 How does the Patient appear (mood-wise)?

Helen‟s First Assessment

Helen was able to complete the three drawings, however, not as instructed. She

did cover the length and width of the paper, but used very little shading, with the

exception of drawing two. She worked quickly moving from one drawing to the next.

She spent 1.25 minutes on drawing one (see Figure A1), 2.50 minutes on drawing two

(see Figure A2), and 1.70 minutes on drawing three (see Figure A3). She went back

to drawing two for the remainder of the time, giving a total of 3.05 minutes for

drawing two. Helen did not speak as she drew, but worked quietly. She stood as she

worked. I called times at a 3-minute marker and a 1-minute marker. She nodded to

indicate that she understood. After she completed the drawings, I instructed her to

title, date, and initial each drawing. She asked me whether or she should use all three

of her initials. I instructed her to use what she preferred.

 58

Figure A1. Helen‟s first drawing of the first assessment. Completed on 5”X8” paper

with Sharpies. Title is “Inverted Concentric Spiral.”

Patient Observation:

Helen stated that she started drawing shapes with which she felt familiar and were

easy to draw. The fillers around and within the geometric shapes are forms that she

tends to doodle. She titled the drawing based upon the shapes she had drawn. The

colors chosen were primary and secondary and are ones she likes.

Therapist Observation:

Helen completed this drawing rapidly, without pause. She drew the central

geometric shapes first and the filled them in. She then filled in around those central

shapes. She did not hesitate in picking colors to use in the drawing, and appeared to

have already known what colors she would choose and perhaps even what she would
 59

draw. Helen did not spend much time thinking about what to name the drawing, and

immediately titled it when instructed to do so.

Notable Points:

1 Helen did not use more than one medium on this first drawing.

2 Helen used the most restrictive medium.

3 Helen limited herself to the following colors: red, blue and green.

4 Helen chose to draw recognizable geometric shapes.

Figure A2. Helen‟s second drawing of the first assessment. Completed on 9”X12”

paper with chalk and oil pastels. Title is “Bend Not Break.”

Patient Observation:
 60

“I like willow trees because they move with the wind.” Patient stated that she did

not know she was going to draw a tree, but like that she developed the idea. Patient

was critical of this drawing, stating that it was not “very good.” Patient noted that the

leaves of the tree reminded her of stitches.

Therapist Observation:

Helen began this drawing on the right-hand side using blue. She then made the

marks that became the trunk of the tree. From that point, she developed the drawing

into an image of the „willow tree‟ with the blue acting as the sky in the background

and the green as grass at the base of the tree. Again, Helen took little time in giving

this drawing a title. Helen also did not discuss this drawing in much detail. She

worked on this drawing quickly as well, but she paused at various points to assess the

drawing.

Notable Points:

1 Helen used two media in this drawing: chalk and oil pastels.

2 Helen appeared more involved with this drawing.

3 Helen returned to the drawing after completing the third drawing.

4 Helen used her fingers to smudge this drawing.

5 Helen wiped her forehead with her hands dirtied.

6 Helen appears to be able to tolerate being dirtied.

7 Helen does not associate herself to the title given to this drawing.
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Figure A3. Helen‟s third drawing of the first assessment. Completed on 16”X20”

paper with charcoal and oil pastels. Title is “Firecracker.”

Patient Observation:

Drawing reminded Patient of her sister, stating that her sister likes firecrackers.

Hence, she titled the drawing „Firecracker.‟ Patient stated that she tends to draw spiral

shapes. Patient stated that she used charcoal because she hadn‟t used it in any of the

other drawings. Patient stated that she does not like to use charcoal, because she does

not know how to use it.

Therapist Observation:
 62

This is the quickest drawing completed of the three. Patient did not use the entire

space. Patient picked up the charcoal and made large circular marks, and then

accented those marks with primary and secondary-colored oil pastels. Patient

appeared nostalgic when discussing this drawing in reference to her sister.

Notable Points:

1 Helen did not smudge the charcoal.

2 Helen did not color the entire page, but made large marks to represent

covering the page.

3 Most abstract drawing with little detail.

Art Task 2: Response to Music

I find that the integration of music into art therapeutic process essential in

working with adolescents, whether working in a group setting or individually. As such, a

part of my work with Helen was to understand the role of music in her life and how that

might help her in developing her artistic ability. Based upon Helen‟s self-report, she

played the cello and often performed in musical theatre. She gave that up, however, to

join the cheerleading team, which eventually contributed to her eating disorder and

distorted sense of self. In this first session, she discussed with me her desire to begin

playing the cello once again. We discussed the notion of integrating music, either

through instruments, such as guitar and drum, or through recorded music, into the

sessions. I explained to Helen that we could use music as a way to tap into present and

past emotions and have create drawing or written responses to that to capture those

emotions.
 63

In this last task, the patient is asked to listen to a selection of music as provided by

the therapist. Patient is instructed to create a response to the music either written and/or

artistic. The patient is given no other instruction. If the patient needs further explanation

on the term 'response,' the therapist can explain that the response means whatever the

patient wishes to write or create based upon her experience of the music.

Population Appropriateness: Music could be said to define the stage of

adolescence. Most adolescents have a favorite band, singer, or song. Adolescents often

use music as a way of expressing their innermost thoughts and feelings, from rage to

love.

Materials:

CD player, 3 to 5 minute song, and art and writing materials.

What I look for in this process:

1. Can the patient complete the task as instructed?

2. How does the patient tolerate minimally structured tasks?

3. What modality does the patient use in her response?

4. What is the length of time that passes before the patient begins her response.

5. Is there a sense of nostalgia created through the music? If so, what is the time period

and what was the patient‟s view of herself during that time?

6. Is there a visible shift in the patient‟s mood?

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Helen‟s First Music Response

Music Choice:

Artist: Frou Frou, Title: Let Go

“Drink up baby down

Are you in or are you out?
Leave your things behind
'Cause it's all going off without you
Excuse me too busy you're writing a tragedy
These mess-ups
You bubble-wrap
When you've no idea what you're like
So, let go - Jump in
Oh well, what you waiting for?
It's all right
'Cause there's beauty in the breakdown
So, let go - Just get in
Oh, it's so amazing here
It's all right
'Cause there's beauty in the breakdown
It gains the more it gives
And then advances with the form
So, honey, back for more
Can't you see that all the stuff's essential?
Such boundless pleasure
We've no time for later
Now you can wait
You roll your eyes
We've twenty seconds to comply
So, let go- Jump in
Oh well, what you waiting for?
It's al right
'Cause there's beauty in the breakdown
So, let go- Just get in
Oh, it's so amazing here
It's all right
'Cause there's beauty in the breakdown

Patient Observation:

Patient chose to do a written response to the music. Patient found the music

brought a sense of nostalgia. Patient explained that the message of the song was helpful
 65

in altering her mood, from sad to happy, as it brought her back to a time when she felt

"confident."

Patient's Response:

"This song makes me feel invigorated and powerful. I got into Frou Frou right

around the time I started theatre again in winter of 2004. I love the mix of techno beat

and synthesizer. It just feels so good. I was doing things I felt confident in and was being

industrious. The message was appropriate too. Let Go! I needed to put my past behind

me. Something I'm still working on. And there really is beauty in the breakdown,

Especially now."

Therapist Observation:

Patient listened to the music for the first minute and then began to write. She did

not speak during this process, and appeared focus on listening to the music and writing a

response to the music.

Notable Points:

1. Helen needed minimal explanation of how to complete task.

2. Helen smiled upon hearing the music and as she wrote.

3. Helen was able to identify and reflect on a time when she felt confident and

productive which is in direct contrast to her current baseline mood.

4. Helen was able to connect with the music and create a response to it.

5. Helen was able to identify with the lyrics of the song and incorporate them into her

writing.
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Art Task 3: Mindfulness

Patient is asked to create a drawing based upon her present emotional state (see

Figure A4). Time allotted is 5 minutes. Patient is asked to date, initial and title the art

created. Purpose: to aid patient in identifying emotional state, containing emotions, and

reflecting upon emotions, in order to gain an objective view of present circumstance.

Population appropriateness: Gives structure in terms of materials available for

use, time management, and subject/theme. Gives independence in choice of use of

materials and artistic expression, i.e. patient can be either abstract or figurative.

Materials:

5X8 drawing paper

Chalk Pastels, Craypas (Oil Pastels), Charcoal, Sharpies

What I look for in this process:

1. Can the patient complete the task as instructed?

2. Does patient need more clarification on instructions?

3. Is patient able to verbally discuss the art in a reflective manner?

4. Is there a visible shift in mood of patient?

5. Are there themes in the art as identified by the patient?

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Helen‟s Mindfulness Drawing

Figure A4. Helen‟s mindfulness drawing. Completed on 5”X8” paper with oil pastels.

Title is “Protection->Chaos.”

Patient Observation:

Patient stated that she “felt better” upon completing the task. When asked what

she meant by this, patient stated that she felt “calmer” and not “angry” as before. Patient

titled this drawing “Protection->Chaos,” which she saw as her present situation, i.e.,

being in the midst of uncertainty. Patient did not identify any themes within the drawing,

but noted that she enjoyed working with oil pastels, which she used to complete the

drawing.

Therapist Observation:

Patient stood while she drew and was silent. Patient worked continuously until

prompted to end the drawing. Patient appeared to be less agitated, but was critical of the

work she produced, and apologized for the quality. Patient was able to discuss the

drawing minimally, and was not able to identify themes within the work. Patient‟s work

is organized and compartmentalized, containing recognizable geometric shapes, similar

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to the smallest drawing completed in the first session. Patient covered almost 100% of

the paper, leaving little white space. Patient did not initial work as instructed to.

Notable Points:

1. Patient was able to complete drawing within the allotted time.

2. Patient used one medium for the drawing.

3. Patient covered almost 100% of the paper.

4. Patient used primary and secondary colors.

5. Patient acknowledged a shift in mood after completing the drawing.

6. Patient did not discuss any themes related to the drawing.

Art Task 4: Opposites

Patient is asked to create two drawings. The first drawing is to reflect the patient‟s

primary emotional state (see Figure A5). The second drawing is a response drawing to

the first, and is to reflect the opposite emotional state (see Figure A6). Time allotted is 10

minutes. Patient is asked to date, initial and title the art created. Purpose: exploration and

identification of emotions and cognitive reframing.

Population appropriateness: Gives structure in terms of materials available for

use, time management, and subject/theme. Gives independence in choice of use of

materials and artistic expression, i.e. patient can be either abstract or figurative.

Materials:

9X12 drawing paper

Pencils, Chalk Pastels, Craypas (Oil Pastels), Charcoal, Sharpies**

What I look for in this process:

1. Can the patient complete the task as instructed?

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2. Does patient need more clarification on instructions?

3. Is patient able to verbally discuss the art in a reflective manner?

4. Is there a visible shift in mood of patient?

5. Are there themes in the art as identified by the patient?

Helen‟s Opposites Task

Figure A5. Helen‟s drawing of her primary emotional state. Completed on 9”X12”

paper with chalk and graphite. Title is “Burning Fury.”

Patient Observation:

Patient saw her primary emotion as being anger, stating that she has been “feeling

angry all the time.” Patient was again apologetic about the her drawing ability and

explained the image that she drew as an isolated fire, representing herself, and her

longing to perform, represented by the stick figure drawings. Patient stated that she

continues to choose primary and secondary colors as she prefers to use them.

Therapist Observation:

Patient stood while she worked on this drawing. She worked in silence. Patient

drew fire image towards the center of the paper first, thereafter she colored in around this
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primary image. She drew in pencil stick figures in a „thought bubble‟ last, incorporating

her previous primary style of pencil drawing as indicated by her in our last session.

Notable Points:

1. Patient was able to complete drawing within the allotted time.

2. Patient used two media for the drawing.

3. Patient covered 100% of the paper.

4. Patient used primary and secondary colors.

5. Patient layered and blended colors.

6. Patient used pencil and incorporated stick figure drawings.

Figure A6. Helen‟s drawing of her opposite emotion. Completed on 9”X12” paper

with chalk and graphite. Title is “Pillars of Strength.”

Patient Observation:
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Patient immediately explained that she was trying to draw columns in an outside

setting. Patient stated that she wished that she could be strong, which she believed was of

being angry. Patient noted that the pillars did not look strong, but attributed that to her

lack of ability in drawing.

Therapist Observation:

Patient stood as she drew, and began the drawing by using blue, then green. The

blue and green-formed three „I‟-like shapes that she outlined in graphite. Within each

shape, she used blue chalk to make vertical lines that she later smudged with her fingers.

There after, she smudged the outline of the three shapes.

Notable Points:

1. Patient was able to complete drawing within the allotted time.

2. Patient used two media for the drawing.

3. Patient covered almost 100% of the paper.

4. Patient used primary and secondary colors.

Art Task 5: Self-Portrait

Patient is asked to draw a self-portrait using a blurred mirror, focusing on light

and shadow areas that are visible (see Figure A7). Time allotted 15 minutes. Patient is

asked to date, initial and title the art created. Purpose: to aid patient in gaining an

objective view of self and develop artistic ability.

Population appropriateness: Gives structure in terms of materials available for

use, time management, and subject/theme. Give the opportunity for patient to externalize

her impression of herself as well as gain an objective view of self.

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Materials:

9X12 drawing paper

Charcoal

What I look for in this process:

1. Can the patient complete the task as instructed?

2. Does patient need more clarification on instructions?

3. Is patient able to verbally discuss the art in a reflective manner?

4. Is there a visible shift in mood of patient?

Helen‟s Self-Portrait Task

Figure A7. Helen‟s self-portrait. Completed on 9”X12” paper with charcoal. It is

untitled.
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Patient Observation:

Patient stated that the drawing did not look like her, and that she felt frustrated

that she was not able to draw herself as she believed herself to look. Patient stated that

she did not like using charcoal. Patient was very critical of the drawing.

Therapist Observation:

Patient sat during this drawing, more out of necessity than choice. Patient began

by drawing an outline of her face. During the process of drawing, patient rarely looked at

mirror to complete drawing. Patient spoke throughout the entire process, asking for

direction from me. Also, she asked whether or not she was “doing it right.” Patient

asked for direct assistance in drawing hair. Patient was shown how to manipulate

charcoal in order to create a grayscale. Patient‟s mood visibly shifted during this process,

and patient indicated to me that she felt “frustrated.”

Notable Points:

1. Patient was able to complete drawing within the allotted time.

2. Patient used appropriate medium for the drawing (did not ask to change material

although experiencing difficulty using the selected medium).

3. Patient covered almost 80% of the paper.

4. Patient became visibly frustrated and was highly critical of drawing.

5. Patient did not use mirror to complete drawing.

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APPENDIX B

Mindfulness Art Journal

Task is to complete one drawing per day. Patient is instructed to “stop at one point in the

day, and create a drawing based upon what she is feeling in the moment, not the moment

before or after. Upon completing the drawing, put it away. Later in the day, take out the

drawing and write a response to the drawing.”

Helen, for example, was given a 5”X8” drawing pad with 8 sheets of drawing

paper and set of oil pastels. Helen indicated that she had access to other drawing

materials as well, such as pencils, markers, chalk, pencil crayons, etc.

Sample Entries from Helen‟s Mindfulness Art Journals

Week One:

Figure B1. First journal entry of week one. Completed on 5”X8” paper with oil pastels.

Title is “Serene Chaos”.

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Figure B2. Third journal entry of week one. Completed on 5”X8” paper with chalk

pastels. Title is “Teardrops”.

Figure B3. Fifth journal entry of week one. Completed on 5”X8” paper with oil pastels.

Title is “Hope Overgrown”.

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Figure B4. Last journal entry of week one. Completed on 5”X8” paper with oil pastels.

Title is “Untitled: 9:30AM”.

Week Two:

Figure B5. First journal entry of week two. Completed on 5”X8” paper with oil pastels.

It is untitled.
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Figure B6. Second journal entry of week two. Completed on 5”X8” paper with chalk, pen

and markers. Title is “What if.”

Figure B7. Fourth journal entry of week two. Completed on 5”X8” paper with oil pastels

and pencil. Title is “The Faithless.”

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Figure B8. Sixth journal entry of week two. Completed on 5”X8” paper with chalk

pastels. Title is “Pinwheel.”

Week Three:

Figure B9. First journal entry of week three. Completed on 9”X12” paper with chalk and

oil pastels. Title is “Interdependence.”

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Figure B10. Third journal entry of week three. Completed on 9”X12” paper with chalk

and oil pastels. Title is “Starry Night.”

Figure B11. Fourth journal entry of week three. Completed on 9”X12” paper with chalk

and oil pastels. Title is “Late Nights.”

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Figure B12. Last journal entry of week three. Completed on 9”X12” paper with oil

pastels. Title is “Beacon of Hope.”

Week Four:

Figure B13. First journal entry of week four. Completed on 5”X8” paper with oil pastels,

pencil and markers. Title is “Among Many Things.”

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Figure B14. Third journal entry of week four. Completed on 5”X8” paper with pen,

pencil and markers. Title is “A Spoonful of Sugar”

Figure B15. Fourth journal entry of week four. Completed on 5”X8” paper with pencil

and markers. Title is “Passages.”

Figure B16. Fifth journal entry of week four. Completed on 5”X8” paper with pencil. It is

untitled.
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Figure B17. Sixth journal entry of week four. Completed on 5”X8” paper with oil pastels.

Title is “Good Samaritans.”

Figure B18. Last journal entry of week four. Completed on 5”X8” paper with oil pastels.

Title is “The Other Side.”

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