Running Head: ART THERAPY FOR SUBSTANCE ABUSE TREATMENT Colorful Recovery: Art Therapy for Substance Abuse and Addiction Treatment
Courtney Chandler
Metropolitan State University of Denver
1 ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 2 Abstract
Does art therapy enhance the process of recovery and therefore increase the probability of
long-term sobriety for individuals seeking treatment from substance abuse addiction?
This paper will discuss the benefits of art therapy, when used as a therapeutic
intervention that complements another substance abuse treatment modality (such as CBT,
DBT, or a 12-step program). Research over the past few decades has demonstrated that
art therapy has been successful in reducing shame (Grosch, 1994) and anxiety (Curry &
Kasser, 2011; van der Vennet & Serice, 2012), which is paramount to overcoming
addiction (Wilson, 2012). The interwoven relationship between art and spirituality will be
discussed with specific emphasis on how art therapy can increase a sense of spiritual
connection (Miller, 1995) and therefore be valuable to the recovery process. Mindfulness
practices shall be explained in detail as they align with similar philosophies of art
therapy, thus supporting the argument that art therapy is a uniquely beneficial
complement to existing substance abuse treatment programs, and is likely to enhance
overall success rate probability for long-term sobriety. Plans for further research, which
include a proposed research study to obtain quantitative data, will also be discussed.
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT “The aim of art is to represent
not the outward appearance of things,
but their inward significance.”
–Aristotle
Acknowledgements
I am eternally grateful to my family and friends for their support and their everinspiring love and enthusiasm for my endeavors. I am also grateful to all my professors,
staff, and the Honors Program at Metropolitan State University of Denver, for their
assistance, support and encouragement throughout my Undergraduate career. I give
special thanks and recognition to my thesis committee advisors, Katherine Hill, Ph.D.,
Anna Ropp, Ph.D., and Cynthia Sutton, Ph.D.
3 ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 4 Table of Contents
Abstract ............................................................................................................................ 2
Acknowledgements .......................................................................................................... 3
Table of Contents .............................................................................................................4
Introduction ......................................................................................................................5
Art Therapy ..................................................................................................................... 6
Substance Abuse / Addiction .......................................................................................... 7
Historiography / Literature Review ............................................................................... 9
Existing Outcome Studies ............................................................................................. 17
Art Therapy & Clinical Neuroscience ..........................................................................19
Meaningful Engagement ............................................................................................... 20
Mindfulness-Based Relapse Prevention ....................................................................... 21
Art Therapy & Mindfulness ......................................................................................... 26
Spirituality ...................................................................................................................... 29
Shame Reduction ........................................................................................................... 33
Anxiety Reduction .......................................................................................................... 34
Limitations of Existing Research .................................................................................. 35
Proposal for New Assessment Tools & Recommendations for Further Research ... 36
Conclusion ...................................................................................................................... 41
References ....................................................................................................................... 43
Appendices ...................................................................................................................... 54
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 5 Colorful Recovery: Art Therapy for Substance Abuse and Addiction Treatment
Life can be difficult and challenging—this is an agreed upon fact. Everyone
manages their struggles in life slightly differently, but we are all human; therefore, we are
all flawed. Gaining acceptance of flaws and ‘weaknesses’ is a feat that some people may
struggle with more than others, for a variety of biological and psychosocial reasons. For
some, the effects of the mental and emotional turmoil encountered throughout life’s
hardships can be too much to bear, making life feel hopeless and seemingly without
purpose.
So what happens when addictive substances become the ‘solution’ to a problem?
What happens when drugs or alcohol are used and abused in an effort to cover up dark
emotions—to avoid struggles or challenges—creating an illusion of manageability? For
many, this coping mechanism can spiral into the depths of dependency and addiction,
ultimately creating even more problems that result in lonely despair. However, full-blown
addiction is not necessarily a result of choice, and there is always an argument of nature
versus nurture to consider. Research has found evidence that addiction may be largely
linked to genetics, as supported through clinical studies on twins (Ruden & Byalick,
1997). Research findings suggest that addiction is not a matter of choice, but rather a
biological predisposition associated with heredity (Cloninger, 1987; Pitkens & Svilkis,
2000; Ruden & Byalick, 1997). Luckily—regardless of the cause—there is hope; there is
a solution.
The field of psychology offers many forms of therapy to aid in substance abuse
treatment and addiction recovery, spanning from cognitive-behavioral therapy (CBT),
dialectical-behavioral therapy (DBT), or humanistic applications of psychotherapy
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 6 (Tanner-Smith, Wilson, & Lipsey, 2013). Other treatment forms with positive efficacy
rates are non-therapy based, such as 12-step programs including Alcoholics Anonymous
and Narcotics Anonymous (Bogenschutz, 2008; Borkman, 2008; Laudet, 2003), which
provide members with a sense of purpose, helping others with shared experiences while
reinforcing rewards of staying sober (Pagano et al., 2004). However, there is one
relatively new form of treatment that is lesser known, but uniquely beneficial for helping
those who suffer from addiction—this is the field of art therapy (Johnson, 1990; Mahony,
1999; Miller, 1995). While research has yet to specifically evaluate the efficacy of art
therapy to treat addiction, this paper aims to support the following hypothesis: Art
therapy, when used in conjunction with an addiction treatment program, can enhance the
process of recovery for the individual by improving mindfulness, building a means of
spiritual connection, and reducing shame and anxiety, therefore increasing the likelihood
of long standing sobriety.
Art Therapy
Since its emergence in 1969, art therapy is a mental health treatment that utilizes
traditional processes of counseling and psychotherapy integrated with creative processes
of artistic expression (American Art Therapy Association, 2014). This treatment modality
helps people resolve conflict(s), reduce stress and anxiety, manage grief, increase selfesteem and wellbeing, and work through maladjusted behaviors, attitudes, or conditions
(Allen, 1995; American Art Therapy Association, 2014; Holt & Kaiser, 2009; Wilson,
2012).
Art therapy is a creative, therapeutic engagement between therapist and client,
largely focused on art making as a form of emotional expression. Often, specific art
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 7 projects are offered by the art therapist in a treatment plan specifically geared towards the
client needs, but other times the art making is free from constraints and can be
spontaneous. Regardless, the art therapist places “emphasis on empowering the
participant to self-interpret their non-verbal expression, with the guidance of the art
therapist” (American Art Therapy Association, 2014). The art created is not to be
diagnosed, as is a common misconception; rather, the goal of therapy is fostered between
and within the client-therapist relationship (similar to other traditional forms of
psychotherapy). In other words, it is not the final aesthetical product of the artwork that is
of interest; it is the experience of creating art and the growth of self-awareness,
transformation, and emotional exploration that comes from the process of art making in a
therapeutic setting that is of primary benefit. As eloquently stated by de Button and
Armstrong (2013), “art is one resource that can lead us back to a more accurate
assessment of what is valuable by working against habit and inviting us to recalibrate
what we admire or love” (p. 98).
Substance Abuse / Addiction
Drug and alcohol addiction is a huge problem in the United States today—it is a
terrifying epidemic, destroying the lives of millions. Even those who do not abuse
substances themselves are likely to be negatively impacted by the effects of addiction in a
secondary sense, watching someone they know and love suffer under the grips of
chemical dependency (National Council on Alcoholism and Drug Dependence, 2015).
According to the 2014 National Survey on Drug Use and Health (NSDUH), 21.5 million
people in the United States were found to have a substance use disorder (SUD) within the
past year (Substance Abuse and Mental Health Services Administration, 2015), while an
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 8 estimated 27.0 million people (ages 12 and older) self-reported they used prescription
drugs for nonmedical purposes within the past 30 days (National Council on Alcoholism
and Drug Dependence, 2015). Statistically speaking, approximately one out of every ten
people in the U.S. admits to frequently abusing drugs and/or alcohol, or are already
addicted; many of those who are not yet claiming to be addicted are dangerously teetering
the risky fine line of dependence (National Council on Alcoholism and Drug
Dependence, 2015; Substance Abuse and Mental Health Services Administration, 2015).
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines
substance dependence as a maladaptive pattern of drug use leading to impaired distress,
presenting with symptoms (such as increased tolerance, withdrawal, continuing to use
drugs despite negative consequences, etc.) lasting for a period longer than one year
(DSM-VI, cited in Wilcox and Erickson, 2000). The addicted individual eventually loses
the ability to control thoughts, emotions, or behaviors, and may begin to completely lose
sight of his/her own ‘self’ once the substance has completely taken over (Ruden &
Byalick, 2000; Wilcox & Erickson, 2000). Upon habitual intake, the individual’s brain
and body functioning will become fully reliant on the presence of the drug (physiological
dependence), and a persistent phenomenon of craving (psychological dependence) will
also occur (National Council on Alcoholism and Drug Dependence, 2015).
Most addictive substances infringe their way into the nucleus accumbens (the
pleasure center of the brain), linking themselves with dopamine function. When the
substance reaches the brain, it produces a surge of dopamine, flooding the limbic system,
allowing the individual to experience heightened ‘pleasure.’ As this initial on-set
chemical reaction of the drug wears off, “it must also rebound below the initial baseline
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 9 of neural activity before returning to it” (Wilcox & Erickson, 2000, p. 121). This
‘rebound’ effect evolves into an intense craving—both a physiological and psychological
phenomenon—insisting on a new dose of the substance to be taken in order to return to
homeostasis. Eventually, this cycle continues to the point of no return; the brain can no
longer maintain homeostasis without the drug, yet due to tolerance levels increasing, the
drug no longer produces the desired effect. When the brain is unable to produce (or
regulate) adequate levels of dopamine, the individual is subsequently left with an
unmanageable chemical dependency, depression, and hopeless despair (Ruden &
Byalick, 2000; Wilcox & Erickson, 2000).
Historiography / Literature Review
A review of art therapy literature shows that over the past 30 years, art therapy
has been used in various forms of application to treat substance abuse, yet there is a
minimal amount of published quantitative studies relating to its effectiveness. Through
anecdotal accounts from therapists working with substance abusing clients and qualitative
research studies involving participants answering Likert-scale questionnaires, there have
been a handful of studies in support of the therapeutic rationale behind art therapy for
substance abuse (Chickerneo, 1993; Feen-Calligan, 2007; Holt & Kaiser, 2009; Horay,
2006; Mahony, 1999; Matto, 2002). Although the effectiveness has yet to be thoroughly
researched at the quantitative level, the work that is being conducted in the field of art
therapy for addictions shows promise.
Feen-Calligan (1996; 2007) developed art therapy programming surrounding the
traditions of 12-step groups such as Alcoholics Anonymous. By focusing her art therapy
sessions on issues and concepts relevant to the 12-steps (such as powerlessness,
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 10 unmanageability, and connecting with a Higher Power), clients can experience
cohesiveness with concepts they are already dealing with in their recovery program
outside of the art therapy intervention. Feen-Calligan (2007) asserts that art therapy is an
exceptionally powerful tool that can be used as relapse prevention, by “encouraging
patients to visualize their relapse triggers or other barriers that might prohibit recovery,
and in particular, how to recognize feelings as potential relapse triggers” (p. 19). Further,
she describes the experience of art as therapy as being a meditative, inspiring, and
spiritual practice, and that recovery, art, and spirituality share qualities that provide a
supportive bond of treatment for addiction (Feen-Calligan, 1995).
Chickerneo (1993) offered her contribution with an extensive exploration of art
therapy as it relates to spirituality (not necessarily linked with the spiritual aspects of 12step programs). More specifically, she has many documented case studies of her
experiences using art therapy with people suffering from chemical dependency and/or codependency and claims that, “all addiction is attachment, and the recovery process from
all addiction requires breaking the attachment” (p. 7). Chickerneo argued within the
philosophical construct that art is a way to break free from the chaos of the fast-paced
culture that we live in as prisoners of the clock, and relearn how to find peace, sanity, and
balance in life.
Matto (2002) published practice guidelines and techniques for art therapists that
are beneficial for use in substance abuse treatment in a short-term, inpatient hospital
setting. Though she does not have a set curriculum, Matto claims that art directives
should be short, simple, and promote movement toward change and taking action in a
way that is both challenging and exciting. Short-term treatment goals focus on expressing
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 11 feelings, identifying safe places and new behaviors for coping and self-exploration, as a
construct to approach long-term goals. Matto (2002) promotes art therapy to occur in a
group setting in an inpatient substance abuse treatment facility, as it can be a valuable,
supportive additive for clients struggling in early recovery. By encouraging healthy risktaking (trying something new through art making), enhancing self-awareness, and
establishing interconnectedness, Matto claims that art can be used to broaden
relationships and increase active participation and engagement in treatment.
Cox and Price (1990) developed art therapy treatment plans to have their
adolescent substance abusing clients use “Incident Drawing” to facilitate acceptance of
the disease of addiction, through creative, nonthreatening confrontation with their
experiences of denial, loss, shame, and guilt. These treatment plans were developed with
the goal of resolving any underlying trauma that resulted in substance abuse. The goal of
the “Incident Drawing” technique is to offer insight into the unmanageability of the
individual’s addiction, so he/she can clearly see that many of the traumatic incidents were
linked to drug use.
Cox and Price designed this specific art therapy intervention to be integrated into
any substance treatment program at least twice per week for 45-minute sessions, in a
group format. Each art therapy session under this technique is to be introduced with the
instruction, “draw about an incident that occurred during the time you were
drinking/drugging. (…) Recall a significant event and express the incident visually” (Cox
& Price, 1990, p. 335). Tempera paint is intentionally the only media provided, as it is
more difficult to use than pencils or markers, thus acting as somewhat as a metaphor for
the unmanageability of addiction.
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 12 Once completed, the incident drawings (along with any emotions that may have
surfaced) are discussed among the group. Because the group focus can be directed on the
drawings rather than as a spotlight on the individual, the individual may feel less
threatened and therefore more apt to divulge feelings and attitudes (Cox & Price, 1990).
After the group discussion, the art therapist will ask the individual to explore the
following five questions, writing answers to them on the back of their drawing to
promote further contemplation and self-appraisal: “What was your thinking pattern at the
time? What were your feelings at the time? What were the values contradicted? What
relationships were affected? What would a sober person do in this situation?” (Cox &
Price, 1990, p. 338).
Holt and Kaiser (2009) constructed art therapy directives related to themes within
the 12-step recovery model that are geared toward targeting denial and identifying
ambivalence, which give rise to eventual acceptance of new lifestyle changes in order to
live a life of sobriety. The five directives developed by Holt and Kaiser, called “The First
Step Series,” were designed to be used during the initial stages of substance abuse
treatment and exhibit an active mind-body strategy believed to be especially helpful
throughout the recovery process.
Rooted in the treatment models of Motivational Interviewing (MI) and Stages of
Change (SOC), “The First Step Series” serves as a strategy for taking an active role in
recovery. MI is a client-centered counseling model that approaches client defensive
mechanisms (such as denial) to understand how and why people change, with the goal of
enhancing intrinsic motivation for change (Holt & Kaiser, 2009; Miller & Rollnick,
2002). The SOC model uses a five-stage continuum progressing from pre-contemplation
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 13 through contemplation, preparation, action, and finally maintenance, to delineate the
client’s readiness or willingness for change (DiClemente & Velasquez, 2002; Holt &
Kaiser, 2009). Both MI and SOC emphasize that motivation for change is imperative to
the recovery process, which occurs in progressive stages. Research suggests that active
engagement in treatment models of MI, also referred to as Motivational Enhancement
Therapy (MET), help individuals with chemical dependency significantly decrease
alcohol consumption (Project MATCH Research Group, cited in Polcin, 2002).
Using a similar five-stage continuum to increase motivation for change, “The
First Step Series” uses five specific art directives. The first is a Crisis Directive that was
designed to evaluate the individual’s perception of the situation at hand, and target any
ambivalence for letting go of his/her substance of choice, or readiness for change. This
art directive specifically asks the client to “depict the crisis or incident that brought you
to treatment” (Holt & Kaiser, 2009, p. 247). This directive offers a parallel to Step One in
12-step programs, which states: “We admitted we were powerless over alcohol—that our
lives had become unmanageable” (Alcoholics Anonymous, 2001, p. 21). The drawings
are then openly discussed in a group therapy setting, for which any personal dilemmas or
traumatic experiences brought forth through the imagery can be incorporated into a
treatment plan (Holt & Kaiser, 2009).
The second directive is a Recovery Bridge Drawing, where the task is to
“complete a bridge depicting where you have been, where you are now, and where you
want to be in relation to your recovery” (Holt & Kaiser, 2009, p. 247). Imagery that
emerges from this prompt can provide insight into any anxiety, ambivalence, or hesitation
felt about entering treatment. This is particularly true in regards to working toward a
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 14 dramatic life change from active substance abuse to sobriety. If the metaphorical bridge
was drawn with the inclusion of fire, for example, the individual will likely discuss the
intensity of fear or anxiety associated with the process of getting sober (Holt & Kaiser,
2009). A group therapy session also follows this directive to allow for further insight to
be discussed in a supportive setting.
The third activity is a Costs-Benefits Collage, which asks the individual to “make
a collage exploring the costs and benefits of staying the same, and the costs and benefits
of changing” (Holt & Kaiser, 2009, p. 248). Again, opportunity for ambivalence and/or
fear surrounding the recovery process can be identified and discussed. In practice, this art
exercise has also offered individuals the opportunity to address any cravings to use
substances, which can be beneficial for relapse prevention (Holt & Kaiser, 2009).
Further, open exploration of these two realities (changing versus staying the same)
clarifies there is a choice between seeking a life of sobriety or remaining physiologically
and psychologically addicted.
The fourth directive is a popular art therapy exercise that encourages selfreevaluation with the intention to raise conscious awareness through imagining future
scenarios (Holt & Kaiser, 2009). Building off topics explored in the previous directive,
this fourth task has two components. First, to “depict yourself as you imagine you will be
in a year if you make the changes that support recovery” and second, “depict yourself as
you imagine you will be in a year if you do not make the changes” (Holt & Kaiser, 2009,
p. 249).
The fifth and final directive in “The First Step Series” prompts the individual to
“make a picture that illustrates the barriers you see to making the changes necessary for
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 15 recovery” (Holt & Kaiser, 2009, p. 249). Real or perceived issues, fears, stresses, or
concerns can be addressed within this prompt, which can be helpful to the therapist (or
treatment team) regarding individualized care. For the individual, it can be especially
beneficial for understanding ambivalence, and/or unveil what may be a hindrance
underlying the motivation to change (Holt & Kaiser, 2009).
Through their experiences as art therapists, Holt and Kaiser (2009) find that the
act of creating art is a process that engages the individual in a profound self-assessment
of thoughts and emotions. Through “The First Step Series,” individuals can use artwork
as a safe container to work through perceptions, beliefs, doubts, and fears, to ultimately
open up a window of opportunity to support motivation for change.
Horay (2006) decided to take a more broad range of focus for his own practice,
after he noticed that the majority of art therapy in the substance abuse treatment field was
derived from the 12-step model. Understanding that many individuals who receive
treatment for addiction held ambivalent feelings about recovery, Horay based his art
therapy treatment approach off of SOC and MI therapeutic models that would address
such ambivalence through various phases along the road to recovery (Hinz, 2009; Horay,
2006). Horay (2006) conceives that art therapy is unique to encouraging self-efficacy
within the individual seeking treatment, claiming:
Artmaking, no matter what media or directive, generally involves utilizing those
same cognitive processes of valuing, choosing, and deciding. Additionally, the
creative process itself—carried out through gathering materials, exploring media,
choosing tools, and active making and revising—corresponds remarkably well to
the five stages of change. (p. 17).
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 16 Horay’s (2006) art therapy program outlined a combination of both individual and
group art therapy sessions within an outpatient addiction treatment setting. To address—
and ultimately move beyond—ambivalent thoughts and feelings about recovery, several
specific art directives are suggested. First, the individual is asked to create a Pro-Con
Collage, assembling magazine images and/or word clippings to represent either “the pros
of using” and “the cons of using,” or, “the pros of not using” and “the cons of not using”
(Horay, 2006, p. 18). The second art therapy session entails creating a Hypothetical
Greeting Card, whereas the individual will create a card as if it were to be sent to
him/her, from someone they care about. This exercise is intended to examine what the
individual values in relationships, which can be used as motivational support for relapse
prevention (Horay, 2006).
All subsequent art therapy sessions utilize Check-In Drawings to identify any
feelings and emotions recently experienced. For these art exercises, individuals can chose
from a variety of materials to use to illustrate their current emotional state. Through these
less structured directives, individuals exhibit self-efficacy and free choice (a primary aim
of MI and SOC) as they explore their ambivalence and progress in recovery (Horay,
2006).
As detailed above, art therapy is used in the treatment of addiction through several
methods of application. Many art therapy programs align with 12-step philosophies,
while others use art directives with the theoretical underpinnings of MI and SOC to
increase motivation to change. Regardless of the approach, the intention of increasing
self-awareness to support progress through recovery is of primary interest in the art
therapy process.
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 17 Existing Outcome Studies
Slayton, D’Archer, and Kaplan (2011) published a comprehensive review of
outcome studies found in the literature which had an isolated focus of art therapy as the
specific intervention (rather than an addition to another treatment modality), completed
between 1999-2007. Their review summarized that the authors of all qualitative studies
(seven total) yielded benefits from the art therapy interventions (Slayton, D’Archer, &
Kaplan, 2011). The population focus for each of these seven studies was different; one
focused on young children with attachment disorders (Ball, 2002), another with adults
with Lupus (Nowicka-Sauer, 2007). Also researched were a group of incarcerated adult
women who experienced a death of a loved one during incarceration (Ferszt et al., 2004),
mothers and toddlers (Hosea, 2006), elder adults with Alzheimer’s disease (Seifert &
Baker, 2002), adults in forensic institutions (Smeijsters & Cleven, 2006), and 10 year old
children with family grief (Gersch & Sao Joao Goncalves, 2006). The art therapy
interventions for each of these studies were different, but all occurred in a group setting.
Interviews with the participants and/or the art therapist were conducted to compile a
qualitative analysis of the studies. Results reflected that issues were successfully
addressed by art therapy, and participants reported that art therapy helped them cope with
their emotions, safely explore grief, and identify positive change/growth (Slayton,
D’Archer, & Kaplan, 2011).
Also examined within the aforementioned outcome studies review were research
designs utilizing control groups. Four clinical trials were completed, for which three of
the four resulted in statistically significant findings. The three studies were focused on
individual art therapy sessions with adult cancer patients (resulting in improvements in
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 18 depression and fatigue levels) (Bar-Sela et al., 2007), group art therapy interventions with
adolescent girls convicted of felonies (resulting in improved self-esteem) (Hartz & Thick,
2005), and group art therapy sessions for medical staff working with oncology patients
(resulting in decreased burnout) (Italia et al., 2008). The trial that did not conclude with
significant findings focused on group art therapy for children with leukemia, which was
documented to be beneficial in promoting cooperative behavior during painful
interventions (Favara-Scacco et al., 2001), yet the tools/measurement data were not
available (Slayton, D’Archer, & Kaplan, 2011). The other quantitative data were obtained
through pre/post-test design studies, which appeared to be the most prevalent (a total of
20 studies conducted), for which 55% of studies resulted in statistically significant
findings; all others were reported to have positive trends (Slayton, D’Archer, & Kaplan,
2011).
This review of findings of outcome studies reflects a wide range of art therapy
interventions involving numerous measurement tools and populations (Slayton,
D’Archer, & Kaplan, 2011), yet does not include any focused studies of populations of
substance abusers and/or addicts. Similarly, the American Art Therapy Association
(2015) has a publicized up-to-date list of art therapy outcome studies. This bibliographic
list specifies only three studies that have been conducted on art therapy interventions to
treat chemical dependency and/or substance abuse, each of which were of the qualitative
nature (American Art Therapy Association Research Committee, 2015).
After noticing in the literature that there was almost an absence of art therapy
being provided for people with substance abuse issues, Mahony (1999) carried out a
research project with the intention to explore and potentially explain why art therapy was
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 19 not being widely utilized as a treatment approach for this population. As such, she sent
out questionnaires to 26 different addiction treatment facilities (in the UK), of which 16
provided responses. Of the 16 facilities, only one replied that they had a registered art
therapist on staff. Half of the treatment programs confirmed they do integrate art
activities into their treatment plans, just not through a licensed art therapist. The
questionnaire responses also provided information as to why art therapy was not offered;
financial reasons and limitations of facility space were popular answers. Four of the eight
facilities that reported to have no art program offerings stated that it was a deliberate
choice, yet did not specify why. However, the eight facilities that had no art offerings
were also found to not employ any medical staff or psychologists. Mahony (1999)
concluded her findings by pointing out there is an overall interest to provide art therapy
in treatment programs, but there seems to be a lack of access, in addition to a lack of
awareness of such programs altogether.
Art Therapy & Clinical Neuroscience
The practice of creating art (whether or not it is for the purposes of therapy) can
yield an experience of pleasurable thrill and provide the individual with a rewarding
feeling of achievement, so long as anxiety or learning struggles do not create too much of
a hindrance throughout the process. This sense of ‘reward’ is attributed to dopamine
(DA), which is intrinsic to the underlying neurochemical processes of many of the
activities and outcomes of art therapy (Hass-Cohen & Carr, 2008). According to
neurological research findings, “movement related actions, basic emotions, visceral
functions, reward-based learning and decision-making emerge from the DA pathways”
(Hass-Cohen & Carr, 2008, p. 82).
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 20 The mesocortical DA pathway becomes active when something known is
challenged, and has been found to be involved with meta-cognitive changes that occur
during art therapy. Having too little DA in the brain has been linked to depressed feelings
such as worthlessness, social withdrawal, poor concentration, and unbalanced emotional
perception (Hass-Cohen & Carr, 2008). Although acute use of many drugs increases DA
levels, habitual substance abuse leads to huge deceases in the natural production of DA.
Therefore, creating art that helps promote DA pathway activation can be especially
beneficial for people in recovery to produce DA without the use of drugs.
Meaningful Engagement
Lambert (2008) theorized that depression could be conquered without the use of
antidepressant drugs through meaningful psychomotor endeavors, such as problem
solving combined with movement; specifically, through use of the hands to produce
effort-driven rewards. To test her theory, Lambert (2008) focused specifically on
studying the nucleus accumbens, explaining:
The accumbens is positioned in proximity to the brain’s motor system, or stratum,
which controls our movements, and the limbic system, a collection of structures
involved in emotion and learning. Essentially, the accumbens is a critical interface
between our emotions and our actions. The closely linked motor and emotional
systems also extend to the prefrontal cortex, which controls our thought
processes, including problem solving, planning and decision making. (p. 35).
Lambert (2008) refers to this system—that connects processes of movement,
emotion, and thinking—as the “accumbens-stratal-cortical network,” or, the “effortdriven-rewards circuit” (p. 35). Through her research on rats (who have all the same parts
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 21 of the brain as humans, just smaller and less complex), Lambert (2008) found that
“working rats” (who were engaged in activities that actively engaged the effort-drivenrewards circuit) were 60% more persistent to solve challenges to seek a reward, and less
likely to give up, than non-working rats. These findings suggest that when faced with a
challenge in life, attending to meaningful-activities can engage the brain in a way that is
beneficial to mental health. By participating in activities that actively stimulate the effortdriven-rewards circuit, the brain can get a boost of ‘rewarding’ neurochemicals, such as
serotonin, endorphins and dopamine, without the use of drugs (Lambert, 2008).
Through art therapy, an individual will connect emotion, thought, and movement
(with the hands) to create a work of art, which will arouse his/her effort-driven-rewards
circuit resulting in a neurochemical ‘reward’ boost. As such, this active form of creative
expression can promote self-esteem and overall sense of wellbeing. Furthermore, creating
art is a form of meaningful engagement that an individual can easily and realistically
utilize even after treatment ends, thus supporting sustainable, long-term sobriety.
Mindfulness-Based Relapse Prevention
In early recovery, after the individual has detoxed from the substance(s), he/she
will experience physiological and psychological urges, cravings, and temptations to use
the substance again (Ruden & Byalick, 2000; Wilcox & Erickson, 2000). In order to
handle these intense impulses without consuming drugs and/or alcohol, the individual
must essentially relearn how to cope with stress in order to ward off relapse. Based on the
cognitive-behavioral model, the most critical predictor of relapse is the individual’s
ability to implement effective coping mechanisms to deal with stressful, tempting and/or
dangerous situations (Witkiewitz et al., 2005).
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 22 Practices of mindfulness have been found to enhance awareness and cultivate
healthy alternatives to impulsive thinking and behavior (Farmer, 1994; Marcus, 1974;
Rosenthal, 2011; Witkiewitz et al., 2014). According to Farmer (1994), “In the context of
addictions, mindfulness might mean becoming aware of triggers for craving…and
choosing to do something else which might ameliorate or prevent craving, so weakening
the habitual response” (p. 189). On this concept, Mindfulness-Based Relapse Prevention
(MBRP) programs have been created and adopted with the goal of utilizing mindfulness
skills for the development of coping strategies and acceptance of uncomfortable reactions
and sensations experienced during substance withdrawal, therefore decreasing the
probability of relapse (Witkiewitz et al., 2005).
There have been several preliminary studies over the past 40 years reflecting
positive outcomes from mindfulness-based practices in the addictions field. The first
documented studies relating to meditation and substance abuse date back to the early
1970s, with the emergence of a practice referred to as a Transcendental Meditation (TM)
technique (Aron & Aron, 1983; Marcus, 1974; Witkiewitz et al., 2005). TM is a
meditation practice that involves sitting comfortably for a period of 20 minutes (ideally,
twice daily; once in the morning and once in the evening) while silently repeating a
mantra, with a goal to achieve a profound state of physical and mental relaxation and
awareness (Rosenthal, 2011). The repetitive silent/mental mantra used for meditation is a
sound—or a word without meaning—that is believed to be the central ingredient for TM,
allowing attention to be shifted inward (Marcus, 1974).
Five different survey studies were conducted in the 1970s and 1980s that looked
at TM for substance abuse treatment, involving various participant group sizes (ranging
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 23 from 60 to 1,862 subjects). Each of these five studies resulted in positive outcomes,
suggesting that this mindfulness meditation technique is effectively capable of reducing
stress, anxiety, and tension (Aron & Aron, 1983; Marcus, 1974, Transcendental
Meditation, 2015). As the aimed goal of drug use by abusers is often parallel to that of
the TM outcomes (to be relieved from stress, anxiety, etc.), it is suggested that TM may
be an effective treatment option for relapse prevention (Marcus, 1974).
While many of these early studies of TM draw subjective conclusions, there have
been some that included questionnaires directed at monitoring the amount of drug use for
a prolonged period of time after the TM practices were introduced. More specifically, in a
1983 study, it was reported that substance abuse had gradually decreased or ceased
altogether among participants who integrated a TM practice into their daily lives for a
period of two years (Aron & Aron, 1983). A similar study in 1984 that was replicated in
1986 used a randomized trial to measure the efficacy of relaxation techniques, including
TM, as a means of substance abuse reduction; participants (all heavy-drinking college
students) who were administered the TM treatment were compared to a “no treatment”
control group. Results reflected that the participants in the TM group self-reported a
significant reduction in drug and alcohol use compared to the control group (Murphy et
al., 1986; Witkiewitz et al., 2005).
More recently, in 2009, a Mindfulness-Based Stress Reduction program (MBSR),
initially developed by Kabat-Zinn in 1990 (Rappaport, 2014) found successful outcomes
when implemented as a relapse prevention method at a community-based addiction
treatment program for women. The MBSR program used for this 2009 study involved
body scan exercise techniques to improve mind-body awareness, seated meditation aimed
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 24 toward non-judgmental thought awareness and impulse control, mindful hatha yoga to
encourage self-care and attentiveness to sensations in the body, and walking meditations
to practice mindfulness of living in the present moment (Vallejo & Amaro, 2009).
The MBSR framework was constructed to have participants gain the ability to
observe their emotions, bodily sensations, and thoughts in a systematic way that was free
from judgment. This would initiate freedom to choose how to respond to urges, cravings,
and unwanted mental noises that commonly present in early recovery, instead of acting
on impulse (Vallejo & Amaro, 2009). Though the attrition rate of this study was high
(57% of the 101 participants dropped out of the substance abuse treatment program—a
statistic that is not uncommon in the field of addictions), the remainder who did complete
the program self-reported positive feedback in relation to the MBSR. This study was
based on participant ratings on 13 items relating to the MBSR, at three different intervals
throughout the eight-week substance abuse treatment program (Vallejo & Amaro, 2009).
Of the rating comparisons, 11 of the 13 survey response items were found to have
statistically significant improvements between the beginning and end of the eight-week
program (Vallejo & Amaro, 2009).
Mindfulness-Based Relapse Prevention (MBRP) was developed as an adaptation
of MBSR targeted to the needs for individuals with addictive behaviors (Bowen et al.,
2009; Rappaport, 2014). According to Bowen et al. (2009), MBRP practices “focus on
increasing acceptance and tolerance of positive and negative physical, emotional, and
cognitive states, such as craving, thereby decreasing the need to alleviate associated
discomfort by engaging in substance use” (p. 296). As designed, each 50-minute biweekly session of the MBRP is to begin with a brief guided meditation (e.g., body scan
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 25 meditation, or seated meditation) specifically focusing on using mindfulness-based skills
to decrease reactivity of high-risk situations that could lead to relapse, followed by a
group discussion. Participants of MBRP are also assigned exercise “homework”
(provided via handouts) to practice on their own between sessions (Witkiewitz et al.,
2014). Through its intentionally mindful application, MBRP is designed to raise
awareness of internal and external triggers and recognize onset of cravings, while at the
same time foster more skillful behavioral choices (Bowen et al., 2009; Witkiewitz et al.,
2014).
There is exciting research data supporting the efficacy of MBRP. A pilot study
published in 2009 used a randomized-controlled trial to evaluate the feasibility and
efficacy of an eight-week MBRP program at an outpatient treatment facility (Bowen et
al., 2009). Assessments were administered to the participants at the MBRP program
initiation, upon the completion of the eight-week program, and at two and four months
post-intervention. The assessments focused on measurements of craving, acceptance,
awareness, and days of substance use. Results indicated participants who received MBRP
treatment had statistically significant decreases on all items measured, compared to the
control group who received treatment as usual (Bowen et al., 2009).
More recently, in 2010-2011, a randomized trial comparing MBRP to standard
Relapse Prevention (RP) was conducted with female offenders who were referred to a
residential addictions treatment program through the criminal justice system (Witkiewitz
et al., 2014). Assessments were provided to 105 participants upon initial admission to
treatment (baseline), at the midpoint of treatment, and completion of treatment. Followup assessments were also provided to participants at 15-weeks post-treatment (of which
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 26 80 participants completed). Statistically significant results of the study indicated that
participants who received MBRP compared to RP had 96% fewer days of drug use at the
15-week follow up date (Witkiewitz et al., 2014).
The outcomes research on TM, MBSR and MBRP all suggest that mindfulness
practices can bring happiness or contentment, release stress and tension, and expand
awareness of consciousness without the use of substances (Marcus, 1974; Murphy et al.,
1986; Witkiewitz et al., 2005), and can therefore be a useful mechanism for managing
physiological and psychological urges and cravings during early recovery.
Art Therapy & Mindfulness
Art and mindfulness have deep and profound connections in both application and
experience (Bowen et al., 2009; Rappaport, 2014; Rosenthall, 2011). When used in
conjunction with one another, these treatment methodologies are found to promote a
balance of inward reflection through mindfulness and outward expression through art. As
stated by Rappaport (2014):
Together, they help to develop skillfulness in being able to become more aware of
various dimensions of inner experience—feelings, thoughts, sensations, and
energies; and transform them through mindfulness practices and/or creative
means, release them in constructive ways, access inner wisdom, cultivate selfcompassion and compassion toward others. (p. 16).
Art therapy has been implemented as an adaptation of, and in addition to, other
mindfulness practices. In 2012, a Music, Imagery, and Mindfulness group was held at an
undisclosed drug and alcohol rehabilitation facility for 10 weeks in an outpatient setting
(van Dort & Grocke, 2014). Each bi-weekly session within the 10-week treatment series
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 27 lasted for 90 minutes, and was comprised of mindfulness relaxation (listening to music)
followed by a moment for silent mental imagery reflection, and concluded with members
drawing a mandala—art created in a circular form used to explore the unconscious self
(Malchiodi, 2010)—relating to their experience of the music provoked mental imagery
(van Dort & Grocke, 2014). Prior to each session, participants were led into the
music/imagery component with a mindfulness relaxation induction by the facilitator,
where they were asked to focus on the sensations of each breath as it moved through each
part of the body. Participants were asked to become aware of any images that arose
behind closed eyes, and allow them to take shape; free from judgment, criticism, or
grasping. To conclude each session, participants were asked to share their mandala
drawing of their experience in the group setting. Documented interviews with the
participants reflect that the mindful art exercises produced rich, emotional experiences
that could be explored in a safe environment, offering new realizations and understanding
of “self” (van Dort & Grocke, 2014).
The integration of art therapy and mindfulness blend so nicely that there has been
an emergence of new practice applications with positive outcomes. Peterson (2006)
created an eight-week treatment program known today as Mindfulness-Based Art
Therapy (MBAT), combining art therapy with Kabat-Zinn’s Mindfulness-Based Stress
Reduction (MBSR) model (Monti et al., 2006; Rappaport, 2014). The overall goal of
MBAT is to decrease levels of distress and improve quality of life, through use of both
verbal and nonverbal expression. In a supportive group format, MBAT is structured to
enhance support, promote self-regulation, and expand coping strategies (Monti et al.,
2006). The eight-week MBAT program design includes body scan and loving-kindness
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 28 meditations, walking meditations, gentle yoga, and guided imagery practices, coupled
with mindful art activities, such as self-picture assessments and free art-making open
studio time (Monti et al., 2006). A detailed outline of the eight-week MBAT program
curriculum is referenced herein as Appendix A.
A randomized, controlled trial was conducted to investigate the MBAT treatment
program for women with cancer, and test the hypothesis that MBAT (alongside usual
medical care) would reduce symptoms of distress and improve health-related quality of
life, compared to those who received medical care alone (Monti et al., 2006). Through
use of pre/post-test surveys, distress was measured using the Symptoms Checklist
Revised (SCL-90-R), which assesses 90 varying indicators of stress levels, including
depression, anxiety, paranoid ideation, hostility, etc. Health-related quality of life was
measured by the Medical Outcomes Study Short-Form Health Survey (SF-36), which
focused on assessing 36 different health concepts such as bodily pain, general health
perception, limitations in activities due to health problems, vitality (energy and fatigues),
etc. Survey data was also obtained at a 16-week follow-up date. As consistent with the
hypothesis, this study found that patients who received the MBAT intervention
demonstrated statistically significant decreases in distress compared to those who
received medical treatment alone, as well as statistically significant increased
improvements of many of the 36 items within the quality of life measurements, such as
mental health, general health, social functioning, and vitality (Monti et al., 2006). Followup survey results reflected slight increases between week 8 and week 16, which suggest
positive maintenance of treatment effect (Monti et al., 2006, p. 369).
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 29 As previously discussed, there has been encouraging and significantly beneficial
research findings for Mindfulness-Based Relapse Prevention (MBRP). In the past few
years, art therapy has been blended with mindfulness practices. It can be reasonably
hypothesized therefore, that mindful art therapy would have similar outcome findings if
researched at the quantitative level. Unfortunately, the emergence of MBAT is so new
that such trials have yet to be conducted.
Spirituality
Hopelessness is a serious internal battle that many cannot combat successfully
alone. Many successful addiction recovery programs are rooted in spiritual principles, as
a means to offer support and guide the individual through (and eventually out of) the state
of hopelessness, comforting them to know they are not going through this battle alone.
Clinical research has found that spirituality is a critical component of quality of life,
especially for those who are suffering from chronic or terminal disease, and is a crucial
resource for individuals coping with illness (Monod et al., 2011).
A theory held by Alcoholics Anonymous (2001) suggests that addiction is a
disease deep-rooted in trauma, and is often a result of a spiritual malady. But what is
spirituality? According to Oriah Mountain Dreamer (2005):
Our spirituality is our direct experience of that which is paradoxically both the
essence of what we are, the stuff of which everything is made, and that which is
larger than us. We can call it God, the Sacred Mystery, the Great Mother, the
divine life force, fertile emptiness, clear light awareness, love, beauty, truth. The
possibilities are endless. (…) Fully present we experience a presence within and
around us, an all-inclusive vastness that is beyond words or thoughts. These
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 30 moments of being awake to the divine within and around us offer us a sense of
purpose and meaning, an appreciation for the wholeness of life even as what we
experience in these moments may be impossible to articulate or explain. (p. 5).
Spirituality has been a primary foundation for the recovery process within 12-step
programs since their emergence in 1935 with the founding of Alcoholics Anonymous. In
a 12-step program, the person in recovery is advised that it is essential to discover a
Power greater than him/herself, and rediscover what is important in life: “Just to stop
drinking without other growth or change would simply frustrate a person who had not
learned any other way to meet basic human needs” (Farley-Hansen, 2001, p. 102).
Maintaining and developing spiritual connectedness (a key component to finding success
in recovery) involves recognizing the spiritual aspect of the “self”—discovering one’s
own values and priorities, while learning what is true and meaningful in life, and
ultimately create (or re-create) a life worth living.
Treating substance abuse/addiction through a 12-step program suggests that all
individuals must adopt a belief in a “Higher Power” in order to be successful in recovery
and personal growth. One must essentially trade their belief that a substance—drugs or
alcohol—is what gives them what they need, for a belief that there is a Power in the
Universe that can help them remain clean and sober. This idea is strongly emphasized not
only in early recovery, but also as a means of achieving long-term sobriety. According to
the book of Alcoholics Anonymous (2001), “In nearly all cases, their ideals must be
grounded in a power greater than themselves, if they are to re-create their lives” (p.
xxviii).
Although fellowship (social support) in 12-step programs can encourage
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 31 successful sobriety (Borkman, 2008; Pagano et al., 2004), many individuals have a strong
resistance toward trusting in a Power greater than his/herself, and are therefore unwilling
to work the steps of the program as outlined (Laudet, 2003); without willingness, no true
individual progress can be made (Pagano et al., 2004). Art therapy can be a vehicle for
spiritual connection for those who are unwilling to adopt a Higher Power in early sobriety
(Feen-Calligan, 1995). The simple act of creating art is therapeutic by nature (Malchiodi,
2012) and can be expression of spirituality aside from believing in a Higher Power. For
example, unconscious thoughts can be visually realized through art making (Chickerneo,
1993), which can be a humbling and meaningful endeavor (Feen-Calligan, 1995). In this
regard, art therapy could potentially be a recovery tool more beneficial than a 12-step
program for individuals who are not open-minded about spirituality.
Art therapy interventions have been successful in promoting spirituality for
individuals seeking recovery from addiction. Miller (1995) documented a clinical art
therapy program where weekly art groups were held with the primary goal of spiritual
growth. Upon treatment intake, patients/clients complete a questionnaire on spirituality.
Throughout treatment, participants attend weekly art groups that specifically aimed to
promote awareness of personal spirituality, while defining his/her relation to a Higher
Power. At the end of treatment, a second spirituality questionnaire was administered.
Findings validated that 90% of patients self-reported that art group increased their
spiritual awareness (Miller, 1995).
There is an intimate relationship that exists between art and spirituality. FarleyHansen (2001) states:
Its fruits resemble the outcome of many spiritual practices: a heightened
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 32 awareness of self and other, a reawaking of the senses and the body, a new ability
to inhabit fully the present moment, a sense of awe at the mysterious ways that the
images which visit us speak of realities beyond our conscious understanding, a
greater sense of acceptance for all aspects of ourselves and others, love,
compassion and gratitude for some larger, deeper, ineffable presence to which we
all (human beings, animals, plants) belong. (p. 24).
Art therapy allows emotional turmoil, which may be difficult or uncomfortable to
explain with words, to be expressed nonverbally (Farley-Hansen, 2001; Wilson, 2012). It
provides the individual with a unique outlet for creativity to be brought into the recovery
process, granting personal freedom and a gentle invitation into spiritual health. As FeenCallahan (1995) states, “Recovery, art, and spirituality share certain qualities that lend
support to the use of art as therapy in addiction treatment: Recovery, art, and spirituality
all require commitment and consistent effort to know them” (p. 48).
12-step programs can be helpful in treating addiction (and achieving long-term
sobriety) not only due to their emphasis on following spiritual principals, but also
because of their format of offering strong social support connections with other
individuals seeking the same goal—being free from the grips of addiction—in order to
live a full, happy life (Borkman, 2008). The nature of art therapy as a treatment process
aligns with the principals of 12-step programs, as it offers a creative outlet for expression,
acts as a vessel for spiritual connection, encourages relaxation and meditation, and in a
group setting, can offer positive social engagement and support (Feen-Calligan, 2007;
Holt & Kaiser, 2009). Addicts seeking sobriety must essentially rediscover their emotions
without the mask of the substance(s), which can be a painful process. These individuals
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 33 likely have lost sight of who they are, how they feel, and what is important to them, and
may feel lost and alone in the world (Wilson, 2002). 12-step programs and art therapy
group practices alike can be successful in guiding addicted individuals through a
transformative, emotional process, with the support of others who have personally gone
through the similar process—sharing the common goal (and therefore means of bonding)
of achieving sobriety.
Shame Reduction
Shame and addiction appear to have an interwoven relationship; shame is
attributed to being both the catalyst for addictive behaviors and a reason that they
continue (Wilson, 2012). Reducing shame is crucial to the recovery process, but has been
noted to be rather difficult to directly address during treatment (Johnson, 1990; Wilson,
2012). According to Wilson (2012), “shame, by its very nature, seems difficult to
describe with words or even to access through cognitive processes since shame is largely
an unconscious experience defended against by a variety of maladaptive responses” (p.
305).
Addicts in early recovery are often confronted with intense and overwhelming
feelings of shame and remorse when faced with the reality of past behaviors and
potentially traumatizing experiences. Art therapist Marie Wilson (2012) feels the
expressive art therapy approaches are well suited to reduce shame. She claims “shameful
feelings may flow more easily and be more directly accessed via nonverbal, creative
approaches since they bypass rather than actively confront well-practiced defenses” (p.
305), and can teach recovery concepts so the addict can address shame in a supportive
manner, yet be held accountable. Additionally, art therapy can help addicts recognize and
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 34 identify their own manifestations of shame, by learning how to label it, separate shameful
feelings from reality, and decrease cognitive distortions (Grosch, 1994; Wilson, 2012).
Anxiety Reduction
Anxiety and addiction often overlap, existing concurrently (DuPont, 1995). Acute
anxiety is a common unpleasant effect of drug and/or alcohol withdrawal, but is also a
reason many people abuse substances in the first place, as a means to self-medicate
(DuPont, 1995; Kushner, Sher, & Beitman,1990). Reducing anxiety (a psychological and
physiological stress response) is a necessary and important in order for an individual to
make progressive strives in treatment (Malchiodi, 2012; Wilson, 2012). Art therapy is a
unique, beneficial tool that can be used to uncover and identify sensory aspects of stress
in the body, through visual expression (Malchiodi, 2012). Additionally, the act of making
art can be a soothing, mindful activity, and thus reduce stress and anxiety (Curry &
Kasser, 2011; Malchiodi, 2012; van der Vennet & Serice, 2012).
The act of coloring in symmetrical, complex patterns (such as a mandala) has
been documented to induce a calming state of mind-body similar to meditation (Curry &
Kasser, 2011; Malchiodi, 2010). Curry and Kasser (2011) conducted a study to examine
the effectiveness of various art activities in relation to stress reduction. Anxiety levels
were measured at three intervals throughout the study, occurring at the beginning
(baseline), after a brief anxiety induction, and again after the coloring exercise. Three
comparison groups were used where all three groups were asked to write for four minutes
about a time they experienced intense fear, as a means of inducing anxiety. Participants
were then randomly assigned to one of three groups—either to color a mandala, a plaid
design, or a blank piece of paper (to free-form draw/color)—where they would color for a
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 35 period of 20 minutes. Anxiety measurements reflected that both the mandala and plaid
coloring groups had statistically significant reduction in anxiety levels after the 20minute coloring period, from baseline anxiety. Findings were attributed to the notion that
coloring complex designs has meditative qualities (Curry & Kasser, 2011). These
outcomes were consistent within a replication study conducted one year later (van der
Vennet & Serice, 2012), suggesting that coloring a symmetrical, pre-drawn design can be
an effective way to reduce anxiety.
Limitations of Existing Research
There are only a handful of published research studies found in the art therapy
literature that demonstrates treatment specific for substance abuse and addiction. As
Slayton, D’Archer and Kaplan (2011) pronounced, “it is ever more important that art
therapists provide evidence to support our intuitive knowledge that art heals” (p. 108).
The vast majority of research supports evidence for the therapeutic rationale for using art
therapy as a treatment modality, rather than its measured efficacy. Moreover, the studies
conducted thus far in relation to art therapy for addiction have limitations of efficacy
findings due to the data being qualitative rather than quantitative, making them largely
subjective by nature. Those that are quantitative are quasi-experimental, so evaluating the
efficacy of art therapy is difficult. Nearly all of the published articles and books available
on the subject reference the need and recommendation for additional research.
It is impossible not to wonder…why? Why has there not been any research to
quantify the efficacy of art therapy as a treatment for addiction? Perhaps it is due to the
fact that it is extremely difficult to conduct research within the addiction population due
to such high attrition rates. As evidenced within a recent review, approximately 75% to
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 36 80% of substance use disorder treatment seekers in the U.S. disengage and do not
complete their treatment program (Loveland & Driscoll, 2014). Since the attrition rate is
so high within the completion of treatment programs themselves, it can be sensibly
predicted that efficacy research involving post-treatment follow-ups would have similarly
high, if not higher, attrition rates. As such, obtaining accurate data on long-term sobriety
success/failure seems arduous and unattainable.
Mental illness co-occurring along with a substance use disorder (known as
comorbidity) is another factor posing a challenge for efficacy research to be accurately
conducted within this population. Comorbidity is a factor that may not be known by the
researcher or the participant. Therefore, it is nearly impossibly to evaluate the efficacy of
treatment for only the substance abuse disorder. As explained by Nora Volkow (2010):
It is often difficult to disentangle the overlapping symptoms of drug addiction and
other mental illnesses, making diagnosis and treatment complex. Correct
diagnosis is critical to ensuring appropriate and effective treatment. Ignorance of
or failure to treat a comorbid disorder can jeopardize a patient’s chance of
recovery. (p. 1).
Proposal for New Assessment Tools & Recommendations for Further Research
As the literature promotes, art therapy is an important tool that is currently being
utilized in the treatment of addiction, yet there is a lack of research. Due to an absence of
studies with respect to the efficacy of art therapy for substance abuse and addiction, it is
recommended that quantitative research measures be sought in order to obtain data. This
research is necessary in order to demonstrate the degree of effectiveness, and provide
insight as to why it is effective. It would be valuable for further studies to test the
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 37 following hypothesis: Art therapy, when integrated into an addiction treatment program,
will decrease participants’ levels of shame and anxiety, while increasing mindfulness and
spiritual connection, thus reducing risk of relapse.
The proposed study to test this hypothesis is envisioned to have the design of a
controlled experiment. Ideally, this study would take place at an inpatient addiction
rehabilitation treatment facility (30 day program), as opposed to using an outpatient
treatment program, to reduce confounding variables. In order to evaluate treatment
efficacy, two groups would be compared. The control group of participants would receive
treatment as usual (TAU), while the experimental group would participate in art therapy
interventions in addition to TAU. Similar to randomized-controlled trial research design
studies that were conducted to test efficacy of Mindfulness-Based Relapse Prevention
(MBRP) programs (Bowen et al., 2009; Witkiewitz et al., 2014), art therapy intervention
sessions for this proposed study shall be 50-minutes in length, offered four times per
week. During the time the experimental group receives art therapy interventions, the
control group will participate in 50-minutes of small-group talk therapy.
Assessments (in the form of surveys using a Likert-scale format) are to be
administered initially at the beginning of treatment (admittance) to obtain baseline data,
again at the end of week two (midway through treatment), and week four (prior to
discharge). Follow-up surveys will be administered at three months and six months posttreatment. A rolling admission format would be necessary for this population (Witkiewitz
et al., 2014) to allow for the desired total number of participants in the sample size
(N=88, or more) to be monitored from beginning through post-treatment assessment
marks, to account for likely high attrition rate and aim for a margin for random error
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 38 (MRE) to be no more than 10% (Fox, Hunn, & Mathers, 2009). Art therapy sessions
facilitated through licensed art therapists for this proposed study will take place in both
group (twice per week) and individual settings (twice per week), and explore themes
related to recovery, including but not limited to powerlessness, acceptance, spirituality,
grief, and gratitude.
For statistical analysis, biographical information will be requested at the top of the
initial survey administered upon admittance. An identification number will be assigned to
each participant to ensure confidentiality; each survey will be tracked by participant ID
numbers. Relevant questions for each of the assessments for this proposed study are
intended to measure shame, anxiety, spirituality, mindfulness, frequency and strength of
urges to use, and perceived helpfulness of the art therapy interventions. Follow-up
assessments will also investigate days of alcohol and/or drug use, using the Timeline
Followback (TLFB) measurement model. The TLFB is a self-report survey method that
asks individuals to retrospectively report days of cigarette, alcohol, and drug use within
the past week (Sobell & Sobell, 2000). This survey was initially developed in the 1970s,
but even today appears to be the most commonly used follow-up method to obtain
quantitative data relating to drug use in clinical research (Robinson et al., 2014).
Existing assessment instruments commonly used in other various clinical studies
have been reviewed and will be used for the purposes of this proposed study, as an effort
to support validity and reliability of what is being evaluated. Levels of shame will be
measured with the State Shame and Guilt Scale (SSGS) (Marschall, Sanftner, &
Tangney, 1994). The SSGS is a widely used instrument to measure shame and/or guilt,
and contains 10 questions on a five-point Likert scale (Rusch et al., 2007). An example of
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 39 the SSGS is referenced herein as Appendix B.
Levels of anxiety will be evaluated through the Beck Anxiety Inventory (BAI), a
reliable measurement of anxiety (separate from depression). The BAI is a 21 questions
survey that uses a four-point Likert scale. Self-report items describe physiological
symptoms (e.g. heart pounding) and cognitive aspects of anxiety (e.g. fear of dying).
Individuals are asked to rate items according to how bothered they are by each symptom
(Fydrich, Dowdell, & Chambless, 1992). An example of the BAI survey is referenced
herein as Appendix C.
Spirituality will be measured by the Spirituality Index of Well-Being (SWBS), a
commonly used assessment of spirituality and health outcomes in clinical research
pertinent to substance abuse treatment (Monod et al., 2011). The SWBS consists of 20
questions in four categories to assess overall general perceived well-being and life
satisfaction, on a five-point Likert scale: belief in God, search for meaning, feeling of
security, and mindfulness (Ellison & Paloutzian, 1982). For the purposes of this proposed
study, questions that contain the word “God” have been slightly modified to instead
reference “Higher Power,” to remove religious connotation. An example of this modified
SWBS is included as Appendix D.
Mindfulness will be evaluated using the Five Facet Mindfulness Questionnaire
(MMFQ), which consists of 39 questions on a five-point Likert scale, specifically
intended to measure levels of mindfulness. The five facets measured within the FFMQ
design are categorized as follows: observing (the ability to observe experience),
describing (the ability to describe emotions), acting with awareness (the tendency to pay
attention to thoughts and actions), non-judging (the capacity to accept emotions without
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 40 judgment), and non-reactivity (the capacity to accept emotions without reacting)
(Fernandez et al., 2010). An example of the FFMQ is referenced herein as Appendix E.
Cravings will be assessed through the Penn Alcohol Craving Scale (PACS),
which has been found in clinical trials to be the strongest predictor of drinking (Flannery
et al., 2003). The PACS only contains five questions, and is measured on a six-point
Likert scale. For the purposes of this proposed study, the PACS questionnaire wording
will be slightly modified to include “and/or using [drugs]” in addition to alcohol, to make
the verbiage more inclusive to measure cravings for any addictive substances—not just
alcohol. An example of the modified PACS survey is included herein as Appendix F.
Questions to evaluate whether or not there is a relationship between the efficacy
of art therapy and having an interest in the arts will be administered through an additional
questionnaire. Referred to herein as the Art Interest Questionnaire (AIQ), this
questionnaire contains 10 items on a five-point Likert scale, and was developed for the
purposes of this proposed study. An example of the AIQ is provided in Appendix G.
These six surveys (SSGS, BAI, SWBS, FFMQ, PACS, and AIQ) will be
administered as a packet for all individuals to complete at each of the time intervals
previously stated: admittance, end of week two, and discharge. Post-treatment surveys
will be administered (at 3 months and 6 months post-treatment), consisting of the six
questionnaires plus the TLFB assessment to also capture data on alcohol consumption
and/or drug use. An example of the TLFB is incorporated herein as Appendix H.
A comparative analysis will be conducted to evaluate responses between groups
at the various times surveys were administered throughout the duration of the study.
Expected results would reflect a greater decrease in shame as well as anxiety for
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 41 participants who received the art therapy interventions, compared to TAU, within the
treatment timeframe. Survey results are also expected to indicate a greater increase of
mindfulness and spiritually in the art therapy (experimental) group compared to the TAU
(control) group. Additionally, it is expected that the frequency and intensity of cravings
will decrease within both groups throughout treatment, but slightly more for the
experimental group.
Post-treatment comparisons should indicate whether or not adding an art therapy
component to an existing substance abuse treatment program improves treatment
outcomes. Days of alcohol consumption and/or drug use reported on the TLFB surveys
can be examined between comparative groups, and determine if there are any interesting
relationships. For example, if both cravings and days of use are lower in the experimental
group, than the treatment outcomes for art therapy are more effective than TAU. In
addition to quantifying the efficacy of art therapy for substance abuse treatment and/or
relapse prevention, the results that may come from this proposed study would help inform
addiction treatment programming.
Conclusion
Art therapy alone is not capable of treating the initial physiological effects of
chemical dependency; therefore, an individual should seek necessary medical treatment
in order to safely withdraw from substances. However, once the substance(s) are
completely removed from the body and withdrawal symptoms are lifted, psychological
cravings may likely remain (Ruden & Byalick, 2000). Additionally, the physical and
emotional struggle of anxiety that likely accompanies the addiction (DuPont, 1995) may
make it all the more difficult for the individual to move toward sobriety. Art therapy
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 42 interventions can guide the addicted individual through the process of recovery, helping
him/her discover new ways to handle life, cope with cravings (Malchiodi, 2012), and
ultimately learn how to express any raw, harsh emotions freely, without the numbness of
a drug. Furthermore, art making is a healthy, creative outlet that can be utilized even after
treatment ends, to promote anxiety and stress reduction (Curry & Kasser, 2011; van der
Vennet & Serice, 2012).
Through mindful engagement and emotional release, the act of creating art in and
of itself is therapeutic (Malchiodi, 2012) and can support sustainable sobriety. Art
therapy is a unique treatment method that allows for creative, expressive means of
reconnecting to the true ‘self,’ while fostering new, healthy means of navigating life
without drugs and/or alcohol. Art making can replace the desire and false need to depend
on a substance to be the sole provider of comfort and joy by fostering spiritual
transformation (Farley-Hansen, 2001), and by stimulating natural (drug-free),
neurochemical ‘reward’ boosts through meaningful engagement (Lambert, 2008). Art
therapy can help individuals find acceptance around struggles and challenges, so they can
be viewed through a different perspective. Creative self-expression allows the
unconscious to become conscious, so emotional turmoil can be brought to the surface and
no longer be buried in fear. Through expressive art therapy, addictive thoughts and
behaviors no longer need to take control of the body and mind leaving one feeling
hopeless—life’s challenges can be a canvas for colorful growth through recovery.
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ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 54 Appendix A
Mindfulness-Based Art Therapy (MBAT) eight-week program curriculum developed by
Monti et al., 2006.
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 55 Appendix B
State Shame and Guilt Scale (SSGS) developed by Marschall, Sanftner, & Tangney, 1994.
The following are some statements that may or may not
describe how you are feeling. Please circle the rating for each
statement based on how you are feeling right now.
I do not
feel this
way at
all
I feel this
way
somewhat
I feel this
way very
strongly
I want to sink into the floor and disappear.
1
2
3
4
5
I feel like I am a bad person.
1
2
3
4
5
I feel worthless, powerless.
1
2
3
4
5
I feel humiliated, disgraced.
1
2
3
4
5
I feel small.
1
2
3
4
5
I feel bad about something I have done.
1
2
3
4
5
I feel like apologizing, confessing.
1
2
3
4
5
I cannot stop thinking about something I have done.
1
2
3
4
5
I feel tension about something I have done.
1
2
3
4
5
I feel remorse, regret.
1
2
3
4
5
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 56 Appendix C
Beck Anxiety Inventory (BAI) developed by Beck and Steer, 1990.
Below is a list of common symptoms of anxiety. Please carefully read each item in the list. Indicate how much
you have been bothered by that symptom during the past month, including today, by circling the number in
the corresponding space in the column next to each symptom.
Numbness or tingling
Feeling hot
Wobbliness in legs
Unable to relax
Fear of worst happening
Dizzy or lightheaded
Heart pounding / racing
Unsteady
Terrified or afraid
Nervous
Feeling of choking
Hands trembling
Shaky / unsteady
Fear of losing control
Difficulty in breathing
Fear of dying
Scared
Indigestion
Faint / lightheaded
Face flushed
Hot and/or cold sweats
Column Sum
Not At All
Mildly but it didn’t Moderately - it wasn’t Severely – it
bother me much. pleasant at times
bothered me a lot
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
Scoring - Sum each column. Then sum the column totals to achieve a grand score. Write that score here
____________ .
Interpretation
A grand sum between 0 – 21 indicates very low anxiety.
A grand sum between 22 – 35 indicates moderate anxiety.
A grand sum that exceeds 36 is a potential cause for concern.
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 57 Appendix D
Spiritual Well-Being Scale (SWBS) developed by Ellison and Paloutzian, 1983.
Never or
very
rarely
Rarely
true
Sometimes
true
Often
true
Always
or very
often
true
I trust in a Higher Power.
1
2
3
4
5
My faith helps me to cope with problems.
1
2
3
4
5
I trust in my faith for decisions.
1
2
3
4
5
I feel the love of a Higher Power.
1
2
3
4
5
I feel that a Higher Power is my friend.
1
2
3
4
5
My life means searching and asking.
1
2
3
4
5
I look for insight and coherence.
1
2
3
4
5
I try to open my mind.
1
2
3
4
5
I try to expand my soul.
1
2
3
4
5
I search for the spirit.
1
2
3
4
5
I try to deal consciously with others.
1
2
3
4
5
I deal consciously with environment.
1
2
3
4
5
I try to help others.
1
2
3
4
5
I try to be patient and tolerent.
1
2
3
4
5
I try to be empathetic with others.
1
2
3
4
5
I feel peace deep inside me.
1
2
3
4
5
My life is peace and joy.
1
2
3
4
5
I feel at one with the world.
1
2
3
4
5
I see a friendly world around me.
1
2
3
4
5
I feel there is a lot of love in the world.
1
2
3
4
5
Please rate each of the following statements by circling the number
that best describes your own opinion of what is generally true for you.
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 58 Appendix E
Five Facet Mindfulness Questionnaire
! (FFMQ) developed by Baer, Smith, Hopkins, and
Toney, 2006.
Five Facet Mindfulness Questionnaire (FFMQ)
Please rate each of the following statements
with the number that best describes your own
opinion of what is generally true for you.
FFQM
1
FFQM
2
FFQM
3
FFQM
4
FFQM
5
FFQM
6
FFQM
7
FFQM
8
FFQM
9
FFQM
10
FFQM
11
FFQM
12
FFQM
13
FFQM
14
FFQM
15
FFQM
16
FFQM
17
FFQM
18
!
When I’m walking, I deliberately notice
the sensations of my body moving.
(OBS)
I’m good at finding words to describe
my feelings. (D)
I criticize myself for having irrational or
inappropriate emotions. (NJ-R)
I perceive my feelings and emotions
without having to react to them. (NR)
When I do things, my mind wanders off
and I’m easily distracted. (AA-R)
When I take a shower or bath, I stay
alert to the sensations of water on my
body. (OBS)
I can easily put my beliefs, opinions,
and expectations into words. (D)
I don’t pay attention to what I’m doing
because I’m daydreaming, worrying, or
otherwise distracted. (AA-R)
I watch my feelings without getting lost
in them. (NR)
I tell myself I shouldn’t be feeling the
way I’m feeling. (NJ-R)
I notice how foods and drinks affect my
thoughts, bodily sensations, and
emotions. (OBS)
It’s hard for me to find the words to
describe what I’m thinking. (D-R)
I am easily distracted. (AA-R)
I believe some of my thoughts are
abnormal or bad and I shouldn’t think
that way. (NJ-R)
I pay attention to sensations, such as
the wind in my hair or sun on my face.
(OBS)
I have trouble thinking of the right
words to express how I feel about
things. (D-R)
I make judgments about whether my
thoughts are good or bad. (NJ-R)
I find it difficult to stay focused on
what’s happening in the present. (AAR)
!
Never or
very rarely
true
Rarely
true
Sometimes
true
Often
true
Very
often or
always
true
1
2
3
4
5
1
2
3
4
5
5
4
3
2
1
1
2
3
4
5
5
4
3
2
1
1
2
3
4
5
1
2
3
4
5
5
4
3
2
1
1
2
3
4
5
5
4
3
2
1
1
2
3
4
5
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
1
2
3
4
5
5
4
3
2
1
5
4
3
2
1
5
4
3
2
1
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 59 !
FFQM
19
FFQM
20
FFQM
21
FFQM
22
FFQM
23
FFQM
24
FFQM
25
FFQM
26
FFQM
27
FFQM
28
FFQM
29
FFQM
30
FFQM
31
FFQM
32
FFQM
33
FFQM
34
FFQM
35
FFQM
36
!
When I have distressing thoughts or
images, I “step back” and am aware of
the thought or image without getting
taken over by it. (NR)
I pay attention to sounds, such as
clocks ticking, birds chirping, or cars
passing. (OBS)
In difficult situations, I can pause
without immediately reacting. (NR)
When I have a sensation in my body,
it’s difficult for me to describe it
because I can’t find the right words.
(D-R)
It seems I am “running on automatic”
without much awareness of what I’m
doing. (AA-R)
When I have distressing thoughts or
images, I feel calm soon after. (NR)
I tell myself that I shouldn’t be thinking
the way I’m thinking. (NJ-R)
I notice the smells and aromas of
things. (OBS)
Even when I’m feeling terribly upset, I
can find a way to put it into words. (D)
I rush through activities without being
really attentive to them. (AA-R)
When I have distressing thoughts or
images, I am able just to notice them
without reacting. (NR)
I think some of my emotions are bad
or inappropriate and I shouldn’t feel
them. (NJ-R)
I notice visual elements in art or
nature, such as colors, shapes,
textures, or patterns of light and
shadow. (OBS)
My natural tendency is to put my
experiences into words. (D)
When I have distressing thoughts or
images, I just notice them and let them
go. (NR)
I do jobs or tasks automatically without
being aware of what I’m doing. (AA-R)
When I have distressing thoughts or
images, I judge myself as good or bad
depending what the thought or image
is about. (NJ-R)
I pay attention to how my emotions
affect my thoughts and behavior. OBS)
!
Never or
very rarely
true
Rarely
true
Sometimes
true
Often
true
Very
often or
always
true
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
5
4
3
2
1
5
4
3
2
1
1
2
3
4
5
5
4
3
2
1
1
2
3
4
5
1
2
3
4
5
5
4
3
2
1
1
2
3
4
5
5
4
3
2
1
1
2
3
4
5
1
2
3
4
5
1
2
3
4
5
5
4
3
2
1
5
4
3
2
1
1
2
3
4
5
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 60 !
FFQM
37
FFQM
38
FFQM
39
I can usually describe how I feel at the
moment in considerable detail. (D)
I find myself doing things without
paying attention. (AA-R)
I disapprove of myself when I have
irrational ideas. (NJ-R)
Never or
very rarely
true
Rarely
true
Sometimes
true
Often
true
Very
often or
always
true
1
2
3
4
5
5
4
3
2
1
5
4
3
2
1
Scoring:
(Note: R = reverse-scored item)
Subscale Directions
Observing: Sum items
1 + 6 + 11 + 15 + 20 + 26 + 31 + 36
Describing: Sum items
2 + 7 + 12R + 16R + 22R + 27 + 32
+ 37.
Acting with Awareness: Sum
items
5R + 8R + 13R + 18R + 23R + 28R
+ 34R + 38R.
Nonjudging of inner experience:
Sum items 3R + 10R + 14R + 17R +
25R + 30R + 35R + 39R.
Nonreactivity to inner experience:
Sum items 4 + 9 + 19 + 21 + 24 +
29 + 33.
TOTAL FFMQ (add subscale
scores)
Your Score TOTAL
Your score item Avg.
NOTE: Some researchers divide the total in each category by the number of items in that category to get
an average category score. The Total FFMQ can be divided by 39 to get an average item score.
Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment
methods to explore facets of mindfulness. Assessment, 13(1), 27-45.
!
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 61 Appendix F
Penn Alcohol Craving Scale (PACS) developed by Flannery, Volpicelli, and Pettinati, 1999.
Please read each item carefully and circle the number that best describes your craving during the past week.
1.) During the past week how often have you thought about drinking and/or using drugs, or about how good drinking/drugging would make
you feel?
0
Never (1 times during the past week)
1
Rarely (1 to 2 times during the past week)
2
Occasionally (3 to 44 times during the past week)
3
Sometimes (5 to 10 times during the past week, or 1 to 2 times per day)
4
Often (11 to 20 times during the past week, or 2 to 3 times per day)
5
Most of the time (20 to 40 times during the past week, or 3 to 6 times per day)
6
Nearly all of the time (more than 40 times during the past week, or more than 6 times per day)
2.) At its most sever point, how strong was your craving during the past week?
0
None at all
1
Slight, that is a very mild urge
2
Mild urge
3
Moderate urge
4
Strong urge, but easily controlled
5
Strong urge and difficult to control
6
Strong urge and would have drunk alcohol or used drugs if it were available
3.) During the past week how difficult would it have been to resist taking a drink or drug if you had known it was in your house?
0
Not difficult at all
1
Very mildly difficult
2
Mildly difficult
3
Moderately difficult
4
Very difficult
5
Extremely difficult
6
Would not be able to resist
4.) Keeping in mind your responses to the previous questions, please rate your overall average alcohol craving for the past week.
0
Never thought about drinking or using drugs and never had the urge to drink or use
1
Rarely thought about drinking or using drugs and rarely had the urge to drink or use
2
Occasionally thought about drinking or using drugs and occasionally had the urge to drink or use
3
Sometimes thought about drinking or using drugs and sometimes had the urge to drink or use
4
Often thought about drinking or using drugs and often had the urge to drink or use
5
Thought about drinking or using drugs most of the time and had the urge to drink or use most of the time
6
Thought about drinking or using drugs nearly all of the time and had the urge to drink or use nearly all of the time
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 62 Appendix G
Art Interest Questionnaire (AIQ).
Never or
very
rarely
Rarely
true
Sometimes
true
Often
true
Always
or very
often
true
I consider myself creative, and often think outside the box.
1
2
3
4
5
I do not particularly care about the arts.
1
2
3
4
5
I enjoy drawing.
1
2
3
4
5
I engage in art activities in my free time.
1
2
3
4
5
I consider myself artistic.
1
2
3
4
5
I find that doodling helps me concentrate.
1
2
3
4
5
I can express myself through art.
1
2
3
4
5
I have trouble expressing my emotions with words.
1
2
3
4
5
I do not believe I have any artistic talent.
1
2
3
4
5
I feel that the arts play an important role in my life.
1
2
3
4
5
Please rate each of the following statements by circling the number
that best describes your own opinion of what is generally true for you.
ART THERAPY FOR SUBSTANCE ABUSE TREATMENT Appendix H
Timeline Followback (TLFB) developed by Sobell et al., 1979.
63 ART THERAPY FOR SUBSTANCE ABUSE TREATMENT 64