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Colorful recovery : art therapy for substance abuse and addiction treatment

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Colorful recovery : art therapy for substance abuse and addiction treatment
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Chandler, Courtney
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Metropolitan State University of Denver
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Colorful Recovery: Art Therapy for Substance Abuse and Addiction Treatment
by Courtney Chandler
An undergraduate thesis submitted in partial completion of the Metropolitan State University of Denver Honors Program
December 2015
Dr. Anna Ropp
Dr. Katherine Hill Dr. Megan Hughes-Zarzo
Primary Advisor
Second Reader
Honors Program Director


Running Head: ART THERAPY FOR SUBSTANCE ABUSE TREATMENT
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Colorful Recovery: Art Therapy for Substance Abuse and Addiction Treatment
Courtney Chandler
Metropolitan State University of Denver


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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.


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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 ever-inspiring 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., AnnaRopp, Ph.D., and Cynthia Sutton, Ph.D.


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Table of Contents
Abstract.................................................................
Acknowledgements.........................................................
Table of Contents........................................................
Introduction.............................................................
Art Therapy..............................................................
Substance Abuse / Addiction..............................................
Historiography / Literature Review.......................................
Existing Outcome Studies.................................................
Art Therapy & Clinical Neuroscience......................................
Meaningful Engagement....................................................
Mindfulness-Based Relapse Prevention.....................................
Art Therapy & Mindfulness................................................
Spirituality.............................................................
Shame Reduction..........................................................
Anxiety Reduction........................................................
Limitations of Existing Research.........................................
Proposal for New Assessment Tools & Recommendations for Further Research ...
Conclusion...............................................................
References...............................................................
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Appendices
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Colorful Recovery: Art Therapy for Substance Abuse and Addiction Treatment
Life can be difficult and challengingthis 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 lifes 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 emotionsto avoid struggles or challengescreating 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). Luckilyregardless of the causethere 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


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(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 addictionthis 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


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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 todayit 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


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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). Eipon habitual intake, the individuals 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


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of neural activity before returning to it (Wilcox & Erickson, 2000, p. 121). This rebound effect evolves into an intense cravingboth a physiological and psychological phenomenoninsisting 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,


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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 12-step 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


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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 individuals 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.


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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


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through contemplation, preparation, action, and finally maintenance, to delineate the clients 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 individuals 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 alcoholthat 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


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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


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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 itselfcarried out through gathering materials, exploring media, choosing tools, and active making and revisingcorresponds remarkably well to the five stages of change, (p. 17).


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Horays (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 beyondambivalent 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.


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Existing Outcome Studies
Slayton, DArcher, 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, DArcher, & 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 Alzheimers 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, DArcher, & 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


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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, DArcher, & 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, DArcher, & Kaplan, 2011).
This review of findings of outcome studies reflects a wide range of art therapy interventions involving numerous measurement tools and populations (Slayton,
DArcher, & 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


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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).


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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 brains 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 systemthat connects processes of movement, emotion, and thinkingas the accumbens-stratal-cortical network, or, the effort-driven-rewards circuit (p. 35). Through her research on rats (who have all the same parts


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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-driven-rewards 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 effort-driven-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 individuals ability to implement effective coping mechanisms to deal with stressful, tempting and/or dangerous situations (Witkiewitz et al., 2005).


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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 soundor a word without meaningthat 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


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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 MB SR program used for this 2009 study involved body scan exercise techniques to improve mind-body awareness, seated meditation aimed


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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 MB SR 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 programa 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


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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


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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, MB SR 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 experiencefeelings, 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


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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 mandalaart 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-Zinns Mindfulness-Based Stress Reduction (MBSR) model (Monti et al., 2006; Rappaport, 2014). The overall goal of MB AT is to decrease levels of distress and improve quality of life, through use of both verbal and nonverbal expression. In a supportive group format, MB AT is structured to enhance support, promote self-regulation, and expand coping strategies (Monti et al., 2006). The eight-week MB AT program design includes body scan and loving-kindness


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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).


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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


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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 selfdiscovering ones 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 substancedrugs or alcoholis 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


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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. Farley-Hansen (2001) states:
Its fruits resemble the outcome of many spiritual practices: a heightened


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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 Feen-Callahan (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 goalbeing free from the grips of addictionin 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


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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 processsharing 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


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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 groupseither to color a mandala, a plaid design, or a blank piece of paper (to free-form draw/color)where they would color for a


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period of 20 minutes. Anxiety measurements reflected that both the mandala and plaid coloring groups had statistically significant reduction in anxiety levels after the 20-minute 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, DArcher 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


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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 patients 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


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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


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(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


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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


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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 substancesnot 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


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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


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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 hopelesslifes challenges can be a canvas for colorful growth through recovery.


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Appendix A
Mindfulness-Based Art Therapy (MBAT) eight-week program curriculum developed by
Monti et al., 2006.
Table 1. MBAT eight-week program curriculum
Week Mindfulness skills development: MBSR curriculum content* Mindful art activity
Home and in-group practice discussion, didactic, experiential components included in each session Group discussion of direct experience of process and pictures in each session
1 Introduction to Program and Intervention Embodied well-being: responding vs Reacting to the stress of life Body scan meditation Introduction to art-making. Draw a complete picture of yourself Self-picture assessment (SPA) task
2 Body scan meditation Attitudinal foundations of mindfulness Anchoring attention with the breath (AOB) Mindful exploration of art materials (colored pencil, marker, pastel, watercolor crayon, paint). Awareness of sensory stimulus and response
3 Gentle yoga and sitting meditation Intending well-being/loving kindness meditation Exploring the mind body relationship: pre-post assessment of mind/body relationship before and after gentle yoga
4 Cultivating receptive attention Gentle yoga and sitting meditation Loving kindness meditation Creative problem solving/imaging self-care. Transforming mental, emotional and physical pain; introducing self-care imagery into the pictureb
5 Expanding awareness Sitting (meditation) with thoughts and feelings Loving kindness meditation Exploring meditation practice experience: art productions, using collage element, serve as basis for increasing skills with mindfulness practice in the realm of thoughts and feelings
6 The physiology of stress Walking meditation Loving kindness meditation Stressful and pleasant event pictures as introduction to the physiology of stress including stressful communication/ non-reactive communication skills
7 An evening (or) afternoon silent retreat: guided meditation practices and open studio Open studio: free art-making
8 Guided imagery to a place of healing Program review and discussion of program close as new beginning. Closing ceremony Drawing from the healing place Draw a complete picture of yourself Self-picture assessment (SPA) task
a Derived from Kabat-Zinn and Santorelli (1999). b Derived from Fleming and Cox (1989)._____


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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


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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.
Not At All Mildly but it didnt bother me much. Moderately it wasnt pleasant at times Severely it bothered me a lot
Numbness or tingling 0 1 2 3
Feeling hot 0 1 2 3
Wobbliness in legs 0 1 2 3
Unable to relax 0 1 2 3
Fear of worst happening 0 1 2 3
Dizzy or lightheaded 0 1 2 3
Heart pounding / racing 0 1 2 3
Unsteady 0 1 2 3
Terrified or afraid 0 1 2 3
Nervous 0 1 2 3
Feeling of choking 0 1 2 3
Hands trembling 0 1 2 3
Shaky / unsteady 0 1 2 3
Fear of losing control 0 1 2 3
Difficulty in breathing 0 1 2 3
Fear of dying 0 1 2 3
Scared 0 1 2 3
Indigestion 0 1 2 3
Faint / lightheaded 0 1 2 3
Face flushed 0 1 2 3
Hot and/or cold sweats 0 1 2 3
Column Sum
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.


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Appendix D
Spiritual Well-Being Scale (SWBS) developed by Ellison and Paloutzian, 1983.
Never or Always
Please rate each of the following statements by circling the number Rarely Sometimes Often or very
that best describes your own opinion of what is generally true for you. very rarely true true true 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


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Appendix E
Five Facet Mindfulness Questionnaire (FFMQ) developed by Baer, Smith, Hopkins, and
Toney, 2006.
Please rate each of the following statements with the number that best describes your own opinion of what is generally true for you. Never or very rarely true Rarely true Sometimes true Often true Very often or always true
When Im walking, I deliberately notice 1 2 3 4 5
1 the sensations of my body moving. (OBS)

FFQM Im good at finding words to describe ~n~ n
2 my feelings. (D) 1 2 3 4 5
FFQM I criticize myself for having irrational or
3 inappropriate emotions. (NJ-R) 5 4 3 2 1
FFQM I perceive my feelings and emotions
4 without having to react to them. (NR) 1 2 3 4 5
FFQM When I do things, my mind wanders off ~rr n
5 and Im easily distracted. (AA-R) 5 4 3 2 1
FFQM 6 When I take a shower or bath, I stay alert to the sensations of water on my 1
body. (OBS)
FFQM I can easily put my beliefs, opinions, ~n~ ~n~ ~n~ n ~n~
7 and expectations into words. (D) 1 2 3 4 5
FFQM 8 I dont pay attention to what Im doing because Im daydreaming, worrying, or r A 9 1
otherwise distracted. (AA-R)
FFQM I watch my feelings without getting lost ~n~ ~n~ ~n~ n ~n~
9 in them. (NR) 1 2 3 4 5
FFQM I tell myself I shouldnt be feeling the n
10 way Im feeling. (NJ-R) 5 4 3 2 1
FFQM 11 I notice how foods and drinks affect my thoughts, bodily sensations, and 1 o A R
emotions. (OBS)
FFQM Its hard for me to find the words to ~n~ ~n~ ~n~ n ~n~
12 describe what Im thinking. (D-R) 5 4 3 2 1
FFQM 13 I am easily distracted. (AA-R) 5 4 3 2 1
FFQM 14 I believe some of my thoughts are abnormal or bad and I shouldnt think that way. (NJ-R) 5 4 3 2 1
FFQM 15 I pay attention to sensations, such as the wind in my hair or sun on my face. 1 2 3 4 5
(OBS)
FFQM 16 I have trouble thinking of the right words to express how I feel about things. (D-R) 5 4 3 2 1
FFQM I make judgments about whether my n
17 thoughts are good or bad. (NJ-R) 5 4 3 2 1
FFQM 18 I find it difficult to stay focused on whats happening in the present. (AA-R) 5 4 3 2 1


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Never or very rarely true Rarely true Sometimes true Often true Very often or always true
FFQM 19 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) 1 2 3 4 5
FFQM 20 I pay attention to sounds, such as clocks ticking, birds chirping, or cars passing. (OBS) 1 2 3 4 5
FFQM 21 In difficult situations, I can pause without immediately reacting. (NR) 1 n 2 ~n~ 3 n 4 5
FFQM When I have a sensation in my body, its difficult for me to describe it
22 because I cant find the right words. (D-R) 5 4 3 2 1
FFQM 23 It seems I am running on automatic without much awareness of what Im doing. (AA-R) 5 4 3 2 1
FFQM 24 When I have distressing thoughts or images, I feel calm soon after. (NR) 1 2 3 4 5
FFQM 25 I tell myself that I shouldnt be thinking the way Im thinking. (NJ-R) 5 n 4 _ 3 n 2 1
FFQM I notice the smells and aromas of
26 things. (OBS) 1 2 3 4 5
FFQM 27 Even when Im feeling terribly upset, I can find a way to put it into words. (D) 1 n 2 ~n~ 3 n 4 5
FFQM 28 I rush through activities without being really attentive to them. (AA-R) 5 4 3 2 1
FFQM 29 When I have distressing thoughts or images, I am able just to notice them without reacting. (NR) 1 2 3 4 5
FFQM 30 I think some of my emotions are bad or inappropriate and I shouldnt feel them. (NJ-R) 5 4 3 2 1
I notice visual elements in art or
FFQM 31 nature, such as colors, shapes, textures, or patterns of light and shadow. (OBS) 1 2 3 4 5
FFQM 32 My natural tendency is to put my experiences into words. (D) ~n~ 1 2 _ 3 4 ~n~ 5
FFQM 33 When I have distressing thoughts or images, I just notice them and let them go. (NR) 1 2 3 4 5
FFQM 34 I do jobs or tasks automatically without being aware of what Im doing. (AA-R) ~u~ 5 n 4 _ 3 n 2 ~U~ 1
FFQM 35 When I have distressing thoughts or images, I judge myself as good or bad depending what the thought or image is about. (NJ-R) 5 4 3 2 1
FFQM 36 I pay attention to how my emotions affect my thoughts and behavior. OBS) ~n~ 1 2 _ 3 4 ~n~ 5


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Never or very rarely true Rarely true Sometimes true Often true Very often or always true
FFQM 1 can usually describe how 1 feel at the
37 moment in considerable detail. (D) 1 2 3 4 5
FFQM 1 find myself doing things without ~~ ~~
38 paying attention. (AA-R) 5 4 3 2 1
FFQM 1 disapprove of myself when 1 have n n~ U n~
39 irrational ideas. (NJ-R) 5 4 3 2 1
Scoring:
(Note: R = reverse-scored item)
Subscale Directions Your Score TOTAL Your score item Avg.
Observing: Sum items 1 +6 + 11 + 15 + 20 + 26 + 31 +36
Describing: Sum items 2 + 7 + 12R + 16R + 22 R + 27 + 32 + 37.
Acting with Awareness: Sum items 5R + 8R + 13R + 18R + 23R + 28R + 34 R + 38R.
Nonjudging of inner experience: Sum items 3R + 10R + 14R + 17R + 25 R + 30 R + 35 R + 39R.
Non reactivity to inner experience: Sum items 4 + 9 + 19 + 21 +24 + 29 + 33.
TOTAL FFMQ (add subscale scores)
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.


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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).
Please rate each of the following statements by circling the number that best describes your own opinion of what is generally true for you. 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


ART THERAPY FOR SUBSTANCE ABUSE TREATMENT
63
Appendix H
Timeline Followback (TLFB) developed by Sobell et al., 1979.
NIDA Clinical Trials Network Timeline Followback (TFB) Method Assessment
Instructions
Complete Questions on the form each day for 7 days or as directed by dm cal personnel.
TFB Wook Start Date: (mrrVdd/yyyy)_I_/_____
Day
Sunday Wednesday Saturday
Monday Thursday
Tuesday Friday
Date (mm/dd/yyyy) ___/___/.
1. Have any Illicit substances or alcohol been used on this day?
No Yes
2. Alcohol number of standard drinks (xx):
3. Cannabmolds/ Marijuana
No Yes
4. Cocaine
No Yes
5. Crack
No Yes
6 Amphotamlno-typo stimulants
No Yes
7. Opioid analgesics, including mothadone
No Yes
8 Heroin
No Yes


ART THERAPY FOR SUBSTANCE ABUSE TREATMENT
64
9 Hallucinogens, Including MDMA/ecstasy
No Yes
10. Sedatives and hypnotics, excluding Benzodiazepine
No Yes
11. Bonzodiazepines
No Yes
12. Inhalants
No Yes
Othor Drugs
13. Other drug, specify (enter name -1):
No Yes
14. Other drug, specify (enter name 2):
No Yes
Comments:


Full Text

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Colorful Recovery: Art Therapy for Substance Abuse and Addiction Treatment by Courtney Chandler An undergraduate thesis submitted in partial completion of the M etropolitan State University of D enver Honors Program December 2015 Dr. Anna Ropp Dr. Katherine Hill Dr. Megan Hughes Zarzo Primary Advisor Second Reader Honors Program Director

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!"##$#%&'()*+&,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& 9 & Colorful Recovery: Art Therapy for Substance Abuse and Addiction Treatment Courtney Chandler Metropolitan State University of Denver

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& : & Abstract Does art therapy enhance the process of recovery and therefore increa se the probability of long term s obriety 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. M indfulness practices shall be e xplained 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 r esearch which include a proposed research study to obtain quantitative data, will also be discussed.

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& ; & "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 famil y and friends for their support and their ever inspiring 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 sp ecial thanks and recognition to my thesis committee advisors, Katherine Hill, Ph D Anna Ropp Ph D and Cynthia Sutton, Ph D.

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& < & 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 .......................................................................................................... 3 4 Limitations of Existing Research .................................................................................. 35 Proposal for New Assessment Tools & Recommendations for Further Research ... 36 Conclusion ............................................................................... ....................................... 41 References ....................................................................................................................... 43 Appendices ...................................................................................................................... 5 4

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& = & Colorful Recovery: Art Therapy for Substan ce Abuse and Addiction Treatment Life can be diff icult and challenging this is an agreed u pon fact. Everyone manages their strugg les in life slightly different ly 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 substan ces 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 a n illusion of manageability? For many, this coping mechanism can spiral into th e 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 t here 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 o n twins ( Ruden & Byalick, 1997 ). Research findings suggest that addi ction is not a matter of choice, but rather a biological predisposition associat ed with heredity (Cloninger, 1987; Pitkens & Svilkis, 2000; Ruden & Byalick, 1997) Luckily r egardless 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

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& > & (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 sob er (Pagano et al., 2004) However, th ere is one relatively new form of treatment that is lesser known but uniquel y beneficial for helping th ose who suffer from addiction t his is the field of art therapy ( Johnson, 1990; Mahony, 1999 ; Miller, 1995 ) W h ile research has yet to specifically evaluate the efficacy of art therapy to treat addi c tion, this paper aims to support the following hypothesis: Art therapy, wh en used in conjunction with an addiction treatment program, can enhan ce the process of recover y 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 pro cesses of artistic expression ( American Art Therapy Association, 2014 ). This treatment modality help s people resolve co nflict(s), reduce stress and anxiety, manage grief, increase self esteem 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

PAGE 8

,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& ? & projects are offered by the art therapist in a treatment plan specifica lly geared towards the client ne eds, 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" (Americ an 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 art work 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 therape utic 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 ad mire or love" (p. 98). Substance Abuse / Addiction Drug and alcohol addiction is a huge proble m in the United States today it i s 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 addi c tion 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 Dru g Use and Health (NSDUH), 21.5 million people in the United S tates were found to have a substance use disorder (SUD) within the past year (Substance Abuse and Mental Health Services Administration, 2015) while an

PAGE 9

,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& @ & 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 t en people in th e U.S. admit s to frequently abusing drugs and/or alcohol, or are already addicted; many of those who are not yet claiming to be addicted are dange rously teetering the risky fine line of dependence (National Council on Alcoholism and Drug Dependence 2015 ; Substance Abu se and Mental Health Services Administration, 2015 ) The Diagnostic and Statistical Manual of Mental Disorders ( DSM I V ) defines substance dependence as a maladaptive pattern of drug us e leading to impaired distress, presenting with symptoms (such as incre ased tolerance, withdrawal, continuing to use drugs despite negative consequences, etc.) lasting for a period longer than one year ( DSM VI, cited in Wilcox and Eri c kson, 2000 ) The addicted individual eventually lo ses 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 prese nce 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 th eir way into the nucleus accumbens ( the pleasure center of the brain ) linking themselves with dopamine function When the substance reaches the brain it produce s a surge of dopamine, flooding the limbic system, allowing the individual to experience heigh tened pleasure As this initial on set chemical reaction of the drug wears off, "it must also rebound below the initial baseline

PAGE 10

,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& A & of neural activity bef ore returning to it" (Wilcox & Eri c kson, 2000, p. 121). This rebound' effect evol ves into an intense craving both a physiological and psychol ogical 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 with out 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 dependenc y, depression and hopeless despair (Ruden & Byalick, 2000; Wilcox & Erickson, 2000 ). Historiography / Literature Review A re view of art therapy literature shows that over the past 30 years, art therapy has been used in various forms of application to tr eat substance abuse, yet there is a minimal amount of published quant itative studies relating to its effectiveness. Through anecdotal accounts from therapists working wi th 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 t he traditions of 12 step groups such as Alcoholics Anonymous. By focusing her art therapy sessions on issues and con cepts relevant to the 12 steps ( such as powerlessness,

PAGE 11

,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& 9B & unmanageability, and connecting with a Higher Powe r ) clients can expe rience cohesive ness 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 12 step programs). More specifically, she has many documented case studies of her experiences using art therapy with people suffering from chemical dependency and/o r co dependency and claims that, "all addiction is attachment, and the recovery process from all addiction requires breaking the attachment" (p. 7). Chickerneo argu ed 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, Mat to claims that art directive s should be short, simple, and promote movement toward change and taking action in a way that is both challenging and exciting. Short te rm treatment goals focus on expressing

PAGE 12

,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& 99 & 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 risk taking (trying something new through art making), enhancing self awareness, and establishing interconnectedness, Ma tto 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 D rawing" to facilitate acceptance of the disease of addiction, through creative, nonthreatening confrontation with their experiences of denial, loss, shame and guilt. The s e treatment plan s were de veloped with the goal of resolving any underlying trauma that resul ted in substance abuse The goal of the "Incident D rawing" technique is to offer insight into the unmanageability of the individual's addiction, so he/she can clear ly see that many of the traumatic incidents w ere 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 ab out 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.

PAGE 13

,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& 9: & Once completed, the incident d rawings (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 va lues contradicted? What relationships were affected? What would a sober person do in this situation?" (Co x & Price, 1990, p. 338). Holt and Kaiser ( 2009 ) constructed art therapy directives related to themes within the 12 step recovery model that are geare d toward targeting denial and identifying ambivalence which give rise to eventual acceptance of new lifestyle changes in order t o live a life of sobriety. The five directives developed by Holt and Kaiser called The First Step Series were designed to b e used during the initial stage s of substance abuse treatment and exhibit an active mind body strategy believe d to be especially helpful t hroughout 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 approach es client defensive mechanisms (such as denial) to understand how and why people change, with the goal of enha ncing intrinsic motivation for change (Holt & Kaiser, 2009; Miller & Rollnick, 2002). The SOC model uses a five stage continuum progressing from pre contemp lation

PAGE 14

,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& 9; & through contemplation, preparation, action and finally maintenance, to delineate the client' s read iness or willingness for change (DiClemente & Velasquez, 2002; Holt & Kaiser, 2009). Both MI and SOC emphasize that motivation for change is imperat ive to the recovery process, which occurs in progre ssive stages. Research suggests that active engagem ent 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 C risis Directive that was designed to evaluate the individual's perception of the situation at hand, and target any ambivalenc e 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 St ep O ne in 12 s tep programs which states : "We admitted w e were powerless over alcohol t hat 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 dil emmas 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 ab out entering treatment. This is particularly tr ue in regards to working toward a

PAGE 15

,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& 9< & 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 discuss ed in a supportive setting. The third activity is a Costs Benefits Collage which asks the individual to m ake 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 sur rounding 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 ex plor ation 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 self reevaluation 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 a s 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

PAGE 16

,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& 9= & recovery" (Holt & Kaiser, 2009, p. 249). Real or perceived issues, fears, stresses, or concerns can be addressed within this pr ompt, 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 (Hol t & Kaiser, 2009 ) Through their experiences as art therapists, Holt and Kaiser (2009) find that the act of creating art is a process that engage s 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 pe rceptions, beliefs, doubts, and fears, to ultimately open up a window of opportunity to support motivation for change. Horay (2006) decided to ta ke 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 mode l Understanding that many individuals who receive treatment for addiction held a mbivalent feelings about recovery, Horay based his art therapy treatment approach o ff of SOC and MI therapeutic model s 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. Additi onally, 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).

PAGE 17

,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& 9> & Horay's (2006) art therapy program outlined a c ombination of both individual and group art therap y sessions within an outpat ient 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 usi ng" (Horay, 2006, p. 18). The se cond 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.

PAGE 18

,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& 9? & 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 s ummarized that the authors of all qualitative studies (seven total) yielded benefits from the art therapy interventions (Slayton, D'Archer, & Kaplan, 2011). Th e population focus for each of these seven studies was different; one focused on young children w ith 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 (H osea, 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 afo rementioned outcome studies review were research designs utilizing control groups Four clinical trial s w ere completed for which three of the four resulted in statistically signi ficant findings. The three studies were focused on individual art therapy ses sions with adult cancer patients (resulting in improvements in

PAGE 19

,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& 9@ & 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) an d 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 w as documented to be beneficial in promoting cooperative behavior during painful interventions (Favara Scacco et al., 2001) ye t the tools/measurement data were not available (Slayton, D'Archer, & Kaplan, 2011 ) The o ther quantitative data were obtain ed thr ough pre/post test design studies, which appeared to be the most prevalent (a total o f 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 populatio ns (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 interv entions 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 p rovided 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

PAGE 20

,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& 9A & 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 fa cilities 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 al so 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 awar eness of such programs altogether Art Therapy & Clinical Neuroscience The practice of creating art (whethe r or not it is for the purposes of therapy ) can yield an e xperience 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 und erlying neurochemical processes of many of the activities and outcomes of art ther apy (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).

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& :B & 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 t herapy. Having too li ttle DA in the brain has been linked to depressed feelings such as worthlessness, social withdrawal, poor concentration, and unba lanced emotional perception (Has s Cohen & Carr, 2008). Although acute use of many drug s increases DA levels, habitual s ubstance abuse leads to huge decease s in the natur al 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 tha t depression could be conquered without the use of anti depressant drugs through meaningful psycho motor endeavors, such as problem solving combined with movement; specifically, through use of the hands to produce effort driven rewards To tes t 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 structur es 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, includi ng problem solving, planning and decision making. (p. 35). Lambert (2008) refers to this system that connects processes of movement, emotion and thinking as the acc umbens stratal cortical network ," or, the effort driven rewards circuit (p. 35). Through her research on rats (who have all the same parts

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& :9 & 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 driven rewards circuit ) were 60% mo re 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 m ental health. By participating in activities that actively stimulate the effort driven rewards circuit, the brain can get a boost of rewarding' neuro chemicals, 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, c reating art is a form of meaningful engagement that an individual can easily and realistically utilize eve n 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 th e substance again (Ruden & Byalick, 2000; Wilcox & Erickson, 2000 ). In order t o handle these intense impulse s 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 behavior al 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).

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& :: & Prac tices 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), "I n the context of addictions, mindfulness might mean becoming aware of triggers for cravingand 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 creat ed 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 dec reasing the probability of relapse (Witkiewitz et al., 2005). There have been several preliminary studies over the past 40 years reflec ting 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 s itting 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 (Ro senthal, 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 T M for substance abuse treatment involving various participant group sizes (ranging

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& :; & 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 dra w subjective conclusions, there have been some that included questionnaires directed at monitoring the am ount 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 in to 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; partici pants (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 compar ed 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

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& :< & toward non judgmental thought aw areness 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 comm only 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, 200 9). 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 increasi ng acceptance and tolerance of positive and nega tive 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 bi weekly se ssion of the MBRP is to begin with a brief guided meditation (e.g., body scan

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& := & 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 o wn between sessions (Witkiewitz et al., 2014). Through its intentionally mindful application MB R P is designed & to raise awareness of internal and external triggers and recognize onset of cravings, while at the same time foster more skillful behavi oral choices (Bowen et al., 2009 ; Witkiewitz et al., 2014 ). There is exciting research data supporting the efficacy of MBRP. A pilot study p ublished in 2009 used a randomized controlled trial to evaluate the feasi bility 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, acc eptance, 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. Follow up assessments were also provided to participants at 15 week s post treatment (of which

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& :> & 80 participants completed) Statistically significant r esults of the study indicated that participants who received MBRP compared to RP had 96% fewer days of drug use at t he 15 week follow up date (Witkiewitz et al. 2014). The outcomes research on TM MBSR and MB R P 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 mecha nism 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 self compassi on 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 M indfulness group was held at a n undisclosed drug and alcohol rehabilitation facility for 10 weeks in an outpatient setting (v an Dort & Grocke, 2014) Each bi weekly session within the 10 week treatment series

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& :? & lasted for 90 minutes, and was comprised of m indfulness relaxation (listening t o 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 (v an Dort & Grocke, 2014). Prior to each session, participants were led into the music/imagery component with a mindfulness relaxation induct ion 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 beco me aware of any images that aros e behind closed eyes, and allow them to take shape ; free from judgment, criticism, or grasping. To conclude eac h session, participants were asked to share their mandala drawing of their e xperience in the group setting. Documented interviews with the participants reflect that the mindful art exercises produced rich, emotional experien ces that could be explored in a safe environment, offering new realization s and understanding of "self" (v an 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 (MB SR) 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

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& :@ & 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 t ime (Monti et al., 2006) A detailed outline of the eight week MBAT program curriculum is referenced herein as Appendix A. A randomized, contro lled trial was conducted to investigate the MBAT treatment program for women with cancer and test the hypothesis that MBAT (along side 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, di stress 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 Outcome s 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), et c. Survey data was also ob tained at a 16 week follow up date. As con sistent 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 sta tistically 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). Follow up survey results reflected slig ht increases between week 8 and week 16, which suggest positive maintenance of treatment effect (Monti et al., 2006, p. 369).

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& :A & A s previously discussed, there has been encouraging and significantly benefici al research findings for Mindfulness Based Relapse P revention (MBRP). In the past few years, art therapy has been blended with mindfulness p ractices. 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 spiritu al princip l e s, 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 g oing 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 addictio n is a disease deep rooted in trauma, and is often a result of a spiritual malady But what is spirituality? According t o Oriah Mountain Dreamer (2005): Our spirituality is our direct experience of that which is paradoxically both the essence of what we ar e, 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 endles s. () Fully present we experience a presence within and around us, an all inclusive vastness that is beyond words or thoughts. These

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& ;B & moments of being awake to the divine within and around us offer us a sense of purpose and meaning, an appreciation for the wholen ess of life even as what we experience in these moments may be impossible to articulate or explain (p. 5). Spiritua lity has been a primary foundation for the recovery process within 12 step programs since their emergence in 1935 with the founding of Alcoh olics Anonymous In a 12 s tep program, the person in recovery is advised that it is essential to discover a P ower greater than him /herself, and redis cover what is important in life: "Just to stop drinking without other growth or change would simply frustr ate 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 recognizin g the spiritual aspect of the "s elf" 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 substanc e abuse/ addiction through a 12 s tep 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 U niverse t hat 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). Al though fellowship (social support) in 12 step programs can encourage

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& ;9 & successful sobriety ( Borkman 2008; Pagano et al., 2004 ) many individuals have a strong resistance toward trus ting 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 earl y sobriety (Feen Calligan, 1995 ). The simple act of creating art is therapeutic by nature (Malchiodi, 2012) and c an 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 ab out 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 group s that specifically aim ed to promote awareness of personal spirituality, while defining his/her re lation to a Higher Power. At the end of tre atment, a second spirituality questionnaire wa s administered. Findings validate d that 90% of patients self reported that art group increased their spiritual awareness (Miller, 1995). There is an intimate relations hip that exists between art and spirituality Farley Hansen (2001) states: I ts fruits resemble the outcome of many spiritual practices: a heightened

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& ;: & awareness of self and other, a reawaking of the senses and the body, a new ability to inhabit fully the pre sent 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 Feen Callahan (1995) states, "Recovery, art, and spirituality share certai n 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 help ful 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 or der to live a full, happy life (Borkman, 2008). The nature of art therapy as a treatment process a ligns 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 m editation, and in a group setting, can offer positive social engagement and support (Feen Calligan, 2007; Holt & Kaiser, 2009) A ddicts seeking sobriety must essentially rediscover their e motions without the mask of the substance (s) which can be a painful process. These individuals

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& ;; & 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 succes sful in guiding addicted individual s through a transformative, emotional process, with the support of other s who have personally gone through the similar process sharing the common goal (and therefor e means of bonding) of achieving sobriety. Shame Reduc tion Shame and a ddictio n appear to have an interwoven relationship; s hame is attributed to being both the catalyst f or addictive behaviors an d 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 sha me 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 ar e well suited to reduce shame. S he claims "shameful feelings may flow mor e 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

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& ;< & 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 addicti on often overlap, exist ing 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 i n treatment (Malchiodi, 2012 ; Wilson, 2012 ). A rt 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 r educe stress and anxiety (Curry & Kasser, 2011; Malchiodi, 2012; van der Vennet & Serice, 2012). The act of coloring in symmetrical, compl ex patterns (such as a mandala) has been documented to induce a calming state of mind body similar to meditation ( Cur ry & 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 be ginning (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 anx iety. 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

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& ;= & period of 20 minutes. Anxiety measurements reflected that both the mandal a and plaid coloring groups had statistically significant reduction in anxiety levels after the 20 minute coloring period, from baseline anxiety. Findings were attributed to the notion that coloring complex designs has meditative qualities (Curry & Kasser, 2011). Th ese 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. Limita tions 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 mo re 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 meas ured 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 quan titative 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 recommen dation for additional research. It is impossible not to wonderw hy? 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

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& ;> & 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 up s would have similarly high, if not higher, attrition rates. As such, obtaining accurate data on l ong term sobriety success/failure seems arduous and unattainable. M ental 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 popul ation. 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 diffi cult 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 di sorder 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 a ddict ion, it is recommended that quant itative research measures be sought in order to obtain data This r esearch is necessary in order to demonstrate the degree of e ffectiveness, and provide insight as to why it is effective It would be valuable for furth er studies to test the

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& ;? & following hypothesis: A rt therapy, when integrated into an addiction treatment program, will dec rease participants levels of shame and anxiet y, while increasing mindfulness and spiritual connection thus reducing risk of relapse. The proposed study to test this hypothesis is e nvisioned 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 a n outpatient tre atment program to reduce confounding variables. In order to evaluate treatment efficacy, two groups would be compared T he 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 co nducted 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 leng th, offered four times per week During the time the experimental group receives art therapy interv entions, the control group will participate in 50 minutes of small gro up 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 (p rior to discharge). Follow up surveys will be administered at three months and six months post treatment. A rolling admission format would be necessary for this population (Witkiewitz et al., 2014) to allow for the desired total number of participants in t he sample size (N= 88 or more) to be monitored from beginning through post treatment assessment marks, to ac count for likely high attrition rate and aim for a margin f or random error

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& ;@ & (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, accept ance, spirituality, grief, and gratitude. For statistical analysis, biographical information will be requested at the top of the initial survey administered upon admittance. A n identification number will be assigned to each participant to ensure confidenti ality; e ach s urvey will be tracked by participant ID numbers. Relevant questions for each of the assessments for this proposed study are intended to measure shame, anxiety, spirit uality, 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 t o retrospectively report days of cigarette, alcohol, and drug use with in 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 da ta 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 valid ity and reliability of what is being evaluated. Levels of s hame will be measured with the Sta te Shame and Guilt Scale (SSGS) ( Marsch all, 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

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& ;A & the SSGS is referenced herein as Appendix B Levels of anxiety will be evaluated through the Be ck 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 t he S pirituality 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 Liker t scale : belief in God search for meaning, feeling of security, and mindfulness (Ellison & Paloutzian, 1982) For the purposes of this proposed study, questions th at 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 (th e 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

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& <9 & 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 decr ease 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. D ays of alcohol consumption an d/or drug use reported on the T LFB surveys can be examined between comparative g roups, and determine if there are an y 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 ab use treatment and/or relapse prevention, t he results that may come from this proposed study would help inform addiction treatment programming. Conclusion Art therapy alone is no t capable of treating the initial physiological effects of chemical dependency; therefore an individual should seek necessary medical treatment in order to sa fely 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 A rt therapy

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& <: & interventions can guide th e 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, a rt making is a healthy, creative outlet that can be util ized 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 ar t in and of itself is therapeutic (Malchiodi, 2012) and can support sustainable sobriety. Art therapy is a uniq ue treatment method that allows for creative, expressive means of reconnecting to the true s elf ,' 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, s o they can be viewed through a different perspective. Creative self expression allows th e unconscious to become conscious, so emotional turmoil can be brought to the surface and no longer be buried in fear. Thro ugh expressive art therapy, addictive thoughts and behaviors no lo nger 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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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& <; & References Alcoholics Anonymous. (2001). Alcoholics anonymous (4th ed.). New York, NY: Alcoholics Anonymous World S ervices, Inc. Allen, P. B. (1995). Art is a way of knowing: A guide to self knowledge and spiritual fulfillment through creativity. Boston, MA: Shambhala. American Art Therapy Association. (2014). History and background. Retrieved from http://www.americana rttherapyassociation.org/aata history background.html. American Art Therapy Association Research Committee. (2015). Art Therapy Outcome Bibliography. Retrieved from http://arttherapy.org/upload/outcomebibliographyresearchcmte.pdf Aron, E & Aron, A (1983). The patterns of reduction of drug and alcohol use among transcendental meditation participants. Bulletin of the Society of Psychologists in Addictive Behaviors 2 (1), 28 33. Baer, R. A., Smith, G. T., Hopkins, J., & Toney, L. (2006). Using self report assessment methods to explore facets of mindfulness. Assessment, 13, 27 45. Ball, B. (2002). Moments of change in the art therapy process. The Arts in Psychotherapy, 29 (2), 79 92. Bar Sela, G., Atid, L., Danos, S., Gaba y, N., & Epelbaum, R. (2007). Art therapy improved depression and influenced fatigue levels in cancer patients on chemotherapy. Psycho oncology, 16 980 984. Bec k, A. T., & Steer, R. A. (1990). Manual for the Beck Anxiety Inventory. San Antonio, TX : Psycho logical Corporation.

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& << & Bo genschutz, M. P. (2008). Individual and contextual factors that influence AA affiliation and outcomes. In M. Galanter, & L. A. Kaskutas (Eds.), Recent Developments in Alcoholism Volume 18: Research on Alcoholics Anonymous and Spirituality in Addiction Recovery (413 433). Totowa, NJ: Springer. Borkman, T. (2008). The twelve step recovery model of AA: A voluntary mutual help association. In M. Galan ter, & L. A. Kaskutas (Eds.), Recent Developments in Alcoholism Volume 18: Research on Alcoholics Anonymous and Spirituality in Addiction Recovery (9 35). Totowa, NJ: Springer. Bowen, S., Chawla, N., Collins, S. E., Witkiewitz, K., Hsu, S., et al. (2009). Mindfulness based relapse prevention for substance use disorders: A pilot efficacy trial. Substance Abuse, 30 (4), 295 305. Chapman, L., Morabito, D., Ladakakos, C., Schreier, H., & Knudson, M. M. (2011). The effectiveness of art therapy interventions in r educing post traumatic stress disorder (PTSD) symptoms in pediatric patients. Art Therapy: Journal of the American Art Therapy Association, 18 (2): 100 104. Chickerneo, N. B. (1993). Portraits of spirituality in recovery: The use of art in recovery from co dependency and/or chemical dependency. Springfield, IL: Charles C. Thomas. Cloninger, C. R. (1987). Neurogenetic and adaptive mechanism in alcoholism. Science, 236 : 410 16. Cox, K., & Price K. ( 1990). Breaking through: Incident drawings with adolescent substance abusers. The Arts in Psychotherapy 17 333 337.

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& <= & Curry, N. A. & Kasser, T. (2011). Can coloring mandalas reduce anxiety? Art Therapy: Journal of the American Art Therapy Association, 22 (2), 81 8 5. Davis, B. J. (2015). Mindful art therapy: A foundation for practice. Philadelphia, PA: Jessica Kingsley Publishers. d e Botton, A., & Armstrong, J. (2013). Art as therapy. New York, NY: Phaidon Press. DiClemente, C. C., & Velasquez, M. M. (2002). Motivational interviewing and the stages of change. In W. R. Miller, & S. Rollnick (Eds.), Motiva tional interviewing: Preparing people to c hange (pp. 201 216) New York, NY: Guilford Press. DuPont, R. L. (1995). Anxiety and addiction: A clinical perspectiv e on comorbidity. Bulletin of the Menninger Clinic, 52 (2) A53 A72. Ellison, C. W. & Paloutzian, R. F. (1983). Spiritual well being: Conceptualization and measurement. Journal of Psychology and Theology 11 (4): 330 340. Farley Hansen, M. (Ed.). (2001). Spirituality and art therapy: Living the connection. Philadelphia, PA: Jessica Kingsley Publishers. Favara Scacco, D., Smirne, G., Schiliro, G., & Di Cataldo, A. (2001). Art therapy as support for children with leukemia during painful procedures. Medical P ediatric Oncology, 26 (4), 478 480. Feen Calligan, H. (1995). The use of art therapy treatment programs to promote spiritual recovery from addiction. Art Therapy: Journal of the American Art Therapy Association, 12 (1), 46 50. Feen Calligan, H. (2007). The use of art therapy in detoxification from chemical addiction. Canadian Art Therapy Association Journal, 20 ( 1 ), 16 28.

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& <> & Fernandez, A. C., Wood, Mark D., Stein, L. A. R., & Ross, J. R. (2010). Measuring mindfulness and examining its relationship with alcohol use and negative consequences. Psychology of Addictive Behavior, 24 (4): 608 616. Ferszt, G. G., Hayes, P. M., DeFedele, S., & Horn, L. (2004). Art therapy with incarcerated women who have experienced the death of a loved one. Art Therapy: Journal of the A merican Art Therapy Association, 9 (4), 191 199. Flannery, B. A., Poole, S. A., Gallop, R. J., & Volpicelli, J. R. (2003). Alcohol craving predicts drinking during treatment: An analysis of three assessment instruments. Journal of Studies on Alcohol 64 (1), 120 126. Flannery, B. A., Volpicelli, J. R., & Pettinati, H. M. (1999). Psychometric properties of the penn alcohol craving scale. Alcoholism: Clinical Research and Experimental Research, 23 (8): 1289 1295. Fox, N., Hunn, A., & Mathers, N. (2009). Sampling and sample size calculation. The National Institute for Health Research. Retrieved from http://www.researchgate.net/file.PostFileLoader.html?id=54d7ce52cf57d78c6f8b 4585&key=9473a565 6f3a 4867 8b94 2476bb1a9844&assetKey=AS%3A273695229054978%401442265435766 & 1C*D$EFG&-HG&IJK*)LLG&IHG&M&7F)NOL(PPG&IH&Q9AA: RH&!(L$)O$L$SC&)#*&T)L$*$SC&JU&SF(&5(EV& ,#W$(SC&X#T(#SJDCH& !"#$%&'(")(*%+,-./(0,1"$2-$13(4 G&== Y >9H & Gersch, I., & Sao Joao Goncalves, S. (2006). Creative arts therapies and educational psychology: Let's get together. International Journal of Art Therapyy, 11 (1), 22 32. &

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& <@ & Johnson D. R. (1990). Introduction to the special issue on cr eative arts therapies in the treatment of substance abuse. The Arts in Psychotherapy, 17 295 298. Johnson, L. (1990). Creative therapies in the treatment of addictions: The art of transforming shame. The Arts in Psychotherapy, 17 299 308. Kass, J. D., & Trantham, S. M. (2015). Perspectives from clinical neuroscience: Mindfulness and the therapeutic use of the arts. In Rappaport, L. (Ed.), Mindfulness and the arts therapies: Theory and practice (288 315) Philadelphia, PA: Jessica Kingsley Publishers. Kush ner, M. G., Sher, K. J., & Beitman, B. D. (1990). The relation between alcohol problems and the anxiety disorders. American Journal of Psychiatry, 147 (6), 685 695. Lambert, K. (2008). Lifting depression: A neuroscientist's hands on approach to activating y our brain's healing power. New York, NY: Basic Books. Laudet, A. B. (2003). Attitudes and beliefs about 12 step groups among addiction treatment clients and clinicians: Toward identifying obstacles to participation. Substance Use & Misuse, 38 (14): 2017 2047. Loveland, D., & Driscoll, H. (2014). Examining attrition rates at one specialty addiction treatment provider in the United States: A case study using a retrospective chart review. Substance Abuse Treatment, Prevention, and Policy, 9 (41): 1 13. M ahony, J. (1999). Art therapy and art activities in alcohol services: A research project. In Waller, D., & Mahony, J. (Eds.) Treatment of addiction: Current issues for art therapies (pp. 117 140). New York, NY: Routledge.

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& =B & Monti, D. A., Peterson, C., Kunkel, E. J. S., Hauck, W. W., & Pequignot, E. (2006). A randomized, controlled trial of mindfulness based art therapy (MBAT) for women with cancer. Psycho Oncology 15 (5), 363 373. Murphy, T. J., Pagano, R. R., & Marlatt, G. A. (1986). Lifestyle modification with heavy alcohol drinkers: Effects of aerobic exercise and meditation. Addictive Behaviors, 11 (2), 175 186. National Council on Alcoholism and Drug Dependence, Inc. (2015 ). Alcohol and drug information. Retrieved from https://ncadd.org/about addiction/faq/facts about drugs and https://ncadd.org/about addiction/alcohol/facts about alcohol Nowicka Sauer, K. (2007). Patients' perspective: Lup us in patients' drawings: Assessing drawing as a diagnostic and therapeutic method. Clinical Rheumatology, 26 (9), 1523 1525. Oriah Mountain Dreamer. (2005). What we ache for: Creativity and the unfolding of your soul. New York, NY: HarperCollins Publishers Inc. Pagano, M. E., Friend, K. B., Tonigan, J. S., & Stout, R. L. (2004). Helping other alcoholics in Alcoholics Anonymous and drinking outcomes: Findings from project MATCH. Alcohol, 65 766 773. Petrillo, L. D., & Winner, E. (2011). Does art improve mood? A test of a key assumption underlying art therapy. Art Therapy: Journal of the American Art Therapy Association, 22 (4), 205 212. Pickens, R. W., & Svilkis, D. S. (1991). Genetic influences in human substance abuse Journal of Addictive Disorders, 10, 205 213.

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& =: & Smeijsters, H., & Cleven, G. (2006). The treatment of aggression using arts therapies in forensic psychiatry: Results of a qualitative inquiry. The Arts in Psychotherapy 33 (1), 37 58. Sobell, L. C., Maisto, S. A., Sobell, M. B., & Cooper, A. M. (1979). Reliability of alcohol abusers' self reports of drinking behavior. Behavior Research Thera py, 17 157 160. Sobell, L. C. & Sobell, M. B. (2000). Alcohol timeline f ollowback (TFLB). In American Psychiatric Association (Ed.), Handbook of psychiatric m easures (pp. 477 479). Washington, DC: American Psychiatric Association. Tanner Smith, E. E., Wilson, S. J., & Lipsey, M. W. (2013). The comparative effectiveness of outpatient treatment for adolescent substance abuse: A meta analysis. Journal of Substance Abuse Treatment, 44 (2), 145 158. Transcendental Meditation. (2015). What 's the evidence?: Reduced Substance Abuse. Retrieved from https://www.tm.org/research on meditation Vallejo, Z., & Amaro, H. (2009). Adaptation of mindfulness based stress reduction program for addiction relapse prevention. The Humanistic Psychologist, 37 (2), 192 206. v an d er Vennet, R., & Serice, S. (2012). Can coloring mandalas reduce anxiety? A replication study. Art Therapy: Journal of the American Art Therapy Association, 29 (2), 87 92. Van Dort, C., & Grocke, D. (2014). Music, imagery, and mindfulness in substance dependency. In Rappaport, L. (Ed.) Mindfulness and the arts therapies: Theory and practice (pp. 117 128). Philadelphia, PA: Jessica Kingsley Publishers.

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& =; & Volkow, N. D. (2010). Comorbidity: Addiction and other mental illness. National Institute on Drug Abuse: Research Report Series. Retrieved from https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf Waller, D., & Mahony, J. (Eds.). (1999). Treatment of addiction: Current issues for arts therapies. New York, NY: Routledge. Wilcox, R. E., & Erickson, C. K. (2000). Neurobiological aspects of a ddictions. Journal of Addictions Nursing, 12 (3/4), 117 132. Wilson, M. (2012). Art therapy in addictions treatment: Creat ivity and shame reduction. In Cathy A. Malchiodi (Ed.), Handbook of art t hera py (pp. 302 319). New York, NY : The Guil ford Press. Witkiewitz, K., Marlatt, G. A., & Walker, D. (2005). Mindfulness based relapse prevention for alcohol and substance use disorders. Journal of Cognitive Psychotherapy: An International Quarterly, 19 (3), 21 1 228. Witkiewitz, K., Warner, K., Sully, B., Barricks, A., Stauffer, C., Thompson, B. L., et al. (2014). Randomized trial comparing mindfulness based relapse prevention with relapse prevention for women offenders at a residential treatment center. Substance Use & Misuse, 49 (5), 536 546.

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& =< & Appendix A Mindfulness Based Art Therapy (MBAT) eight week program curriculum developed by Monti et al., 2006.

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& == & Appendix B Sta te Shame and Guilt Scale (SSGS) developed by Marsch all, 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

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& => & 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 nex t to each symptom. Not At All Mildly but it didn't bother me much. Moderately it wasn't pleasant at times Severely it bothered me a lot Numbness or tingling 0 1 2 3 Feeling hot 0 1 2 3 Wobbliness in legs 0 1 2 3 Unable to relax 0 1 2 3 Fear of worst happening 0 1 2 3 Dizzy or lightheaded 0 1 2 3 Heart pounding / racing 0 1 2 3 Unsteady 0 1 2 3 Terrified or afraid 0 1 2 3 Nervous 0 1 2 3 Feeling of choking 0 1 2 3 Hands trembling 0 1 2 3 Shaky / unsteady 0 1 2 3 Fear of losing control 0 1 2 3 Difficulty in breathing 0 1 2 3 Fear of dying 0 1 2 3 Scared 0 1 2 3 Indigestion 0 1 2 3 Faint / lightheaded 0 1 2 3 Face flushed 0 1 2 3 Hot and/or cold sweats 0 1 2 3 Column Sum 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.

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& =? & Appendix D Sp iritual Well Being Scale (SWBS) developed by Ellison and Paloutzian, 1983 Please rate each of the following statements by circling the number that best describes your own opinion of what is generally true for you 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

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& =@ & 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 Never or very rarely true Rarely true Sometimes true Often true Very often or always true FFQM 1 When I'm walking, I deliberately notice the sensations of my body moving. (OBS) 1 2 3 4 5 FFQM 2 I'm good at finding words to describe my feelings. (D) 1 2 3 4 5 FFQM 3 I criticize myself for having irrational or inappropriate emotions. (NJ R) 5 4 3 2 1 FFQM 4 I perceive my feelings and emotions without having to react to them. (NR) 1 2 3 4 5 FFQM 5 When I do things, my mind wanders off and I'm easily distracted. (AA R) 5 4 3 2 1 FFQM 6 When I take a shower or bath, I stay alert to the sensations of water on my body. (OBS) 1 2 3 4 5 FFQM 7 I can easily put my beliefs, opinions, and expectations into words. (D) 1 2 3 4 5 FFQM 8 I don't pay attention to what I'm doing because I'm daydreaming, worrying, or otherwise distracted. (AA R) 5 4 3 2 1 FFQM 9 I watch my feelings without getting lost in them. (NR) 1 2 3 4 5 FFQM 10 I tell myself I shouldn't be feeling the way I'm feeling. (NJ R) 5 4 3 2 1 FFQM 11 I notice how foods and drinks affect my thoughts, bodily sensations, and emotions. (OBS) 1 2 3 4 5 FFQM 12 It's hard for me to find the words to describe what I'm thinking. (D R) 5 4 3 2 1 FFQM 13 I am easily distracted. (AA R) 5 4 3 2 1 FFQM 14 I believe some of my thoughts are abnormal or bad and I shouldn't think that way. (NJ R) 5 4 3 2 1 FFQM 15 I pay attention to sensations, such as the wind in my hair or sun on my face. (OBS) 1 2 3 4 5 FFQM 16 I have trouble thinking of the right words to express how I feel about things. (D R) 5 4 3 2 1 FFQM 17 I make judgments about whether my thoughts are good or bad. (NJ R) 5 4 3 2 1 FFQM 18 I find it difficult to stay focused on what's happening in the present. (AA R) 5 4 3 2 1

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& =A & Never or very rarely true Rarely true Sometimes true Often true Very often or always true FFQM 19 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) 1 2 3 4 5 FFQM 20 I pay attention to sounds, such as clocks ticking, birds chirping, or cars passing. (OBS) 1 2 3 4 5 FFQM 21 In difficult situations, I can pause without immediately reacting. (NR) 1 2 3 4 5 FFQM 22 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) 5 4 3 2 1 FFQM 23 It seems I am "running on automatic" without much awareness of what I'm doing. (AA R) 5 4 3 2 1 FFQM 24 When I have distressing thoughts or images, I feel calm soon after. (NR) 1 2 3 4 5 FFQM 25 I tell myself that I shouldn't be thinking the way I'm thinking. (NJ R) 5 4 3 2 1 FFQM 26 I notice the smells and aromas of things. (OBS) 1 2 3 4 5 FFQM 27 Even when I'm feeling terribly upset, I can find a way to put it into words. (D) 1 2 3 4 5 FFQM 28 I rush through activities without being really attentive to them. (AA R) 5 4 3 2 1 FFQM 29 When I have distressing thoughts or images, I am able just to notice them without reacting. (NR) 1 2 3 4 5 FFQM 30 I think some of my emotions are bad or inappropriate and I shouldn't feel them. (NJ R) 5 4 3 2 1 FFQM 31 I notice visual elements in art or nature, such as colors, shapes, textures, or patterns of light and shadow. (OBS) 1 2 3 4 5 FFQM 32 My natural tendency is to put my experiences into words. (D) 1 2 3 4 5 FFQM 33 When I have distressing thoughts or images, I just notice them and let them go. (NR) 1 2 3 4 5 FFQM 34 I do jobs or tasks automatically without being aware of what I'm doing. (AA R) 5 4 3 2 1 FFQM 35 When I have distressing thoughts or images, I judge myself as good or bad depending what the thought or image is about. (NJ R) 5 4 3 2 1 FFQM 36 I pay attention to how my emotions affect my thoughts and behavior. OBS) 1 2 3 4 5

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& >B & Never or very rarely true Rarely true Sometimes true Often true Very often or always true FFQM 37 I can usually describe how I feel at the moment in considerable detail. (D) 1 2 3 4 5 FFQM 38 I find myself doing things without paying attention. (AA R) 5 4 3 2 1 FFQM 39 I disapprove of myself when I have irrational ideas. (NJ R) 5 4 3 2 1 Scoring: (Note: R = reverse scored item) Subscale Directions Your Score TOTAL Your score item Avg. 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 i tems 4 + 9 + 19 + 21 + 24 + 29 + 33. TOTAL FFMQ (add subscale scores) 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.

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& >9 & 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

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& >: & Appendix G Art Interest Questionnaire (AIQ). Please rate each of the following statements by circling the number that best describes your own opinion of what is generally true for you 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

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,!-&-'.!,/0&12!&3453-,67.&,543.&-!.,-8.6& >; & Appen d ix H Timeline Followback (TLFB) developed by Sobell et al., 1979.

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