Art Therapy, Trauma, and Neuroscience: Theoretical and Practical Perspectives [1 ed.] 1032050543, 9781032050546

Table of contents :
Cover
Half Title
Series Page
Title Page
Copyright Page
Dedication Page
Contents
Preface for the Classic Edition
Preface
Foreword
Acknowledgments
List of Contributors
1 Introduction
2 Neuroscience Concepts in Clinical Practice
3 The Expressive Therapies Continuum as a Framework in the Treatment of Trauma
4 The Image Comes First: Treating Preverbal Trauma with Art Therapy
5 Secure Resiliency: Art Therapy Relational Neuroscience Trauma Treatment Principles and Guidelines
6 Neuroscience and Art Therapy with Severely Traumatized Children: The Art is the Evidence
7 Practical Applications of Neuroscience in Art Therapy: A Holistic Approach to Treating Trauma in Children
8 A Body-Based Bilateral Art Protocol for Reprocessing Trauma
9 Medical Art Therapy Applied to the Trauma Experienced by those Diagnosed with Parkinson’s Disease
10 Conclusion
Index

Citation preview

Art Terapy, Trauma, and Neuroscience

Art Terapy, Trauma, and Neuroscience combines theory, research, and practice with traumatized populations in a neuroscience framework. Te classic edition includes a new preface from the author discussing advances in the feld. Recognizing the importance of a neuroscience- and trauma-informed approach to art therapy practice, research, and education, some of the most renowned fgures in art therapy and trauma use translational and integrative neuroscience to provide theoretical and applied techniques for use in clinical practice. Graduate students, therapists, and educators will come away from this book with a refned understanding of brain-based interventions in a dynamic yet accessible format. Juliet L. King is an associate professor of art therapy at Te George Washington University and adjunct associate professor of neurology at the Indiana University School of Medicine. She is currently pursuing doctoral studies in translational health sciences.

Routledge Mental Health Classic Editions

The Routledge Mental Health Classic Edition series celebrates Routledge’s commitment to excellence within the feld of mental health. Tese books are recognized as timeless classics covering a range of important issues and continue to be recommended as key reading for professionals and students in the area. With a new introduction that explores what has changed since the books were frst published, and why these books are as relevant now as ever, the series presents key ideas to a new generation. African American Grief (Classic Edition) By Paul C. Rosenblatt and Beverly R. Wallace Do Funerals Matter? Te Purposes and Practices of Death Rituals in Global Perspective (Classic Edition) By William G. Hoy Rhythms of Recovery Trauma, Nature, and the Body (Classic Edition) By Leslie E. Korn Grief and Bereavement in Contemporary Society Bridging Research and Practice (Classic Edition) By Robert A. Neimeyer, Darcy L. Harris, Howard R. Winokuer, and Gordon F. Tornton Art Terapy, Trauma, and Neuroscience Teoretical and Practical Perspectives (Classic Edition) Edited by Juliet L. King Users and Abusers of Psychiatry A Critical Look at Psychiatric Practice (Classic Edition) By Lucy Johnston For more information about this series, please visit: https://www.routledge.com

Art Terapy, Trauma, and Neuroscience Teoretical and Practical Perspectives Classic Edition

Edited by Juliet L. King

Classic edition published 2022 by Routledge 605 Tird Avenue, New York, NY 10158 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2022 selection and editorial matter, Juliet L. King; individual chapters, the contributors Te right of Juliet L. King to be identifed as the author of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafer invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identifcation and explanation without intent to infringe. First edition published by Routledge 2016 Publisher’s Note References within each chapter are as they appear in the original complete work Library of Congress Cataloging-in-Publication Data Names: Awais, Yasmine J., author. | Blausey, Daniel, author. Title: Foundations of art therapy supervision : creating common ground for supervisees and supervisors / Yasmine J. Awais, Daniel Blausey. Description: New York, NY : Routledge, 2020. | Includes bibliographical references and index. Identifers: LCCN 2020009541 (print) | LCCN 2020009542 (ebook) | ISBN 9781138212145 (hardback) | ISBN 9781138212152 (paperback) | ISBN 9781315451176 (ebook) Subjects: MESH: Art Terapy—organization & administration | Interprofessional Relations Classifcation: LCC RC489.A7 (print) | LCC RC489.A7 (ebook) | NLM WM 450.5.A8 | DDC 616.89/1656—dc23 LC record available at https://lccn.loc.gov/2020009541 LC ebook record available at https://lccn.loc.gov/2020009542 ISBN: 978-1-032-05054-6 (hbk) ISBN: 978-1-032-05053-9 (pbk) ISBN: 978-1-003-19624-2 (ebk) DOI: 10.4324/9781003196242 Typeset in Minion by Apex CoVantage, LLC Access the Support Material: www.routledge.com/9781032050539

Tis book is dedicated to Ronald E. Hays, MA, ATR-BC, LPC, DVATA HLM. May we all work together to build the bridges that help us understand more about what we don’t already know.

Contents

Preface for the Classic Edition Preface Foreword by Robert M. Pascuzzi, MD Acknowledgments List of Contributors 1 Introduction

ix xii xiv xvii xviii 1

J U L I E T L . K I N G M A , AT R- B C , L P C

2 Neuroscience Concepts in Clinical Practice

11

LU KA S Z M . KO N O P K A A M , P H D, E C N S , B C IA- E E G

3 Te Expressive Terapies Continuum as a Framework in the Treatment of Trauma

42

V I JA B. LU SE B R I N K P H D, AT R , H L M A N D L I S A D. H I N Z P H D, AT R

4 Te Image Comes First: Treating Preverbal Trauma with Art Terapy

67

L I N DA G A N T T P H D, AT R- B C A N D TA L LY T R I P P M A , M S W, L C S W, AT R- B C , C T T

5 Secure Resiliency: Art Terapy Relational Neuroscience Trauma Treatment Principles and Guidelines

100

N OA H HA S S - C O H E N P SY- D, AT R- B C

6 Neuroscience and Art Terapy with Severely Traumatized Children: Te Art is the Evidence P. G U S SI E K L O R E R P H D, AT R- B C , L C P C , L C S W, H L M

139

viii

Contents

7 Practical Applications of Neuroscience in Art Terapy: A Holistic Approach to Treating Trauma in Children

157

C H R I S T O P H E R M . B E L KO F E R P H D, L P C , AT R A N D E M I LY N O L A N DAT, AT R- B C , L P C

8 A Body-Based Bilateral Art Protocol for Reprocessing Trauma

173

TA L LY T R I P P M A , M S W, L C S W, AT R- B C , C T T

9 Medical Art Terapy Applied to the Trauma Experienced by those Diagnosed with Parkinson’s Disease

195

D E B O R A H E L K I S - A BU HO F F P H D, L C AT, AT R- B C , B C P C A N D M O R G A N G AY D O S M A , L C AT, AT R- B C

10 Conclusion

211

J U L I E T L . K I N G M A , AT R- B C , L P C W I T H K E R RY K RU K M S , L P C , C S AC , AT R- B C

Index    

224

Preface for the Classic Edition

Psychological and physical trauma are pervasive, universal, and can signifcantly impact mental health and overall wellness. Te complex presentation of trauma remains a challenge to those who provide clinical care, as trauma compromises multiple nervous system functions, is manifested physiologically, and fractures the capacity to communicate verbally. Despite increasing explorations in the treatment of trauma, not enough attention has been given to art therapy. Research in art therapy is becoming more robust and great strides have been made to understand best practices for trauma sequalae since the initial publication of this text in 2016. Over the last fve years the art therapy community has made considerable advances in the diagnosis and management of physical and psychological trauma and has produced meaningful advances in understanding art therapy and the ever-expanding universe of neuroscience. Attention has shifed to the intersection of neuroscience, arts, and related therapeutics. Collaborative interdisciplinary eforts expand scientifc inquiry and illuminate the brain mechanisms involved in health and disease states. Tese data advance the potentials to study the psychological mechanisms of change in art psychotherapy, bolster existing clinical interventions, and infuence the development new treatment strategies. Art therapy has shown to have a profound clinical efect on people who have endured psychological trauma, and the literature supports the use of nonverbal therapies as benefcial in treatment. Art therapy is a brain-based profession that inherently activates cognitive, emotional, visual, sensory, motor, and perceptual systems. Many art therapists hold some awareness that neuroscience informs their practice, as neuroscience informs everything in one way or another! Tis is a topic of critical importance in psychotherapy practice, and while the allied health professions and psychological sciences are readily relying on neuroscience to inform research and intervention strategies, art therapists are called to be even more mindful in how to best understand and utilize the science without compromising the integrity of the subjective creative process. Te primary goal of this book is to provide an accessible framework for how the disciplines of art therapy and neuroscience complement and support one

x Preface for the Classic Edition another in the contribution to traumatology practice and intervention. Tis is the frst text to discuss the integration of art therapy and neuroscience in the treatment of trauma, and leading clinicians explain how they integrate theory into practice, with diverse populations ofering real world examples. Intended for academics, students, and clinicians, the authors discuss a range of contemporary neurobiological theories to inform and explain their work, together providing a foundation upon which to grow and evolve teaching, practice, and research potentials. Art therapists have intuited the connections between artistic expression and brain processes with a range of approaches found in this book. For example, Vija Lusebrink and Lisa Hinz (Chapter 3) provide an expanded lens for how the Expressive Terapies Continuum helps to contextualize and treat impaired brain function as the result of childhood trauma, and Noah Hass-Cohen (Chapter 5) addresses complex trauma symptoms with a comprehensive and detailed account of the neurocircuitry involved in memory recall and reconsolidation with recommendations for a relational neuroscience approach that can be applied in practice. Art therapy involves the whole body in treatment, and according to Tally Tripp (Chapters 4 and 8) is ofered as a treatment of choice for trauma due to the range of bio-psycho-social and spiritual benefts of art therapy interventions. Te more we learn about the brain, the more body-based interventions are indicated, and contemporary technology can support the expansion of research potentials. In the last fve years, art therapy researchers have utilized mobile electroencephalography (EEG), functional magnetic resonance imaging (fMRI), and functional near-infrared spectroscopy (fNIRS) to advance the understanding of brain wave activities involved in art therapy processes. Neurological conditions, such as Parkinson’s disease, Alzheimer’s disease, and amyotrophic lateral sclerosis (ALS) constitute the need for advancement of research into communication technology, including brain-computer interface (BCI). Art therapists can provide meaningful information for how clinical observations and behavior dimensionality contribute to our understanding of the nuances of complicated human behavior. Psychotherapy research can be enhanced with contemporary technology such as Mobile Brain/Body Imaging (MoBI), which can help to produce a sharper picture of how the brain communicates in a real-world environment when engaged in the arts. Tese advances position art therapists and neuroscientists as partners in the advancement of practice and research potentials. Tis text serves as a framework to continue the conversation across disciplines. It is important to identify the mechanisms of psychological change in art therapy and to seek to answer how and why this form of psychotherapy is so meaningful. Tere is a need to defne these mechanisms of change, then quantify and test them. Simultaneously, it seems crucial to adapt a philosophical and epistemological inquiry that engages the entire continuum of natural, social, and transpersonal sciences. Tis includes quantitative, qualitative, mixed-methods, and arts-based research as ways of knowing and testing the elements of art therapy intervention. Tis text provides a framework for theory building towards a systematic integration of art therapy and neuroscience. Te framework might

Preface for the Classic Edition xi build upon the three primary tenets of art therapy, all of which can be underscored with neuroscience principles: the art making process and the artwork itself are integral components of treatment that help to understand and elicit verbal and nonverbal communication within an attuned therapeutic relationship; the creative process enhances neuroplasticity, is healing and life enhancing; and the materials and methods utilized afect self-expression, assist in self-regulation, and are applied with specialized expertise. Tese tenets underscore art therapy scope of practice across populations and with varied approaches, from a medical model through community-based studio interventions. With this original text as a foundation, it is intended that the next edition will broaden the important intersection of art therapy and neuroscience through the inclusion of applications in less traditional treatment settings, the translation of theory to practice through graduate student education and preparedness, the expansion of art therapy approaches with neurological diseases, and recommendations for the use of contemporary neuroimaging to advance research across disciplines.

Preface

What do dreams know of boundaries? Amelia Earhart

Amelia Earhart and I share the same birthday. At times I wonder about this— does the similarity have meaning for my life, or more accurately, does a coincidence of time hold any signifcant purpose? Understanding Earhart’s imprint begins with her legacy as the frst female pilot to fy solo over the Atlantic, underscored by her work as a nurse’s aide to wounded soldiers and her career as a social worker. Tese are historical facts that I can, at best, ambiguously connect to my identity as an art therapist and my desire to explore my work within the boundless arena of neuroscience. Tese data are limited and do not hold even remote causality when approached with the scientifc method. Tus, the embodiment of Amelia Earhart’s spirit as seen in my career choice and overall life’s purpose is nothing more than a subjective, and quite fighty, opinion. However, to entertain the concept of spirit is to embark on an important and equally valid journey, one that has been explored since the beginning of time through the attempts to defne the complexities of human experience with the study of the brain, behavior, and mind. We have advanced signifcantly in trying to understand the meaning of spirit, or soul. We have articulated the mechanics of human functioning while piloting through the Aristotelian logic of the heart, soaring within the physiology of Galen’s pneuma (breath), and wandering about the mercurial and vast terrain of memory circuits. Even as modern neuroscience moves us closer to an objective description of the structures and functions of the brain, any sound neurologist will acknowledge that, in considering the soul, a traditional medical approach might allow us to explore potentials at the molecular level but not much beyond that. Because the concept of soul has much to do with how we function as people, it is important to embrace fexibility and imagination as we investigate the many aspects of what it means to be alive. It is in this paradigm that Amelia Earhart transcends her own history and becomes symbolic of courage, possibility, and potential. Art Terapy, Trauma, and Neuroscience: Teoretical and Practical Perspectives is a compilation of the work of a neuroscientist and art therapists. Tis book ofers

Preface

xiii

the reader multiple ways to conceptualize the application of art therapy in the clinical treatment of traumatized patients within the context of neuroscience. Of equal importance is the invitation to explore two seemingly distinct academic and therapeutic felds of study as we chart an exciting territory together. With our patients as the copilots, the Neuroscientist and Art Terapist shall soar collectively toward a destination of healing and change.

Foreword

Indianapolis 2015. Implacable March 30th weather. Van Gogh’s birthday. A neuroscience center flled with patients and their families, and foors of endless hallways with testing and services for our patients. One of the largest medical schools in the land. And best. And then something happens. Something small that changes us forever. While I am not an art therapist and know little about the profession, as a neurologist I see patients with chronic progressive degenerative neurological disorders and am aware of how much we physicians can do for them. Every day I also see the limitations of our expertise and impact. Our direct involvement in diagnosis and management is considerable, and the advances in neurology and psychiatry are truly impressive. But in the end we are limited. We need to think more broadly about how we can provide the best physical and psychological environment for patients. On this day something small is a form of art therapy for a number of our patients with Parkinson’s disease. I watch and learn how much more we can do for these patients in gaining insight, sharing the good and bad parts of their situations with others who understand, bonding, comradery, fostering refection and awareness, and in the end feeling better about their circumstances. I sense that such professional engagement will favorably afect the long-term progression of many such neurological conditions. It is not all about medication. As a neurologist I question: Why is this working? It can’t be the art itself. Is it refection, is it the time spent with the patient, is it counseling? Is it color or form or the creative process? Is there a center in the brain for this creative expression and refection? Is this a nonspecifc therapeutic efect or is there something precise and focused that is so infuencing these patients? How does this therapy relate to their neurophysiology? Synaptic connections? Neurotransmitters? I need to understand what is going on, the neuroscience behind this wonderful therapy. I would like to wrap my arms around what I witnessed and give it to all the others who have such a burning need. Perhaps there is some way to enhance and enrich this process for even greater therapeutic power. Te starting point to all these questions needing answers is Art Terapy, Trauma, and Neuroscience: Teoretical and Practical Applications. Tis exploration of

Foreword

xv

neuroscience and art therapy serves as a scientifc foundation for the beneft of our patients and advancement in the state of knowledge of creativity and brain anatomy, physiology, brain-behavior relationships, and the role of art and art therapy in healthy and injured patients. Art and Science unite in launching a new mission to elucidate the neuroscientifc basis for art therapy, to understand the neuroscience underlying creativity, art, and treatment. Observing and chatting with many of the patients with Parkinson’s disease, I must confess to being incredibly afected by their comments. Tey indicated warm and deep feelings about the sessions, and they emphasized their sense of well-being and landing in a better place at the conclusion of the program. I glimpsed how much we can do today for such patients if we work collectively. In this setting, these patients have revealed all that we know and the amazing advances that we use in our current treatment; at the same moment, we see so clearly all that needs to be discovered and perfected to more efectively treat these people. Something small happened on this March day, but something unforgettable. Te breadth and impact of neurological and psychiatric disorders afecting the human population is staggering and ever-changing. Epilepsy (recurrent seizures) afects two percent of the population. Stroke is the third leading cause of death and the leading cause of long-term disability in adults in the U.S. Depression is present in at least 10 percent of the population, and a similar number are submerged in disorders of anxiety. Traumatic brain injury is an increasingly recognized cause for major disability, be it from military duty, sports injury, or motor vehicular accident. Furthermore, with the impressive successes of modern medicine in recognizing and managing hypertension, diabetes, heart disease, and cancer (with screening, education, medical and surgical advances, and lifestyle improvement), we are living longer as a population. While longevity is an ultimate goal of health science, it walks the aging population into the reality of degenerative brain disease. Dementia is becoming a healthcare crisis as life expectancy improves. Dementia afects fve percent of people age 65. Te prevalence doubles with each fve years of increasing age, and at age 85 years fully half the population sufers from dementia and 2/3 of those have Alzheimer’s disease. Parkinson’s disease afects 10 percent of the elderly population. Each of these disorders presents major challenges to patients, families, and communities, and each has limited therapeutic options. We are in desperate need of far better therapies to ofer our patients. And we are only now appreciating the heart-breaking impact of such chronic neurological and psychiatric illness on the patients’ caregivers, family, and friends. Tus, it is essential that any strategy to improve our ability to prevent and manage these common disorders be identifed and perfected. Juliet King, the esteemed editor of this compendium, is in a unique position to lead such a pivotal mission. Ms. King received a BA degree with a dual concentration in Studio Art and Mass Communications from Bloomsburg University in Pennsylvania and an MA degree in Art Terapy from Hahnemann University (now Drexel University) in Philadelphia. She was a supervisor and professor of

xvi Foreword Art Terapy at Drexel University from 1999–2011, prior to her current position as Director of Art Terapy and Assistant Professor at Herron School of Art and Design at Indiana University-Purdue University Indianapolis. An Adjunct Assistant Professor of Neurology at Indiana University School of Medicine, she is integrated within the broad neuroscience community at IU. She served as Director of Behavioral Health Rehabilitation Services, Wordsworth Human Services, from 2003–2009, and has been active in the clinical practice of behavioral medicine, psychotherapy, and art therapy for over a decade. Ms. King maintains status as a Licensed Professional Counselor and currently serves on the Board of Directors for the American Art Terapy Association. As recognition for her work she received the Frank C. Springer Family Innovative Research Award. Current research includes the study of art therapy and veterans with PTSD (post-traumatic stress disorder) and the recent creation of a documentary. Her scholarly work and national presentations focus on art therapy and neuroscience with a particular emphasis on trauma. She has participated in the educational programing for medical students at Indiana University School of Medicine, and she has worked with a variety of clinical departments within the school and those afliated with IU Health. Her leadership has fostered the development of 30 art therapy clinical internship programs in the city of Indianapolis and surrounding communities. Central to her research is the discovery of the neuroscientifc basis for art therapy and related therapeutics. Te project birthed herein by Professor King and her distinguished colleagues represents the beginning of a new and essential chapter in neuroscience: a transition to a new level of scientifc study of brain and behavior and the establishment of an infrastructure of neuroscience as it relates to art and art therapy. Tis collection of articles is about art, therapy, and neuroscience. It represents the pathway of enlightenment using the considerable science and technology related to brain function and human behavior to more formally study the great wealth of theories and application of art and art therapy. From the classic tools of neuroscience (neuroanatomy, localization, neurophysiology, neurotransmitters, neuropharmacology) to the new dawn of studying and understanding brain function (functional neuroimaging, neuropsychology, genomics, proteomics, the connectome), we are witnessing the establishment of fundamental neuroscientifc truths that will launch a new generation of therapeutic applications of art therapy. With Art Terapy, Trauma, and Neuroscience: Teoretical and Practical Applications, Ms. King and her esteemed colleagues have provided the worlds of neuroscience and art therapy with the framework to propel collaborative research of the interface between art and brain with an emphasis on the neurological mechanisms involving art therapy. From such work we will see new opportunities to more efectively help the patients and families in such striking need. Something small happened. Something large is on the horizon. Robert M. Pascuzzi, MD Professor and Chair, Department of Neurology Indiana University School of Medicine

Acknowledgments

Although I may have thought that editing a textbook would be placed on my list of “things to only do once,” the esteemed colleagues who contribute to this frst attempt have helped me readjust my perspective. Te authors graciously agreed to entrust me with the dissemination of their important work and have been patient and thoughtful throughout the entire process, fostering a collegiate dialog and using words like please and thank you along the way. When we respect one another, it is really quite simple to cultivate a culture of partnership instead of competition, and what results is an organic microcosm of shared knowledge. I encourage us all to be kind, thoughtful, and energized as we approach our exciting work together and am thankful to many, including art therapy pioneer Judy Rubin, for being exemplary role models in this regard. I am grateful for the support of Herron School of Art and Design, and Te Springer Family, including Cathy Springer Brown and Rick Brown of Indianapolis and Mary Ann and Scott Hillstrom of the Chicago area, who created the Frank C. Springer Family Innovative Faculty Award. Tis award inspires Herron faculty members to expand their artistic, creative, and scholarly work in innovative directions that will yield new insights into the human condition. I am honored to be the frst recipient of this prestigious award. Te consistent and meticulous work of my copy editor, Master of Reference and all things Edit, Leslie Weaver, has signifcantly helped this book come to fruition. VA psychologist Dr. Brandi Luedtke is an ideal example of whom anyone would want to work with in both research and practice, and art therapist Amy Granger is, among other things, the perfect research assistant. A special thanks is given to my beloved art therapy professor, Dr. Nancy Gerber, who is unfailingly available for an exciting discussion, necessary clarifcation, and the sharing of her sage wisdom. Bob Pascuzzi, MD, has not only graced me with his legendary mentorship but has provided me with opportunities beyond what I could ever imagine— opportunities that allow for us all to contribute to the greater good of humankind while remembering to “Have fun with it!” along the way. I wish for everyone to have a Dr. Pascuzzi in their corner and at their back. Te support of my friends, old, new, simian, and special, has been essential in helping me fnd the “simplest words” and reminding me to integrate “female Elvis” and sunshine into my work. And, as always, I acknowledge my dear family, who are always with me, no matter where I might be or where I could go.

Contributors

Christopher M. Belkofer PhD, LPC, ATR Department Chair, Art Terapy, Mount Mary University, Milwaukee WI. Private practice, Bloom: Center for Art and Integrated Terapies. Deborah Elkis-Abuhof PhD, LCAT, ATR-BC, BCPC Associate Professor, Creative Arts Terapy, Department of Counseling and Mental Health Professions, School of Health Sciences and Human Services, Hofstra University, Hempstead NY. Assistant Investigator, Center for Neuroscience, Feinstein Institute for Medical Research, North Shore/Long Island Jewish Health System. Linda Gantt PhD, ATR-BC Executive Director, Intensive Trauma Terapy, Inc., Morgantown WV. Morgan Gaydos MA, LCAT, ATR-BC Department of Terapeutic Recreation, Nassau University Medical Center, East Meadow NY. Noah Hass-Cohen Psy-D, ATR-BC Associate Professor, Couple and Family Masters and Doctoral Programs, California School of Professional Psychology at Alliant International University, Alhambra CA. Author, Hass-Cohen, N. & Clyde Findlay, J. (2015). Art Terapy & the Neuroscience of Relationships, Creativity, and Resiliency. Te Interpersonal Neurobiology Series. New York: W.W. Norton and Hass-Cohen, N. & Carr, R. (Eds.). (2008). Art Terapy and Clinical Neuroscience. London & Philadelphia: Jessica Kingsley. Lisa D. Hinz PhD, ATR Adjunct Professor, Art Terapy, Saint Mary-of-the Woods College, Saint Mary-of-the-Woods IN. Author, Expressive Terapies Continuum: A Framework for Using Art in Terapy (2009) and Drawing from Within: Using Art to Treat Eating Disorders (2006). Lecturer, St. Helena Lifestyle Medicine Institute. Private practice, Saint Helena CA. Juliet L. King MA, ATR-BC, LPC Director, Art Terapy, and Assistant Professor, Herron School of Art and Design, Indiana University-Purdue University Indianapolis, Indianapolis IN. Adjunct Assistant Professor, Department of Neurology, Indiana University School of Medicine. P. Gussie Klorer PhD, ATR-BC, LCPC, LCSW, HLM Professor, Art Terapy Counseling, Southern Illinois University Edwardsville, Edwardsville IL.

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Private practice in Art Terapy and Counseling. Author, Expressive Terapy with Troubled Children (2000). Lukasz M. Konopka AM, PhD, ECNS, BCIA-EEG Senior Executive DirectorSpectrum for Integrative Neuroscience, McHenry IL. Department of Psychiatry LUMC, Marywood IL. Kerry Kruk MS, LPC, CSAC, ATR-BC Human Rights Coordinator, Dept. of Human Services—Continuous Quality Improvement Division, City of Virginia Beach. Adjunct faculty, Eastern Virginia Medical School, Graduate Art Terapy and Counseling, Norfolk VA. Vija B. Lusebrink PhD, ATR, HLM Professor Emerita, University of Louisville, Louisville KY. Author, Imagery and Visual Expression in Terapy (2009). Emily Nolan DAT, ATR-BC, LPC Assistant Professor, Art Terapy, Mount Mary University, Milwaukee WI. Private practice, Bloom: Center for Art and Integrated Terapies. Tally Tripp MA, MSW, LCSW, ATR-BC, CTT Assistant Professor, Art Terapy, George Washington University, Washington DC. Director, George Washington University Art Terapy Clinic. Private practice, Art Terapy and Psychotherapy.

1

Introduction Juliet L. King

Always try the problem that matters most to you. Andrew Wiles, mathematician

The mind operates in binaries, where emotion tends to overrule reason and vice versa, initially limiting the capacity for language and the ability to express oneself completely. It is in our very nature to operate in polarities in that the basic component of the brain, the neuron, functions this way too. A neuron is either on or it is off; neurons either combine to create a pattern of activation or they do not. This is the truth shown by scientific facts: either—or, yes—no, on—off, is—isn’t. Due to a consistent information flow, however, the excitability of the neuron is variable, and the potential to create action is ongoing and limitless. There are three primary goals for developing and publishing this textbook. The first is to provide an accessible framework for how the disciplines of art therapy, science, and medicine complement one another and contribute to the field of traumatology. Although complex and varied, human responses to traumatic experiences of any kind are natural, subjective, informed by the processes of evolution, and have a biological basis, all of which are axiomatic in contemporary trauma treatment. An introductory chapter describes an overview of brain processes, providing the reader with a common language to understand how neuronal mechanisms are involved in clinical treatment, and in further chapters leading clinicians explain how they combine principles of neuroscience with the practice of art therapy. The second goal is an invitation to medical and healthcare professionals to further discuss the synthesis of neuroscience and art therapy in the building of theory and the development of research designs that enhance biological, psychological, social, and spiritual health. This is the focus of the concluding chapter, which offers additional methods of understanding neuroscience related to art therapy practice and highlights the use of neuroimaging as a tool to gather and test the crucial questions we must answer: How does art therapy work? What are the mechanisms involved? Can we quantify these, and what are the best ways to do this?

DOI: 10.4324/9781003196242-1

2 Juliet L. King The third goal for this volume is to contribute to the development of a revolutionized definition of art therapy itself, one that is necessary for the evolution and survival of the profession. There is only one thing stronger than all the armies in the world, and that is an idea whose time has come. (Victor Hugo, poet and author (n.d.)) Those in clinical and academic practice continue to perceive the profession as a dichotomy of art-as-art versus art psychotherapy. Well-established authors on the subject have explained the history of this division and the current movement toward a definition of an inclusion that exists on a continuum (Hinz, 2009; Junge, 2014; Ulman, 2001; Wadeson, 2010). While such a dichotomy may have been necessary in the past, and is certainly understandable, it is no longer useful and has no factual or scientific basis. I am pleased to see that there is currently a special issue call for papers asking “Is there a Need to Redefine Art Therapy?” from Art Therapy: Journal of the American Art Therapy Association, which seeks to examine the historical definition of art therapy from a contemporary perspective. This is an important and timely call, and I suspect that the submissions will include consideration of the polarities that once defined our most noble profession as parallel to those of hard science and soft science. Most interesting questions usually do not have simple yes and no answers, and the hard science that has traditionally defined neuroscience is based on what can be seen under a microscope. The more indirect methods of the so-called soft science of psychology are concerned with large and complex issues that require sophisticated but often less clear-cut approaches (Pigliucci, 2010). What we can readily observe, measure, and test has been considered to be science; thus, less understood phenomena of ambiguous psychological processes are considered soft. However, the brain does not distinguish the processes of scientific invention and the making of art, which are in fact found to be similar (Konopka, 2014, p. 73). This functional similarity helps to conceptualize the replacement of a dichotomized perception of hard and soft sciences, and of art-as and art psychotherapy, within one continuum of what we know we can explain on one end (the left) and what is more difficult to capture on the other (the right). Investigating this continuum does not require a microscope when naming the cytoarchitecture of its structure, but it does require imagination as we learn how to bridge these operations through the relationships of its components. To consider the intricacies that take place in the process of any therapeutic discipline through an objective lens is not only mainstream best practice but also an ethical and professional responsibility. Perhaps there is a sense that this type of inquiry reduces the magic from the many complexities involved in therapeutic practice and art-making in general. This is an unnecessary bias, in that the concept of magic encompasses unlimited definitions, all of which depend upon the way it is considered. For example, Anna Freud thought defense mechanisms relied on “magical operations” (Combs, 2013), resiliency can be considered a type of “ordinary magic” (Masten, 2001), and linguistic scholars have determined that

Introduction

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imagination evolves from the root word magic (Cheak, 2004). Since the beginning of time, human beings have sought to understand themselves and assign meaning to their lives that informs the capacity to be open minded, to live nondefensively with the question of how to live (Lear, 1998). I interpret Lear’s work in reference to a philosophical and psychological capacity that is ingrained in the training of the art therapist and that can be applied in a wide range of dimensions. Humans can be curious, flexible, and creative as we tolerate the ambiguity inherent in human relationships and the process of healing. To imply that science detracts from any type of relational experience is outdated and counterintuitive to our roots in art and medicine. As the prolific and everlasting neurologist Oliver Sacks (1973, 255) said: We rationalize, we dissimilate, we pretend: we pretend that modern science is a rational science, all facts, no nonsense, and just what it seems. But we have only to tap its glossy veneer for it to split wide open, and reveal to us its roots and foundations, its old dark heart of metaphysics, mysticism, magic and myth. Medicine is the oldest of the arts, and the oldest of the sciences: would we not expect it to spring from the deepest knowledge and feelings we have? Exploring the unconscious in the context of the therapeutic relationship allows access to this deepest knowledge and is bedrock of art therapist training. There is so much about humanity that is unknown, and much of the rhetoric is untrue. Applying a scientific understanding to processes less known creates more questions than answers and, like the medicines of art,” . . . are not confined within fixed borders” (McNiff, 2004, p. 5). The unconscious is where many of our capacities are born, and as Carl Jung (1957) said, “That’s the beauty of it!” The beauty is that we only have glimpses into this realm, and regardless of any theoretical orientation, it is well known that aspects of this great universe such as memories, perceptions, judgment, affect, and motivations are not always consciously accessible (Schedler, 2010). In his healing work as a neurologist and psychiatrist, Freud (1992) provided us with a “Royal Road” to explore dreams as the most direct representation of the unconscious. Medical training in the twenty-first century is highly specialized, and physicians are not taught to understand representative unconscious as it relates to physical symptoms. For example, when a patient consults a sleep specialist to resolve an issue of somnambulism, the neurologist is trained to treat the symptom at the cellular and molecular levels in determining the etiology of the interrupted sleep cycles. Many sleep specialists will report, however, that patients are often interested in sharing their dreams. Although the dreams might be interesting, the doctors have no idea what they could mean; therefore, the expression of the dream or the dream itself is not considered as a part of treatment. Psychiatry is the branch of medicine that would typically be more attuned to the unconscious of the patient, but is not clearly embedded in contemporary medical practice and is often far removed from issues like sleepwalking. This is a looming gap, where the patients desire to connect and explain aspects of their condition the best way they know how to a doctor

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who is not prepared to understand. A lack of interpersonal awareness affects the quality of healthcare and perpetuates a systematic disconnectedness in the delivery of service. I am not suggesting that sleep specialists become psychoanalysts, nor am I inferring that physicians do not care about the relationship that they have with their patients, but this is an opportunity for art therapists and neurologists to work together in the efforts to legitimize mechanisms of the unconscious. Doing so will support and enhance relationships between doctors, therapists, and patients across all medical and healthcare disciplines. Many aspects of human behavior are difficult to study, and art itself is a complicated topic that involves innumerable considerations that span the bridge of understanding. Different forms of expression are connected to brain processes that include the interconnections of neuroanatomy, neurophysiology, and the integrity of neurotransmitters, yet finding correspondence between certain neuronal organization and specific brain functions remains a problem in neuroscience (Amaducci, Grassi, & Boller, 2002). Defined as “the study of the neuronal processes that underlie aesthetic behavior” (Skov & Vartanian, 2009, p. 3), the growing field of neuroaesthetics investigates important connections between science and art. Pioneer Semir Zeki (1999) claims that art stems from physiology and focuses on the “biological basis of aesthetic experience” in his work, seeing that the function of art is an extension of the functions of the brain (p. 76). Art therapists have studied what is also being explained through neuroaesthetics in the development of theory. For example, the Expressive Therapies Continuum (ETC) (Kagin & Lusebrink, 1978; Lusebrink, 1990, 2004, 2010; Hinz, 2009) has long led art therapists in understanding the interface of the multileveled neurologic regions that are involved in creative expression. Neuroaesthetics supports this theory by reporting that creativity involves several interconnected systems in the brain, is the result of cognitive flexibility, and involves memory, sustained attention, and judgment (Dietrich, 2004). There have been several studies in the field of art therapy that have served to clarify the impact that art-making has on the brain through the use of neuroimaging technology (Belkofer & Konopka, 2008; Belkofer, Van Hecke, & Konopka, 2014; Kruk, Aravich, Deaver, & deBeus, 2014), all of which share a generalized conclusion that artistic production is not localized to certain neurological regions and leads us to see that art is, in fact, all over the brain (Belkofer, 2012). The exciting complexities that make it difficult to explain and correlate the creative process with neurological functions point us to the wild terra incognitae that is ready to be further explored. Neuroaesthetics does not focus on how the brain and art are applied in a therapeutic context, yet further investigation of how the physiological and psychological aspects of aesthetic experience relate to one another is an important goal that will expand in the future (Chatterjee, 2010). Here is an opportunity for art therapists to collaborate with neuroaesthetics researchers in developing a greater understanding of important psychic connections and learn how best to apply this information in treatment. Lusebrink and Hinz provide an example of how to do this in chapter 3 through the initial description of the two interacting neural streams responsible for visual information processing, one that

Introduction

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identifies what object we look at, and the other that tells us where the object is, which is also nicely described in the neuroaesthetics literature by Chatterjee (2014). However, Lusebrink and Hinz break new ground to consolidate this information and apply it to the treatment of trauma by establishing an emotional balance that is related to a sense of oneself in space. This supports the interface of scientists and artists, who Huang (2009) refers to as “coinvestigators of reality,” sharing the common goal of seeking knowledge (p. 24). Neuroaesthetics and art therapy help to explain that human behavior and cognition represent inherent fundamental collections of highest levels of cerebral function. With this we understand more clearly how the study of human behavior, addressed by the fields of psychology, psychotherapy, and art therapy, should be based in neuroscience (R. Pascuzzi, personal communication, June 16, 2015). When studying brain science it is easy to get lost in technical jargon, wandering about sulci and gyri in the efforts to navigate the matter. The many types of neuroscience can also become confusing as they branch out, like synapses, to form interdisciplinary fields of research and practice. Neuroscience is defined simply as the study of the nervous system. The main categories of neuroscience are named as these: developmental, how the brain grows and changes; cognitive, how language, thought, and memory are understood; molecular and cellular, which focuses on proteins, genes, and molecules; behavioral, which examines processes underlying animal and human behavior; and clinical, the study of disease and health (National Institutes of Health, 2015). These categories are not mutually exclusive. For example, to understand autism, developmental neuroscience intertwines with behavioral, also a form of cognitive, in the study of clinical goals, all of which have molecular and cellular roots! We are traveling at light speed as we learn about the brain in the context of the living, and although “we do not have an intellectually satisfactory biological understanding of any complex mental processes” (Kandel, 1999, p. 612), leaders in the field of neurobiology, psychiatry, and psychology have propelled a response to this, which has “helped to redefine our understanding of the neuroscience of psychotherapy and ushered in a revolution in mental health” (Belkofer & Nolan, ch. 7) The authors in this text build upon the foundation of psychobiology that binds neurology and psychotherapy (Cozolino, 2010) and make steps on the bridge that links the theory, practice, and research of art therapy to all categories of neuroscience in the collective effort of figuring out the “magic synthesis” (Arieti, 1976) of what these relationships are. For example, Klorer (ch. 6), Gantt and Tripp (ch. 4), and Lusebrink and Hinz (ch. 3) explain the repercussions of damaged attachment systems that are the result of early childhood and preverbal traumas and show how art therapy interventions provide potential to re-form these relational attachment patterns in a context based in clinical neuroscience. Noah Hass-Cohen (ch. 5) provides a detailed overview of the neurobiology of chronic traumatic symptoms, autobiographical memory, and creativity and resilience, and then synthesizes this to explain the working knowledge of the basics of trauma treatment, conditions of therapy, and development of interventions. This chapter links the molecular and cellular processes that create biological systems in the identification of how

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to understand the behavior of the people we work with and the best ways to provide care. A while back I was describing to a sage mentor a teaching strategy that I wanted to implement in the classroom, based on some things that I had read recently. After hearing my description, she suggested I try it and reflected that as I am a creative arts therapist, I “learn by doing.” The more I work with clients who have trauma and learned colleagues such as the authors in this book, and the more I read, write, and speak on the topic, I have come to understand my innate doing within the context of neurogenesis (the growing of new neurons) and neuroplasticity (the capacity for neurons to connect and form new pathways), the processes of which occur throughout the entire life span. The reality that a person can influence the brain to change its own structure is the most important shift in understanding the brain beyond what we once knew about its anatomy and basic component, the neuron (Doidge, 2007). The tenets of art therapy are underscored with neurobiological principles, and all of the intervention strategies included in this book are enhanced and further explained with knowledge of neuroplasticity. These primary tenets are that 1) the bilateral and multidirectional process of creativity is healing and life enhancing, 2) the materials and methods utilized effect self-expression, assist in self-regulation, and are applied in specialized ways, and 3) the art-making process and the artwork itself are integral components of treatment that help to understand and elicit verbal and nonverbal communication within an attuned therapeutic relationship. Explaining these tenets and their interventions in a neurobiological framework is especially relevant in the treatment of trauma, in that by definition trauma is a biological and “wordless event” (P. Isley, personal communication, July 30, 2015). The response that humans have to any traumatic experience disrupts physical and mental homeostasis. Changes in the sympathetic nervous system, endocrine system, and the structures of the brain cause responses in cardio, respiratory, and muscular systems (Solomon & Heide, 2005), and this dysregulation creates myriad physical and sensory integration problems that, although natural, make it difficult to identify, understand, and express one’s lived experience in a cohesive and subjective way. As many systems in the body become disrupted and fragmented, the capacity to verbally communicate is stifled, which is often seen in clinical practice as the inability to integrate memories of the traumatic experience(s) with the verbal processing of such events. I am paraplegic in my mind. (Veteran in art therapy treatment) I had the great fortune of working with OEF/OIF veterans of combat at the Roudebush VA in Indianapolis, where I joined forces with research psychologist Dr. Brandi Luedtke in the development and implementation of mindfulness-based art therapy groups (MBAT). Dr. Luedke brought the mindfulness and I the art therapy to the implementation of two successful pilot studies that provided services for veterans of combat, all of who were diagnosed with PTSD and in some cases

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traumatic brain injury (TBI). We conducted a research study that primarily sought to show how participants exhibited a decrease in self-reported and clinician reported PTSD symptoms and depression pre- and post-treatment and an increase in self-reported mindfulness skills and higher levels of compassion. The results revealed a statistically significant improvement in total self-compassion and self-judgment and a trend improvement in the symptom of isolation. There was also a statistically significant improvement shown through the self-reported PTSD scale (PCL) in the reexperiencing of symptoms and a trend improvement in avoidance. The feedback evaluation forms indicated that all 11 participants got something of positive and lasting value out of the treatment and on the average rated the importance of the program a 9.5 out of 10. Every participant expressed an interest in participating in future MBAT groups at the VA if they were available and shared many personal thoughts about the experience, including that the groups offered “a new and creative way to talk about feelings associated with trauma,” and that the program “helped to open new doors for me, identifying underlying issues that I need to address either individually or in other group sessions.” The statistical and qualitative data indicated that MBAT was successful in treating symptoms of PTSD and TBI with veterans, and further remarks from the group members led me to understand how the tenets of art therapy impact veterans who are coping with traumatic experiences. Participants stated: “Making art makes it easier to think . . . It gives us something to do while we’re trying to talk about things that are hard to talk about . . . ,” and There seems to be a language barrier we create when confronting issues of trauma. I think, through art, we basically are constructing a bridge to better understand our psychological wounds . . . I believe [art therapy] to be an excellent medium to reach intangible emotions. (Veteran in art therapy treatment) This is very important data that hopefully will provide evidence for continued MBAT programming at the VA, as art therapists face an ongoing challenge as we work through the politics of an overarching system that only defines reimbursable care with certain credentials. Amid the political battles that I fight in the advocacy for art therapy services, I always remember how the most enlightening experiences with these service members came by way of being present in their process while they created art and talked about it. Regardless of the task that was initially presented to the group, common themes of a changed identity would present as the members expressed narratives of combat and return from war. The veterans felt that they were different people than they once were and had difficulty piecing the shattered parts of their experiences together, which resulted in an overall sense of despair. The artwork created most often superseded these initial descriptions, as the images that emerged often included powerful themes of light and dark colors. In viewing the work, we were able to talk about the dichotomy of color and its placement on the page. This context sparked conversation of a different nature: another way to see one’s self as having components of light at the same time as dark.

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I often wondered to myself if the artwork was reflective of the brain, where the light represented the limbic system and the dark the frontal lobe as the people maneuvered their own unpredictable terrains together in the group. I would think about patterns in artwork and patterns of mind and consider how trauma impacts the ego ideal, and as it hurts us could it also help us? With this vision I encouraged the group members to talk to one another and talk about their artwork, to consider the metaphor that a wholeness may exist somewhere within. Among these recapitulative emotional experiences, initial hopeless discussions became those of possibility and potential. Working with the veterans helped me understand more about the experiences of people who have endured multiple traumas at war and has also given me a perspective for how to conceptualize possibility in a system that is fragmented and disconnected. When I presented on this topic to an audience of art therapists, I was surprised to get the feedback from a working professional that “We don’t deal with the ego ideal in art therapy with veterans. It is irrelevant.” I believe, after talking further with her, that she was trying to inform me of some successful approaches that she uses, and how they do not have such focus. However, it rests with me, years later, that the quickness with which a colleague would dismiss a philosophy that I, and my clients, find to be quite pertinent, is a call to action for art therapists to be flexible and open minded in their philosophies. To find ‘the best ways’ to help others is resultant of an integrative and team-oriented approach, entrained within our own and other professions. I urge us all to engage in conscientious and thoughtful debate, not one those of judgment and exclusion. It is in the clinical work of the psychotherapist to address the questions of meaning, and regardless of a diagnosis, the sources of ontological insecurity are universal and involve a concerted exploration for what it means to be alive. These themes are difficult to approach for any mind, and regardless of the theoretical orientation, it will always be important to consider the paradox of traumatic experiences, the impact they have on the psyche of the individual, and what the significance of this is in the larger questions of defining meaning and purpose in the world. It’s the relationship that heals, the relationship that heals, the relationship that heals—my professional rosary. (Irvin Yalom, psychiatrist and psychotherapist, cited in Feltham, 1999) Just as an artist needs to learn to paint a representation before communicating the abstract, a therapist needs to work with patients in order to understand the most powerful intervention of all: the relationship. All of the contributors to chapters in this textbook include the therapist-patient relationship as central to progress in their treatment with trauma survivors. Regardless of the discipline, it is the therapeutic relationship that provides the template for change, and empirical research in cognitive science has shown that the most effective therapists are those who recognize the importance of the relationship in healing (Schedler, 2010). This therapeutic tenet is understood at the intellectual level in

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the learning process, but it is only through concentrated work that a clinician experiences a holistic understanding of what this really means. Neuroscience has provided art therapy with a developed understanding of the importance of our work at a fundamental level, and we in turn offer the ability to embody these essential scientific principles as they are actualized in applied and thoughtful clinical care. Neuroscience is the clay, offering an inherent structured medium that art therapists can then sculpt and develop into form as we forage the liminal space on the way to imago of growth. And just as the complexities of artistic expression float throughout the whole brain and the “. . . mainstream of art’s medicine will always flow through the studio” (McNiff, 2004, p. 27), it is through the relationship that we all become whole.

References Amaducci, L., Grassi, E., & Boller, F. (2002). Maurice Ravel and right-hemisphere musical creativity: Influence of disease on his last musical works? European Journal of Neurology, 9(1), 75–82. Arieti, S. (1976). Creativity: The magic synthesis. New York: Basic Books. Belkofer, C. M. (2012). The impact of visual art-making on the brain. Unpublished doctoral dissertation. Lesley University. Cambridge, MA. Belkofer, C. M., & Konopka, L. M. (2008). Conducting art therapy research using qualitative EEG measures. Art Therapy: Journal of the American Art Therapy Association, 25(2), 56–63. doi: 10.1080/07421656.2008.10129412 Belkofer, C. M., Van Hecke, A. V., & Konopka, L. M. (2014). Effects of drawing on alpha activity: A quantitative EEG study with implications for art therapy. Art Therapy: Journal of the American Art Therapy Association, 31(2), 61–68. Chatterjee, A. (2010). Neuroaesthetics: A coming of age story. Journal of Cognitive Neuroscience, 32(1), 53–62. Chatterjee, A. (2014). Neuroaesthetics. Scientist, 28(5), 32–38. Retrieved from: www.thescientist.com/?articles.view/articleNo/39802/title/Neuroaesthetics/) Cheak, A. (2004). Magic through the linguistic lenses of Greek mágos, Indo-European *mag(h)-, Sanskrit mâyâ and Pharaonic Egyptian heka. Journal for the Academic Study of Magic, 2, 260–286. Combs, A. (2013). Transcend and include: Ken Wilber’s contribution to transpersonal Psychology. In H. Friedman and G. Hartelius (Eds.), The Wiley-Blackwell handbook of transpersonal psychology (pp. 166–186). Malden, MA: John Wiley. Cozolino, L. (2002). The neuroscience of psychotherapy: Healing the social brain. (2nd ed.). New York: W.W. Norton. Dietrich, A. (2004). The cognitive neuroscience of creativity. Psychonomic Bulletin & Review, 11(6), 1011–1026. Doidge, N. (2007). The brain that changes itself: Stories of personal triumph from the frontiers of brain science. New York: Penguin. Feltham C. (ed.), (1999). Understanding the counselling relationship (p. 14). London, England: Sage. Freud, S. (1992). Interpretation of Dreams (Rev. ed.). New York: Penguin. Hinz, L. (2009). Expressive therapies continuum: A framework for using art in therapy. New York: Routledge. Huang, M. (2009). The neuroscience of art. Stanford Journal of Neuroscience, 2(1), 24–26.

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Hugo, Victor. (n.d.). Quotation. Retrived from: www.goodreads.com/quotes/333543there-is-one-thing-stronger-than-all-the-armies-in Jung, C. G. (1957, August 5–August 8). Interview by R. Evans Jung on Film. Zurich, Switzerland. (Available from Segallar Films, Dept. of Psychology University of Houston). Junge, M. B. (2014). Identity and art therapy: Personal and professional perspectives. Springfield, IL: Charles C Thomas. Kagin, S. L., & Lusebrink, V. B. (1978). The expressive therapies continuum. Art Psychotherapy, 5(4), 171–180. Kandel, E. (1999). Biology and the future of psychoanalysis: A new intellectual framework for psychiatry revisited. Psychoanalytic Review, 99(4), 607–644. Konopka, L. (2014). Where art meets neuroscience: A new horizon of art therapy. Croatia Medical Journal, 55, 73–4. doi:10.3325/cmj.2014.55.73 Kruk, K. A., Aravich, P. F., Deaver, S. P., & deBeus, R. (2014). Comparison of brain activity during drawing and clay sculpting: A preliminary qEEG study. Art Therapy: Journal of the American Art Therapy Association, 31(2), 52–60. doi:10.1080/07421656.2014. 903826 Lear, J. (1998). Open minded, working out the logic of the soul. Cambridge, MA: Harvard University Press. Lusebrink, V. B. (1990). Imagery and visual expression in therapy. Emotions, personality, and psychotherapy. New York: Plenum Press. Lusebrink, V. B. (2004). Art therapy and the brain: An attempt to understand the underlying processes of art expression in therapy. Art Therapy: Journal of the American Art Therapy Association, 21(3), 125–135. Lusebrink, V. B. (2010). Assessment and therapeutic application of the expressive therapies continuum: Implications for brain structures and functions. Art Therapy: Journal of the American Art Therapy Association, 27(4), 168–177. Masten, A. S. (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56(3), 227–238. doi:10.1037/0003-066X.56.3.227 National Institutes of Health. (2015). What are the different areas of neuroscience?. Retrieved 16 October 2015, from www.nichd.nih.gov/health/topics/neuro/condition info/Pages/areas.aspx McNiff, S. (2004). Art heals: How creativity cures the soul. Boston, MA: Shambala Publications. Pigliucci, M. (2010). Nonsense on stilts: How to tell science from bunk. Chicago, IL: University of Chicago Press. Sacks, O. (1973). Awakenings. In E. Huth and T. J. Murray (Eds.). (2006). Medicine in quotations: Views of health and disease through the ages (2nd ed.). (p. 255). Philadelphia, PA: American College of Physicians. Schedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109. American Psychological Association. doi: 10.1037/a0018378 Skov, M. & Vartanian, O. (2009). Introduction: What is neuroaesthetics? In M. Skov & O. Vartanian (Eds.), Neuroaesthetics (pp. 1–7). Amityville, NY: Baywood. Solomon, E. P., & Heide, K. M. (2005). The biology of trauma: Implications for treatment. Journal of Interpersonal Violence, 20(1), 51–60. doi:10.1177/0886260504268119 Ulman, E. (2001). Art therapy: Problems of definition. American Journal of Art Therapy, 40(1), 16–26. Wadeson, H. (2010). Art psychotherapy. Hoboken, NJ: John Wiley. Wiles, Andrew. (n.d.). Quotation. Retrieved from: http://izquotes.com/quote/278342 Zeki, S. (1999). Art and the brain. Journal of Consciousness Studies, 6(6–7), 76–96.

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Neuroscience Concepts in Clinical Practice Lukasz M. Konopka

Introduction This chapter proposes a functional anatomical and neurophysiological schema for enhancing the way clinicians think about their patients’ lifelong neural plasticity. To that end, the chapter presents recent neuroscientific data on behavior, assessment, genetics, and structural and functional neuroimaging as a conceptual template to help clinicians select tools for constructing unique logical data-driven diagnoses and optimal therapies that include standard interventions as well as art therapy. To exemplify this multimodal neuroscientific approach, the chapter will include clinical cases that illustrate how logical defendable scientific research, diagnosis, and treatment can encourage a common clinical language accessible across diagnostic and therapeutic silos. Hopefully, as communication and collaboration between art therapy and related fields improves, art therapy will become accepted and appreciated as a valuable, substantiated therapy within the standard armamentarium.

Brain Cellular Processes: Overview Structure A hundred billion neurons compose the human brain, an organ devoted to organizing functional neuronal units and electrophysiological networks that integrate many divergent sensory systems. These electrophysiological networks become neuronal units and patterns that are coded by action potentials. Eventually, various neuronal morphologies emerge throughout the brain. These structures include the outer layer or the cortex, also known as gray matter, and subcortical regions that are comprised of combinations of gray and white matter such as the thalamus and the basal ganglia. Within these structures, individual morphologies range from simple bipolar neurons to the extensive and complex neurons of the cerebellar cortex. All neurons, including neocortical neurons, receive input from their dendrites. The dendrites are a specialized sensory part of the neuron that responds to chemical signals called neurotransmitters. Each neuron’s elaborate dendritic projections receive various neurotransmitters that may stimulate numerous specialized receptors. Dendritic structures look similar

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to trees with branching referred to as dendritic arbors that can integrate 10,000 to 100,000 functional informational inputs. As such, all dendritic interactions are complex processes of integration, generation, and propagation that end in sending an action potential down the axon, the output portion of the cell. Cellular Function An action potential is an all or none event caused by electrical signals that shift across a cell membrane. Eventually the signals reach a threshold, which depolarizes the membrane, opens voltage-gated channels, and generates an action potential. Nevertheless, most dendrites do not generate action potentials. For an action potential, the cell must compute the numerous depolarizing (excitatory) and hyperpolarizing (inhibitory) membrane potentials that influence the final integrated membrane potential in the cell body, the soma. An action potential begins only with sufficient depolarization, and the input closest to the soma has the strongest influence on the synaptic signals, i.e., the closer the input, the greater the impact on excitation or inhibition of the neuron. Unlike action potentials that regenerate as they travel down the axon, synaptic potentials lose amplitude as they travel toward the soma. As the distance from the soma increases, the synaptic electrical signal amplitude decreases. Therefore, the most effective excitatory membrane potential (EPSP) synapses or inhibitory membrane potential (IPSP) synapses are located closest to the cell body, and the more the soma receives common inputs with common timing, the greater the probability of action potential generation. Action potential generation is uncertain without input synchrony, because synchrony provides greater probability for reaching the critical threshold. For example, if a single input stimulates a cell, the cell requires greater EPSP amplitude to fire an action potential than when two or three smaller independent inputs, EPSPs, converge on the same soma. This principle, spatial summation, has been substantiated at the cellular level (Dan & Poo, 2004). Learning at the cellular level Spatial summation indicates that cellular learning occurs most efficiently with converging multisensory input, which, from the standpoint of human behavior, can be used to understand memory establishment. For instance, when we learn using only one sensory modality, such as vision, it takes more time and effort to master the task and form a memory; however, if we have learned using two modalities, such as vision and audition, the converging sensory information will expedite our learning. Initially, the brain requires significant resources to make unfamiliar behaviors routine, but, as the brain adapts, efficient networks develop that require less effort for learning (Grabner, Neubauer, & Stern, 2006). When individuals find learning difficult, they become frustrated and often abandon their efforts, but just as new exercise produces sore muscles and few rewards, repeated training increases muscle strength and requires less effort. Similarly,

Neuroscience Concepts 13 the brain initially requires multiple networks when leaning novel cognitive tasks, but eventually it trims superfluous networks, focusing its activity and optimizing its performance. One of the best examples is learning to ride a bicycle, a task that initially requires significant brain effort, but over time becomes simple and natural. Although most of us have learned to ride a bike, we would find it nearly impossible to describe the individual steps that led to our success because our learning resulted from numerous unconscious structural and biochemical changes, i.e., neuroplasticity.

Neuroplasticity Neuroplasticity reflects the dynamic neuronal response to environmental and intrinsic stimuli that gradually alter cellular structure and function. Precisely controlled tissue-culture experiments routinely demonstrate structural and functional synaptic alterations, long-term potentiation or long-term depression, and improved synaptic efficiency all of which evolve from repeated stimulation of a particular neural pathway (Thomas, Laroche, Errington, Bliss, & Hunt, 1994). Repetition causes neural evolution throughout the brain. For example, we can measure how exercise yields remarkable quantifiable structural brain changes that positively affect our equilibrium and confirm our brain’s neuroplasticity (Lewis, Baldassarre, Committeri, Romani, & Corbetta, 2009). At the cellular level, synaptic plasticity is seen when receptors adjust their responses to specific stimulating molecules known as neurotransmitters. The synapse may contain two types of receptors: relatively simple, fast, ionotropic receptors that combine with receptor ion channel structures and more complex metabotropic receptors that use serial biochemical reactions to alter neuronal function and protein synthesis to alter structure. Since experience constantly adjusts and remodels our brains, it is not surprising that most central nervous system receptors belong to the metabotropic receptor family. Besides neurotransmitters, other molecules influence synaptic efficiency and modify neuronal networks by enhancing or pruning synaptic contacts, another aspect of neuronal plasticity. One of these molecules, brain derived growth factor (BDNF), comes from a family of small proteins that impact neuronal growth, maintenance, and survival. How well a brain regulates BDNF seems to affect various brain-related disorders such as schizophrenia, bipolar illness, and autism-spectrum disorders (Holtzman & Mobley, 1994; Martinowich, Manji, & Lu, 2007). Generally, these factors are decreased during acute stages of illness.

Cellular Communication and Networks Depending upon the behavioral state, our brains engage different networks for our emotions and cognition (Bullmore & Sporns, 2009; Power et al., 2011). A simple way to understand cognition is to conceptualize how the brain makes decisions. First, transduction takes discernible sensory inputs such as vision, audition, sensation, or olfaction and changes them into electrical signals. Then,

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specified sensory pathways acknowledge these signals and, eventually, integrate them into specified neuronal signals. The sensory pathways find their way to the brain’s parietal lobes, located posterior to the central sulcus and dedicated to integrating multisensory input. As the parietal lobes integrate sensory input, they communicate with another large brain region, the motor brain or the frontal lobes, an area that controls behavioral choices, generates actions or inhibitions, and continually manages how we relate to the environment. Neural complexities, numerous neuronal entities, individual connections, and distinct long and short myelinated and unmyelinated tracts force us to ask many questions about the brain’s organization. Let us begin with the idea of networks, a conceptual framework for the brain’s anatomical and functional connections. Our brain has many interactive networks. If we understand their normal connectivity and functions, this will also help us understand individuals with behavioral pathologies. Normal networks 1) integrate communication between brain regions and their functions, 2) monitor alterations and aberrant behaviors, 3) interpret internal and external data, and 4) are impacted by age, gender, and environment. Fortunately, we have benign techniques that allow investigation of the brain’s networks. For example, an electroencephalogram (EEG) records electrophysiological signals from the scalp via electrodes and identifies interregional neuronal firing frequencies that vary in function and connectivity. Synchronized slow frequencies, such as delta, theta, and alpha-1, mostly support distant communication. Short distance communications are primarily dependent on higher beta and gamma frequencies (Von Stein, Chiang, & König, Konig, 2000). Brain regions communicate through synchronized activity, and synchronized activity reflects functional connectivity. Synchronization is a dynamic process for rapidly gathering and sharing information. For instance, depending on a patient’s age, electrophysiological patterns show distinct transitions from wakefulness to sleep (Carrier, Land, Buysse, Kupfer, & Monk, 2001), and theta and alpha change during working memory processes (Klimesch, 1999). Moreover, gamma frequencies synchronize in consciousness and during attention (Lutz, Lachaux, Martinerie, & Varela, 2002; Vidal, Chaumon, O’Regan, & TallonBaudry, 2006). Human network assessments evaluate the brain’s hierarchical organization of structure and function. First, clustered, closely interrelated neurons form local networks, and then, networks combine to create modules with smaller modules acting within the larger modules. Lastly, the brain’s five to six modules seem to arrange into functional subsystems (He & Evans, 2010). Overlying this dynamic structure, the brain oscillates between enhanced and decreased connectivity determined by a particular engagement and may express an observable behavior. Both excessive connection and disconnection lead to significant consequences, as we see in children who have disconnected hemispheres due to agenesis of the corpus callosum. These children have no interhemispheric communication, clearly demonstrated by the lack of electroencephalographic (EEG) coherence (Koeda et al., 1995), and significant behavioral deficits. Clinicians often observe coherence abnormalities in individuals with brain injuries, such as mild TBI,

Neuroscience Concepts 15 who do not have clearly identifiable abnormal structural imaging studies. Conversely, epilepsy exemplifies acute extreme connectivity and interregional communication (Lehnertz et al., 2009; Lieb, Hoque, Skomer, & Song, 1987), resulting in ongoing behavioral aberrations. Chronic hyper-synchronization also occurs in degenerative disease. For instance, in early Parkinsonism, only 8–12 Hz alpha synchrony is increased (Stoffers et al., 2008), but later, additional reduction occurs at 8–35 Hz (Kuhn, Kupsch, Schneider, & Brown, 2006).

Brain Development Childhood brain development is critical for determining how well future adult brain networks will interact and process data, i.e., think. During brain development, very complex precisely organized processes cause neurons to migrate into cortical and subcortical layers and form appropriate connections between brain regions (Hatten, 1990; Sidman & Rakic, 1973). Although we have an incomplete understanding of these developmental mechanisms, we know that, in addition to their physical location, young neurons are very sensitive to the environmental input of biochemical factors. At first, non-neuronal cells known as glial cells guide the migration of individual neurons. As the brain’s gray matter develops, cells migrate outward from a region next to the ventricles. As emerging cells travel to their final destination, new neurons must travel past established cellular layers, eventually differentiating the neocortex into six distinct strata with welldefined connections and functional tasks. Once the cells reach their terminus, they develop complex dendritic connections with incoming axon projections and define their role within the complex communication networks. As the cell’s axons grow, trajectories and connections are guided and defined by the attraction or repulsion of the environment and biochemical signals (Heffner, Lumsden, & O’Leary, 1990). In addition to environmental and biochemical signals, the axon secretes its own chemical molecules that may provide chemo-attraction or chemo-repulsion to a given target. Therefore, before a synapse forms, both physical and biochemical signals must direct an axon toward its eventual target (Tessier-Lavigne & Goodman, 1996). Minutes after the axon matches with a target, the axon initiates communication with its target and releases neurotransmitters that interact with the target’s receptors. Then within days, the axon develops a fully functional synapse (Toni, Buchs, Nikonenko, Bron, & Muller, 1999; Vicario-Abejan, Collin, McKay, & Segal, 1998) and increases the receptor density within the synaptic region. Initially, many brain regions have excess neurons and neuronal contacts, but not all neurons will survive. So for its survival, the neuron must participate in synaptic activity and avail itself of trophic factors, i.e., neurons compete for their place in the final network. As such, the network’s efficiency determines the ideal neuronal numbers; excess cells will experience natural cell death or apoptosis (Paolicelli et al., 2011). In addition to their initial target connections, synapses are often refined during well-defined windows of organ maturation. On many levels, the refinement process is very similar to memory formation, which calls

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for an optimization of resources. These critical developmental windows have been well studied in electrophysiological studies of vision, audition, and sensation (Gogtay et al., 2004). Neuronal electrical activity is directly related to the release or inhibition of neurotransmitters. Thus, neurotransmitters exert significant impact on neuronal development, shaping the connections between specific neurons. For example, although excitatory neurotransmitters such as glutamate increase intracellular calcium and, subsequently, the connections between neuronal targets, inhibitory neurotransmitters such as GABA may decrease synaptic formation (Ge et al., 2006; Yuste & Katz, 1991). To address structural human brain development, we must use a brain-tobehavior approach and quantify the neuronal changes in brain structure that are reflected in behavior. Although historically, science has used observational data to infer developmental brain changes, today’s advanced imaging technologies allow us to ask how behavior changes the developing brain’s neurobiological structure and function. For example, magnetic resonance imaging (MRI) has uncovered key anatomical brain changes in children and adolescents such as progressively increased white matter volume with parallel changes in gray matter that reflect an inverted U function (Lenroot & Giedd, 2006). Generally, increases in white matter volume are associated with decreases in gray matter volume. Moreover, gender differences affect total brain volume and show that male brains are significantly larger than female brains (Lenroot & Giedd, 2010). In addition to volumetric differences, the male brain has larger lateral ventricles and more gray matter than the female brain. These structural variations do not suggest a functional relationship to cognitive performance, but brain structure is always highly responsive and readily modified by various environmental forces and genetic vulnerabilities. Significant stress can be such a factor, and each developing organism is variably vulnerable to stress. Significant stress may cause the brain to compensate by restructuring its anatomy and function, i.e., the brain adapts to its environment. For example, studies have shown that patients with PTSD have decreased hippocampal volumes as well as decreased function (Bremner et al., 2003; Douglas, 1995). Other studies that compared London taxi drivers to normal controls identified significantly greater hippocampal volume in taxi drivers, suggesting that the taxi drivers’ brains adapted to navigating the complex city of London (Maguire et al., 2000; Woollett & Maguire, 2011). In summary, based on structural neuroimaging evaluations, the brain’s developmental trajectories apparently vary widely among individuals and genders and are influenced by numerous biological and environmental factors.

Imaging Methods Besides the scientific and clinical importance, there is tremendous privilege and excitement connected to the exploration of the live human brain. The excitement has waxed and waned, particularly the excitement that has surrounded brain

Neuroscience Concepts 17 imaging. Nevertheless, a positive trajectory began for brain imaging after Dr. Hans Berger, the father of clinical electroencephalography, successfully used EEG to record physiologically meaningful electrical signals from the human scalp and attempted to understand its various electrophysiological signals (Gloor, 1994). With consistent repeatable studies, he correlated observable clinical findings to the brain’s potential functional mechanisms, and, despite postulating brain pathology through clinical observations, postmortem analyses verified his conclusions. Early attempts to look into the living human brain and correlate function with structure were driven by emerging x-ray techniques. However, with the exception of the skull and cerebrospinal fluid, x-rays saw brain tissue as homogeneous matter. So, when clinicians wondered whether a case required surgical intervention, they were forced to use pneumoencephalography, a risky visualization technique that injected an air bolus into the cerebrospinal space (Di Chiro, 1964) to catch a potential glimpse of pathology. Later, thanks to advanced computer technology, post-acquisition x-ray processing yielded clearer brain images of structural integrity (Gawler, Du Boulay, Bull, & Marshall, 1976). Today, computed tomography or CT is a popular x-ray technique that uses multiple brain images enhanced by mathematical computer programs. For some time, clinicians have used CT as the first step for evaluating brain injury, particularly when they suspect vascular involvement or injury to the bone, but the limited image quality and radiation exposure of CT prevent its use in routine cases. Now, some researchers are asking whether chronic abnormal behavior could be correlated with and explained by substantial variations in brain structure and, therefore, justify newer technologies for evaluating severe psychiatric disorders (Mulert & Shenton, 2014; Wahlund, Agartz, Saaf, Wetterberg, & Marions, 1992). Recently, newer MRI principles have spawned more benign imaging techniques (Semelka, Armao, Elias, & Huda, 2007). Magnetic resonance relies solely on soft tissue properties and eliminates the patient’s exposure to radiation. The brain’s gray matter, white matter, and cerebrospinal fluid contain clearly defined soft tissue densities that allow MRI’s magnetic field to identify and distinguish structures based on their unique molecular behaviors. Therefore, clinicians can easily recognize the brain’s differing structural components and, consequently, measure the brain’s total volume relative to individual structures. From volumetric studies, it is increasingly clear that normal brains contain consistent structural integrity and appropriate volume for age and gender. With such data, one can objectively identify the structural differences that may lead to cognitive and/or emotional difficulty. These data may provide clinical understanding for targeted interventions. In addition, volumetric brain imaging can aid in evaluating therapies that impact particular brain regions by showing tissue volume recovery as a consequence of those interventions (De Lange et al., 2008). Numerous discoveries have refined our understanding of behavior by identifying the biological underpinnings for some behavioral disorders. Psychiatry has published such data on patients with PTSD (Vermetten, Vythilingam, Southwick,

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Charney, & Bremner, 2003) and bipolar illness (Yucel et al., 2008). Naturally, these findings have received significant publicity and brought psychiatry to the forefront of medicine. Yet despite these findings, psychiatric and psychological training still neglects educating future clinicians about the importance of routine imaging. Some member of the mental health fields remain reticent to use imaging because they have not learned how to generalize research imaging data that averages many subjects in a given diagnostic category to individual patients. For example, although patients may have clearly defined clinical depression, the imaging may show various disquieting unexpected results. Therefore, there appears to be low sensitivity and specificity of these tools. As such, clinicians consider the data as clinically irrelevant if they do not fit a set of research findings, i.e., clinical diagnoses often have highly diverse biological mechanisms and imaging results. In addition to structural brain imaging, there are various functional imaging techniques that are less practical and less available because they generally rely on non-standardized activation protocols. One such technique, BOLD-MRI, correlates brain blood flow to increases in regional neuronal activity using magnetic resonance to find changes in blood oxygenation. This noninvasive method provides excellent three-dimensional resolution of the brain’s perfusion changes. For example, BOLD-MRI allows one to compare the brain’s resting activity to the brain’s activity during visualization and interpretation of facial expressions (Kesler et al., 2001) for normal controls and patients who struggle with facial interpretation (Ogai et al., 2003). These studies have begun to identify specific interpretive brain regions and advance our understanding of the deficits related to symptoms. Despite its strengths, BOLD-MRI wrestles with data acquisition because a patient must engage in a mental task while restricted and lying motionless within the MRI camera. This limits using BOLD-MRI with compliant patients who are not suffering from overwhelming deregulation. This technique is also disadvantaged by its neurobiological underpinnings: this method measures the blood-flow changes that occur as the result of neuronal electrical activity, and neuronal electrical activity is generally measured in milliseconds, but blood perfusion changes are 1000 times slower. Therefore, BOLD is an indirect measure of neuronal activity (Schridde et al., 2008). Magnetic resonance can also detect the brain’s biochemical makeup (Kato, Shioiri, Takahashi, & Inubushi, 1991) with a technique called MRI spectroscopy (MRS) that uses magnetic fields to identify the unique characteristics of specific molecules. Since molecules have unique profiles, this method can image a specific regional focus, evaluate its biochemical makeup, clarify the integrity or pathology of a given brain area, and track its neuroplasticity. For instance, after patients received surgery for a seizure disorder, the MRS showed recovery of the contralateral hippocampal tissue (Vermathen et al., 2002). MRS can also elucidate existing abnormalities and effectively track specific biochemical changes that occur as a consequence of therapy and, depending on the medication, image how medications distribute to the various brain regions, providing evidence of therapeutic efficacy (Renshaw et al., 1992). Nevertheless, because

Neuroscience Concepts 19 the current MRS methods lack standardization and the processing and interpretation are significantly complex, spectroscopy has limited clinical use. Another magnetic resonance technique, diffusion tensor imaging (DTI), identifies the integrity of primary myelinated axonal brain pathways that connect brain regions. This technique evaluates the water molecules within axons (Assaf & Pasternak, 2008). Two other functional imaging methods, single photon computed tomography (SPECT) and positron emission tomography (PET), use specialized gamma cameras to view specific radioactive tracer molecules called ligands. First, the ligand is injected into a patient’s vein. Then it is tracked while it circulates through all the organs of the body. After the ligand permeates the tissues, the imaging process begins. The timing of this process depends on the type of ligand. Ligands have a limited half-life—the time it takes for a 50 percent reduction in radioactivity. Some ligands have a half-life of hours and others just minutes. As such, the study and the ligand’s administration must be very precisely planned. Sometimes the radioactive ligands arrive at the imaging center after being synthesized in distant laboratories. Specific ligands are chosen depending on whether they are being used to evaluate the brain’s glucose metabolism, oxygen utilization, or blood flow. One can achieve more specific imaging with molecules that bind to targeted brain receptors and show the presence or absence of specific cellular receptor-types related to the patient’s symptoms and vulnerabilities. For example, patients who have substance addictions may have more deregulated dopamine receptors than controls (Volkow et al., 1993). Also, competitive binding studies can unveil the available receptors in a specified brain region to help evaluate the effects of medication (Farde et al., 1995). Nevertheless, nuclear medicine studies are complicated because they require specialized personnel and equipment and small doses of radiation. In addition, nuclear medicine studies are particularly complex because the ligand’s molecular half-life dictates the study design and determines the time of administration and scanning. Although radiation exposure is ethically debatable for scientific inquiry, these techniques are clearly appropriate diagnostic tools that help select the best therapeutic methods for many medical conditions. Therefore, functional MRI and nuclear medicine techniques help us define functional brain networks and locate their receptors. So, use of these existing electrical, volumetric and biochemical, and connectivity tools would give us significant diagnostic power for assessing the integrity of the brain. Besides MRI and nuclear medicine techniques, quantitative EEG is now considered part of the neuroimaging repertoire because statistical analysis and data manipulation have significantly transformed and improved electroencephalography (EEG). Moreover, today’s digitally acquired EEG data lends itself to post-acquisition processing, and EEG data recorded with the standard 10:20 scalp electrode application allows clinicians to compare an individual’s cortical EEG patterns to those of age-matched controls in a normative database (Prichep, 2005). First, EEG records real-time neuronal activity. Then, the data is extracted from the time-domain and mathematically transformed into specific frequencies. After comparing the data to commercial scientifically validated

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databases, other measures can be computed such as absolute and relative power measures, symmetry, coherence, phase, and combined measures such as frequency ratios (Thatcher, Walker, Biver, North, & Curtin, 2003). This method correlates the patient’s brain activity to behavior and other imaging modalities. EEG is a simple and flexible technique, but EEG requires significant training to optimize its use. The encephalographer must evaluate the analog signal’s validity by changing electrode recording patterns (montages) to identify specific focally abnormal EEG patterns such as sharp waves, spike and wave, or slow waves. To interpret the statistical data, the encephalographer must identify these events and understand their significance before making any suggestion for treatment or additional assessment. For example, in numerous recent studies, sharp waves are emerging as very clinically significant. Quantitative EEG (qEEG) uses statistical and mathematical computations to interpret electrical activity patterns. Quantitative EEG is inexpensive, readily available, noninvasive, reproducible, simple, and stable. qEEG can be done almost anywhere with true resolution that allows real-time recording and evaluation of brain activity. Although these qualities make it superior to functional MRI, qEEG data are very sensitive to artifacts that can be easily misinterpreted by individuals who are not well versed in this technology. (See above.) It is crucial that the interpreter understand the difference between the expected EEG patterns of various brain states and artifacts generated by sources other than neuronal activity. Some common artifacts are eye movement, eye blink, sweating, tongue movement, swallowing, yawning, teeth clenching, tense facial and temporal muscles, and generalized muscle tension around the face and neck. In some individuals, electrocardiogram artifact can be clearly seen in the EEG signal and may be misinterpreted as a brain event. In addition, before the data are interpreted and submitted for statistical analysis, the technologist should note the patient’s medications and state of consciousness. We can analyze digitized EEG data in many ways; one method, electrical source localization, relies on low-resolution brain electromagnetic tomography (LORETA) (Konopka & Poprawski, 2008). With LORETA, we identify the anatomical source of electrical activity, extract statistically significant abnormal EEG activity, and map the activity on a standardized MRI atlas (Pascual-Marqui, 1994). qEEG is also used to develop discriminant functions that characterize the electrical patterns found within specific patient populations. The mild traumatic brain index (mTBI) is a qEEG method using commercially available discriminant functions to statistically analyze EEG variables within a data set for predicting the likelihood of membership in a particular patient population. Robert Thatcher developed a mild TBI discriminant function (mTBI) that compares a patient’s brain patterns to those of patients who have had verified head injuries (Thatcher, Walker, Gerson, & Geisler, 1989). The mTBI discriminant function indicates the likelihood that an individual suffered TBI and the severity of such an injury. qEEG’s discriminant analysis is useful because imaging methods such as CT and MRI (Andreasen, 1989; Hollister & Boutros, 1991) often miss deficits that are primarily functional. In part, Robert Thatcher’s method relies on MRI voxel

Neuroscience Concepts 21 assessments of the white and gray matter interface at the cell axon junction to identify cellular injury from acceleration and deceleration. Clinically, discriminant function mTBI analysis in parallel with other clinical and neurobehavioral data can support or call into question the possibility of malingering (Thatcher, Biver, McAlaster, Salazar, 1998). mTBI gives clinicians an objective evaluation of patients who complain of cognitive deficits, mood deregulation, and loss of function and who, according to standardized structural imaging, lack clear evidence of injury. In some cases, patients show no mTBI findings despite a clear, verifiable history of mild TBI or positive findings without a clearly defined event. In addition, variables such as medications or illicit drugs may produce false negative or positive results; thus, when interpreting functional imaging data, we must consider the patient’s medication status (Konopka & Zimmerman, 2013). In summary, when compared to normal controls and a well-defined patient population, qEEG can inform us about abnormal brain activity. With this in mind, it remains absolutely critical that EEG, qEEG research, and clinical activities must utilize highly trained, skilled professionals with a thorough understanding of clinical neurophysiology. Another technique, electrical activity mapping or Evoked Potentials, is often recorded in conjunction with EEG while the patient performs a specified task. During the EEG recording, the task’s components are precisely marked for analysis, which deploys time-domain averaging to uncover a robust signal from events hidden in the background EEG signal. Averaging numerous responses within the same category differentiates random brain activity from the signal generated from purposeful tasks. Evoked potentials record the sensory activities of audition, vision, touch, olfaction, and emotion related to facial expression or auditory content and cognition. Cognitive evoked potentials may be visual or auditory and are often called the P-300 (positivity at 300 ms). The P300 reflects how well the patient sustains attention during a task specifically oriented to an infrequent stimulus (Polich & Kok, 1995), and a significant body of literature supports the use of these tools for evaluating cognition (Polich & Corey-Bloom, 2005). Clinical evoked potentials enhance our understanding of a patient’s clinical presentation, especially when we correlate them with other tests that engage similar networks. For example, an individual who prefers auditory rather than visual stimulation may learn more easily through auditory input. Consequently, we can teach the patient to adopt learning strategies that enhance his or her learning (Duffy, 2005). A more uncommon method that records magnetic fields from the brain’s surface is called magnetoencephalography (MEG). Although MEG exploits the neuronal electrical properties that generate magnetic fields undistorted by biological tissues such as bone, this technique requires expensive instrumentation and a specialized electrically insulated environment. Also, as with MRI, the patient must remain very still during the recording. Although much of the current MEG data show that MEG results are very similar to EEG (Cohen & Cuffin, 1983) and that the two techniques often complement each other, the cost of equipment and maintenance and the restrictive recording positions for

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patients make MEG practical only in research settings (Henson, Mouchlianitis, & Friston, 2009). In summary, one can easily see which neuroimaging methods are most appropriate for evaluating patients, designing interventions, and studying their effects. In addition, as there is no perfect technique, one needs to understand the limitations of imaging before initiating therapies. Each method has challenges and potentially confounding variables to data interpretation. Clearly, one selects a technique based on specific questions. For instance, quantitative EEG would be chosen to determine a therapy’s influence on brain function when a measurement of potential structural change is not needed. On the other hand, to examine how a therapy enhances visual, auditory, or motor activity, one could combine EEG with specific evoked potentials.

Lateralization Advanced neuroimaging has helped us evaluate the brain’s structure and function, but it has simultaneously heightened our need to understand brain asymmetries, something neuroscientists have attempted for over a hundred years. Because of the inherent plasticity of the brain and its adaptation to the environment including pathology, the concept of pure hemispheric specialization is modified as the new data emerge, however, in general, neuroscientists have discovered that the left hemisphere plays a special role in language comprehension and controls movement on the right side. Conversely, the right hemisphere specializes in perception and the synthesis of nonverbal information including music, facial expression, and movement on the left side of the body. Initial studies on cerebral asymmetries were published by Geschwind and Levitsky, who demonstrated significant differences between the posterior primary auditory cortex’s planum temporale of the left and right hemispheres (Geschwind & Levitsky, 1968). More recent studies support these data and show a wide variation between the left and right hemispheres (Shapleske, Rossell, Woodruff, & David, 1999). The right hemisphere appears larger and heavier than the left hemisphere with a lower ratio of white matter to gray matter. Functionally, the left hemisphere seems to specialize in language and the right hemisphere in music (Peretz & Zatorre, 2005). Since cortical activity is closely related to subcortical structures such as the thalamus, one would expect thalamic specialization, and it does appear that the left thalamus participates in language (Hebb & Ojemann, 2013). Another significant language area is called the frontal operculum, which is organized very differently in the left hemisphere than the right. In the left hemisphere, the frontal operculum, known as Broca’s area, participates in motor activity related to speech. Broca’s specialization was demonstrated at the cellular level where there was significantly greater branching of pyramidal neuronal dendrites in the left hemisphere. Dendritic branching is thought to facilitate greater plasticity and flexibility in modulating the neuronal activity that produces the very complex neurophysiology of speech (Scheibel, 1991).

Neuroscience Concepts 23 We can learn more about hemispheric specialization from patients who have undergone surgery that separates the two hemispheres to restrict the spread of seizures. After surgery, these split-brain patients became models for testing how one hemisphere interprets sensory information. When researchers presented an image to the right hemisphere, the patient could not name the object since the right hemisphere could not produce speech (Levy & Trevarthen, 1977). The research also showed that the right hemisphere is particularly sensitive to recognizing faces presented in the left visual field (Turk et al., 2002; Yovel, Tambini, & Brandman, 2008). It appears that we most efficiently perceive specific information according to hemispheric specialization, e.g., words are perceived by the left hemisphere and faces and visual-spatial images by the right. Regarding sound, the right ear excels in dichotically presented speech, and the left ear has the advantage in perceiving melodies (Kimura, 1967). Moreover, somatosensory lateralization in right-handers gives them better tactile shape recognition with the left hand and superior identification of letters using the right hand (Finlayson & Reitan, 1976; Gibson & Bryden, 1983). These examples demonstrate cortical specialization that relates directly to sensory adaptation. Motor output also shows asymmetries. Observational studies have demonstrated that speech begins on the right side of the mouth which indicates speech initiation in the left hemisphere (Wolf & Goodale, 1987). Facial expressions also begin on the left side of the face indicating that the right hemisphere modulates facial emotional expression (Dimberg, Thunberg, & Elmehed, 2000; Sackeim, Gur, & Saucy, 1978). Besides anatomical lateralization, evidence suggests that neurotransmitters such as serotonin (Fink et al., 2009), gamma-aminobutyric acid (Iseki et al., 2009), norepinephrine (Fitzgerald, 2012), dopamine (Andersen & Teicher, 2000), and cannabinoids (Fritzsche, 2003) also have lateralized distribution, and variable neurotransmitter and receptor distribution means variable medication effects on hemispheric function. This finding has particular impact for patients taking psychotropic medications. From these data, one sees the brain as a highly specialized organ with well-defined networks similar across individuals.

Gender Differences Gender also impacts lateralization and related functions because hormones drive brain development. Across the globe, male brain-size is approximately 10 percent larger than female brain-size (Peters, 1991). In addition, a recent study showed that significant differences exist between males and females in specific brain areas (Raz et al., 2004). Behaviorally, research has clearly demonstrated that there are gender differences in neurocognitive performance: males excel in throwing, whereas women excel in fine motor skills (Hall & Kimura, 1995). In spatial analysis, men do better on mental rotation, spatial navigation, and geography, but women outperform men on spatial memory (McBurney, Gaulin, Devineni, & Adams, 1997). Mathematical aptitude favors men in mathematical reasoning and women in computational skills—the differences are small but real (Hyde, Fennema, & Lamon, 1990).

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In terms of perception, women outperform men in sensitivity to sensory stimuli, perceptual speed, sensitivity to facial and bodily expressions, and visual recognition (Velle, 1987). In language, women outperform men in fluency and verbal memory (Hyde & Linn, 1988; McGuinness, Olson, & Chapman, 1990). In a recent large population study, the authors argued that if variables are properly controlled, gender differences may not be as apparent (Wallentin, 2009). Nevertheless, various forces may drive these differences including genetics, hormones, brain development, maturation rate, environmental gender expectations, and preferred cognitive strategies. Factors such as unique personal experience, brain plasticity, and given vulnerabilities come together to influence individual development. For example, neuroimaging studies on twins showed smaller structural variability than in unrelated individuals indicating significant genetic impact on brain structure (Peper et al., 2007; Thompson et al., 2001). Studies on deafness show that the brain alters its structure and function when it lacks auditory input, i.e., it adapts to the sensory deficit (Bavelier & Hirshorn, 2010). When individuals are significantly deprived of environmental input, they develop varied and significant developmental impairments, e.g., when compared to age-matched controls, abused children’s brain-size, including the hippocampus and amygdala, and corpus callosum connectivity were abnormal (Eluvathingal et al., 2006; Mehta et al., 2009). If brain development and network organization experience severe disruption, they will yield substantial cognitive and emotional deregulation. We must guard against simplifying our understanding of brain function. Different brains share not only the same basic organizational patterns but also unique hemispheric differences that make them more distinct than similar or more relative than absolute. This perspective fits quite well into our earlier paradigm that addressed the brain’s considerable neuroplasticity, particularly when the brain encounters psychological challenges and/or physical injury.

Case Studies The following section demonstrates how we can use qEEG and other imaging techniques to understand individual patient’s clinical presentations. Allison Allison, a struggling, 22-year-old woman with a complex clinical picture, had a long-standing history of serious anxiety and depression that started in childhood and had not improved for any sustained period of time. In addition, she described symptoms of heightened autonomic arousal, such as increased heart rate, rapid breathing, muscle tension, poor temperature control, and deregulated sleep. Allison also experienced feeling overwhelmed, helpless, apathetic, and unmotivated. Several times she attempted suicide. In adolescence, Allison coped by disordered eating and self-injurious behaviors, including binging, purging, overexercising, restriction, diuretics, and cutting. After struggling with these

Neuroscience Concepts 25 behaviors for several years, she was diagnosed with Generalized Anxiety Disorder, Panic Disorder, Major Depressive Disorder, Persistent Depressive Disorder, Eating Disorder NOS, and Personality Disorder NOS. Clinicians assessed Allison with neurobehavioral and neurophysiological measures that revealed problems with language production, sustained attention, planning, and problem solving. Her qEEG results indicated significant frontal lobe dysregulation with paroxysmal activities (see Figure 2.1.). Paroxysms are abrupt electrophysiological bursts. In Allison’s case, the paroxysmal activity likely took her brain “off-line,” prevented complete thoughts, and disrupted her attention and executive function (Aarts, Binnie, Smit, & Wilkins, 1984). As her paroxysmal events increased, she had increased emotional and physiological stress (Zimmerman & Konopka, 2014). As seen in her auditory and visual evoked potentials (Figure 2.1), Allison could process and receive information, but she could not sustain attention because her cognition was impaired by the disruption in her attentional networks. Furthermore, LORETA demonstrated that Allison had statistically significant, focal, electrophysiological abnormalities in her left mesial temporal lobe, a region that impacts emotion, language, and verbal memory (see Figure 2.2). These data led Allison’s clinicians to change the design of Allison’s therapy. They learned that Allison could only manage small quantities of information, particularly when the topic was emotionally charged, and that her left hemispheric deregulation significantly impacted her perceptions and verbal expression. Therefore, Allison’s therapeutic sessions included short cognitive exchanges with immediate feedback, and other therapies, such as art therapy, were now given consideration.

Figure 2.1 Recorded with eyes-open; the arrow indicates paroxysmal discharges in the left frontal lobe. At other times, this pattern was also seen in the right hemisphere. Color version available at http://www.routledge.com/9781032050539

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Art therapy is a well-established therapy that facilitates nonverbal emotional expression and facilitates therapeutic communication. Allison was referred to our program for art therapy because of her deregulation. We hoped that art therapy would engage her left hemisphere and give her a tool for describing her emotions. Fortunately, she felt comfortable participating in art projects, which allowed her to focus and enhance her attention. We hoped that eventually she could apply her increased attentiveness to enhance her attention in other verbal processing domains. A quantitative EEG easily evaluates neuronal electrical brain activity with real-time resolution but is less equipped to directly evaluate the involvement of subcortical structures. Nevertheless, quantitative EEG’s cortical assessment can indirectly evaluate subcortical deregulation in structures such as the thalamus. To help determine whether EEG findings reflect potential subcortical involvement, we can combine quantitative EEG with other imaging modalities, such as structural (MRI) and functional (PET) imaging. By using independent imaging methods, we can better interpret how deviations converge across modalities and by doing so focus on the abnormalities of specific brain structures. Then, we can surmise the specific cortical and subcortical brain networks that produce specific findings reflected in aberrant behaviors (Poprawski et al., 2007; Chennamchetty, Poprawski, Crayton, Hamilton, & Konopka, 2009). With converging independent imaging data, we can prioritize and correlate the identified brain regions to functional networks, link them to clinical symptoms, and use the data to guide us in the development of data-driven interventions (Boutros, Thatcher, Galderisi, Yudofsky, & Hales, 2008). One such method was developed by Goforth et al. (2004). This method administers an imaging ligand while simultaneously recording EEG and a functional nuclear image such as PET or SPECT. As the ligand distributes throughout the brain, the nuclear image captures the brain state during the EEG recording. This technique allows one to evaluate brain function and enhances the reliability of the results by comparison to a normative database (Gordon & Konopka, 2005). As mentioned earlier, neuro-imaging has different strengths

Figure 2.2 LORETA, qEEG alpha-1 excess, left hippocampal/parahippocampal Color version available at http://www.routledge.com/9781032050539

Neuroscience Concepts 27 and weaknesses; unlike nuclear imaging (SPECT or PET), qEEG captures the brain’s activity in real-time, but alone, qEEG’s sensitivity is insufficient for detecting subcortical involvement. For instance, if one uses standard qEEG analysis, hypoactivity may be undetected in subcortical structures, such as the thalamus; however, if one uses qEEG in conjunction with PET, thalamic abnormalities may be more readily identified. Their combination can provide additional information directly related to a reported clinical presentation, e.g., in chronic, localized pain (Iadarola et al., 1995) or potential genetic vulnerabilities (Zimmerman, Konopka, Epstein, & Konopka, 2013). Combining structural and functional imaging can also highlight possible structural deficits underlying neuronal dysregulation and may elucidate potential contributing factors of specific impairments or symptoms. Allison was discharged to a lower level of care with significantly improved symptoms. Daniel Daniel, a 24-year-old man, was referred after his first serious suicide attempt. Growing up, Daniel had difficulty with fine motor movement, speech development, and writing and struggled with a long-standing history of severe depression. He also perceived himself as a victim of parental neglect and bullying inside and outside the home. To manage his depression and anxiety, Daniel used substances such as alcohol and marijuana. Daniel presented with rigid thought and obsessive-compulsive behaviors. Daniel’s previous treatment included adult outpatient and inpatient interventions with a diagnosis of Major Depressive Disorder, Autistic Disorder, Acute Stress Disorder, Generalized Anxiety Disorder, Alcohol Abuse, Cannabis Abuse, and Personality Disorder NOS. A detailed clinical interview revealed that Daniel had several incidents of potentially serious head trauma, including falling down stairs at age two, hitting his head, and losing consciousness. In middle school, he was hit on the head while playing soccer. Neuropsychological testing indicated that Daniel had slow reaction time, poor planning skills, limited cognitive flexibility, and limbic dysregulation. The EEG revealed abnormalities in brain regions including the sensory/motor cortex and the dorsal cingulate and right insular regions that correlated with many of Daniel’s symptoms and converged with his nuclear imaging (PET) (see Figure 2.3; Kennedy et al., 2001). In addition to functional abnormalities, the MRI’s structural images also revealed an unexpected finding—a 3.5 cm posterior fossa cyst compressing the vermis of the cerebellum. The cerebellum, particularly the vermis, is increasingly recognized for its role in regulating emotions, higher-order cognition, and movement (Schmahmann, 2004). The cyst was direct objective data that added significance to Daniel’s complex clinical and psychiatric presentation (Heath, Franklin, & Shraberg, 1979). Since cysts are generally non-symptomatic and often develop early in childhood, the brain adapts to the tissue loss caused by the cyst, but in Daniel’s case, we can surmise that because of its location, the cyst caused neural tissue loss that affected his early motor coordination and language

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Anterior

Right hemisphere displayed

Cingulate Cortex

Patient Right

Patient Left

Anterior

Posterior

Posterior

Figure 2.3 qEEG, excess beta, sensorimotor and dorsal cingulate regions (top circled) and PET, dorsal cingulate and sub-colossal regions (bottom circled) Color version available at http://www.routledge.com/9781032050539

Anterior

Posterior fossa cyst/ Arachnoid cyst Patient Right

Patient Left Posterior

Figure 2.4 MRI and PET images showing structural and functional abnormality of the medial cerebellum, the vermis (MRI, 3.5mm arachnoid cyst); T1-MRI image on the left; co-registered, MRI and PET images on the right Color version available at http://www.routledge.com/9781032050539

Neuroscience Concepts 29 development. As a consequence of these data, neurology will follow Daniel to ensure the stability of the cyst. Despite his resistance, Daniel also was referred to our art therapy program to learn how to freely engage his motor skills using multiple art media. Daniel preferred simple well-controlled media that provided optimal control such as pencil drawing. Interestingly, his behavior in art therapy was very similar to his behavior in verbal psychotherapy, i.e., he would seize on an idea and struggle to extend the concept beyond his immediate experience. He strongly resisted flexible thinking, indicating that such thoughts created significant anxiety. We saw that our suggestions increased his anxiety, which increased his rigid thinking. Consequently, his therapy began to focus on managing his chronic and acute anxiety and included creative writing to foster his cognitive flexibility (Goncalves & Perrone-McGovern, 2014). For Daniel, progress was slow, but a clear indication of positive therapeutic impact was seen. His treatment intensity decreased, and he is working in the community while being in the less intense therapy.

Developing a Person-Centered Approach When we combine multimodality imaging with a detailed clinical history, subjective symptoms, clinical observation, and objective neurobehavioral assessment, we can define a patient’s unique strengths and weaknesses and gain greater understanding of the person. This is the person-centered, diagnostic approach (Bras et al., 2011). Person-centered diagnostic medicine seeks more precise and effective treatments by incorporating neuroimaging within the psychological and neuropsychological paradigms. Consequently, person-centered medicine frequently confronts opposition from traditional practitioners who have received insufficient training from traditional training programs and misunderstand the relevance of neuroimaging. Despite this resistance, the person-centered diagnostic approach is gaining recognition. Generally, clinicians’ understanding of disorders from scientific studies that compare control groups to diagnostic categories results in potentially generalized statements about a given diagnostic group, but when we evaluate neurobiological disorders, such as schizophrenia, we realize the data are highly variable, as if it was collected from biologically heterogeneous populations. For example, we often accept that some individuals with schizophrenia have enlarged brain ventricles and others do not (Kasparek et al., 2007). Despite the obvious anatomical heterogeneity, we often combine these two patient groups into one entity as though they were the same. We do this because most studies define clinical populations based solely upon the symptoms, without the use of biological markers such as imaging data. It would be more useful if we defined patients based on their diagnosis as well as their objective biological findings (Kasparek et al., 2007). Clinicians who assess patient disorders for the neurobiological underpinnings using the brain-to-behavior approach realize that individuals have significantly diverse genetics, developmental histories, therapeutic histories, and imaging findings. As such, when all the variables are considered, any patient may defy

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the diagnostic categories represented in the literature. Consequently, study results may provide variable outcomes that are difficult to interpret when using diagnostic standards as the basic paradigm. Very recently, authors of peerreviewed papers are recognizing and acknowledging the biological diversity of their subjects and report on that diversity. To illustrate this point, two cases are presented. There were two female patients with depression and anxiety: 19-yearold Irene and 18-year-old Patty. Irene and Patty scored similarly on the Beck Anxiety Inventory (BAI), Irene “21” and Patty “22,” and on the Beck Depression Inventory (BDI), Irene “24” and Patty “25.” These measures are standardized normed self-report tools that define the levels of symptom severity. Generally, scores over 15 become clinically important. Both women engaged in self-harm behaviors and food restrictions. Both attempted suicide and used drugs, such as alcohol and cannabis. Both used illicit drugs to manage their symptoms. They had similar developmental histories with difficult upbringings and internal family conflict. Therefore, although we might assume that these two individuals would share similar biological findings, there were also differences. Similarities

Figure 2.5 Irene Color version available at http://www.routledge.com/9781032050539

Figure 2.6 Patty Color version available at http://www.routledge.com/9781032050539

Neuroscience Concepts 31 At rest, Irene and Patty had an excess 12 Hz in the posterior cingulate region (red). The posterior cingulate region is a part of the emotional brain system called the limbic system, it is also well connected with networks that monitor the eye movement, and respond to the sensory information. Functionally it is a part of the default network that stays active by collecting information about the world as well as about yourself; particularly when one is at rest. One may think of it as the system that allows for behavioral readiness and vigilance. Differences In addition, during an emotional activation, Patty showed paroxysmal discharges, indicating periods of disrupted brain activity. Furthermore, she had focal, right hemispheric deregulation at rest. These findings indicated that Patty had a deregulated right hemisphere and generalized cognitive difficulty that coincided with her paroxysmal activities. Irene, on the other hand, had no additional findings; thus, she was a simpler therapeutic case. Without these objective data, we may have attempted very similar treatments, but these data indicated that Patty was a better candidate for mood stabilizing pharmacotherapy. In addition to

Figure 2.7 At rest, Irene had 11 Hz deregulation in the left temporal lobe (circled). Color version available at http://www.routledge.com/9781032050539

Figure 2.8 At rest, Patty had 18 Hz deregulation in the right parahippocampal and fusiform areas (circled). Color version available at http://www.routledge.com/9781032050539

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clinical information, proper pharmacotherapy requires neuroimaging data and genetic information that provide the patient’s pertinent pharmacokinetic and pharmacodynamic characteristics.

Genetic mapping Currently, genetic mapping methods use a simple cheek swab or saliva collection and are readily available through commercial laboratories. These data enhance our understanding of the individual patient and may facilitate characterization of patient groups based on common genetic profiles (Hamilton, Konopka, & Konopka, 2013). In the clinic, if we combine clinical and objective data generated by imaging, neurobehavioral evaluations, and genetic mapping, i.e., compare standardized data to well-defined normative populations, we can create personalized biological treatments tailored to each individual patient. In addition, by using these standardized approaches and sharing clinical data across facilities that use electronic medical records, we can move the field of mental health in a very new direction. In addition to informing clinicians, the information generated by objective data benefits patients and their families. When we understand brain function and its relationship to behavior, we have a powerful tool for characterizing and understanding the way patients perceive their world. Patients’ clinical presentations may vary depending on their sensory perceptions, cognition, and emotions and on how they integrate them into their personal experience. For example, a student who has learned to compensate for unidentified visual or auditory difficulties may fail when demands are increased. As a result, he/she may experience chronic stress and aberrant adaptive behaviors. The failure may be unrelated to willingness to study, laziness, or lack of interest or motivation but rather be related to an inability to appropriately process information in the face of increased demand. Depending on the circumstances, when individuals experience repeated failures and are unaware of their deficits, they may develop anxiety, decreased self-worth, and, if unmanaged, depression. This process may eventually lead to deregulation within the family system and cause conflicts, blame, distrust, and potential aggression. In many cases, when young people face chronic stressors, they tend to reject their families and turn to peers for support, and peers often support and utilize behaviors that acutely change an individual’s state of mind but give only temporary relief. Often these behaviors focus on alcohol, illicit drug-use, and eventual self-harm. When patients have such histories, it is important to understand the potential causes of their behaviors and symptoms. Once we identify the root causes, we can start rehabilitation and cognitive restructuring (Cicerone et al., 2011). Cognitive restructuring includes therapies such as individualized pharmacological interventions, cognitive training that capitalizes on the patient’s strengths to address weaknesses, in-depth psychotherapy that focuses on root causes of symptoms, biofeedback, neurofeedback, family therapy, and less-structured treatments such as integrated therapies that include

Neuroscience Concepts 33 art therapy. These therapeutic approaches can be clearly guided by a careful person-centered approach that incorporates data from all available sources (Bryant et al., 2008).

Summary This chapter provides a background for how neurons act within neuronal networks and how their interactions shape behavior. Current neuro-scientific data informs us about the specificity of sensory information processing and data integration and how patients utilize these processes to initiate and sustain behaviors. Despite the brain’s highly specialized neuronal circuits, we know that there are no absolutes for brain function; brain function is as unique as individuals. Clearly, the brain is a highly malleable organ capable of learning throughout our life span, but learning requires distinct efficient neuronal networks. The brain establishes networks by altering its structure and function in response to demands. Newly developed neuroimaging techniques are available to clinicians and researchers and can identify and measure these changes in a living brain. Through careful study, we can observe the brain as it changes in response to maturation. By understanding maturation, we begin to appreciate brain development, particularly in early adulthood when the brain attempts to optimize its performance via increases in myelination and selective decreases in neuronal populations. We are beginning to recognize that each person develops differently through different brain processes that depend on genetics, gender, and environment. We know that genetic mutations may cause neuromodulation that results in abnormal connections and leads to aberrant, inefficient brain activity and behaviors. In addition, environmental factors such as stress greatly impact brain development, maturation, and the expression of vulnerabilities. Clearly, the brain’s plasticity can be a double-edged sword. With our current multimodal tools, integrated knowledge, and principles of neuromodulation, we can develop and optimize individualized therapies that help normalize behavior and provide optimal opportunity for each patient. These therapies are predicated on our understanding the variables that underlie dysfunction. Therefore, to discover the best therapeutic course for each and every patient, we must prioritize our therapeutic approaches and continually evaluate the efficacy of our interventions. When we combine multimodality imaging with a detailed clinical history, subjective symptoms, clinical observation, and objective neurobehavioral assessment, we can define a patient’s unique strengths and weaknesses and gain greater understanding of the person. This is the person-centered, diagnostic approach (Zimmerman, Golla, Paciora, Epstein, & Konopka, 2012). With this new approach in mind there is a very specific need to develop a full range of complementary or adjunct therapies. This includes art therapy as an accepted field (Konopka, 2013) that is validated by scientific methods and supported by subjective and objective data.

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The Expressive Therapies Continuum as a Framework in the Treatment of Trauma Vija B. Lusebrink and Lisa D. Hinz

Art Therapy in the Treatment of Trauma Psychological trauma has been defined as the occurrence of an event or series of events that overwhelms an individual’s ability to cope (American Psychiatric Association, 2013). Trauma survivors of all ages often have difficulty expressing themselves verbally, especially if they have experienced early trauma which may have interfered with haptic perception and the development of elemental language skills (Elbrecht, 2013). Early trauma and childhood maltreatment or neglect contribute to under-stimulation or overstimulation of the infant brain, thus disrupting right hemispheric development and the subsequent ability to regulate emotion, process pain, and maintain attention (Schore, 2013). Experiencing trauma causes neuroendocrine responses that can result in structural and functional changes in the developing brain (Hass-Cohen, Findlay, Carr, & Vanderlan, 2014; McHenry, Sikorski, & McHenry, 2014; Schore, 2013; Tyrka, Burgers, Philip, Price, & Carpenter, 2013). Specifically, childhood maltreatment may impair the ability of the prefrontal cortex to exert control over limbic system responses through the Prefrontal Cortex (PFC)-amygdalahippocampal network. Consequently, unregulated signals from the amygdala may lead to excessive anxiety due to insufficient cognitive discrimination, resulting in emotional deregulation (Hass-Cohen et al., 2014; Tyrka et al., 2013). In addition, trauma is associated with memory deficits and reduced hippocampal volume (McHenry, Sikorski, & McHenry, 2014), as well as decreased corpus callosum volume and difficulties processing language and regulating emotion and behavior (Bücker et al., 2014; McCrory, De Brito, & Viding, 2010). Karlsson (2013) and McHenry, Sikorski, and McHenry (2014) have proposed that future psychotherapies will be based on brain imaging studies that demonstrate how different forms of therapy target specific brain structures and functions. For example, the encoding of traumatic memories and the intense emotions associated with them is characterized by decreased cognitive activity when integrating sensory-motor information associated with trauma. As a result, traumatic sensory-motor memories are stored nonverbally and are accessible

DOI: 10.4324/9781003196242-3

The Expressive Therapies Continuum 43 primarily through expressions involving the body as the main entry point (Ogden & Minton, 2000; van der Kolk, 2006). Further complicating the treatment of trauma is that nonverbal and verbal memories of trauma remain as disjointed segments without a temporal narrative organization. Understanding the neuroscience underlying brain functioning and, more specifically, the neurobiological effects of trauma can increase the effectiveness of art therapy for post-traumatic stress disorder (Crenshaw, 2006; Klorer, 2005). Johnson (2009), though, has cautioned art therapists not to indiscriminately abandon art therapy foundations for neuroscience because research on trauma-related structural changes is still in the preliminary stages. In addition, mental processes including creativity are distributed across both hemispheres of the brain, and, in Johnson’s opinion, expressive arts theories and techniques adequately address the treatment of trauma without the introduction of neuroscience. In addressing the use of art therapy in the treatment of trauma, several authors recently have referred to information about the neuroscience foundations of brain functions and behavior, differentiating various components involved in nonverbal expressions (Chapman, 2014; Crenshaw, 2006; Gantt & Tinnin, 2009; Hass-Cohen & Carr; 2008; Hass-Cohen et al., 2014; Klorer, 2005; Lusebrink, 2004, 2010; McNamee, 2005, 2006; Pifalo, 2009; Sarid & Huss, 2010; Talwar, 2007). In addition, these authors discuss the importance of the sensory-motor aspects involved in expression through art media to access images and emotions resulting from trauma, emphasizing that the experience of trauma is encoded as nonverbal sensation, which may remain unaltered as implicit memory. The second aspect common to art therapists’ approaches to trauma patients is the ability of art to aid in the cognitive restructuring and subsequent integration of traumatic experiences; these cognitive processes have been defined by some authors as the creation, organization, and integration of a trauma narrative (Gantt & Tinnin, 2009; Hass-Cohen et al., 2014; Naff, 2014; Pifalo, 2009; Talwar, 2007). The goal of all the above approaches to trauma is the integration of nonverbal implicit memories stored in the right hemisphere with the left hemisphere verbal functions to form explicit, reconstructed, and coherent verbal memories. The resulting holistic reformulation can allow for the experience of flow (a state of highly focused attention associated with feelings of satisfaction and joy and long-lasting well-being) and post-traumatic growth (Chilton, 2013; Hass-Cohen et al., 2014; Lee, 2013). This chapter proposes integrating expressive arts therapies and neuroscience theories through the conceptual model of the ETC. Understanding the ETC with its three stepwise levels can refine and individualize the art therapy treatment of trauma using various art media. It is further proposed that art therapy can uniquely enhance post-traumatic growth opportunities through engaging clients in flow experiences (Chilton, 2013; Lee, 2013). The concept of the ETC can be used in trauma therapy with different age groups, even though it is illustrated here by applying the ETC to art therapy with children.

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The ETC and Brain Functions The Expressive Therapies Continuum (ETC, Kagin & Lusebrink, 1978; Lusebrink, 1990), with its conceptual approach to the multileveled nature of visual expression, facilitates the individualization of art therapy treatment strategies with trauma patients. The three stepwise levels of the ETC, namely Kinesthetic/Sensory, Perceptual/Affective, and Cognitive/Symbolic, reflect the increasing complexity of visual expression and information processing, including the increasing complexity of imagery formation (Figure 3.1). Based on Fuster’s (2003) classification of the different brain areas involved in the processing of sensory information, Lusebrink (2004, 2010) proposed that the different levels of the ETC parallel the brain areas and functions involved in the creation and processing of visual expressions. According to Fuster (2003), the processing of sensory information proceeds from the analysis of elementary sensory features in the primary sensory cortices to the analysis of associated features in a given modality, in respective unimodal association cortices (visual, somatosensory, motor, and audio). In contrast, processing across several sensory and non-sensory modalities occurs in the transmodal or multimodal association cortex in the parietal lobe. The characteristics of visual expression, and the possible areas of the brain predominantly involved, are addressed on each level of the ETC. Based on data from visual information processing and imagery formation, the regions and functions of the brain hypothesized to be associated with each level of the ETC are addressed in their general, schematically predominant manner. This approach assumes that the brain functions holistically with many reciprocal interactions between the different parts. Each ETC level is described as a continuum between two polarities representing gradations and variations in visual expression. (See Figure 3.1.) CR | | C < - - - - - - - - - - - - - - - - - - - > Sy | | P < - - - - - - - - - - - - - - - - - - - > A | | K < - - - - - - - - - - - - - - - - - - - - > S Figure 3.1 The Expressive Therapies Continuum. K refers to Kinesthetic component, S—Sensory, P—Perceptual, A—Affective, C—Cognitive, Sy—Symbolic, CR—Creative Also available at http://www.routledge.com/9781032050539

The Expressive Therapies Continuum 45 The extremes at each level could indicate psychopathology (Lusebrink, 2010); however, this chapter focuses on trauma work and does not address the activity of the brain concomitant with possible psychopathological variations (examples of the latter are described in Hinz, 2009, and Lusebrink, 2010). Kinesthetic/Sensory (K/S) Level The K/S level represents simple motor expressions with art media and their corresponding visual manifestations of energy and sensory involvement. Because of the bipolar nature of ETC levels, an emphasis on the Kinesthetic (K) component of the K/S level decreases awareness of sensory functioning. On the other hand, emphasizing the Sensory (S) component of this level decreases and slows down kinesthetic action because attention is focused on the experience of sensations. Focusing on movement and the release of tension, the K component reflects the predominant involvement of the basal ganglia and the primary motor cortex (Christian, 2008; Lusebrink, 2010). The sensory component of visual expression focuses attention on the sensory exploration of materials, surfaces, and textures and appears to involve the primary sensory-motor cortex. Visual information on this level is processed in the primary striated visual-cortex occipital lobe where the cells are sensitive to color, to lattices and their spatial frequency, and to orientation and movement (Carlson, 2001). Brain activity on the K/S level appears to be fundamental to internal imagery formation. Damasio (Damasio, 2012; Meyer & Damasio, 2009) proposed that imagery formation involves basic visual, sensory, motor, and audio components, thus supporting the importance of kinesthetic and sensory involvement with art media in art therapy (Hinz, 2009; Lusebrink, 2014). In trauma treatment, K/S work may release tension, awaken the senses, elicit preverbal bodily memories, and establish healing rhythms (Elbrecht, 2013). Perceptual/Affective Level (P/A) The Perceptual (P) component of the P/A level focuses on the formal elements of visual expression whereby forms are defined by lines and/or color as boundaries. This component of the ETC emphasizes the formal elements of visual expression, such as figure/ground differentiation, definition of forms, and the spatial relationships between them. Visual information, first processed in the brain in the primary visual association and extrastriate cortices, is then divided into two streams of analysis. Both streams travel to the second level of the visual association cortex, but in different lobes. The lower or ventral stream travels to the inferior temporal lobe that responds to features and shapes and integrates their forms and colors, while the upper or dorsal stream travels to the parietal lobe and the multimodal association cortex that respond to spatial locations (Christian, 2008; Fuster, 2003; Hass-Cohen & Loya, 2008; Kosslyn, Behrmann, & Jeannerod, 1995; Lusebrink, 2004, 2010). This distinction between the two visual

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streams is important in understanding visual expressions in art therapy because it separates information about form or “what is it?” from information about spatial location or “where is it?” Both visual streams have direct reciprocal connections with the prefrontal cortex (PFC) and both connect in the principal sulcus of frontal lobe (Carlson, 2001). The Affective (A) component of the P/A level is characterized by increasing involvement with emotion, its expression, and the affective modification of forms. The presence, differentiation, and transformation of affect are indicated by increases and/or variations in the use of hues and their values. The A component appears to primarily reflect the processing of emotions in the amygdala, located in the subcortical limbic system, and its influence on the visual stream (Christian, 2008; Lusebrink, 2004). Input from the amygdala is modified by the hippocampus and two cortical structures: the cingulate cortex and the orbitofrontal cortex. The amygdala connects directly to the PFC and indirectly to the right orbitofrontal cortex (OFC) through the thalamus (Fuster, 2003; HassCohen & Loya, 2008). The interplay between the P and A components in visual expression involves transition from feature-based information processing at the P polarity on the left side of the ETC schema to the amygdala-based information processing at the A polarity on the right side. The interchange between these two ETC components is critical in trauma work as exposure to trauma elicits affect and structured perceptual work contains it. Cognitive/Symbolic Level (C/Sy) The Cognitive (C) component of the C/Sy level emphasizes cognitive operations and is characterized by concept formation, categorization, problem solving, and differentiation of meaning of objective images and abstractions (Lusebrink, 2004, 2010). The cognitive component of the ETC presumably reflects the activity of the PFC and the OFC. The PFC performs the integrative functions of working memory. It generates a time-limited memory based on “the joint activation of the neural components of a large cognitive network of perceptual and executive memory” used in the processing of daily activities (Fuster, 2003, p. 159). In addition, the PFC is responsible for maintaining attention and inhibition, including integrating information from the posterior cortex (the multimodal parietal cortex) and the different sensory information stored in the temporal and occipital cortices (Dietrich, 2004). The C component of the ETC also appears to reflect the regulatory “top-down” influences of the dorsolateral prefrontal cortex and possibly the anterior part of the cingulate cortex (Christian, 2008; Lusebrink, 2010). The OFC is likely involved in emotional regulation, whereas areas of the PFC have been conceptualized as dealing with affective working memory and anticipating the consequences of positive and negative emotions (Davidson, 2000; Davidson, Putnam, & Larson, 2000). Affective working memory can be seen as a time-limited joint activation of the neural components of a large network of perceptual and cognitive memory activated by a particular set of emotions.

The Expressive Therapies Continuum 47 The Symbolic (Sy) component of the C/Sy level emphasizes intuitive processing of experiences and visual information through input from sensory and affective sources, autobiographical processing, and symbolic expressions. It is characterized by symbolic affective images, symbolic use of color, symbolic abstractions, and intuitive, integrative concept formation (Lusebrink, 2004, 2010). The Sy component appears to predominantly reflect the processes of the OFC and possibly the posterior part of the cingulate cortex and the ventromedial part of the PFC. The integrative function of the OFC includes the retrieval of autobiographical consciousness (Carr, 2008). Both the Cognitive and Symbolic aspects of the C/Sy level are necessary for memory work, and both aspects rely on information stored in the multimodal cortex in the parietal lobe (Fuster, 2003). C/Sy work in trauma aids in constructing a coherent trauma narrative (Gantt & Tinnin, 2009; Hass-Cohen et al., 2014). In addition, C/Sy art therapy is important for cognitive restructuring (Ford, Nader, & Fletcher, 2013), and for teaching appropriate coping skills (Crenshaw, 2006; Ford, Nader, & Fletcher, 2013). Creative Level (CR) The Creative (CR) level of the ETC is conceptualized as a perpendicular intersection of all three levels. The CR level can be present on each of the levels at the intersection between the two polarities; at the same time, it can involve information processing from all of the ETC levels. Artistically, creative visual expression can encompass the characteristics along the whole continuum, spanning any level of the ETC, whereby the preference for a particular level in the expression is reflected in the artistic style (Feldman, 1972; Lusebrink, 1990). Critical reviews of the cognitive neuroscience of creativity (Dietrich, 2004; Sawyer, 2011; Zaidel, 2005) assert that the creative process consists of many interactive cognitive processes and emotions, and that the right and left hemispheres of the brain are equally active in most creative tasks. According to Dietrich (2004), “creative insights can arise in two processing modes: spontaneous or deliberate” (p. 1015). Creative insights based on deliberate searches are initiated in the PFC; they encompass intentionally recruited long-term memory retrieval from storage in the parietal, temporal, and occipital cortices and its temporal representation in working memory. In contrast, creative insights in the spontaneous processing mode happen effortlessly; they are based on intuition, which can be “conceptualized as knowledge obtained while the frontal attention system does not control the content of consciousness” (Dietrich, 2004: 1017). Spontaneous creative insights can also emerge in working memory from the parietal, temporal, and occipital cortices while the PFC is downregulated during altered states such as dreaming or daydreaming (Dietrich, 2004).

The ETC and Two Functional Systems The schematic representation of the ETC (Figure 3.1) visually illustrates two different functional systems as they process their respective information hierarchically on different levels of complexity. The left side of the schema

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incorporates the activity of visual pathways in the brain involved in the perception and expression of visual forms on the Perceptual pole, which, in turn, creates basic input for cognitive processing of this information in PFC on the Cognitive pole. The right side represents the emotional experiences and values based on input from the amygdala with the Affective pole. This information is forwarded to the cingulate cortex in the limbic brain and then to the ventromedial prefrontal cortex (VMPFC), forming emotionally charged symbolic images on the Symbolic pole. This differentiation of the ETC into two different functional systems appears similar to Dietrich’s (2004) conclusions based on his review of the literature on brain functions involved in information processing. According to Dietrich, the brain has developed two different types of neural systems for processing different kinds of information from the environment; one system processes emotional responses and attaches a value tag to the incoming information indicating its subjective biological and emotional importance to the individual, whereas the other “is designed to perform detailed feature analyses,” namely an objective perceptual evaluation of the environment forming the basis for cognitive processing (p. 1012). The first type of analysis provides information about, how valuable is this stimulus for my survival? The second analysis answers the question, what aspects of this item will benefit my survival? Initially, affective content is processed in the amygdala, then in the higher limbic system structures, namely, the cingulate cortex and the ventromedial PFC (VMPFC). The perceptual and conceptual content is processed in the three posterior cortices—occipital, temporal, and parietal—and then forwarded to the dorsolateral prefrontal cortex (DLPFC). Dietrich (2004) refers to Fuster (2003), stating that “although there are multiple connections at various levels between the two information processing systems, the full reintegration of emotional and cognitive information does not appear to happen until both types of computations converge back to the dorsolateral prefrontal cortex” (Dietrich, 2004: 1012). The ETC schematically indicates the connections between the two information processing systems on different levels of complexity. On the K/S level, sensory-motor integration between the two components for routine and automatic behaviors occurs in circular loops of neural connectivity at the basal ganglia, hypothalamus, and other lower levels of the neural hierarchies involving primary sensory and motor cortices. Corresponding cortical association areas become engaged with novel and more complex expressions on the P/A level. On the C/Sy level, activity in the PFC presumably involves the DLPFC, processing cognitive information at the C polarity, with increasing input from the VMPFC incorporating the limbic system-based affective input at the Sy polarity.

The Use of the ETC in the Treatment of Trauma Structure of the ETC The three-tiered structure of the ETC is based on the idea that several component functions may be involved in visual expression, but that one

The Expressive Therapies Continuum 49 component or level usually predominates. In using the ETC as a framework for therapy, it is important to distinguish which of the components of client expression reflect strengths in visual expression and which reflect respective deficits. It is hypothesized that personal resources or shortcomings demonstrated in ETC component processing mirror preferences in the reception, processing, integration, and expression of information, emotion, and action in other aspects of life (Hinz, 2009). For example, a person who is rational and analytical in life will demonstrate an affinity for Cognitive processes; one who is caught up in emotion will favor Affective processes. Art therapy in the context of the ETC focuses on enhancing client strengths on different levels, while at the same time improving areas of weakness (Hinz, 2009; Lusebrink, 2004, 2010; Lusebrink, Mārtinsone, & Dzilna-Šilova, 2013). Clients enter therapy with unique constellations of personal assets and deficits that are addressed in specific ways, not through “cookbook” formulas (Hinz, 2009). Typically work begins with the component process, where clients demonstrate strengths, and subsequently moves in a stepwise fashion to enhance less well-developed areas of functioning (Hinz, 2009; Lusebrink, 1990; Lusebrink, Mārtinsone, & Dzilna-Šilova, 2013). Using the ETC allows therapists to customize interventions and goals in the treatment of trauma; all clients are not treated similarly. The ETC encourages individualized choices of media, art directives, and treatment goals. Effective trauma treatment allows for the controlled exposure to trauma triggers and associated affect, alternated with opportunities for conscious withdrawal and containment (Hass-Cohen et al., 2014; Hinz & Ragsdell, 1991; Johnson, 2009; Sarid & Huss, 2010). Thus, the two different functioning systems of information processing represented on the left and right sides of the ETC can be differentially and deliberately accessed and activated in treating trauma. Information processing on the right side permits exposure through Affective and/or Symbolic channels; processing on the left side provides containment and restructuring through perceptual and cognitive functions. As compared to other clinical art therapy approaches in the treatment of trauma (e.g., Chapman, 2014; Gantt & Tinnin, 2009; Hass-Cohen et al., 2014; McNamee, 2005, 2006), the concept of the ETC provides a flexible and comprehensive template marking horizontal and vertical movement in therapy. As mentioned above, vertical movement occurs between levels of the ETC. Horizontal movement takes place within each level between the polarities of a particular level. The three levels of the ETC also can be considered for their vertical, “top-down” and “bottom-up” methods of action. The bottom-up manner of information integration proceeds from the K/S level of sensorymotor responses to the differentiation of forms and affective input in the unimodal cortices and their multimodal integration in the parietal cortex on the P/A level, and then to cognitive integration in the PFC on the C/Sy level. The top-down sequence of information processing starts on the C/Sy level with activity in the PFC and is followed by a gradual differentiation of form, affect, and sensory-motor-based information in the parietal, temporal, and occipital cortices on the P/A and K/S levels respectively.

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Media Choices and the ETC Media choices can influence processing channels to promote or contain brain functioning. Fluid media such as watercolors and chalk pastels are likely to evoke and allow for emotional expression. Sensory engaging materials such as finger paint and wet clay quickly will bring a client in touch with trauma memories (Sarid & Huss, 2010). Therefore, materials such as paints and pastels channel information processing through the right side of the ETC hierarchy and create the careful emotional exposure associated with successful trauma work. The use of fluid and sensory materials also can produce ambiguous forms, which can be interpreted as personal or universal symbols, further promoting affectively laden work on the right-hand side of the ETC. Resistive media such as hard clay or crayon on rough paper are likely to require vigorous work to manipulate and thus engage the Kinesthetic component. A focus on formal artistic elements required for work with the Perceptual component is accomplished by media and processes that emphasize clarity in the definition and differentiation of forms. Media such as collage materials or sculpture, which have inherent structure and require multiple steps to reach the end product, will elicit work with the Cognitive component as clients work through the multiple steps to project completion (Naff, 2014). These left-hand functions support the detailed feature analyses necessary for occasional emotional respite and promote cognitive restructuring. Flow and Post-traumatic Growth Ultimately, integration of the two different functional systems of information processing using all the levels of the ETC contributes to healing and posttraumatic psychological growth. It is hypothesized that the fluid transition between the two systems and the different levels of the ETC could reflect the experience of “flow” (Chilton, 2013; Csikszentmihalyi, 2008; Lee, 2013). Flow is an optimal state of functioning in which clients are challenged by a task, engage in problem solving behavior to adjust skills and goals, and are able to achieve mastery (Lee, 2013). While in flow, clients can experience highly focused behavior, an altered sense of time, and moments of peak joy. The occurrence is intrinsically rewarding and is followed by longer lasting periods of increased well-being (Csikszentmihalyi, 2008). Increased well-being is exemplified by more satisfying interpersonal relationships, an enhanced view of the self, and changes in life philosophy: three cardinal features of post-traumatic growth (Joseph, Murphy, & Regel, 2012). The following case studies demonstrate the processes by which two brothers emerge from childhood trauma via flow experiences in art therapy.

Case Studies Demonstrating the Use of the ETC Introduction to Two Brothers: Art Therapy Approaches to Trauma Two brothers, aged seven (Steven, a pseudonym) and eight years (Ed, also a pseudonym), were referred for art therapy by their social services caseworker.

The Expressive Therapies Continuum 51 The boys had been removed from their mother’s custody following Ed’s disclosure that the mother’s live-in boyfriend was sexually abusing them. The children first were placed with their biological father and his girlfriend, but Ed ran away from that living situation because the girlfriend was physically and emotionally abusive. The brothers were placed in separate foster homes and referred for therapy. After introduction to the art materials and a description of art therapy, the brothers completed their first free drawings (see Figures 3.2 and 3.3). Both boys drew houses, and, while the brothers experienced similar trauma, their depictions of these houses and their preferred ways of processing information were diametrically opposed. Ed described his house (Figure 3.2) as being surrounded by a tornado. Alternating energy and control can be seen in his precise coloring of the house and his expansive creation of the swirling storm. Prominent features of the drawing also include the use of many colors, the pointed black roof, and a gutter drawn on the side of the house to allow “dirty water to escape.” Based on this drawing, Ed was characterized as energetic, assertive, expansive, actionoriented, and an externalizer of emotion and as experiencing unpleasantness needing expression. Using the framework of the ETC, one could say that although the house drawing was on the C/Sy level, kinesthetic action was Ed’s predominant mode of processing emotionally threatening information. In contrast, 7-year-old Steven described his house as a castle that had many windows and doors, including the key-shaped window in the center. Additionally, he pointed out an intruder on a ladder trying to gain access to the house. Prominent

Figure 3.2 Ed’s first free drawing, “House” Color version available at http://www.routledge.com/9781032050539

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Figure 3.3 Steven’s first free drawing, “House/Castle” Color version available at http://www.routledge.com/9781032050539

features of this drawing include geometric shapes, two chimneys, and a dearth of color. The drawing indicated that this boy was tentative, thought- or fantasyoriented, an internalizer of emotion, and possibly experiencing guilt, self-blame, and depression. He preferred working on the C/Sy level of the ETC, and his graphic representations were developmentally appropriate for his age. These two different client presentations naturally required different therapeutic approaches but the same ultimate goals for weekly art therapy: the expression of trauma-related thoughts and feelings, including expression and integration of the nonverbal traumatic memories encoded as sensations, the organization of a trauma narrative, and psychological growth allowing the freedom to choose appropriate coping skills based on a positive sense of self-esteem (Crenshaw, 2006; Ford, Nader & Fletcher, 2103; Hass-Cohen et al., 2014). One brother presented with tremendous energy and kinesthetic involvement. He had to discharge a great deal of energy before he could express emotion appropriately and, later, coherently relate his trauma narrative. The second brother was comfortable using cognitive strategies to keep emotions under control. It was important to meet him at the C/Sy level where his strategies could be respected and reinforced before eliciting emotional and K/S learning.

The Expressive Therapies Continuum 53 A Bottom-Up Approach to Trauma Therapy: Art Therapy with Ed Ed began art therapy choosing to work with clay. In the first two sessions he did not shape the clay; he pounded, pushed, pinched, rolled, and tossed it. Sarid and Huss (2010) state that resistive media, those that require energetic manipulation, can help manage the sensory excitation of traumatic memories and allow for a sense of personal control. In addition, Ed achieved a release of energy evidenced in his calm facial expression as he left the sessions. Although these meetings were dominated by action, Ed drew pictures as well. Interestingly, Figure 3.4 demonstrates pent-up energy awaiting discharge in one of the early art therapy sessions. As work continued and he was able to release energy in a controlled, acceptable fashion, Ed’s drawings indicated decreased energy and increased sensory involvement, as seen in the rhythmic horizontal strokes and yellow color of Figure 3.5. In the next phase of art therapy, Ed was educated about the natural presence and purposes of emotions. Psychoeducation combined with art expression allowed Ed to understand that emotions are signals that require appropriate expression. To learn about the range of personal emotions, Ed created collages of facial expressions such as the one depicted in Figure 3.6. Each emotion was examined individually with respect to the event(s) that might have caused it and to what appropriate action might be taken in response to the emotion. Ed, creating paintings of emotions that he personally experienced, also began to separate and discriminate what he previously felt as the undifferentiated, swirling storm. In addition, P/A work involved using art as a method for responding to or soothing emotions.

Figure 3.4 Ed’s drawing showing pent up energy awaiting release Color version available at http://www.routledge.com/9781032050539

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Figure 3.5 Ed’s drawing showing less energy needing an outlet Color version available at http://www.routledge.com/9781032050539

Figure 3.6 Ed’s collage of emotions Color version available at http://www.routledge.com/9781032050539

The Expressive Therapies Continuum 55 In a subsequent stage of therapy, Ed created clay animal figures and told stories about their lives, some of which he also illustrated with drawings (see Figure 3.7.). These stories formed the basis of Ed’s trauma narrative; the metaphoric telling allowed for enough reflective distance so that he could safely tell his life story. The stories also allowed for purposeful cognitive restructuring as the art therapist witnessed the original stories, helped Ed to recognize themes and emotions, and asked Ed to create new chapters or endings that emphasized his strengths and inner resources (Steele & Kuban, 2012). For example, the story that accompanied the drawing in Figure 3.7 was this: Two dogs are traveling and they get lost. They end up on two sides of this big river. The little dog cries to the big dog, I don’t know how to swim! The big dog tells him to shut up, and he (the little dog) gets caught by the dogcatcher. The big dog tries to find his way home, but there are too many signs pointing in too many directions. He doesn’t know the way. Clearly Ed was expressing guilt about leaving his brother, Steven, behind when he ran away from their father’s abusive girlfriend. Steven suffered more abuse, and eventually the boys were placed in separate foster homes. The art therapist commented on how guilt often is manifested as anger at the victim and helped Ed identify positive resources and skills that might be employed if the situation

Figure 3.7 Animal illustration of Ed’s trauma narrative Color version available at http://www.routledge.com/9781032050539

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were encountered in the future. Using cognitive restructuring (Rosal, 2001; Steele & Kuban, 2012), Ed created a chapter that allowed the big dog to help the small dog and a chapter in which the two dogs together found their way home. The new images were reminders of positive and more rewarding approaches to difficult situations. Following the animal stories, Ed used clay to create human figures that he arranged in teams to play basketball or soccer. He engaged the art therapist on the opposing team, and the games provided opportunities for teaching appropriate coping skills (e.g., cooperation alongside competition, compassion, creation instead of destruction). In particular, these sessions offered experiences of flow. Ed was occupied in decidedly focused behavior, problem solving, and mastery. He demonstrated intense enjoyment at his abilities and, further, his precise artistic behavior differed greatly from the unfocused, action-oriented behavior characteristic of his first art therapy sessions. Integration of the two different functional systems of information processing using all the levels of the ETC occurred through the use of clay to create detailed human figures and the use of these figures in fantasy and interactive play. The use of fine motor skill and the planning and thought involved in the creation of the figures required a combination of K/S and C processing. Using the human figures in an interactive, fantasy scenario with the therapist added Sy and A activity. It is hypothesized that the fluid transition between the two systems and the different levels of the ETC could reflect the experience of “flow” which creates unique opportunities for healing and post-traumatic psychological growth. In terms of the ETC, Ed began art therapy on the left-hand side of the hierarchy at the K/S level. In the first two sessions his work was utterly Kinesthetic: he pounded, pushed, pinched, rolled, and tossed clay. The bipolar nature of the K/S level necessitates that as participation with Kinesthetic activity increases, Sensory involvement naturally will decrease. Therefore, if the sensory nature of clay evoked trauma memories as has been hypothesized (e.g., Elbrecht, 2013; Sarid & Huss, 2010), action with the clay provided a necessary release of tension. Pictures drawn during these early meetings demonstrated that after the kinesthetic work and the additional release of energy, Ed could focus on form. Consequently, work moved to the P/A level in order for Ed to identify, discriminate, appropriately express, and soothe emotions. At first the work stayed mainly on the P polarity of the P/A level, as Ed was encouraged to identify and discriminate among other people’s emotions through the use of collage images. The appropriate selection of both task and media encouraged the reflective distance that allowed the experiences to remain more Perceptual than Affective. When Ed demonstrated proficiency with the P polarity, movement to the right side of the ETC was attempted. Again, the art therapist’s choices of tasks and media moved the experience in the desired direction. By encouraging Ed to express his personal emotions and to use paint to do so, the therapist constructed experiences that became more affectively charged.

The Expressive Therapies Continuum 57 The final stages of this bottom-up approach to trauma mastery required moving to the C/Sy level. Although Ed again chose to use clay, his work with the material was more refined than previously in terms of the figures created and the stories imagined. Previously his work was action-oriented and haphazard; creating form was not integral to the experiences. As work moved to the C/Sy level, Ed created figures of animals and detailed pictures and stories to accompany them. The difference can be seen graphically by comparing Figures 3.4 and 3.5 with Figure 3.7. The increasing complexity of these figures and stories demonstrated Ed’s increasing ability to master the trauma experience through Symbolic expression. In addition, through cognitive restructuring, the art therapist encouraged PFC control over limbic system processing; thus, over time, establishing increased conscious control over emotional responding. The Creative level was accessed and flow experiences encouraged through Ed’s creation of complex human figures and his actively and constructively engaging the art therapist in team play. Ed showed problem solving skills and mastery of challenges encountered with the art materials and processes. In dramatic contrast to the trauma narrative related above in which the big dog tells the crying little dog to “shut up,” Ed showed growth in his ability to incorporate and demonstrate cooperation and compassion in his interactions with the art therapist. A Top-Down Approach to Trauma Therapy: Art Therapy with Steven Steven’s first images in art therapy mimicked the style seen in Figure 3.3: line drawings with random color used mainly to outline forms. After a few sessions, Steven began to experience nightmares. Therefore, he was asked to draw his nightmares and create response drawings to them in an attempt to cognitively restructure these highly emotional experiences. In the response drawings, Steven was instructed to change negative images into ones that were more manageable or ones in which he was in control of the outcome (Steele & Kuban, 2012). For example, in one dream his father’s girlfriend was a giant who aggressively pursued Steven. Steven. Steven Steven drew drew aa picture pictureof of the the giant giant (Figure (Figure3.3.8); then he he “cut “cut pursued 8); then her down to size” (Figure 3.9). In a subsequent series of drawings, the perpetrator became smaller and smaller until she was merely a dot that disappeared into the white expanse of paper. Steven’s experience of nightmares is common among trauma survivors. Nightmares are one way that the body re-experiences trauma (Ford, Nader, & Fletcher, 2013), and the drawing technique helped Steven manage the anxiety that he felt as he recounted his dreams in therapy. Consequently, he was coached to use the technique at home so that his sleep gradually was less disrupted. Because the nightmares included many trauma-related incidents, Steven was encouraged to create a trauma narrative (Crenshaw, 2006; Gantt & Tinnin, 2009; Pifalo, 2009; Talwar, 2007) with the goals of organizing the story, increasing understanding, expressing affect, and restructuring self-image from victim

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Figure 3.8 The original view of Steven’s nightmare Color version available at http://www.routledge.com/9781032050539

Figure 3.9 Cognitive Restructuring of Steven’s nightmare Color version available at http://www.routledge.com/9781032050539

The Expressive Therapies Continuum 59 to survivor. Unlike his brother who created emotional distance by telling his story symbolically, Steven told his trauma story in factual pictures as he remembered it over the course of several weeks, each week adding new details and incidents until he felt that the story was complete. It was apparent from his images that Steven was encountering his story with very little emotion. He typically used one marker to create a line drawing, focusing on the details of the scene but not using color appropriately. After Steven illustrated his story, the art therapist engaged him in cognitive restructuring, asking him to create different views of abusive incidents or to create alternative responses. Thus, Steven began to develop and incorporate different views of situations, people, himself, and his coping skills. These activities afforded exposure to the trauma and, at the same time, a safe retreat into the structure and details of the drawings or the cognitive restructuring activities. His growing mastery of the emotion associated with trauma experiences can be seen in the improved line quality and increased developmental level of the drawings, from early to later drawings. Steven was encouraged to elaborate his drawings by adding color. One example can be seen in Figure 3.10. This picture, of Steven imagining his mother’s boyfriend going to jail following Steven’s court testimony, was originally made with only a blue marker that was neither color-appropriate nor particularly emotionally expressive. Following the addition of color, Steven indicated more satisfaction with his expression and willingly added color to other drawings.

Figure 3.10 Adding color to enhance emotional responding Color version available at http://www.routledge.com/9781032050539

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Next he created a collage of faces portraying feelings as described above in the narrative of Ed. The use of collage was chosen as a nonthreatening introduction to the identification and discrimination of feelings. Subsequently, Steven identified his own feelings through the use of magazine collage images, and he later paired magazine pictures that depicted feelings with his own experience of emotions. The next step was depicting four primary emotions in marker, shown in Figure 3.11. Markers were chosen because, while they are somewhat fluid and capable of evoking emotion, they are familiar and manageable enough to allow for the containment of affect. The emotions depicted by Steven were as follows, from top left, in clockwise order: fear, sadness, anger, and happiness. The image shown in Figure 3.11 was a springboard for several sessions in which feelings were further discriminated through paintings. Following three missed visitations by his mother, Steven created the drawing shown in Figure 3.12 that he named, “Alien.” He described the drawing thus: This guy is an alien; you see, his blood is blue and not red. His heart is upside down. No one loves him. He has super powers to kill. His knife is bloody; he is going to kill. Further exploration led to the discovery that Steven was suicidal. He was hospitalized to ensure his safety, and treatment continued on an inpatient basis where Steven was able to express a combination of emotion and energy in various activities.

Figure 3.11 Steven’s Four Primary Feelings picture. From top left, in clockwise order: fear, sadness, anger, and happiness. Color version available at http://www.routledge.com/9781032050539

The Expressive Therapies Continuum 61

Figure 3.12 Steven’s Drawing of the “Alien” Color version available at http://www.routledge.com/9781032050539

Creating handmade paper and papier-mâché were two activities that led to flow experiences. Steven was challenged by the activities and yet masterful as he worked with the art therapist to create meaningful, beautiful products. He developed a sense of power and control, enjoying the experience and wanting to continue it in subsequent sessions. Like his brother, Steven demonstrated a level of focused activity that was not present at the beginning of treatment and which seemed to indicate that he was in flow (Lee, 2013). After one year of art therapy, Steven left art therapy with a greater sense of self-esteem, a greater understanding of his experiences, and a more complete arsenal of coping skills. Art therapy was successfully conducted in a top-down fashion to help this young client. A top-down approach to the art therapy treatment of trauma is necessary when the client presents in a very cognitively controlled fashion with little access to emotion. The goal of such an approach is to gradually expose the client to emotion in ways that emphasize control and mastery. Art therapy with Steven began with work on the right-hand side of the C/Sy level with Sy material presented both in dreams and in free drawings such as the Castle/House in Figure 3.2. However, image formation and information processing quickly moved to the Cognitive component where he seemed more comfortable creating. Responding to nightmares presented the first opportunity to employ cognitive

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reframing. Steven was able to draw scenes from his nightmares, such as the one in Figure 3.8, and then use drawing materials to make the images manageable. With time the nightmares were eliminated, indicating a degree of emotional control and healing. Remaining on the left-hand side of the C/Sy level, Steven was engaged in the creation of a pictorial trauma narrative with factual drawings that helped him develop a sense of order to and increased understanding of life events (Gantt & Tinnin, 2009; Pifalo, 2009; Talwar, 2007). His avoidance of color and increased attention to detail in the early drawings produced in art therapy probably functioned for Steven as Cognitive strategies to contain emotion. The next step in art therapy was to help Steven transition to functioning on the right-hand side of the ETC (P/A level) in order to integrate the experience of emotion and to establish more conscious control of limbic system processes. Therefore, Steven was first asked to integrate color into his trauma narrative drawings. Interestingly, the color was added in a very structured fashion (see Figure 3.10), and this controlled use of color pervaded his drawing of four primary emotions as seen in Figure 3.11. The controlled use of color demonstrated that Steven was functioning with the P polarity of the P/A level. Increased affect was encouraged through the use of watercolor. Following three failed visits with his mother, Steven experienced overwhelming feelings of rejection and suicidal depression. Art therapy continued as an inpatient with sensory and kinesthetic processing, allowing for the release of tension and the integration of sensation and emotion. Thus, Steven started treatment on the right side of the ETC, then slowly integrated information processing and functions from both sides, ending up at the K/S level. Comparison of Two Brothers: Art Therapy Approaches to Trauma These two descriptions demonstrate that, to achieve equivalent therapeutic results, not all trauma survivors can be treated alike as has been suggested by other approaches to trauma work (e.g., Chapman, 2014). Two brothers who experienced similar abusive situations presented with very different images in their first art therapy sessions. These differences in product indicated differences in underlying brain functioning and preferred information processing strategies. Ed’s traumatic memories were apparently encoded predominantly as sensorymotor memories on the K/S level, indicating predominant encoding in the posterior cortex. Steven’s memories of the trauma were presented as predominantly affective symbolic images on the Sy pole of the C/Sy level as confirmed by his nightmare drawings, indicating the predominant involvement of the limbic system and amygdala. Although therapeutic goals were similar for the two boys, the approaches to art therapy were different. Using the framework of the ETC, a bottom-up strategy was used with Ed. Art therapy began on the left side of the ETC on K/S level, allowing for the release of energy and tension. Therapy then moved up to the P/A level to aid in the

The Expressive Therapies Continuum 63 containment and appropriate expression of emotion and to the C/Sy level to support the integration of new information and skills. In contrast, Steven was treated with a top-down approach that began on the right-hand side of the hierarchy at his initial C/Sy level, worked down to the P/A level to invite contained expression of affect, and finally approached the K/S level to allow release of energy and the thoughtful integration of sensation through creative work involving sensory-motor activity with the S component. Through art therapy both boys integrated the two streams of information processing in the brain as indicated by activity on both sides of the ETC schema. They both experienced the CR level and flow as an important healing component of art therapy. Over the course of one year in treatment the brothers incorporated a more positive sense of self supported by appropriate coping skills and improved interpersonal relationships. They demonstrated increases in focused behavior, mastery, and self-esteem, as well as lengthening periods of attention and concentration indicative of having incorporated flow experiences (Chilton, 2013; Csikszentmihalyi, 2008; Lee, 2013).

Conclusions Art therapy as a sensory-motor and visually based expressive modality addresses two important aspects of therapy with trauma survivors: the integration of the nonverbal sensory-motor-based traumatic memories and the temporal organization of segmented verbal memories. The theoretical concept of the ETC with its three hierarchical levels—Kinesthetic/Sensory, Perceptual/Affective, and Cognitive/Symbolic—provides a structure for the organization and integration of trauma memories in a bottom-up or top-down manner. The three levels of the ETC reflect parallel brain activity in the posterior cortex—specifically the occipital, temporal, and parietal cortices—and the PFC. Another important goal of art therapy with trauma survivors is the assimilation of the different types of information processed by the two different neural systems represented by the two sides of the brain. The left side of the ETC schema performs feature analysis and cognitive integration of incoming information, whereas the right side reflects activity of the stream that attaches an affective value tag to it. The full reintegration of emotional and cognitive information is healing; reintegration appears to occur at diverse points along the prefrontal cortex (PFC)-amygdala-hippocampal network until both types of information processing converge in the dorsolateral and ventromedial areas of the prefrontal cortex (Fuster, 2003). An integrated or whole brain experience might lead to post-traumatic growth and flow in the art therapy treatment of trauma.

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The Image Comes First Treating Preverbal Trauma with Art Therapy Linda Gantt and Tally Tripp

Editor’s Note: Louis W. Tinnin, MD, originally the lead author, died February 21, 2014. This chapter is dedicated to his memory. This chapter describes how art therapy is essential to the treatment of preverbal traumas, illustrated with a case example. We discuss the importance of first processing foundation traumas (those occurring prior to three years of age) before tackling other traumatic events. We believe that recent neurobiology research supports the idea that a nonverbal approach, such as art therapy, is ideally suited for working with early developmental trauma. Our case study demonstrates how a foundation trauma (in this case, a birth trauma) can be quickly and effectively processed in a short time by using the treatment model from Intensive Trauma Therapy, Inc. (ITT), a trauma treatment approach pioneered by Linda Gantt and Louis Tinnin in their outpatient clinic in Morgantown, West Virginia, based on their theory the Instinctual Trauma Response.

Brief History of the Treatment of Early Trauma Trauma treatment has made tremendous strides in the last 30 years. As recently as the 1980s it was assumed that talking about the trauma was optimal for producing a cathartic experience, which was the only avenue for healing. We now realize that talking about trauma can, at best, be a difficult experience, and at worst, be re-traumatizing. Early, severe trauma often results in highly dissociative states that leave the individual with myriad debilitating symptoms, including the inability to connect to feelings. Since the 1990s, coined the “decade of the brain,” there has been increased accessibility to neuroimaging studies, and the resulting neuroscience research has greatly impacted our understanding and treatment of psychological trauma. Important to our work as art therapists, it is a now a widely accepted view that traumatic memory is encoded through visual imagery and bodily sensation, rather than through language or cognition, and that unresolved traumatic memory can severely compromise cognitive functioning (van der Kolk, 2006, 2014). Neuroscience studies provide compelling evidence supporting the utility of a “bottom-up” (nonverbal) rather than “top-down”

DOI: 10.4324/9781003196242-4

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(cognitive) approach for working with traumatic memory. This aligns with our long-standing belief that art therapy is an ideal treatment for trauma resolution and is particularly beneficial for working with early, preverbal traumas. Many contemporary writers have described the enduring effects of the earliest childhood traumas (Gaensbauer, 1995; Karr-Morse & Wiley, 1997; Lipsitt, 2012; Perry & Szalavitz, 2007; Terr, 1988, 1990). In The Trauma Spectrum, neurologist Robert Scaer (2005) offers an entire chapter on preverbal trauma in which he describes the traumatizing effects of modern medical treatment, starting with hospital delivery. Other types of trauma in the preverbal period include being neglected by drug-addicted parents (Burton, 1992), witnessing domestic violence (Bogat, DeJonghe, Levendosky, Davidson, & von Eye, 2006; Fantuzzo, Boruch, Beriama, Atkins, & Marcus, 1997), or being sexually or physically abused (Gale, Thompson, Moran, & Sack, 1988). As recently as the end of the twentieth century, the erroneous assumption that the brain was not mature enough to recognize pain dictated our understanding about early trauma related to birth, circumcision, and surgery (Chamberlain, 1989). It was widely assumed that infants and young children did not experience physical pain and, even if they did, would not remember traumatic events. To this day, many therapists do not routinely assess for early traumas, much less treat them systematically. However, we concur with LeDoux (1996) who suggests that traumatic memory is long lasting, resilient and “. . . an indelible form of learning” (p. 204). The very structure of the human brain is such that traumas are especially enduring if they occur before age three and before the corpus callosum has acquired its myelin sheath, enabling the two hemispheres to communicate (Tinnin & Gantt, 2014). The veracity of early traumatic childhood experiences has been well documented through the landmark Adverse Childhood Experiences (ACE) study, which demonstrates a strong correlation between adverse events in childhood (such as sexual and physical abuse, having an addicted parent, or witnessing domestic violence) and negative health outcomes in middle age (Felitti et al., 1998). Understanding the impact of early trauma and how implicit memories affect the mind and body throughout the lifespan should motivate us to refine our methods of trauma treatment.

Basic Tenets of the ITT Approach The ITT clinic and its affiliated ITR Training Institute provide training and education for Master’s and doctoral level therapists in counseling, social work, and psychology as well as art therapy. The treatment team consists of master’s level therapists, with two or three assigned to each individual client working intensively through each seven-hour day. Clients typically stay at ITT for five to ten days. For the woman whose case is the focus of this chapter, the treatment team consisted of Linda (the first author and an art therapist) and Lou (a psychiatrist) as well as other team members who participated in a few of the sessions. Tally (the second author and art therapist and licensed clinical social

The Image Comes First 69 worker) referred this client to the ITT program, and so supported the client’s work by attending all sessions for the first week, observing the process and assisting with the overall treatment. Rather than using art therapy as an ancillary therapy, as often occurs with other approaches, ITT considers art therapy to be a chief means of treatment. Furthermore, we boldly assert that trauma symptoms can be eliminated, not just diminished, when the source for those symptoms is identified as coming from the Instinctual Trauma Response (see section below). Creating imagery that puts the fragments of a trauma back into the context of a specific event causes these bits that we call mental shrapnel to lose the power to create intrusive symptoms. Although our case example focuses on very early childhood, the procedures and concepts we describe here are applicable for treating any trauma. Our basic tenets for working with preverbal trauma can be stated as follows: 1.

2.

3.

Preverbal traumatic memories are stored in the nonverbal mind. These nonverbal memories consist primarily of body experiences of the animal survival instincts that we call the Instinctual Trauma Response (the ITR) (see the section on the ITR below). These evolutionarily acquired survival behaviors are shared with reptiles and mammals (Gazzaniga & Volpe, 1981; MacLean, 1990; Tinnin & Gantt, 2014). The hardwiring of the human brain means the core of the trauma experience happens outside awareness and beyond one’s capacity for conscious choice. Preverbal memories are blocked from awareness by verbal cerebral dominance and are inaccessible to verbal probes. Nonverbal means such as art and external dialogs can access the memories without the client reliving them. This makes it possible to recover the preverbal traumatic experience and imbed it in a verbal narrative that will provide closure and subsequent storage in long-term verbal memory. The reconsolidated trauma memory is retired when converted to past tense, and the emotional arousal connected to the memory becomes neutralized, no longer able to provoke flashbacks or other intrusive symptoms. In the nonverbal mind, imprints of trauma memory lack narrative structure and therefore lack narrative closure. Preverbal traumatic memory may last a lifetime if not treated. When activated, imprints of trauma or implicit memories may be experienced as occurring in the present (a flashback). Art therapy provides the means to retrieve preverbal traumatic memory and to integrate it in a verbal autobiography. In helping a client construct the graphic narrative (our art therapy technique we describe later), the art therapist provides the necessary structure and linear sequence of the traumatic event. When the graphic narrative is re-presented the client can hear and see that the event is truly history; it is no longer felt to be present tense. Not only is the vertical connection of the right hemisphere’s cortical and subcortical limbic systems restored, but also the way is paved for intrahemispheric communication. The left hemisphere’s obligatory rejection of the right hemisphere’s implicit memories can be overcome.

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Brain Structure and Hemispheric Asymmetries The structure of the modern human brain shows its evolutionary history from its bottom to top and its specialization for language through its left/right asymmetries. In a model originally formulated in the 1960s, MacLean (1990) described the theory of the “triune brain,” which has been criticized by some as being overly simplistic but that we find useful for understanding the basic mechanisms of the brain involved in processing traumatic experiences. The triune brain, according to MacLean, consists of three interdependent regions with various functions: the reptilian (instinctual brain) that focuses on regulation of the body’s vital functioning and homeostasis; the paleomammalian (limbic system), related to attachment and the fear response; and the neomammalian (the neocortex), related to executive function, analysis, and interaction with the external world. Understanding the interconnections between these various regions of the brain and the role of these structures in response to trauma has been extremely valuable for trauma therapists. Also of great significance are the neuroscience studies of the 1980s that produced important work on hemispheric asymmetry in the brain (Gazzaniga & Volpe, 1981; Geschwind & Galaburda, 1986; Sperry, 1985). Such work confirmed a supposition extant as early as the 4th century BC—that the two sides of the human brain have different functions (Ornstein, 1997). According to Siegel (1999), the right hemisphere, for example, is the more holistic of the two, and is connected with the “somatosensory system” including expression of emotion and the nonverbal and bodily processes, whereas the left hemisphere is more concerned with linguistic processing and narrative information. While it is useful to consider the different roles of the two hemispheres when looking at the emotional versus cognitive responses to trauma, for example, overgeneralizing about the left/right brain differences can be overly simplistic (Ornstein, 1997; Siegel, 1999; Springer & Deutsch, 1993). Two contemporary theorists especially important to our discussion are Daniel Siegel, a child psychiatrist (1995, 1996, 1999, 2001), and Allan Schore, a neuro psychoanalyst (1994, 1997, 2001, 2002, 2003, 2009). Siegel was instrumental in developing interpersonal neurobiology, a multi-disciplinary field that combines concepts from mindfulness, attachment, and brain structure/function to give the neurobiological underpinnings of interpersonal experience. Schore has written extensively about affect regulation, brain development, and attachment. Of particular interest is that both authors stress the contributions of the right hemisphere in early childhood development. Siegel (1999) emphasizes that normal brain functions are integrated: “In neurologically intact individuals, the activity of both sides . . . contributes to the functioning . . . as a whole with greater or lesser degrees of interdependent activity” (p. 185). He also outlines some ways different people might deal with the interaction of their hemispheres “in which modes of processing interact with each other cooperatively, interact conflictually, or remain rigidly dis-associated” (p. 179). Siegel also points out the problems of disconnection or inhibition as contributing to certain psychological conditions, including PTSD.

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PTSD and the Trauma Diagnosis By including PTSD as a recognized diagnosis, the third edition of the Diagnostic and Statistical Manual (DSM-III) (American Psychiatric Association, 1980) ushered in the crucial idea that life-threatening external events could give rise to a mental illness. This significant change assumes for the first time that PTSD develops in response to external overwhelming experiences (traumatic stressors) and that the response to these traumatic stressors does not indicate an inherent weakness in the individual. PTSD was originally described as resulting from a one-time, out of the ordinary, severe incident, such as rape, assault, or motor vehicle accident. However, in recent years PTSD has been conceptualized more broadly as resulting from multiple, ongoing traumatic events, such as interpersonal violence, child abuse, and neglect. Additionally, the modern understanding of PTSD is more subjective in terms of what actually can be classified as traumatic. We now assume that individuals will respond subjectively, based on their unique experiences to traumatic events, and that each individual has his or her own trauma threshold. Originally classified as an Anxiety Disorder (DSM IV), PTSD is now considered a Trauma and Stressor Related Disorder (DSM 5), a category including all psychiatric diagnoses that originate with trauma (American Psychiatric Association, 2013). The succeeding years have brought extraordinary gains in research and theory about the origins and treatment of trauma of all sorts (Baldwin, 2013; Blaustein & Kinniburgh, 2010; Chapman, 2014; Courtois & Ford, 2013; Evans & Coccoma; 2014; Kendall-Tackett, 2014; Lieberman, Chu, Van Horn, & Harris, 2011; Scaer, 2014; van der Kolk, van der Hart, & Burbridge, 1995; Yehuda & McFarlane, 1995). Numerous studies now look at physiological responses to trauma. With the advent of magnetic resonance imaging (MRI) and other neuroimaging studies in the twenty-first century, we understand more about the way trauma affects the brain and body. Canadian scientist Ruth Lanius is leading the way in brain imaging of traumatized individuals (Lanius, Hopper, & Menon, 2003; Lanius, et al., 2005; Lanius, et al., 2001). For example, one of her MRI studies shows what happens in the brain when a person has a dissociative experience triggered by the retelling of a trauma (Lanius et al., 2002).

The Dual Brain Tinnin and Gantt (2014) base their theory of trauma treatment on the structure of the human brain and animal survival mechanisms. Their dual brain theory starts with the fact that the human brain is really two separate brains at birth and will remain so until the corpus callosum between them develops its mylenating sheath at approximately three years of age: When the child attains spoken language and verbal thinking, the dominant verbal mind will claim ownership of the whole self and deny the actual duality of mind. However, the right brain contains memory of preverbal

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As Schore explains (2009), before the left hemisphere dominates, the right hemisphere performs the crucial role of developing the emotional self and of forming a secure attachment with a caregiver. If an infant or toddler has traumatic experiences before corpus callosal transmission, then we postulate that more than one latent mental self can develop (Tinnin & Gantt, 2014). Several writers also describe this basic organization of the brain as having two major functional components. British psychiatrist C. S. Myers (1940) used the terms “apparently normal personality” (ANP) and “emotional personality” (EP) to describe soldiers he treated with shell shock, as he noted a division between the normal and emotional parts of the personality. These traumatized individuals were noted to be “stuck” in their trauma, recurrently experiencing its overwhelming sensorimotor effects, unable to create a cohesive, narrative memory. More recently, van der Hart, Nijenhuis, and Steele (2006) expanded the idea of ANP and EP in their theory of Structural Dissociation. They propose that the ANP part of the personality, which seems to function normally, has failed to integrate the traumatic experience and is essentially dissociated from the overwhelming, traumatic memory. The EP, on the other hand, holds and experiences the traumatic memory and acts defensively and emotionally to protect the person from a perceived external threat. The EP can intrude upon the ANP and may food flood the system and disrupt disrupt functioning functioning (Nijenhuis, (Nijenjuis, van der Hart, & Steele, 2004). A crucial influence on such latent mental systems can come about due to the ITR.

The Instinctual Trauma Response The ITR is postulated as a universal response to overwhelming, life-threatening events (Tinnin, Bills, & Gantt, 2002; Tinnin & Gantt, 2014). The fundamental components of the ITR are the following: the startle, the thwarted intention to fight or flee, the freeze, an altered state of consciousness, automatic obedience (animal submission), and attempts at self-repair. A person may face a potentially traumatizing situation, but if he/she is successful in fighting off an attacker or escaping, the freeze will not occur and the body naturally initiates a fight/flight response via stimulation of the sympathetic nervous system. However, at times the person (or animal) is not able to fight or is unsuccessful with flight, and in such situations, the freeze response is the last hope for survival. Sometimes a predator loses interest in the frozen prey, but there is a cost to pay. Even if the person survives the attack, there may be traumatic memory and fear in the system that is not adequately discharged or processed. In these situations, when the person is rendered helpless over the fearful situation, he or she falls

The Image Comes First 73 into an altered state of consciousness. Those who experience such peri-traumatic dissociation are more likely to develop PTSD. In the ITR, the explicit and implicit memories of the event become dissociated, and symptoms including affect dysregulation, depersonalization, derealization, numbness, and amnesia are common responses. In the dual brain theory we stress that the ITR is not a strategy that involves an active choice but is an evolutionarily acquired survival mechanism. For example, if an individual could use thinking to avert a trauma, such as successfully hiding from an attacker or swerving to avoid an oncoming car, then the person might be temporarily shaken. However, this would not likely result in a post-traumatic state. If, on the other hand, the person were trapped and/or unable to activate a sympathetic nervous system response to that traumatic stressor, the body would naturally go into a parasympathetic state of freeze and the cascade of the rest of the ITR would occur. Dissociation, a response to overwhelming trauma, has generally been characterized as a defense mechanism and a final survival response to life-threatening events. We see dissociation as a brain process that ensues when the verbal brain goes off-line, agreeing with Meares who states, “dissociation, at its first occurrence, is a consequence of a ‘psychological shock’ or high arousal” (1999: 1853). According to LeDoux (1996), this process favors the “low road” from the sensory input of the thalamus to the amygdala because it is much faster than the “high road” to the amygdala through the sensory cortex. Similarly, Schore sees dissociation as “the loss of the integrative capacity of the vertically organized emotional right brain” (2009,: 126). We propose that the rather recent capacity for language (that is, recent in terms of human evolution), housed in Broca’s area in the left parietal lobe and Wernecki’s area in the left temporal lobe, constitutes what Tinnin and Gantt call the “quadrune mind” (2014). This quadrune mind “includes verbal consciousness as the uppermost and most recently acquired part” (Tinnin & Gantt, 2014: 22). [It is important to note that analogous structures in the right neomammalian part of the brain can also develop language under certain circumstances such as severe brain damage to the left side that occurs before a child reaches puberty.] During trauma, the language centers and triune brain (MacLean, 1990) fail in reverse order of their evolution. If one cannot think one’s way out of a potential trauma, then animal instincts take over. The autonomic nervous system links the major organs of the body via the large vagal nerve. According to Porges’ (2011) polyvagal theory, the ventral vagal complex of this nerve controls the social-engagement processes that are higher-order functions. However, life-threatening situations interfere with these functions and disable the verbal brain. The organization of the right hemisphere is such that it responds to any stimuli more quickly than the left (Buklina, 2005), calling upon the fight/flight instincts of the paleomammalian brain. This is mediated by the sympathetic nervous system. However, when fight/flight does not work, the reptilian parasympathetic vagal system (the dorsal vagal complex) is evoked

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(Porges, 1995, 2011) resulting in a state of freeze or collapse. The dorsal vagal complex is the most primitive part of the nervous system.

Trauma Processing According to the Dual Brain Theory We contend that a complete trauma resolution must restore the vertical integration of the right brain and complete the process with a visual and verbal narrative newly stored in the frontal cortices. According to Schore (2009), vertical integration of the right hemisphere results in access to affective states, regulation of arousal, and coordination of perceptual processes. The trauma processing is complete when the whole brain can see that a specific trauma is undisputedly over. Treating Foundation Traumas First A foundation trauma is not simply a trauma that occurs during the preverbal period but one that sets the stage for later life. Like a house made of bricks, the cracks that originate in the walls are akin to the problems (e.g., symptoms) therapy routinely addresses. Such damage may be clearly observable and seem relatively easy to repair. However, those that actually begin in the foundation are “below grade” and invisible. So it is with early trauma. Such damage cannot be completely repaired if the actual source of the damage has not been found. Also, once foundation traumas are processed it is then easier to address subsequent ones. How does one know one might be dealing with foundation traumas? In general, the symptoms are ones that have been associated with what had been termed neuroses, or diagnoses such as borderline personality disorder or avoidant personality disorder in previous editions of the DSM. Lifelong features such as having chronic anxiety, emotional outbursts, depression, indecisiveness, unstable moods, difficulty in relationships, impulsiveness, problems regulating affect, toggling between intense love and intense hate for another person, feelings of emptiness or boredom, extreme responses to actual or perceived abandonment, or lack of self-worth point to the possibility of foundation traumas. Several important studies on borderline personality disorder come to the same conclusion that people with this disorder have histories of early childhood trauma (Herman, Perry, & van der Kolk, 1989; Ogata et al., 1990; Shearer, Peters, Quaytman, & Ogden, 1990; Westen, Ludolph, Misle, Ruffins, & Block, 1990; Zanarini et al., 2002). Gathering a thorough trauma history including information about the prenatal period and the climate of the household is vital in the screening process.

Description of the ITR Model The essential components of our treatment are the graphic narrative (GN), the re-presentation of the GN, and the externalized dialog (ED). Each trauma is

The Image Comes First 75 processed using the same techniques in the same order. Generally, the client deals with the traumas in chronological order, starting with the foundation traumas. The Graphic Narrative and Its Re-presentation The GN is a structured series of drawings based on the ITR. The ITR encompasses what we hypothesize to be a universal response to overwhelming trauma. The minimum drawings should be: a Before and an After scene, plus one for each of the ITR components (the startle, the thwarted intention of fight or flee, the altered state of consciousness, the automatic obedience, and the attempts at self-repair). It is helpful to put the body sensations in each picture, but a client can also make a separate drawing just focusing on those sensations. Other pictures can be included in the GN, such as a transition drawing showing a change of location, a map picture showing the environment of the event, and a zoom picture depicting important details. By using the ITR as the outline for processing a trauma story, a client can likely capture those implicit memories that are the raw material of flashbacks and other intrusive experiences. As Scaer states, “. . . the trauma victim indeed is at the mercy of the whims of the limbic system and reptilian brain that periodically interrupt the functions of the thinking brain” (2005: 270). We have found that these interruptions (or triggers) are fragments of specific events. When they are put into context in a GN and thoroughly processed with the representation, such triggers cease to generate overpowering intrusive responses. The GN not only provides structure but also affords an opportunity for psychoeducation since it is based on the ITR. Although there are variations, all traumatic events meeting the DSM-5 criteria will have the basic ITR components. Fundamentally, all the components are nonverbal and based on the body’s responses to a life-threatening event (whether experienced firsthand or seen in another person). The re-presentation part of the process truly brings the trauma to a close. Unlike with most art therapy processing in group or individual sessions during which the artist tells about a picture, in our method it is the art therapist who repeats the story to the client in the re-presentation. The pictures are displayed in temporal sequence on the wall, and the art therapist tells the story as the client has recounted it during the process of drawing. Importantly, the art therapist does not provide any interpretation or commentary. Some dramatic elements can be used, such as pitch of voice, pacing, and repetition. However, the task for the therapist is to give back the details in a linear sequence, showing that he or she truly heard the story and confirming that the traumatic event is indeed over. The Externalized Dialog After a GN is completed and re-presented it is time for an externalized dialog (ED). The externalized dialog is similar to the Gestalt therapy process of the

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empty chair (Perls, 1969) in that the focus is an exchange between a person and an imagined entity. However, in the ED, the participants in the exchange are the parts of the client. As van der Kolk says, “A part is considered not just a passing emotional state or customary thought pattern but a distinct mental system with its own history, abilities, needs, and worldview” (2014: 281). The concept of internal parts can be traced back to Jung and Freud. Contemporary practitioners of this are Richard Schwartz (1995) and Nijenhuis, van der Hart, and Steele (2004). The set-up of the ED is quite simple, and there are several useful variations depending on the age and preferences of the client. Originally, we used a video dialog in which the client spoke into a video camera to record one part and then watched the replay, before responding for another part. Changing the view from a wide-angle to telephoto focus made the replay a dramatic conversation between older and younger parts of the client. Puppets, drawn portraits of the parts, and sculptures can be used instead of actual video footage of the client. The entire videotaped dialog can be viewed so that it flows, as would a conversation between two people. The written version of the ED is quite portable and easy to teach. Writing paper and pens in at least two different colors of ink or thin-tipped markers are the basic supplies. The guidelines are also simple: Take turns, do not interrupt, and use complete sentences. The first two of these can be quite difficult for those who are highly dissociative and have multiple streams of consciousness that compete for attention. The client is asked to use the dominant hand in making a written invitation to that part with which he/she wishes to talk. Then the client switches hands and the color of ink or marker to reply on behalf of the part. Here we are using the concept of a “part” as Schwartz (1995) does in his Internal Family Systems work. It is common for a client to be uncomfortable with the writing task and possibly find using the non-dominant hand extremely difficult, but an initially negative response should not be a deterrent. In fact, a strong response (even if it seems negative at first) is often a good prognosis. Clients tend to be intrigued when they are told about the hardwiring of the hands to the opposite side of the body from the two hemispheres (of course, it is not as simple as having only one half of the brain control the other side of the body because there is some enervation to the same side as well). However, many clients have been surprised to experience the non-dominant hand writing responses that are totally unexpected but are revelatory, wise, supportive, or challenging.

The Verbal Brain’s Inhibition of the Nonverbal Brain At about age three, a child’s corpus callosum develops the myelin sheath that enables it to transmit information from one hemisphere to the other. Once this happens, one hemisphere (almost always the right) must yield. As Siegel (1999) states,

The Image Comes First 77 Although certain functions appear to be specialized in each half, the normal functioning of the mind involves ‘cross-talk’ between the two sides of the brain. The connecting tissue between the hemispheres appears to be important for both mutual activation and inhibition of corresponding (‘homologous’) cerebral centers on either side of the brain. (pp. 178–179, emphasis added) This inhibition results in the verbal brain claiming ownership of the whole brain. The result is that material from the right nonverbal brain, particularly implicit processes and memory, is kept from being accessed. Yet the right brain has the capacity for communicating in ways other than words. Many art therapists have experienced a client saying, about an emerging image, “I don’t know where that came from!” Art therapists, however, do have insights about the origin of surprising material. According to Tinnin, “The nonverbal mind is able to gain output that bypasses the censorship of the verbal system in the left hemisphere primarily by means of the autonomic nervous system but it also attains output by motor and symbolic expression” (1990: 11). Furthermore, “because art records and permanently displays the artist’s nonverbal message, it can protect the original emotional communication of the artist from obligatory censorship or disavowal of the artist’s conscious mind” (p. 12).

An Empowerment Model for Recovery from Trauma In her research for The Drama of the Gifted Child (1979/1981), Alice Miller spoke to many adults who had been abused and neglected in childhood. Her prolific writings described the emotional cruelty of poisonous pedagogy (her term for society’s maltreatment of children in the name of supposedly enlightened parenting) (1981/1984, 1980/1990a, 1988/1990b). Miller’s own healing from preverbal trauma depended solely on painting and writing even though she had had a training analysis. Her Pictures of a Childhood (1985/1986) should be required reading, not only for art therapists, who already know the power of art and nonverbal expression, but for anyone seeking to communicate with and understand the child that he or she once was. Miller recounted her discovery that she suffered from severe toilet training: “When I was thirty-three, my mother told me that at the age of five months I no longer wet my diapers” (1985/1986: 10). Miller tells her story through this fascinating book, which presents 66 full-color reproductions of her spontaneous art, offered without commentary or titles. She wanted readers to make their own discoveries. This is the best published example we have found thus far that parallels the therapeutic process we describe in our case. Because she advocated the perspective of the child, Miller was interested in the gentle methods of childbirth championed by French obstetrician Leboyer (1975/2009). Of traumas in the first hours of life, Miller said, “So-called difficult, ‘insufferable’ children have been turned into such by adults. Not always by their

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own parents: Obstetrical and postpartum practices in many hospitals are often the first to contribute in large measure to this process” (1988/1990b: 191). Miller eventually resigned from two psychoanalytic associations since she could no longer support the basis premises of her profession. She felt that psychoanalysts upheld the tenets of the poisonous pedagogy, siding with parents who controlled children with threats and emotional domination, leaving them with no one who truly witnessed their psychic pain. Miller’s first-person account vividly shows that it is possible to access the emotional right brain that Schore (2009) describes. Having such access, either by silencing the left hemisphere or by drawing and painting, makes it possible to do much of the work of recovery on one’s own. In Miller’s work, her art was a resource and a powerful vehicle for expressing the inexpressible. We find this holds true for many traumatized clients. Therefore, we consider our approach to be an empowerment model that lasts far beyond the formal therapy sessions.

A Case Vignette Following is a case of a woman who was able to use intensive trauma therapy to access and integrate preverbal trauma experiences using a structured, traumasensitive art therapy approach. Prior to beginning this trauma treatment, the client had greatly avoided dealing with her traumatic past, a behavior consistent with her PTSD diagnosis. We contend the ITR process facilitated a means to actively uncover and face the feared traumatic material and find successful resolution. Kim (a pseudonym), an attractive, well-educated, professional woman, was 37-years-old when we began to work with her preverbal trauma. She was referred to Tally for art therapy after many years of conventional psychotherapy that both Kim and her previous therapist felt was no longer progressing. At the time, her therapist was dealing with a chronic medical illness that resulted in long breaks in treatment, often with little advance notice, which negatively impacted the frame and consistency of the work. Kim depended heavily upon this therapist, so the physical disruptions in their relationship were extremely destabilizing. Ultimately, referring Kim for art therapy was partly to deal with the preverbal trauma that had never been addressed and partly because of inconsistency of the therapeutic relationship. Kim needed to develop trust in her relationship with Tally before she could effectively use art therapy to explore and express her feelings. At first, Kim was quite guarded and actively avoided making art in sessions, instead focusing on staying safe, managing her feelings, and keeping psychologically grounded. Focusing on words and intellect was a way she could maintain a comfortable distance, as she may have felt more vulnerable in the realm of nonverbal expression. Clients who have experienced developmental trauma often experience great difficulty with affect regulation and may not have developed a consistent sense of self. Kim varied extremely in her ability to be present in the session and in managing the relationship with Tally. She looked to Tally to gauge her own

The Image Comes First 79 self-state, by making Tally the object of desire. For example, Kim vacillated between states of overwhelming yearning for Tally’s “love” (wishing to be a child and sit in Tally’s lap or go home with her) and states of immense rage and disappointment toward Tally for some perceived slight or lack of attunement. These states could arise suddenly, at any time. If Tally were to look down or look away from Kim, even for a second, Kim could perceive this as a rejection. Kim would ask, “Are you looking for something?” or “Is it time for me to leave?” demonstrating her extreme sensitivity and ambivalence toward relationships as well as her fear of abandonment. Tally strove to be fully present and engaged in sessions, in what Daniel Stern describes as the “present moment” of experience (2004). On the other hand, it was necessary to remind Kim at times that she was, in fact, an adult client and not Tally’s child; therefore, Tally would not be taking her home. Perhaps in an attempt to better manage the feelings about the relationship, Kim would spend sessions asking Tally specific questions so she could “know what Tally was thinking.” When Tally did not immediately answer these questions or reveal a lot of personal information, Kim would seem to freeze and go blank, not knowing how to respond, stating that she could only know more about herself through Tally’s eyes. Clearly, therapeutic boundaries were difficult to manage. Boundaries became even more problematic when Kim googled Tally in an effort to discover more about her, which resulted in uncovering some personal photos and other information on the Internet. On the one hand, Kim was proud of her detective work to discover more about her therapist, but at the same time, she was considerably ashamed when her neediness became overwhelming and resulted in the desire to knock on Tally’s front door (which she discovered in this search). Kim’s attempts to forge some kind of special relationship with Tally seemed to be based on parental transference issues since either a cold/aloof mother or a demanding/inappropriate father were her most significant role models. Kim also used her intellect in an attempt to connect with Tally. She read voraciously from the trauma literature, bringing in numerous books and notes on trauma theory in hopes of discussing aspects of her case. There were two probable reasons for her verbal/left brain/defensive focus in the early sessions. First, she felt generally unsafe with interpersonal interactions and believed that she could keep a safe distance if she focused on her therapist or determined what her therapist expected from her, and second, she needed to maintain an intellectual defense against the unbearable grief and traumatic stress that she held inside. This was also a grief for which she had no words. Kim was quite certain that she had experienced early preverbal trauma, but her memories were diffuse, consisting mainly of vague, unsettling somatic body sensations and intrusive imagery. She reported having frequent flashbacks and intrusive thoughts, experiencing feelings of depersonalization and derealization, and seeing unsettling, frightening, and often sexual images in everyday things. One particularly disturbing memory came from a dramatic, all-black image she drew called “Mother’s Crotch.” In the center of the paper is a “Y” shape with the three points of the “Y” touching the edges of the paper, done in heavy strokes

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of pastel. On either side of the “Y” are somewhat lighter applications of black, giving the suggestion of looking at a close-up of a woman’s genitals and the tops of her legs. This powerful image emerged spontaneously and seemed to represent a traumatic birth story, triggering further feelings about early neglect and abuse. Kim also had some explicit recall of sexual play that occurred between the ages of three and five with her brother and other children, as well as at least one incident of sexual abuse by a teenage male babysitter when she was eight. This incident with the babysitter was later reported to her mother who minimized its impact, stating, “Well, it was not your fault,” and then walking away, thereby urging Kim to move on. Further sexual trauma occurred in an early adult relationship when Kim was victimized in a relationship with a controlling boyfriend. Kim’s parents were fundamentalist Christian ministers; her upbringing was strict and without demonstrated affection. Kim felt particularly pushed away by her narcissistic, self-involved mother and believed she was a burden to her. Her father, on the other hand, spent more time with Kim, making her feel special but inappropriately so, as he would take her out to show her off or buy her clothes and behave in a sexualized way that was confusing. Growing up in a family where neither parent was appropriate or available, where boundaries were either too rigid or too loose, Kim spent most of her childhood trying to manage, attempting to blend in without disrupting the balance. In describing her experience with her family she once said: “I evaporate and meld into what they expect me to be, so I can blend in. I become tall, thin, and intelligent, whatever they need so that I can match up with what they expect. Camouflage––that is my first language. It is what I do best.” Themes of not being seen, heard, validated, or comforted permeated Kim’s early life story. For example, she recalled a traumatic memory from age 4 when she choked on a piece of spinach and believed she was going to die. The terror she felt from her father’s lifting her upside down by the heels and shaking her vigorously until she threw up, and of her mother’s backing away from the scene, without comforting her or even explaining what had happened, resulted in conflicts for many years around eating, throwing up, and feeling unsafe and out of control. Kim coped by building a wall between herself and others. She had disconnected from her parents and brother, based on unresolved feelings about her early childhood trauma and neglect. Her emotional life was quite constricted; she was inflexible and rigid. Avoiding expressing needs and feelings, she was extremely uncomfortable in social settings and had no real friends. At the start of treatment, Kim had been married for about five years to a kind but passive man with whom she was unable to have any kind of sexual relationship. Interestingly, this lack of sexual intimacy did not bother either of them. While her external appearance was neat and polished, Kim’s internal state was highly anxious and agitated. She could get to her high-pressure job on Capitol Hill most days because there was a clear expectation and structure about it, but coming to therapy proved to be more challenging, probably because it was less

The Image Comes First 81 structured and required introspection. In her therapy sessions, Kim preferred sitting on the floor to sitting in a chair, and so spent many sessions in this child state, seated on the floor, where she seemed most comfortable. She was not forthcoming with feelings or ideas, but would defer to Tally, often asking Tally to discuss what she was noticing or what theory she was using. In this child state, Kim believed that anything that Tally could offer would be helpful because she, Kim, was so diffuse in her identity. The work of finding a self truly began when Tally did not fully gratify Kim’s wish to have the theoretical base explained or to be told who Tally thought Kim was. Instead, Tally encouraged Kim to be patient and curious about the process and to believe that she would eventually find the answers within. This belief came from the assumption that a more adult self-state would eventually find a way to be present and offer some answers to move the process forward. Early Art Work: Smearing, Primitive, and Unformed Kim’s early art therapy consisted of experimenting with the materials and dealing with the process of not knowing. Like a child’s art works, many of Kim’s early expressive pieces were blended, smudged non-representational pictures with layers of color and no distinguishable form. The smearing was done in a regressive state, and Kim often seemed to dissociate while layering her preferred medium, chalk pastel, on the page. The process of creating seemed to give her some pleasure and often resulted in messy hands, fingerprints, and chalk dust everywhere. Preparing for Intensive Trauma Therapy Kim saw Tally once or twice per week in art psychotherapy for about two years, during which time she finally moved from the regressive child state toward an increasingly adolescent or adult one, although there continued to be variability in her dependency and feelings toward Tally. Judith Herman’s groundbreaking book Trauma and Recovery (1992) outlines a three-phase model of “safety, remembrance and mourning [trauma processing], and reconnection” (p. 156) that has become a model for sequencing trauma treatment. Together Tally and Kim accomplished some of Herman’s important Phase one treatment goals especially working on the extremely difficult task of developing a trusting therapeutic relationship in which there were simultaneously firm boundaries and consistency. Tally navigated a sensitive transference line of being perceived at times as the cold, distant mother and, at other times, as the inappropriate, demanding father. It was clear that working with years of developmental trauma would require a solid base, especially since so many of Kim’s memories were implicit ones that had no explicit verbal recall. Gradually, Tally was able to help Kim find a more curious, adult stance and look inward to gain some access to her hidden emotional life.

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Experientially based art therapy ultimately facilitated this process; the artmaking became expressive, and Kim discovered freedom and joy that she did not get from other parts of her life. At this time Kim also began taking art classes and joined a Survivors of Incest support group. However, the biggest change in her life came just months before Tally recommended more focused trauma work. Kim quit her high-pressure full-time job and found work as a professional dog walker. This meant a substantial salary loss and significant changes in her lifestyle. Despite Tally’s initial reservations, this proved to be the right decision for Kim. The relationship she was able to develop with animals was overwhelmingly positive. They were unconditional in their loyalty and love. Furthermore, she engaged with them in a form of “limbic regulation,” a term coined by Lewis et al. to describe the life-sustaining way that pets and their owners can read each other’s emotional cues, be comforted and soothed by one another, and even regulate one another’s physiology (Lewis, Amini, & Lannon, 2000: 98). This theory also has been authenticated in studies that show that people with pets not only feel better but live longer. The therapeutic work deepened when Kim brought in video clips of the animals, showing Tally vignettes of her happy interactions with her pets and demonstrating her ability to experience an emotional connection. Sharing these videos provided a nice vehicle through which Kim could be attuned to and seen. At this point Tally felt Kim was ready to do some of the Phase two trauma work and address the early issues that were at the core of her interpersonal struggles. Linda and Lou, lecturing at the university art therapy clinic that was a training clinic for Tally’s trauma classes, agreed to see Kim as a teaching case. Based on her history, all three felt Kim might be an ideal candidate for intensive trauma therapy. Assessment Process Tally provided Kim’s medical, family, and treatment histories. Kim filled out the following paper-and-pencil assessments required by ITT: • • • • • •

Toronto Alexithymia Scale (TAS) Impact of Events Scale (IES) Symptom Check List 45 (SCL-45) Dissociative Experiences Scale (DES) Trauma Recovery Scale (TRS) Dissociative Regression Scale (DRS)

These assessments are used to determine the Trauma Profile. Publication information and brief descriptions of these assessments are included at the end of the chapter.

The Image Comes First 83 Screening for Dissociative Regression The Trauma Profile is administered for initial screening and for post-treatment follow-up at one week, three months, and six months. The DRS is the most crucial one for pre-treatment screening because it assesses basic ego functions that must be intact if a person is to be capable of beginning trauma therapy. If a client has dissociative regression (for example, has a disturbed sense of time or has difficulty with volition), ITT requires that therapy be postponed until the regression is reversed. ITT has an anti-regression regimen that is effective in addressing this temporary problem. Making certain that the potential client does not have dissociative regression is analogous to Herman’s (1992) first phase of trauma treatment. Trial Treatment with ITT Methods In the initial ITT session, we worked for an entire day with Kim to explore a GN, with Linda leading the sessions and Lou and Tally assisting. This session cemented our belief that Kim would greatly benefit from the ten-day intensive treatment program at ITT. This session at the university clinic was patterned after the sessions on the first day in an intensive treatment. Since Tally had already provided her with basic material about the ITT program, Kim was well prepared for the intensive trauma processing experience where she revisited her birth trauma. Kim’s Graphic Narrative To begin the session, as he described a normal vaginal birth, Lou showed Kim a handout on the components of the ITR. Then Kim modified the drawings in her GN to fit the circumstances of her own birth—the experiences of labor, birth, and delivery and the first moments of human consciousness. Although we are not claiming that Kim actually recalled the explicit events of her birth, we do believe that birth is a first traumatic experience for everyone, and particularly for individuals where secure attachment is lacking; therefore, we assert it is necessary to review the birth story. In the graphic narrative, clients are invited to imagine the experience of birth, using what they know about their parents, their circumstances, and the setting where they were born. Kim’s drawings show each of the components of the trauma response on separate sheets of 12” x 18” paper. The series begins with a Before picture to set the stage and an After picture to show, once and for all, that the event is over. Putting body sensations and thoughts and feelings on each page completes the GN. Kim added her drawing of “mother’s crotch” into the series. Kim described this as a “horrifying, terrifying image” that she believed to mirror herself in her newborn state, undifferentiated from her mother. Kim’s drawings were abstract but extremely effective in depicting her subjective experience of feeling the pressures of her mother’s labor. The structure of the ITT approach seemed to

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offer Kim a way to map the events in some sort of order, which was different from the diffuse stories, so overwhelming and confusing, that she had been unable to address previously. Kim’s Response to the Re-presentation—“I’m Pink, Not Black” After Kim finished her GN we taped the drawings to the wall in sequential order to prepare for the re-presentation. As Linda, who was standing, explained the process to be used, Kim stopped her, saying, “You just became my mother!” Kim identified that Linda’s standing up and “teaching” sparked her negative response. Fortunately, Kim was content with having Linda sit down while doing the representation, thus returning Linda to the role of therapist. Linda told the story of “About-To-Be-Born Kim,” using as many of Kim’s comments about her drawings as possible. A typical ITR processing of any trauma story provides several passes over the content: the client’s general description of the event in preparation for processing, guided imagery (an option), and the drawing of the GN. The task for the therapist is to stay as close to the client’s material as possible but also to weave into the story the elements of the ITR, especially the nonverbal aspects of the body sensations that accompany it. In the middle of the re-presentation Kim pointed to one of the darkest drawings and emphatically said: “That’s me! That’s what I see to be me— instead of looking into my mother’s eyes and seeing her, I see me. That’s the me!” She had an extraordinarily important insight that the black drawing was not, in fact, a reflection of her, but of her mother. In what seemed to be an instant, Kim’s fundamental assumptions about herself began to change. She saw for the first time how she had entered the world as a pure, “pink” baby, with potential and without evil. The Externalized Dialog Following the GN and re-presentation, Kim was instructed to create a written version of the ED. The following is her dialog between the dominant (DH) and non-dominant (N-DH) hands: DH:

Hi Newborn Kim. I heard your story today and saw what you saw. Is there anything else you want me to know today? N-DH: I like pink. DH: Was there more of you inside before you came out? N-DH: I was pink and everywhere. DH: There were lots more fingerprints behind where you were born. Was that all you too? N-DH: Yes, I had our fingers. [After some coaching and getting some reassurance that she was doing the ED “right,” Kim resumed the dialog.]

The Image Comes First 85 DH:

Hello again Newborn Kim. I will keep trying to write with you— so we can see each other better. N-DH: OK. Kim’s positive (and seemingly immediate) response to the ITT processes boded well. She could see for herself that the idea she was evil and damaged came, not from her own sense of self, but from her mother’s projections onto Kim at birth. In the ITT program it is not uncommon for the first story to provide a theme that encapsulates a person’s trauma history and sets the stage for the work to come. Intensive Therapy at the ITT Clinic About six months later, Kim agreed to participate in two weeks of intensive trauma therapy at the ITT clinic in Morgantown, West Virginia. The goal was for Kim to work on the issues she had begun to address in outpatient therapy and gain more information about her preverbal trauma experiences. As part of her training in ITT methods, Tally supported Kim’s work during the first week. Externalized Dialogs with Warthog We invited Kim to select several stuffed animals or puppets from ITT’s wellstocked playroom to use in the ED process. Kim had used her own stuffed animals for a resource in the earlier session at the university clinic, so we felt puppets would be helpful as a projection of parts of self. Kim immediately eyed the warthog puppet that was “so ugly she was cute.” Although she also used other animals, Warthog was clearly her favorite. We came to understand that Warthog was the tangible representation of Kim’s preverbal self. In her EDs Kim showed exquisite concentration and emotional intensity. She would position a pad of paper in front of her on the table and place Warthog in her lap so she could peer into Warthog’s eyes. Aside from the initial instruction about the ED and some occasional coaching when she got stuck, the therapists said little in the sessions, instead playing the role of “enlightened witness” (Miller, 1988/1990b). Figure 4.1 shows the beginning of the first dialog. It is a meet-and-greet that is reminiscent of a young child showing him/herself to a new adult. Kim’s statement (“I felt what you were feeling yesterday and I know that it was all encompassing and bad”) refers to a preverbal trauma processed the day before. Figures 4.2 through 11 are presented as they occurred in the dialog process. It is tempting to try to determine more of the specific content of Warthog’s responses (just as one would like to do with Miller’s watercolors). However, we contend that what is most important is the communication between the hemispheres, which allows the preverbal experience to be expressed and responded to by internal parts within the session. In a discussion of communicating with her “almost autistic” inner child, Miller stated, “I give her [the child within]

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Figure 4.1 “Hello, Warthog” Color version available at http://www.routledge.com/9781032050539

Figure 4.2 “Fear and confusion” Color version available at http://www.routledge.com/9781032050539

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Figure 4.3 “It doesn't make sense” Color version available at http://www.routledge.com/9781032050539

Figure 4.4 “A mouth crying” Color version available at http://www.routledge.com/9781032050539

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Figure 4.5 “What was it like for you?” Color version available at http://www.routledge.com/9781032050539

Figure 4.6 “That's a huge help, Warthog” Color version available at http://www.routledge.com/9781032050539

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Figure 4.7 “They included you!” Color version available at http://www.routledge.com/9781032050539

Figure 4.8 “Thank you for showing me” Color version available at http://www.routledge.com/9781032050539

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Figure 4.9 “I hear that you are telling me something” Color version available at http://www.routledge.com/9781032050539

Figure 4.10 “The inappropriate feeling became you, and you had nowhere to go” Color version available at http://www.routledge.com/9781032050539

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Figure 4.11 “Thank you, Warthog. This is so much to share!” Color version available at http://www.routledge.com/9781032050539

what she never had before: the supportive presence of an adult who takes seriously what she has to say instead of dominating her with platitudes and destroying her creativity” (Miller, 1985/1986: 17). In our approach, while there is less emphasis on interactions between the therapist and the client, we highlighted the significance of the implicit right brain to right brain nonverbal communication that seems to promote healing. This is the kind of support that Kim needed—to be witnessed by adults who viewed her seriously and to simultaneously discover the adult self-state who could also fill that role. Kim’s Response to the ITT Experience Using the GN process, Kim addressed several early traumas, but most of the work in the two-week intensive program involved EDs. Kim successfully completed the program and continued in outpatient therapy with Tally. The experience in West Virginia facilitated a vast shift in the way Kim saw herself and the way she trusted her internal processes and nonverbal experience. In describing the GN in a post-treatment interview, Kim remarked: “The graphic narrative made it [the trauma] something you could look at . . . Before, it was just a feeling of chaos and confusion that didn’t know it had a place or a source. It [the GN] calmed a fault line at the very base of me.” She added that before the intensive therapy, she would “fall through” such a fault line. This was a beautiful description of repairing a foundation trauma.

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Kim has continued to progress greatly in her outpatient therapy with Tally. After ITT, she left her dependent relationship with her husband because, upon her return, she found he would not listen to her and stated he was not able to believe her story about the early trauma. Kim decided she needed to be with people who understood her and believed her story. Kim discovered new strength of self-awareness that probably would not have happened, and certainly not as quickly, had she not done the intensive work on the foundation trauma. The puppet Warthog gave Kim critical information to help her heal and to deal with that information without becoming destabilized. Even without the dayto-day relationship with her husband, Kim was noticeably stronger, more functional, and less easily triggered. Eventually she established some friendships and sought out a new community through church and other activities. Although feelings of anxiety continued to come and go, she felt “prepared” and believed that living on her own was “not as scary” as she thought it might be. In describing the art therapy process and her experience at ITT, Kim stated: It [the experience] is coming from inside the client. Art is creating a language on paper and making it make sense. As I do it, it becomes something that makes sense. I can tell a story. So the process of doing it accesses information that is projected into the picture, and then it becomes real. Warthog—she expressed a bunch of scribbles that meant something— [my] left hand and Warthog had no words. Follow-up on the Case: Two Years Later Two years after the ITT experience, Kim continues to work with Tally in outpatient therapy. Warthog made the transition with Kim back to her apartment, coming to therapy sessions occasionally in the beginning, but currently the puppet is not needed. Kim continues her work as a dog walker and has been promoted to a staff position at the dog day care center. She has made some meaningful friendships and still loves working with the animals and their owners. Kim has made many changes. She now lives her life in a much more adult state. Rarely do we encounter the rigid, anxious, and shut-down version of Kim that was initially fearful, defensive, and so focused on Tally that she was unable to engage in the present moment. Today, Kim is much more open and resilient; she is increasingly flexible, able to manage in relationships, more grounded in herself, and self-assured. After a year’s separation from her husband, Kim resumed the relationship, and the couple has been working on intimacy and on trusting each other. In a clearly adult state, Kim stated that she prefers keeping the couple’s work separate from her individual therapy with Tally, because in her individual work she wants to continue focusing on the foundational issues of the trauma without taking time away to address what is or is not happening in the marriage. Uncovering and resolving the early trauma appears to be her focus, and this seems reasonable. Also, she seems to understand that her husband

The Image Comes First 93 may never really comprehend the issues that she has begun to put behind her. She believes that once the preverbal trauma is resolved, whether that means she consolidates memory or just attains the perspective that it is truly over and in the past, then the relationship with her husband will also improve. In therapy, Kim and Tally are actively processing the early traumas, using the GN and external dialog as well as other Phase two trauma treatment approaches. Each re-visioning of early experiences seems to lay down new neural connections and strengthen Kim’s resiliency and sense of self. Kim has approached this phase of her treatment with renewed commitment and courage. She is curious about the early traumas and is willing to address these issues directly. She recently stated that she was not sure if she would ever know the entire truth behind these preverbal experiences, but that she feels much more able to live life as a complete person knowing that her story has been witnessed. As she pieces together images and memories, it is remarkable to note that the experience is not as threatening or destabilizing as it had been in the past. Kim is notably stronger and more grounded. She now needs much less assurance from Tally, no longer sits at her feet on the floor, and rarely asks Tally what she thinks of her.

Discussion Trauma researchers agree that traumatic memories are stored primarily in the nonverbal right hemisphere of the brain, where such memories lack access to the analytic “thinking brain” of the left hemisphere (Courtois & Ford, 2013; Schore, 2009; van der Kolk, 2003, 2006). We believe that the expressive therapies, because they can access these implicit memories and do not rely on thinking and verbalization, are a treatment of choice for trauma-related disorders (Gantt & Tinnin, 2009; Tripp, 2007). Art therapy can bypass some of the difficulties inherent in traditional verbal psychodynamic psychotherapy because the emphasis on the art-making process allows the therapy to attend to the images and metaphors produced, rather than focusing primarily on the relationship. Survivors of trauma often resist engaging in trauma work because they fear becoming dysregulated by the intense range of feelings that may be unearthed, and because they distrust any intimate relationship. Art therapy can provide a holding space to safely contain these difficult feelings. It can be a pleasurable process that can build self-confidence in the artist who ultimately, through the action of art-making, takes control of the expression and any subsequent interpretation of the material. The intensive trauma approach further assists the client by providing a structured template through which feelings can be expressed (the GN and ED), thus facilitating the process of telling the trauma story without becoming overwhelmed. Kim’s experience with the ITR methods shows the importance of treating foundation traumas. It also shows how rapidly changes can be accomplished when the focus is on intrahemispheric communication.

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Conclusion The specific methods we have outlined for drawing and writing are straightforward and simple. Once a person has had some practice during art therapy sessions, he or she can easily do the same techniques outside the sessions. The externalized dialog (ED) is flexible and highly adaptable to a client’s situation. We recommend that the dialogs be used preemptively as well (for example, checking in with identified parts when a big event is coming up, such as a family reunion or an evaluation at work, or when the person needs to make a major decision). Miller summarizes her communication with a part of self that had been considered to be mute: I am fascinated by this ongoing dialogue between me as a grown woman and the little child in me, a dialogue which was initiated as a result of my beginning to experiment with colors and which then continued thanks to the aid of my writing. I have been able to give the silent child of long ago the right to her own language and her own story. (Miller, 1986: 17) Kim’s case illustrates the gains that are possible when preverbal (foundation) traumas are processed using the GN and the ED. Knowledge of brain structure and function permits the development of approaches that take advantage of this understanding. However, as Siegel points out, “the issue of ‘left brain or right brain’ is not even really important in the final analysis. What we are concerned with is the subjective experience of minds, not merely the functional anatomy of the brain” (1999: 199). The job of an attuned therapist working with complex trauma is to assist a client in finding a way to confront, express and rework the traumatic material. The goal is not to engage in a treasure hunt to find specific, hidden information, but rather to collaborate with the client in an experiential and creative process. Ultimately we find our methods help the clients co-create a story that provides a beginning, middle and ending for the trauma, and make it clear, once and for all, that the past is past.

Trauma Profile Used By ITT ITT uses a battery of six paper-and-pencil assessments to screen potential clients and to track outcomes. Those marked with an asterisk (*) are in the public domain with the exception of the more recent version of the Toronto Alexithymia Scale (TAS). A handout for scoring and interpreting the assessments is available from ITT ([email protected]). Dissociative Experiences Scale (DES)* The Dissociative Experiences Scale (Bernstein & Putnam, 1986) assesses for various types of dissociation and absorption (including amnesia, derealization, depersonalization, and internal voices).

The Image Comes First 95 Dissociative Regression Scale (DRS)* The DRS (Tinnin, 1995) assesses if a client is sufficiently stable to do trauma therapy. Impact of Events Scale (IES)* The Impact of Events Scale (Horowitz, Wilner, & Alvarez, 1979) measures the effect of a single event by determining degree of arousal, avoidant, and intrusive symptoms. Symptom Check List 45 (SCL-45)* The Symptom Checklist 45 (Alvir, Schooler, Borenstein, Woerner, & Kane, 1988) assesses for general psychiatric symptoms. Toronto Alexithymia Scale (TAS-20) The TAS (Bagby, Parker, & Taylor, 1994; Parker, Bagby, Taylor, Endler, & Schmitz, 1993) measures the capacity to use words for feelings. The original 26item scale is in the public domain. The newer 20-item scale is available for a one-time fee of $40 (U.S. funds) from Graeme Taylor, MD, 104 Rosedale Heights, Toronto, Ontario M4T1C6, Canada. Trauma Recovery Scale (TRS)* The Trauma Recovery Scale (Gentry, n.d.) determines changes in psychological state with respect to trauma symptoms. It can be used on a weekly basis. While the steps of the trauma treatment protocol are fairly simple, one does need specific training in this approach. More information about training opportunities can be found at www.traumatherapytraining.us.

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5

Secure Resiliency Art Therapy Relational Neuroscience Trauma Treatment Principles and Guidelines Noah Hass-Cohen

Introduction Understanding how some people find resiliency, that is, recover from traumatizing memories and master associated complex trauma symptoms (CTS), is a key focus in traumatology research (Agaibi & Wilson, 2005; Richardson, 2002). Through this lens, disturbing CTS symptoms offer beneficial ways of coping with and understanding what has happened (Helgeson, Reynolds, & Tomich, 2006). Thus, the inquiry into a spectrum of post-traumatic behavioral, emotional, cognitive, personal, and interpersonal impacts has generated specific treatment guidelines (Allen, 2001; Cohen, Mannarino, & Deblinger, 2006; Herman, 1997; Lanius, Bluhm, & Frewen, 2011; Scaer, 2007). This inquiry contributes to identifying and operationalizing pre and post-traumatic growth (PTG) resiliency factors and clinical guidelines. Across the traumatology literature, there is an emphasis on achieving and maintaining actual and perceived safety and affect regulation while engaging in contextualized traumatic memory processing, increasing social connections, and decreasing the risk of relapse prevention (Herman, 1997; Lanius et al., 2010a; Lanius et al., 2010b). For people experiencing CTS, there is also a clear need to update old memories so that they become nonthreatening (Herry et al., 2010; Lanius et al., 2010b; Lane, Ryan, Nadel, & Greenberg, 2014; Schiller et al., 2010; Schwabe, Nader, & Pruessner, Preussner, 2014). Specific therapeutic conditions are central to resiliency-oriented and neurobiologically informed trauma treatment. These are conditions that contribute to successful memory reconsolidation and include the following: a) avoiding further activation of traumatic memories by pairing them with new nonthreatening information, b) reducing vulnerability to recurring insults to self and to social resources by increasing a sense of mastery and the capacity for positive emoting, balancing of out-of-control responses, and regulating emotional and cognitive reactivity, and c) developing close supportive relationships. The understanding of trauma-conditioned and altered neurobiological systems also suggests that until change can happen therapeutic conditions must also

DOI: 10.4324/9781003196242-5

Secure Resiliency 101 include a focus on softening the impact of CTS. This therapeutic goal can be realized by encouraging clients’ self-acceptance and the development of mindfulness, empathy and acceptance (Briere & Scott, 2014; Hass-Cohen, 2015; King et al., 2013). The conditions described above can be effectively implemented using art therapy relational neuroscience (ATR-N) principles and traumatology informed arts-based interventions (Hass-Cohen, 2015; Hass-Cohen & Clyde Findlay, 2015; Hass-Cohen, Clyde Findlay, Carr, & Vanderlan, 2014; King-West & Hass-Cohen 2008). The shared implicit nature of CTS and art-based communication, the positive attributes of therapeutic art-making, and the motivation that art activities can provide suggest that ATR-N practices match traumatology goals (Hass-Cohen, 2015). Therefore, to implement the associated interventions and protocols offered here, art therapists should have a working knowledge of applied neurobiology of chronic trauma, autobiographical memory, creativity, and resiliency. One reason that this knowledge is important is because traumatic and resiliency-based reactions as well as expressive arts-based interventions most likely involve the activation of overlapping neuronetworks. The purpose of this chapter is therefore to illustrate how together with their clients, therapists can elicit therapeutic responses that function on the edge of protective and benign controlled responses rather than on the spectrum of hyper, under and overmodulated ones (Hass-Cohen, 2015). Fundamentally, therapeutic art-making provides a sense of safety and pleasure and generates experiences of coping, mastery, and control; these achievements support cognitive and emotional flexibility (Backos & Pagon, 1999; Hass-Cohen, 2008; King-West & Hass-Cohen, 2008; Meekums, 1999). For art therapists, it is also of interest that recovery from crisis and psychological disorders may also be mediated by the appreciation of beauty and interest in learning (Peterson, Ruch, Beerman, Park, & Seligman, 2007) as well as by curiosity (Kashdan, Rose, & Fincham, 2004). A review of trauma-conditioned and altered neurobiological functions (Hass-Cohen, 2015; Lanius, Bluhm, & Frewen, 2011) supports art therapists’ contention that including expressivity and creativity significantly advances traumatology therapeutic aims (Gil, 2010; Gray, 2011; Klorer, 2005; Malchiodi & Crenshaw, 2013).

CTS Autobiographical Memories Recalling traumatic memories is usually considered a critical part of trauma memory processing (Cohen, Mannarino, & Deblinger, 2006). Depending on the severity of the CTS, such secure remembrance of autobiographical memories functions to contextualize, desensitize, and eliminate frightening memories. Autobiographical memory, a contained and coherent organized visual and verbal sense of one’s history and self, is theorized to serve three functions: self, social, and prospective-directive (Rasmussen & Habermas, 2011). The self-function consists of internally imagining, conceptualizing, and managing the self. These internal processes, captured by the term Theory of Mind (ToM), influence the

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quality of relational communications, and social connections and function (Baron-Cohen, Leslie, & Frith, 1985). The third function, the prospective and directive one, guides expectations for and actions in the future (Bluck & Alea, 2011). Autobiographical memory directs future actions by enabling past information to be compared to current experiences (Iordanova, Good, & Honey, 2011). Most importantly, a coherent sense of self is bound together by an individual’s ability to clearly and consistently hold, narrate, and share selfreferential, verbal narratives (Singer, Blagov, Berry, & Oost, 2013). It is the balance between contextualized representations and non-contextualized sensory-based representations that contributes to the integrity or fragmentation of episodic and semantic memory recall (Brewin, Gregory, Lipton, & Burgess, 2010). Unfortunately for CTS survivors, intense episodic or lifetime memories tend to be less well integrated with self-functions and are either recalled out of context or forgotten, negatively affecting autobiographical functions. Perception of sensory stimuli immediately before or during trauma results in a low threshold for retriggering stimuli, when in future such sensory perceptions can reactivate trauma. This retriggering may also present as disturbing flashbacks of non-contextualized images (Brewin et al., 2010; Brewin, 2001). Noncontextualized sensory representations, processed in the brain’s fear center, are often overly vivid and conditioned (Brewin et al., 2010). These are implicit memories that do not have temporal dimensions and do not integrate with contextualized life narratives. As a result, traumatic sensory stimuli are cognitively reinforced and reconditioned as a threat of immediate danger. Complicating treatment is a difficulty in intentional retrieval of trauma memories, which may be due to sensory priming (Brewin et al., 2010). Experiencing CTS also predisposes people toward selective recall of information that is consistent with negative appraisals. Research suggests that people with post-traumatic stress disorder (PTSD; American Psychiatric Association, 2013) present with more traumatic and negatively marked self-defining autobiographical memories than controls (Sutherland & Bryant, 2005). For example, when presented with blurred pictures, individuals with PTSD were better able to identify trauma-related pictures than neutral images (Kleim, Ehring, & Ehlers, 2012). CTS also severely constrains the social self as traumatized persons can be so entangled by CTS memories and fear that they have no time or space for any relationships. More commonly they also have a history of developmental assault (van der Kolk, 2005) or betrayal trauma (Freyd, 1994) that severely constrains their ability to accurately mentalize the intentions of others. Subsequently, actions of both significant and non-significant others are interpreted as threatening. Distinctions between autobiographical and traumatic memory functions, including how they are stored and retrieved, inform the goals of trauma narrative processing (Hass-Cohen, 2008; Hass-Cohen & Clyde Findlay, 2015; Hass-Cohen, et al., 2014; Vance & Wahlin, 2008). CTS symptoms and characteristics create a vicious cycle of intrusive recall of memories, and disturbing experiences of negative emotions, and cognitions

Secure Resiliency 103 Table 5.1 A Comparison of Autobiographical and Traumatic Memory Characteristics Autobiographical Memories

Traumatic Memories

• are integrated “who, what, when, and how” • have adaptive self, directive and social functions • are a contained and coherent sense of one’s history and sense of self • tend to be abstract, familiar, and integrated • are a contained and coherent sense of one’s history and sense of self • are organized by themes and personal episodes • have temporal (when) associations • have visual, spatial (where) connotations • are integrated and retrieved through association with other memories • can inhibit sensory memories that feel as if they are happening right now • allow for mourning of losses related to the self and the loss of others to gradually take place over time • are cognitively held • contribute to accurate interpersonal mentalizing • are activated by and can promote social interaction

• are focused on “what and why” • lead to more intrusive memories due to negative appraisals and continuous threat assessment • lack contextual basis, appearing as flashbacks • lack information and can be fragmented • involve involuntary recollection • provide a false sense of here and now, as if the threat and trauma are occurring in the present • strengthen negative appraisals and rumination • are abnormally encoded as primarily sensory and situational • usually lack integration with verbal and cognitive processing • increase bonding with the lost sense of self as memories of other experiences are inappropriately tied to trauma • have maladaptive self, directive, and social functions • disrupt the coherency of autobiographical memory and negatively impact social relationships

(Ehlers, & Clark, 2000). This cycle reconsolidates fear, prevents contextualizing the trauma as a past event, constrains interpersonal mentalizing, and fragments autobiographical memories (Lane et al., 2014).

The Shared Neurocircuitry of Autobiographical Memories, Mentalizing, and Creativity Functions of autobiographical memory, self, social and prospection represent personally experienced information, whereas mentalizing and intersubjectivity are considered to be functions of one’s imagination and creativity (Summerfield, Hassabis, & Maguire, 2009). However, evidence suggests that the sense of self, foresight, mentalizing, and the ability to intuit others are overlapping and interrelated neurobiological experiences (Hass-Cohen & Clyde Findlay, 2015; a review). For example, the use of memories to direct future actions and the

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mPFC

T

C ues PC un ec Pr

PCC Precunues IPC

Pr P ec CC un ue s

activation of ToM functions reportedly have an 82 percent shared neural network (Spreng & Grady, 2010). This overlap might suggest that resiliency-based art therapy directives that call for the client to imagine an affirmative relational future also support mentalizing abilities, intersubjective internal working models, and relational functioning. The set of shared brain structures that are involved in the three functions of autobiographical memory also involve regions of the default mode network (DMN), which is associated with creativity (Jung, Mead, Carrasco, & Flores, 2013). DMN activation involves the medial prefrontal cortex (mPFC), midline frontal and lateral parietal structures, and medial and lateral temporal-limbic regions (Spreng & Grady, 2010). Autobiographical selfreferential processing also occurs in cortical midline structures, particularly in the mPFC (St. Jacques, 2012) which is the brain’s self-center. According to developing research, it is likely that in tandem with alterations in the mPFC, alterations in the DMN are predictive and/or a result of PTSD (Lanius et al., 2010a; Qin et al., 2012); in trauma-impaired mPFC, the capacity for fear extinction is compromised (Yehuda & LeDoux, 2007; Figure 5.1).

AMY IPC

IPC

mPFC

Front

Figure 5.1 Midline Neurocircuitry of Autobiographical Memories, Mentalizing, and Creativity. Shown on the left side view is the shared midline pathway from the medial prefrontal cortex (mPFC, self-center), through midline frontal and lateral parietal structures, and medial and lateral temporal-limbic regions—crescent shape—which include the inferior parietal cortex (IPC), the posterior cingulate cortex (PCC) and the precuneus, which borders on the visual cortex. Top view on the right demonstrates the same areas. Lines within images represent the ventricles, which are provided for orientation purposes. Also shown are the amygdala (AMY), fear center; hippocampus (H), memory center; and the thalamus (T), gateway of sensory processing. Source: Noah Hass-Cohen

Secure Resiliency 105 ATR-N therapeutic interventions can be designed to take advantage of the neural linkages between autobiographical memory and creativity. Therapists can then creatively help clients to both positively reconsolidate and successfully change autobiographical memories. These changes can directly contribute to vicarious resiliency, the emergence of PTG, and hardiness.

Memory Reconsolidation Processing Risks versus Contextualization As highly charged traumatic memories are processed visually or verbally, they can fade away or integrate into autobiographical and semantic memory, allowing for recovery. Memory processing destabilizes established memories, temporarily making them susceptible to change, and supporting reconsolidation (Schwabe, Nader & Pruessner, Preussner, 2014). During memory recall, synapses in the fear and memory centers of the brain (the lateral amygdala and the hippocampus) loosen and can be modulated by protein synthesis in the hippocampus for about four to six hours after the recollection (Nader, Schafe, & LeDoux, 2000; LeDoux, 2003). Reconsolidation is not a one-time event but rather is repeated with subsequent activation of memories (Nader, et al., 2000; Tronson, & Taylor, 2007). It is interesting that pharmacological attempts at changing how trauma memories are encoded in the immediate aftermath of trauma or just before the recall of trauma are being reported as successful (Kindt, Soeter, & Vervliet, 2009). One exciting avenue of research involves the injection of FDA-approved drugs, such as propranol, a blood pressure, beta-adrenergic blocker medication (Lonergan, Olivera-Figueroa, Pitman, & Brunet, 2013). However, the clinician should be aware that because of conditioned fear responses of the amygdala (AMY), memories might reconsolidate as threatening. From a trauma perspective, there are many conditions, boundaries of memory reconsolidation that may contribute to this problem. For example, if memory reactivation is not immediately followed by learning of interfering material, episodic memories may be strengthened. Thus, unknowingly the retrieval of CTS memories may reinforce trauma-based life outlooks and experiences (Sutherland & Bryant, 2005). This reconsolidation of memory rekindles traumatic responding in the brain and needs to be avoided. Furthermore, experiencing stress after memory reactivation may also affect reconsolidation as stress-associated neurochemicals may either enhance or impair memory functions (Schwabe, Nader, & Pruessner, 2014); however, the neurologically balanced conditions that might affect the direction of how stress affects memory and learning is not clear. It is likely that positive excitation such as therapeutic art-making could potentially have positive effects on memory reconsolidation as the art expression offers vivid interfering material, which can be accompanied by positive excitation, which contributes to a balanced stress response. Thus, CTS likely results not only from the direct encoding of the original trauma memory, but also from current disturbing affective responses to memories and negatively biased cognitive processing of non-contextualized traumatic

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memories (Pearson, Ross, & Webster, 2012). There are ways for therapists to mitigate this cycle. Reminding clients that CTS memory reconsolidation and processing are upsetting now can help clients differentiate between past and current threat and regulate affect. Another way the therapist can reduce the risk of current threat reconsolidation is to avoid any pressures or demands on the client to ascertain the truth or provide a complete picture of what has happened. It is also critical to work with the client to make sure that he or she does not feel trapped. This is because connections from the dorsal raphe nucleus and mPFC to the amygdala modulate fear expression of escapable or inescapable situations (Hartley, Gorun, Reddan, Ramirez, & Phelps, 2014). Experiences and or perceptions of escapable stress involve active coping, which regulates the stress response, whereas inescapable stress involves passive coping and behavioral inhibition. Repeatedly asking clients if they wish to proceed with CTS processing and gently reminding them that they can stop or proceed as quickly or as slowly as they would like to, may increase clients’ sense of control and reduce the likelihood of re-traumatization. If the client’s trauma involved the loss of a loved one, it is important to complete some grief work before attempting memory reconsolidation work. Overall working with clients to explicitly place traumatic autobiographical memories in the past allows for mourning and acceptance and opens up space for new meaning-making and social interaction. For example, in art therapy, aspects of the trauma are externalized as creative expressions and can be symbolically put away, continuously worked on or even destroyed in order to create new meaning. Contextual processing that focuses on how the narrative is actively processed, rather than on the content of the narrative, also more likely allows memories to be put aside or placed in the past (Gold, 2008). Contextual memory processing seeks coherent and contextual narration of the memory rather than a focus on the content of the memory. Therefore, it behooves the therapist to work with the client to access only the necessary upsetting past memories and not the full picture. As this process occurs, a new reconsolidation of memory can update the old memory of trauma, which becomes less or not alarming. The ongoing evaluation of threat by the therapist and client also requires an understanding of the connection of stimulus to reaction (Ehlers & Clark, 2000). The prevalence and persistence of triggering sensory stimuli in trauma (Brewin, et al., 2010) suggests that working with media and imagery presents an important challenge for threat reduction and affirmative memory reconsolidation. Depending on the art therapist’s skills and the client’s condition, sensory interventions or media can have a double-edged effect. In fact, one boundary of memory reconsolidation is that memories, when retrieved, must not have as strong of an arousal value as the new consolidated trauma memory. This is because high stress hormones such as epinephrine clearly play a critical role in consolidating new memories vividly (McGaugh & Roozendaal, 2002). Therefore, the art therapist who encourages clients to express CTS without simultaneous insertion of new information may not be successful in extinguishing the traumatic response and could in fact enhance it. In fact there is a risk that the retrieved memory

Secure Resiliency 107 expressed in the vivid qualities of the art may have a stronger value than therapeutic efforts to soften or change the memory. However, when used appropriately art therapy media can have a soothing and grounding effect and reduce the cycle of CTS reactivity mentioned earlier (HassCohen & Clyde Findlay, 2015). What seems critical is that the sensory-based expression of CTS be dynamically and explicitly explored, and transformed into novel information. This is because in order to achieve such affirmative reconsolidation, it is necessary not only to reactivate some aspect of the traumatic memory, but also pair it with novel information (Schwabe, et al., 2014). This approach contrasts with extinction models, which focus on redefining the values of conditioned and unconditioned stimuli, which have found efficacy in instilling a fear reminder just before extinction (Schiller et al., 2010). This approach, while effective, may be too frightening for people with CTS. This integrativereconsolidation memory model includes two additional essential ingredients: incorporation of verbal meaning-making, and aroused emotional responses (Lane, et al., 2014). These kinds of engagements create the opportunity for adaptive and resilient responding. The newly experienced reconsolidated memory of the trauma can be tied in many ways to events across the person’s life span. The person will hopefully begin to have a cache of times in his or her life where he or she has not responded with extreme distress to the traumatic reminder. This divergent thinking can be supported by attuned relational interactions, imagination, positive anticipation, and creativity. In fact, interpersonally it is critical that the therapist be there for the duration of the process, however long it may take. This is because therapy goals that support reconsolidation include actively reconnecting with trusted others, gaining earned secure attachment, and subsequently building a different repertoire of personal characteristics, such as trust and optimism that are specifically associated with resilience.

The Secure Remembrance Art Therapy Relational Neuroscience Model The art therapy relational neuroscience approach (ATR-N) includes six theoretical principles. Informed by the neuroscience of relationships the principles captured by the acronym CREATE: 1) Creative Embodiment, 2) Relational Resonating, 3) Expressive Communicating, 4) Adaptive Responding, 5) Transformative Integration, and 6) Empathizing and Compassion (Hass-Cohen, 2008; Figure 5.2). Central to ATR-N traumatology work is the principle of adaptive responding (Hass-Cohen, 2008), as it highlights the important role that the expressive arts can play in safely establishing allostatic balance, positive memory reconsolidation, and positive interpersonal and societal connections (Hass-Cohen, et al., 2014; Hass-Cohen & Clyde Findlay, 2015). The principle of adaptive responding also includes my secure remembrance model (SR-5), which has five expressive arts goals/tasks: 1) safety, 2) relationships,

Transformative

Transformative Integrating

Integrating

C reative Embodiment

horizontal

vertical

brain stem, limbic, reward

Relational Resonating limbic, RH, prefrontal

E mpathizing Compassion

E xpressive

A daptive Responding

integrated

Communicating limbic, DMN, PFC

body, brain stem, limbic, reward, cortical

I. HIGHER COGNITIVE PROCESSING: CORTICAL prefrontal cortex: executive, mentalizing, & explicit functions frontal cortex: sensory motor processing lobes: auditory visual spatial functions LH: language / RH: implicit II. CONNECTING & MEDIATING: CORTICAL & SUBCORTICAL insula: mind- body connections medial prefrontal: mediates cortical and subcortical mediating functions midline regions: default mode network (DMN) reflective functions III. IMPLICT & MOTIVATING: SUB CORTICAL limbic system: fear, memory, intersubjectivity reward system: pleasure, stress responses brain stem: survival and movement IV. STRESS FEAR: BODILY RESPONSES vagal system: survival and bonding gut: fear adrenals: stress reactions immune system: stress responses

Transformative Integrating reward system

Figure 5.2 The dynamic interplay of brain and bodily systems and art therapy relational neuroscience principles. The circular diagram indicates the main structures that each CREATE principle, Creative Embodiment, Relational Resonance, Expressive Communicating, Adaptive Responding, Transformative Integrating, Empathizing & Compassion is associated with. The chart on the right indicates four main interpersonal neurobiology pathways activated in CREATE. Transformative horizontal integration refers to right to left hemispheric connections, vertical integration includes bi-directional cortical-subcortical-bodily connections. Source: Noah Hass-Cohen.

Secure Resiliency 109 3) remembrance, 4) reconnection, and 5) resiliency and relapse prevention (Hass-Cohen & Clyde Findlay, 2015). In therapy, the SR-5 goals are not necessarily set or achieved consecutively. Although establishing safety is the first task in traumatology work, developing and maintaining safety and the therapeutic relationship are reiterative tasks. In the same vein, remembrance, which focuses on trauma memory processing, may not be possible for some traumatized people; for others, remembrance may start the first day of treatment (King-West & Hass-Cohen, 2008). The development of the SR-5 model has been influenced primarily by Herman’s tri-phasic model (1997): Safety, Remembering, and Relapse Prevention. Other influential models include Perry’s neurosequential model of therapeutics (NMT; 2006), Chapman’s right hemispheric art therapy model (2014), Lahad’s Basic Ph model (2000), and the research on therapeutic factors. The design of SR-5 underscores theory and clinical evidence suggesting that the therapist-client relationship is critical for therapeutic success (Allen, 2001; Benish, Imel, & Wampold, 2008). Lahad’s model is particularly relevant to working with CTS as the model suggests that each individual has a preferred way to interact with the world and, accordingly, with trauma (2000). The Basic Ph model includes several major dimensions of coping: beliefs, affect, social connectivity, imagination, and cognition. The assumption of individuality and the inclusion of imagination fit well with the neuroscience of resiliency and the expressive arts (Hass-Cohen, 2015) and with data on the recovery from PTSD (Farchi, 2009). Other research, which has focused on resiliency training for soldiers, suggests an additional four factors for recovery: emotional, familial, social, and spiritual (Reivich, Seligman, & McBride, 2011). Six core competencies underlie these four factors: selfawareness, self-regulation, optimism, mental agility, character strengths, and social connection. Additional research on positive psychology factors such as optimism, hope, courage, and creativity (Seligman & Csikszentmihalyi, 2000) provides further support for the importance of these positive markers for resiliency. Based on this theoretical and empirical memory research, it is suggested that the ATR-N CREATE principles and SR-5 tasks are foundational for memory manipulation, reconsolidation, and change. ATR-N therapists can operationalize these principles to successfully promote the necessary recall of trauma. They assist clients in keeping CTS symptoms at bay, coping with excitation and arousing art responses, and engaging with novel opportunities. The rest of this chapter’s organization is in accordance with the SR-5 factors— safety, relationships, remembrance, reconnection, and relapse prevention, which are associated with ATR-N CREATE principles. Within each section, SR-5 therapy goals are linked with the CREATE principles, the relevant neuroscience and the CTS therapy conditions discussed above. The pertinent trauma-based neuronetworks include the polyvagal system, sympathetic and endocrine stress axes, amygdala structural conditioning, reward system circuitry, and cognitiveemotion pathways (Hass-Cohen, 2015). Clinical guidelines also reference the neuroscience of autobiographical memory, theory of mind (ToM), and creativity (Hass-Cohen & Clyde Findlay, 2015).

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Safe and Positive Environments: Creative Embodiment & Expressive Communicating Survival Responses When meeting a client with a history of CTS, the treating art therapist must first assess for clinical clues to survival-based threat responses. These indicate the degree of safety that the client might be experiencing. In fact, a client’s felt security is directly associated with positive outcomes; without which the same interventions can lead to therapeutic failure (Meekums, 1999). Fortunately, due to the felt-sensory and tangible qualities of art-making, art therapists are uniquely positioned to meet the safety needs of clients (Appleton, 2001; Chapman, Morabito, Ladakakos, Schreier, & Knudson, 2001; Hass-Cohen, et al., 2014; King-West & Hass-Cohen, 2008; Pifalo, 2002; Rankin & Taucher, 2003; Sarid & Huss, 2010; Talwar, 2007). As stated earlier tactile and tangible therapeutic artmaking can provide a foundation of comfort, support and pleasure. CTS threat responses involve the sympathetic autonomic nervous system and the polyvagal system threat responses. The polyvagal system, which acts though the parasympathetic nervous system, has two branches. An activated dorsal vagal complex (DVC) brings on a primal immobilizing response. This contrasts to the ventral vagal complex (VVC) relaxation response, associated with interpersonal and social connectivity (Figure 5.3). Clients who respond with severe CTS may be experiencing an impaired vagal tone response (Porges, 2001). It is important to remember that clients’ DVCbased reactions are automatic and non-conscious. Threat-based responses can be observed in non-expressive facial expressions such as a permanently downward facing mouth, lack of prosody and vocal intonation, hypersensitivity to low frequency background noises and sensory cues, and difficulty attuning to the human voice (Porges, 2001). Other clues include consistent negative or aroused appraisals of day-to-day situations. The clinician also must vigilantly obtain a thorough history, as people with autism and other disorders may exhibit the same symptomology, making misdiagnosis possible. The psychotherapy process itself may be frightening to a client. Within the art therapy studio, reduced glare and low frequency noises can calm the DVC reaction and open opportunities for VVC social engagement. Structuring the art therapy environment to support safety and relational resonating is critical. Porges (2013) also recommends that the therapist provide clients with information on the protective utility of the freeze response, reminding them that in the past an immobilized response may have saved them from abuse and danger. Appropriate Interventions As art therapy uses sensory modalities as a medium of change, therapists can be proactive about bringing on sensed and expressed experiences of softness that can moderate the reaction of the client to sensory clues. Implicit reminders of

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VENTRAL POLYVAGAL DORSAL POLYVAGAL

HEART LUNGS

LIVER

GUT

Figure 5.3 Schematic Polyvagal System. Front, ventral broken line represents the social ventral vagal complex (VVC). To the back of the figure, the dorsal dotted line represent the immobilizing dorsal vagal complex (DVC). The polyvagal, the longest cranial nerve, innervates the heart as well as the lungs (represented as a butterfly form), the liver (represented by tear shapes), and the gut (represented by a cloud form). Together with other cranial nerves the polyvagal innervates the face and influences facial expressions. Source: Noah Hass-Cohen.

supportive touch can be achieved through the manipulation and construction of utilizing objects such as cloth (Hass-Cohen, Kim & Mangassarian, 2015). The explicit therapeutic invitation is to play with and mindfully explore the qualities of the media, whether smooth, silky, or rough. Clients can nonverbally identify which soft media feels safe to touch, smear, or manipulate, and which implement is the most accommodating. Implements can range from simple, plastic utensils to high-end brushes to bare or gloved fingers for painting. Providing the invitation is supportive and open-ended, the unstructured qualities of these media should not threaten the self. However fear and a stress response may arise if a perceived demand to explore or create an art product or a failure to identify media that is threatening occurs. Of course, exploring art media is not limited to unstructured materials or directives. Cutting collage images and colorful paper, asking clients for their preferred imagery as well as drawing with pencils and markers can all be part of this exploration. However, just as with

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unstructured media, care should be taken to ensure that constant erasing and frustration does not stymie playful exploration. There are no rigid rules as to which material or approach will work for a client. Initially, cognitive relational or safety-oriented interventions, such as relaxation techniques and insight, are at best immature for the polyvagal-oriented client. Such techniques are less efficacious for DVC sensitive clients; they may not be able to tolerate the social engagement, including resting, relaxation, and social responsivity, associated with the VVC (Porges, 2013). Given their high vigilance, any restful state may remind them of the immobilizing effects of their trauma. Unfortunately, and regardless of the treatment stage or the strength of the relationship, a physiological freeze response immediately impairs higher-level functions and may threaten the therapeutic relationship. Child abuse survivors may have actually experienced the kind of immobilization that a terrifying event brought on. Therefore, relaxation or grounding techniques as a way to gain safety may backfire until the person feels safe with the therapist. Such interventions, which the client may correctly interpret as a demand for change, signal a threat (Porges, 2013) and clients under threat have little access to evolved ways of engaging with therapy. Instead, to promote resiliency, psychological interventions need to first aim at stopping or significantly decreasing the recurrence of the unremitting trauma response and increasing a felt, rather than cognitively perceived, sense of safety. Only then can implicit, VVC-based social interactions occur, followed by cognitive-emotive interventions. Attaining safety promotes allostatic balance and adjustment which is interpersonally and socially mediated (Schulkin, 2011). An important advantage of the studio environment is that it offers interpersonal opportunities to explore options for safeness at their own volition and pace. For example, the hyper-vigilant client may experiment with different seating arrangements, close or far away from the therapist and or media. Alternatively, a client may prefer to work standing up or moving around, shifting body posture, and stance to find relief and motivation (Hass-Cohen, 2007). Such movement, which helps to negotiate interpersonal space and ways to soothe a startle response and release the freeze response illustrates the CREATE principle of creative embodiment. Actual and creative embodiment of movement has additional neurobiological advantages as movement can assist in rewiring cognitive functions (Timmann & Daum, 2007). Motion, which is often taken for granted, includes clients and therapists covering the workspace with protective paper, therapists putting paints where accessible for clients, and together mutually reaching for crayons. Picking up a brush, dipping it in the paint, creating, cleaning brushes, and putting away materials are other examples of important movements. Such simple beginning and ending gestures provide motion-based expressive outlets for emotions and cognitions (Hass-Cohen, 2007). Our hands and bodies perform many automatic movements daily, to which we usually do not pay conscious attention. However, in therapy, these gestures, which can quickly become familiar and anticipated, likely boost felt interpersonal security due to interpersonal mirroring functions. Minute-to-

Secure Resiliency 113 minute art therapist-client interactions can support a sense of safety, especially when purposeful movement is involved. Creative Embodiment and Supportive Mirroring Supportive Mirroring is facilitated by mirror neurons (MN), which are located in the human brain’s prefrontal areas (Mukamel, Ekstrom, Kaplan, Iacoboni, & Fried, 2010). MN fire in recognition and anticipation of one’s own and others’ purposeful and successful movements involving the hands and mouth. In therapy, fingertips brushing against another person’s fingertips are another example of how the art therapist’s “third hand” (Kramer, 1990), in assisting the client, can provide mirroring reassurance, comfort, and security. In dual drawings, therapists and clients also touch the same page as they gesture to each other to co-create. MN establish a sense of familiarity with the art therapist’s activities; these include provision, structuring, and handling of the art materials and the invitation to engage in simple art-making tasks, such as coloring premade shapes. Under therapy conditions, the client’s reactions to these movements build connectivity. MN, which typically function to recognize purposeful actions, can boost clients’ recognition, anticipation, and creative imagination of what will happen next. In therapy, this intersubjective function carries a supportive, nonthreatening role and may present as the following internal dialog: “I do what you do; I can do what you do; and I can recognize and anticipate what you will do.” Once this relational familiarity is established, the therapist can initiate specific safety-oriented directives. Interventions such as “make an anchor from clay,” “depict a safe place, space, thing, or pet,” or “use visual arts [dance, moment, theater, or music] to show how you might feel under safe circumstances” are also appropriate (Hass-Cohen & Clyde Findlay, 2015). These arts-based requests are used to trigger the imagination of diverse representations of safeness. Choosing to “make, show, and tell” one of these representations most likely engages creative- and task-based neurocircuitry that also contributes to reducing rumination and depression. Positive Affect, Motivation, and Creativity: Expressive Communication Neuroscience As stated earlier, the experience of CTS is further compromised by clients’ reduced ability to access and process positive emotions (Litz & Gray, 2002). Yet accessing positive emoting needs to be encouraged as they may undo the influences of negative emotions that remain following a traumatic experience; positive emotions act to produce positive outcomes as well as to negate negative outcomes (Fredrickson, Mancuso, Branigan, & Tugade, 2000). People process emotions on a broad range of physiological responses, behavioral-motor and motivational actions, emotional-psychological functions, and cognitiveappraisals (Scherer, 2000). Safe therapeutic conditions, such as those described for the polyvagal-oriented client, provide a diversity of platforms for pleasurable

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art-making, which can provide motivational and positive experiences intended to counteract past negative impacts. From a neuroscience perspective, there are several models of emotions and feelings (Demaree, Everhart, Youngstrom, & Harrison, 2005; Lane, 2008). These include the following: a) implicit basic emotions expressed by facial expressions (Ekman, 1992), which are modulated by the brain stem and connections with the polyvagal complex; b) implicit motivational and pleasure biased emotions, which are supported by the reward system function; c) implicit and explicit emotions associated with arousal, hypo-arousal, and calm, which are mediated by the interface of subcortical and cortical structures; and d) explicit left hemispheric positive feelings versus right hemispheric implicit negative emotions. The activation of these areas is also impacted by life events such as trauma as well as by genetic vulnerability to PTSD (Skelton, Ressler, Norrholm, Jovanovic, & Bradley-Davino, 2012). Subcortically, positive as well as fear-based emotions are associated with the limbic and reward system functions. In fact, experiencing positive emotions tends to reduce amygdala, fear-based triggering (Phelps & LeDoux, 2005), thus contributing to allostatic balance. Positive affect is linked with the functions of the striatum. A limbic region, the striatum’s dorsal area includes the caudate nucleus and putamen part of the basal ganglia, whereas its ventral areas include the nucleus accumbens, an area associated with the reward system. Thus, the striatum helps coordinate body movement and motivation (Girault, 2012). The reward system, the motivation center of the brain, produces neurotransmitters that aid positive and negative emotions. For example, movement and positive mental states trigger dopamine in the reward system. Positive emotions largely stimulate mesolimbic dopaminergic projections in the brain reward system, extending from the ventral tegmental to the ventral striatum as well as the nucleus accumbens. Dopamine also can potentially balance stress doses of cortisol and norepinephrine (Panksepp & Burgdorf, 2006). When achieved this neurochemical balance may effectively counter the primary activation of the amygdala-fear and hippocampal-memory areas of the brain during negative emotions (Gray & McNaughton, 2003). Serotonin and acetylcholine also take part in controlling responses to negative, aversive stimuli (Hoebel, Avena, & Rada, 2007; Figure 5.4). Cortically, the left hemisphere is biased toward positive emotions. It is highly influenced by activity of the reward system, which is associated with the pleasures of creating (Badenoch, 2008). In the reward system, the raphe nucleus, the locus coeruleus, and the ventral tegmental area connect to the cerebellum, an area responsible for movement. These connections are crucial to affect processing and positive emotions (Konarski, McIntyre, Grupp, & Kennedy, 2005). From a reward system perspective, tactile pleasant experiences, sensory vividness, and mastery contribute to pleasurable feelings. Movements and extroversive expression are triggered by expressive arts interventions; possibly they stimulate dopamine (DA) release and limbic activity that are linked to positive emotions and reinforcement. A generalization affect may occur as the

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ACC mPFC S

BG T

NAc

H

AMY

OFC

Figure 5.4 Limbic and Reward System functions. The striatum (S) includes the caudate nucleus and putamen part of the basal ganglia (BG) and the nucleus accumbens (NAc), an area associated with the reward system that includes the locus coeruleus (LC). Dotted lines represent the dispersion of serotonin in the brain. A main source of serotonin in the brain is the raphe nucleus (RN). Note that dopamine is heavily dispersed in the frontal lobe, specifically the medial prefrontal cortex (mPFC) Also shown is the orbital frontal cortex (OFC). Source: Noah Hass-Cohen.

generation of positive emotions may prompt the emergence of additional positive emotions. In addition, pride in the art product likely stimulates the brain’s natural reward systems, which can then continue to generate positive responses. Therefore, for the client who perceives threat, the recommendation is to focus on the art-making and, at least initially, avoid processing the content of the art, which support increase in positive rewards and decrease in negativity that may arise from the exploration of meaning-making. Activation of the reward system has also been implicated with the processing of the DMN creative circuitry (Jung, Mead, Carrasco, & Flores, 2013; Figure 5.1). The DMN is comprised of a pathway of mid cortical regions that extend from the mPFC to regions adjacent to the visual cortex (Hass-Cohen & Clyde Findlay, 2015). Guided by the principle of expressive communicating the art therapist relies on multimodal expressive means, including dance, music, drama, and crafts

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to stimulate divergent creative expressions and engage in positive emotions. Experiencing positive emotions supports psychological and physical well-being Lyubomirsky, King, & Diener, 2005; Seligman & Csikszentmihalyi, 2000). (Lyubomirksy, Positive emotions, a part of instinctual, survival-based reactions, contribute to physiological equilibrium and homeostasis (Panksepp & Burgdorf, 2006). Fredrickson’s broaden-and-build theory of positive emotion explains the evolutionarily different roles served by positive versus negative emotions (Fredrickson & Levenson, 1998). Negative emotions serve the purpose of perpetuating adaptive traits when one is threatened by fear. In contrast, positive emotions establish themselves during times when there is no threat to one’s life, so that one is able to build physical, psychological, and social resources. Recurring positive emotions play a key role in developing and maintaining resiliency, because they allow for a widening of the range of people’s positive feelings and cognitions. Over time, this broadening can become habitual and contribute to adaptive responding. Indeed, higher trait-resilience was correlated with higher experiences of positive emotions (Tugade & Fredrickson, 2007). In this vein, positive emotions build psychological resources that resilient individuals use to adapt to stress (Fredrickson, Tugade, Waugh, & Larkin, 2003; Tugade & Fredrickson, 2007). For example, a trajectory of coping was predicted for police people who demonstrated positive emotive traits during training versus those who exhibited a negative emotion profile (Galatzer-Levy et al., 2013). The presence of positive emotions in moderation is instrumental for coping processes (Bonanno, 2008; Folkman & Moskowitz, 2000). Additional research on social joy and laughter suggests that happiness is mediated by the amount of time people experience positive emotions and not the strength at which they experience it (Lyubomirsky, et al., 2005). From a neurobiological perspective, positivity and negativity can co-exist, which contributes to an understanding that positive and negative emotions are discrete phenomena that can be worked on simultaneously in therapy. An important frontal area involved in the processing of clues to positive emotion and autobiographical memories is the orbital-frontal cortex (OFC) (Panksepp, & Burgdorf, 2006). Discrete OFC regions, process visuospatial and somatosensory rewarding and or aversive stimuli. For example, pleasant odors activate the medial OFC; unpleasant odors activate the dorsal ACC and mid OFC (Grabenhorst, Rolls, Margot, Da Silva, & Velazco, 2007). Therefore, our brain is adept at simultaneously representing the positive and negative values of a complex stimulus, contributing to effective decision-making. The process of allowing and accepting both the good and the bad hones the ability to examine, consider, and act upon emotional responses. Therapeutic art-making provides opportunities to practice tolerance of the simultaneous arousal of joy and pleasure as well as judgment and pain. This unique quality of art therapy expands clients’ ability to self-regulate and use both positive and negative emotions to make decisions. Therapeutically, positive emotions have been associated with self-mastery, pride, gratitude, and love. Happiness and pleasure are supported by attitudes

Secure Resiliency 117 and behaviors such as curiosity and playfulness (Gallagher & Lopez, 2007). The authors describe curiosity as a combination of two elements: exploration of new situations and absorption. The latter represents the inclination to become fully immersed in life experiences and situations. These therapeutic elements are innately supported through art therapy creative endeavors. Engaging in creative curiosity represents a resilient shift from negative to positive responses. Perhaps this move results in a shift from neuroendocrine-mediated feelings of loss of control to sympathetic nervous system feelings of acceptance or being in control (Henry & Wang, 1998). Furthermore, as the fearful, right hemisphere-activated client is encouraged to explore and become absorbed in art-making, the left hemisphere likely modulates emotional avoidance. Thus playfulness and pleasure in the art-making support the experiencing of positive left hemispheric emotions; these expand perceptions and the range of action and social possibilities (Hass-Cohen & Clyde Findlay, 2015). Retrieval of any positive memories can build upon a sense of self. This may require the assistance of third parties, such as family members, who can provide positive and supportive memories. In therapy, the art therapist might also suggest that the client add some positive features to a dark drawing. First engaging a client in a neutral or positive experience is a useful tactic because it has proven helpful in obtaining a more detailed recollection of the traumatic experience (Cohen, Mannarino, & Deblinger, 2006). In the short-term, this “silver lining” may decrease the effect of negative emotions and throughout therapy provides opportunities for the practice of positive emotional regulation and creativity and resiliency. Thus, integrated creativity (DMN functions) and executive functions (left hemisphere, higher functioning) can support imagining solutions to problems. The art-making likely allows action that may mitigate not only right hemispheric anxiety but also left hemispheric dissociation, which has been associated with lack of action in face of trauma (Lanius, Hopper, & Menon, 2003). Art therapy is particularly suited for this work as the vivid creative positive experiences that it advances have the potential to interfere with traumatic memories. Through spontaneous and structured art therapy and dramatic interventions, the imagination provides clues to what is happening and to the needed solutions (Lahad, 1993, 2000).

Relationships: Relational Resonating Interpersonal and social interactions assist in acquiring resilient hardiness (Maddi, 2006; Schulkin, 2011) and the development of interpersonal supports have been shown to be as important as exposure treatments for PTSD (Markowitz, Milrod, Bleiberg, & Marshall, 2009). For example, a very large survey of U.S. veterans found that seeking support from friends, family, or other social groups after a traumatic event directly contributed to Post Traumatic Growth (PTG), as did engaging in social altruism (Tsai, El-Gabalawy, Sledge, Southwick, & Pietrzak, 2015). In contrast, avoidance of family of origin and emotional hiding were positively correlated with PTSD symptoms (Duax, Bohnert, Rauch, &

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Defever, 2014). From a neurobiological perspective, social features, salience, valence, anticipation, status, control, contact, and support all balance sympathetic, endocrine, and catecholamine systems’ hyperarousal (Schulkin, 2011). The adjustment to complex trauma is linked to the idiosyncratic intrapersonal and social environment of each survivor. Unfortunately, the relational contexts within which traumas occur, often destabilizing or invalidating, continuously shape the lived experiences of individual survivors. Survivors of abuse often express ongoing painful relational experiences with others, including a lack of support and outright disbelief, devaluation, and betrayal. Subsequent to trauma, the person may also develop personality disorders, which present as pervasive difficulties in forming and maintaining healthy relationships (Linehan, 1993a, 1993b). To fully aid recovery, therapy must therefore address relational risks and protective factors. Within the therapy context, the scope of relationships include these: a) the therapeutic relationship, b) past and current personal and social relationships, and c) new personal relationships and social networks. Hence, treatment goals include learning how to avoid the reenactment of or reengagement in abusive relationships, how to build healthy new relationships, and how to reconnect to existing social networks. Many clients with CTS and PTSD have histories of child abuse and relationship issues associated with developmental or attachment deficits, which affects the development of a sound therapeutic relationship (Perry et al., 1995). Thus the traumatized client, especially the adult survivor of childhood sexual abuse (CSA), usually suffers from another social risk factor. They most likely have never had positive mirroring and have not learned to interpret body gestures outside of a threat paradigm (Lane et al., 2014). Comprehending bodily communication is the first way that we learn to interpret implicit interpersonal interactions. Lacking these skills affects the way that the CSA survivor interacts with the world. Without the contextual information given by another during periods of brain development, one’s ability to have a fully formed picture of intersubjective experiences and feelings will be constrained. This will continue to be difficult throughout an individual’s life and will manifest as a high-level implicit emotional response, which was never mirrored nor explicitly contextualized. Therefore, the individual develops negative generalizations that leave her feeling overwhelmed and unable to cognitively process visceral emotional experiences of both routine and extraordinary events and relationships. The art therapy client-therapist gestures provide an opportunity to mend such relational ruptures. In therapy, active gestures associated with active art-making likely activate mirror neuron systems (MNS), presenting an opportunity for social embodiment (Hass-Cohen & Clyde Findlay, 2015). In other words, MNs play a critical role in intersubjective functions because they are not limited to MN function; for example, when observing a significant other being pricked by a pin, the observer’s pain circuitry also fired but without pain (Singer, 2004). This broader mirroring function is an intersubjective function, as without the observer’s internal knowledge of the observed action, he or she cannot understand its purpose (Ammaniti & Gallese, 2014). The client then starts to use his

Secure Resiliency 119 or her own actions to deeply understand and engage interpersonally. Embodied simulation theory shows that “people reuse their own mental states or processes represented in bodily format to functionally attribute them to themselves” (Ammaniti & Gallese, 2014: 16). The trusted therapist becomes an auxiliary-self that reduces heightened fear activation and habituation and shapes new selfmemories. That is, the therapist self becomes a reparative mirror for the client (Hass-Cohen, 2007). Mirroring requires connectivity and familiarity. Familiarity and respect can be developed slowly through instrumental and task-oriented accidental or deliberate mutual touching, for example, of the same piece of paper used for art (Hass-Cohen et al., 2015). Symbolic and physical art-mediated-interpersonaltouch-and-space (AMITS) is one of art therapy’s advantages (Hass-Cohen et al., 2015). For example, positive and safe AMITS include sharing materials and touching one’s own artwork or a client’s artwork, as well as expressing a positive interest in the tactile aspects of artwork. Several opportunities exist to express closeness, interest, curiosity, and support in this way. Early in a therapeutic relationship, the art therapist may suggest that the client touch a smudged pastel area on the therapist’s own page. Alternatively, he or she might ask to touch a client’s page to stabilize it as the client’s scribbling moves it or ask to hold a ball of clay made by a client to sense its weight and power. While the first line of relational support lies in this implicit therapeutic relationship, support can evolve and become symbolized and explicit though dual and dyadic drawing techniques (Bat-Or, 2010; Fish, 2012; Franklin, 2010; Gavron, 2013; Kaiser & Deaver, 2009). Directives from the therapist can also progressively promote an exploration of safe relationships such as “draw a safe place, including growing and changing places such as gardens” and “represent a soothing and trusting living relationship.” Throughout therapy, CTS symptoms threaten the therapist-client relationship, and, unbeknownst to the therapist, may trigger latent traumatic responses. Such responses can rekindle a sense of mistrust, resignation, defeat, guilt, and shame. Therefore, establishing a strong relationship that can mediate the implicit emotional turmoil that explicit narrative trauma processing may entail is critical (Missirlian, Toukmanian, Warwar, & Greenberg, 2005). The therapeutic relationship with a familiar other can then become part of the memory, where the reconsolidation of the trauma memory includes a memory of trusted sharing. As stated earlier Porges (2013) recommends specific clinical guidelines for socially reengaging traumatized clients with CTS. In addition, background music with vocals can help the client attune to human interaction. In session, to clearly convey a positive non-threating interaction, the therapist should use a consistent, sincere, and soft voice as well as caring facial expressions, such as genuine smiling that naturally activates the eye muscles (Ekman, 1992). Social interactions facilitated by gaze, facial expressions, and other socially based sensory cues can mediate aroused autonomic deregulated states. As reviewed by Hass-Cohen & Clyde Findlay (2015) the resolution of short- and long-term stress responses has

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been associated with proactive social responses whereas an altered chronic CTS long-term stress function has been associated with chronic social avoidance and defeat (Wood, Walker, Valentino, & Bhatnagar, Bhantnagar,2010; 2010;Figure Figure5.5). 5.5). Some treatment approaches suggest that outreach to others may be best attempted after successful narrative trauma processing (Herman, 1997). However, information from the neuroscience of PTG suggests that social interaction can directly contribute to adaptive responding (allostatic states) by regulating cortisol and catecholamine levels (Schelling et al., 2006). In fact, a review of PTG

mPFC

Amygdala Hippocampus

Amygdala Hypothalamus Pituitary Gland

Hypothalamus mid brain

Short Term Stress Response SAM Axis Sympathetic Nervous Systems Neurons in Brainstem

Long Term Stress Response HPA Axis Adrenalcorticotropic Hormone ACTH Cortisol feedback

Epinephrine (E) Norepinephrine (NE)

Adrenal Medulla Kidney

Adrenal Cortex Kidney

Figure 5.5 Short and Long Term Stress Response. The stress system is a neurotransmitter and endocrine system that involves the short-term sympathetic adrenomedullary (SAM) axis stress response (left) as well as the long-term hypothalamic-pituitary-adrenal (HPA) axis response (right). Activation of SAM releases norepinephrine (NE) whereas that of the HPA releases cortisol. As shown by the lower dotted semi curve, the two systems work in tandem. Source: Noah Hass-Cohen

Secure Resiliency 121 in veterans underscores the importance of their developing social connections, as well as internal purposefulness and religiosity (Tsai et al., 2015). Thus, it is incumbent that therapists use the art to interact relationally with clients, invite symbolic representations of relationships, and encourage reaching out to social networks. Therapists should also assist in planning for and approaching social interactions outside of the clinic as soon as possible. CTS guidelines for such interactions may be for clients to slowly familiarize themselves with a social milieu before fully engaging with it; they should also have ways to escape or leave uncomfortable situations (Schulkin, 2011). Schulkin’s research suggests that engaging with unfamiliar or unclear situations can increase cortisol secretion, whereas avoidance of potentially threatening events will decrease cortisol. Other research found that having three or more regular social contacts is linked with lower allostatic load scores (Seeman, Singer, Ryff, Dienberg Love, & LevyStorms, 2002). The encouraged relational interaction for polyvagal interactions is dyadic support (Kramer, 1990), rather than larger social contexts or even familial interactions. While it is not possible to fully anticipate all the consequences of social engagement, art therapists should use all these dimensions to help clients anticipate them.

Remembrance, Security and Mastery: Adaptive Responding Successful remembrance and adaptive trauma processing requires achieving, even for short periods, actual and perceived behavioral, personal, interpersonal, and social stability. This reiterative balancing of the internal self is an expression of resiliency (Sapolsky, 2004). Repeated experiences of stability may reduce the neurobiological load created by CTS and possibly contribute to contextual alteration of traumatic memory reminders. Reducing allostatic load requires learning a range of strategies (Schulkin, 2003; Sterling & Eyer, 1988). Addressing these goals for the client who operates from the more evolved stress response, whether short-or long-term, is somewhat of a different task than for the polyvagal oriented client. This is because stress responses occur on an axis of mastery and control that can be mediated by cognitive functions. Therefore, alternative learned responses, such as reduced reactivity to external sensory inputs and internal bodily sensations, may contribute to reduced sympathetic and neuroendocrine arousal. Such adaptive responding and resiliency are associated with rapid resolution of short-and long-term stress responses. The skills necessary for this resolution include these: 1) learning and engaging in relaxation and grounding, affect regulation techniques; 2) practicing mastery and control in the therapy environment; and 3) repeated actual and perceived behavioral mastery and cognitive perception of control outside of the therapy context (de Kloet, Joëls, & Holsboer, 2005). The acquisition of these three skills supports renewed social interactions, narrative trauma processing, secure remembrance, and relapse prevention. Affect regulation skills, repeated cognitive processing, and experiences of mastery support a coherent sense of self, further alleviating the stress response.

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Affect Regulation Affect regulation skills help to decondition the brain’s fear center and decrease AMY firing. Affect regulation skills, specifically the control of feeling as if one is “crazy”, and increased sense of control have been demonstratively associated with PTG (Dekel, Mandl, & Solomon, 2011). As the active coping area of the AMY receives visual and auditory information (Hass-Cohen, 2015-review; Pessoa & Adolphs, 2010), it is likely that art therapy practices can play a strong role in deconditioning the amygdala. Indeed, empirically proven TF-CBT often includes art and play therapy (Cohen, Mannarino, & Deblinger, 2006). Soothing activities such as coloring and playing with clay can also be stabilizing (HassCohen & Clyde Findlay, 2015). Other directives may incorporate relaxation and yoga strategies (Emerson, 2015) as well as asking clients to imagine and draw stable experiences (Hass-Cohen & Clyde Findlay, 2009). In comparison with polyvagal-based interventions, where the intervention itself must be experienced as stabilizing, these later directives focus on helping clients more generally access, process, and control issues regarding safety, interpersonal security, and stability. All these types of interventions must be repeated (Perry, 2006) in order to support affirmative memory reconsolidation. Mastery Art therapists have suggested that therapeutically helping clients achieve mastery over their preferred way of artistic expression and media will also increase a generalized sense of mastery and control (Moon, 2001). Scaffolded according to the clients’ interests and ability, an art therapy approach, which includes the development of artistic mastery, is appropriate (Kramer, 1990). The verbal discussion of artistic mastery in addition to a psychological exploration of the content may help cement these competencies. In addition, creative art-making can be used as a self-care practice that contributes to allostatic adjustment. In therapy, the art-making assists in transforming avoidant or negative responses into positive or assertive striving for control responses (Henry & Wang, 1998). For example, clients’ refusals to draw or making quick marks on the page may indicate adaptive efforts and should not be interpreted negatively. Another example are large gesture drawings. Those gestures may embody fight or flight fantasy and yet represent coping as the exploration of this imagery may increase a sense of mastery. Furthermore, because resiliency is associated with the ability to successfully anticipate the need for coping, it is possible for clients to identify pertinent scenarios and imagine how they might utilize coping strategies (Lahad, 1993). Highlights of contextual processing include transforming implicit imagery, supporting reflexive mentalizing, and making the implicit explicit. The goals are to make the most painful memories speakable, to maintain self-regulation, and to coherently narrate current experiences. This kind of controlled exposure to the traumatic memory is considered a necessary ingredient of art-based trauma processing. Within the studio, such exposure, through excitation, can be safe and therapeutic as the client controls it.

Secure Resiliency 123 Neurobiologically, excitation is expressed as a balanced cortisol and NE discharge and has positive effects. In addition to providing energy, excitation is also associated with heightened attention and focus and the forgetting of traumatic memories. In other words, under the right conditions, the stress response, manifested as excitation, can be beneficial (McEwen, 2007, 2012). Extrapolating from information about the stress response, the therapist may want to introduce novelty and excitation by helping the client maintain a slower pace (Hass-Cohen, 2015). In a similar vein, the art-making can also provide a time of rest which would include drawing images from nature and/or any other studio art-based work not directly related to the trauma history. As appropriate, it is important to explore, on paper or through other media, escape and avoidance routes; these are correlated with lower levels of internalized symptoms (Shahar, Elad-Strenger, & Henrich, 2012). Autobiographical Timelines Therapists have several other strategies available to them. Autobiographicalrelational art therapy timelines are directives that can be used to successfully contextualize and incorporate interpersonal relationships and social contacts (Hass-Cohen & Clyde Findlay, 2015). Creating an art therapy timeline clarifies information related to the person’s chronological history and symptomatology. The autobiographical timeline is a chronologically drawn representation of important people in an individual’s life. The timeline of relationships can be sorted, reordered, and rewoven by the client. Engaging with the timeline can become reparative through the exploration of time gaps and significant emotional investment. Adding, replacing, and removing relationships on the timeline promotes the successful retrieval of forgotten details. Both timelines facilitate the development of causal coherence and reconsolidated remembrance, as well as provide a positive sense of control over one’s life. The directive to build a timeline, articulated as “draw your past, current, and future relationships,” embodies the interface of attachment, creativity, and resiliency personal functions. Two ATR-N protocols, discussed in detail below, are designed to provide secure remembrance through autobiographical memory processing. The protocols require that clients have media choices. These media are provided on a nearby shelf or table, requiring that clients go and bring them to their artmaking space. Physically moving toward and away from the media exercises a sense of purposeful control that can reduce freeze reactions. The core premises of the ATR-N protocols must be 1) sequenced in order to allow for processing, alteration, and transformation of the memory; 2) designed to include internal, interpersonal, and social resources in order to increase resilient responses during and after the art-making; and 3) focused on the exploration of the self. In accordance with information on memory reconsolidation, the protocols’ instructions, as provided below, include implementing them over a two to four hour period (not one clinical hour) with breaks as necessary. To ensure that the

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level of exposure does not reinforce the traumatic memory, it is also necessary to disperse comforting relaxation techniques during the process. The client is usually asked to title each of the directives. Unless otherwise indicated, this narrative processing of the images occurs at the end of the sequence. For descriptive purposes, the instruction is to draw, but any multimodal expressive media can be used instead. The first processing protocol has four directives: 1) “If you were to draw the problem, what would it look like?” 2) “Draw or present yourself, a self-portrait;” 3) “Draw, and represent your internal and external resources;” 4) “Draw or present yourself, a self-portrait.” The fourth purposefully repeats the second directive. It is helpful to start by asking the client to draw the problem, as the problem may not be the memory recollection. The first directive ensures that that the therapist remains attuned to the clients’ needs. It also assists in identifying which aspect of the traumatic event needs processing. The second directive, the self-portrait, elicits the representation of the client’s mental selfimage and can be an invitation to explore how to undo the effects of the trauma on the development and maintenance of selfhood. In addition, this kind of autobiographical portrait often includes clues to the client’s attachment style. The third directive, in identifying resources, empowers the client to make changes. The identification of resilient personal characteristics, behavioral actions, and social resources contributes to successful memory reconsolidation and extinction as well as to coping with trauma (Helgeson, Reynolds, & Tomich, 2006; Linley & Joseph, 2004; Tedeschi & Calhoun, 2004; Zoellner & Maercker, 2006). The final drawing, a repeated self-portrait, may measure change, as it often illustrates the capacity for resiliency that is demonstrated by comparing the drawing characteristics of both self-images (Bridgham & Hass-Cohen, 2008; Hass-Cohen & Clyde Findlay, 2009). A similar-sequenced protocol, “Check,” is more complex. The first directive, “Draw an autobiographical timeline of the traumatic event,” places traumatic events in the past, differentiating them from the here and now. The second directive exposes traumatic memories of the event: “If you were to paint/draw what happened, or an aspect of it that you feel comfortable and safe representing, what would it look like?” Next, a title and narrative are written and shared with the therapist, integrating emotive and cognitive processing, and working toward reducing cognitive distortions. Once the art is photographed, the third directive is provided: Check in; if you could change or keep one aspect of the drawing or painting, which aspect would you choose and what does it look like? You may cut it out, keep or throw away the cut-out, and/or paint over it using the background color of your paper. Consider painting, drawing, or gluing on additional images. Alternatively you may want to glue the rescued parts on a new page and start afresh.

Secure Resiliency 125 The client and therapist can compare the new art with the original that was photographed. Again, the client’s titling and narrative processing of the difference between the images follows, thereby increasing the client’s internal sense of control and emotive awareness while decreasing arousal and/or dissociative responses. To promote resiliency, the next two CHECK directives are these: “Draw your strengths” and “Draw an image of what an optimistic future would look like.” Some useful parameters for this protocol include 1) repetition, such as using the same exciting material repeatedly, and 2) using a range of simple to complex stimuli, such as human figure forms and vivid features, colors, luminance, size, and tactile qualities. The protocols can be repeated. The newly reconsolidated trauma memory can also be beneficially tied in many ways to events across the person’s life span. Overall, benefit finding has been associated with PTG across studies (Helgeson, Reynolds, & Tomich, 2006). Throughout the art-making, the client is supported by attuned relational interactions, imagination, positive anticipation, and creativity. The two protocols are similar in that they are intended to contribute to fear extinction and to memory reconsolidation. Updating the meaning of the traumatic memory can contribute to either of the above. In clinical practice, it may not be possible to differentiate between the two. Clinical examples and further instructions were provided in previous publications (Bridgham & Hass-Cohen, 2008; Clyde Findlay, 2008; Hass-Cohen & Clyde Findlay, 2009; Hass-Cohen & Clyde Findlay, 2015; Hass-Cohen et al., 2014).

Empathizing and Compassion: Relapse Prevention Relapse prevention is critical for CTS interventions. Even after traumatic memory extinction, areas in the amygdala seem to remember the trigger and can be easily re-sensitized to react. This suggests that art therapy interventions, which target in-vivo responses, positive cognitive-emotive appraisals, as well as experiences of mastery and control, may not be sufficiently effective. There is a high remission of CTS even when people are treated with empirical approaches. In addition, some survivors may not be able to tolerate any trauma processing. Others may have some amnesia for the event. For example, childhood sole survivors of airplane crashes may little recollect the event yet still suffer debilitating consequences, although, for the most part, they do not have a specific memory that they can process (Dickens, 2014). Therefore, it may be necessary to attempt reconsolidation of autobiographical memories by actively aiming to update them with information that may seem a mismatch with the client’s expectations (Barreiro et al., 2013). As discussed throughout this chapter, art-making and expressive communication insert novelty into trauma processing and may offer an opportunity for such a mismatch. Often the arts allow for non-integrated sensory representations to integrate with contextualized implicit expressions in surprising ways. This

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quality of art therapy can be helpful because the reconsolidation of memories involves the function of three brain areas that are all sensitive to novel information: the amygdala, hippocampus, and PFC areas (Yamsaki et al., 2002). Acquiring novel information also contributes to the birth of new neurons in areas responsible for memory: the adult hippocampus, lateral ventricles, and olfactory blub (Kays, Hurley, & Taber, 2012). Novelty, and perhaps the kind of novelty that comes with art-making, contributes to the ability of these newborn neurons to flourish and latch on to the memory centers of our brain and survive. Pertinent to memory reconsolidation and resiliency, it is now becoming clear that that neurogenesis assists in coping with stress (Ming & Song, 2011). Under the auspices of a traumatology-trained art therapist, creative artmaking can lead to previously unknown personal strengths and meaning. Two additional treatment avenues reduce risk for relapse prevention: connecting to new social networks and developing the capacity for self-compassion (Neff, Kirkpatrick, & Rude, 2007). For example, personal stories of post trauma growth often include social altruism. In the aforementioned case of sole survivors of airplane crashes, George Lamson Jr. has sought sole survivors like himself. CNN’s remarkable film about this 17-year-old only survivor of a 1985 airline crash that killed his father and 69 others in Reno, Nevada, shows the tremendous benefits of meaningful, social connectivity. As an adult, through supporting other survivors, George experiences tremendous PTG growth and a relief from debilitating symptoms. The temporal dimensions of George’s story are instructional, as he had suffered many years before finding his route to recovery. Therapists may consider mentoring trauma survivors to develop a network of people who have had similar experiences. In addition, the arts can be used to imagine and explore such give and take support (Hass-Cohen & Ziegler, 2014). Development of self- and other-compassion can further lay the foundation for such social connectivity. Empathy and compassion are supported through an increased ability to successfully put oneself in one’s mind and in another’s shoes. Self-compassion skills also help clients accept and forgive themselves for any recurring CTS symptoms, an important step since a one-time triggering of CTS symptoms often spirals into relapse. Providing clients with information on the likelihood of relapse and how to practice self-compassion can soften this reaction and reduce the probability of relapse (Scaer, 2007). Self-acceptance and affect tolerance can also be achieved through mindfulness meditation (Kabat-Zinn, 2005). Non-judgmental attention provides a gateway to compassion, kindness, and the desire to relieve another’s suffering. However, this indirect pathway, possibly requiring many hours of practice and meditating, may be threatening and activating for trauma survivors (Briere & Scott, 2014; Segal, Williams, & Teasdale, 2012). Additional therapy approaches that incorporate acceptance—dialectical-behavior therapy and mindfulness-based cognitive therapy—have proven effective with conditions difficult to treat. These approaches share interventions that focus on disentangling from thinking and learning to stay with an unpleasant experience. However, a more direct path-

Secure Resiliency 127 way to empathy may be available through mindfulness self-compassion (MSC) interventions (Germer & Neff, 2013). There are three MSC components: mindfulness versus over-identification with hurtful painful experiences, selfkindness versus self-judgment, and common humanity versus isolation. All the interventions focus on the self, which is critical as CTS survivors often carry a tremendous amount of guilt and self-intolerance, or even self-hate (Rothschild & Wolf, 2013). In therapy, the development of self-compassion and empathy starts with the art therapist’s sensitivity to embedded relational media transactions, his or her unconditional acceptance of the art product, and transmission of genuine interest, caring, and respect. The art therapist, who then functions as the client’s “third hand,” “third eye,” “right brain,” and “second mind,” overtly and symbolically senses what the client needs. The client also has the opportunity to mimic the therapist’s resonance, forming a language that conveys understanding and empathy. Such reciprocal dialog moves the client toward experiences of felt and anticipated aid. In art therapy, neurobiological activations in response to implied and actual movement, in particular MN and mirroring systems, evoke empathizing compassion, pleasure, and joy. Understanding these mirroring responses embodies empathic reactions to art. Other involved systems include the integration of right and left hemispheric functions, bottom-up arousal and top-down regulation, and balanced activation of positive reward system activation (Siegel, 2006). Explicit MSC interventions, such as the “self-compassion break,” entail the person saying specific mindful, humane, and kindness-oriented phrases (Germer & Neff, 2013) and can easily translate to art therapy. An example would be “ask yourself what you need right now and draw it.” Asking a question and engaging in this self-compassion cultivates goodwill toward oneself. An ATR-N protocol, the autobiographical compassionate timeline incorporates social support and a vision of the future (Hass-Cohen & Clyde Findlay, 2015). The timeline request is to “draw your past, present, and future, as they would be seen by someone who loves or cares for you or from a kind and supportive self-perspective.” For a traumatized person, it is often more culturally acceptable or easier to care for another person than for the self. As it is often easier to start with caring for another, a necessary preliminary step might be needed, for example, “imagine and draw a future for someone you love or care for.” Different directives might be needed for individuals with disruptive attachment or trauma histories as they may have a foreshortened sense of the future. Depending on the client’s situation, directive wording or sequencing might be further adapted, such as “Draw your future, as it would be foreseen by someone who loved or cared for you in the past.” A very isolated individual may be unable to identify a current or past caring relationship. Then the caring person could be a pet, a beloved person who has passed, or a therapist. All variations of the directive are implemented in the same way: Taking three pieces of paper, draw a timeline on each. Each paper is devoted to one period in time: past, present, and future.

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Starting with any section that you like, make sure to put one event in each period. See if you can draw each timeframe from a compassionate perspective. Particularly for the future, draw something that a person who cares for and loves you might wish for you, or something compassionate that you would wish for yourself. As part of the art-making, art observation and perception may further contribute to memory reconsolidation. As the art therapist and the client discuss the completed art directive, they engage in element construction and deconstruction. Safely resolving visual ambiguity is psychologically cathartic, bringing joy and satisfaction. When shared, the process promotes social connectivity and empathy. There is also a sense of universality, because discussing the art raises a presumed, shared understanding of what is meaningful and beautiful (Ramachandran & Hirstein, 1999). Thought to be mediated by the activation of mirror neuron systems (MNS), such confident aesthetic experiences have also been associated with activating reward-related brain circuitry (Kawabata & Zeki, 2004). These directives help reconsolidate the self, other, and prospective functions of memory.

Summary Therapeutic experiences happen through the continued process of reactivation, re-encoding, and reconsolidation of memories. Through this process, new rules or schemas (internal working models) will be updated, allowing clients more flexible ways of engaging with autobiographical narratives. The degree to which change is lasting will vary, based on how generalized the reconsolidation of memory is or how wide or narrow of a context the new memory applies to. The changes to traumatic memories being made in art psychotherapy are not only new memories being created or new semantic structures being established. The changes represent a transformative integration of the autobiographical mind and body and social self. Art therapy practices directly contribute to reconsolidating and updating new memories. As stated earlier, essential components of transformative integration and creating therapeutic change include reactivating old memories, engaging in new emotional experiences that are incorporated in these reactivated memories, and reinforcing the change. The more contexts in which this new way of experiencing the world is practiced, the stronger the change (Lane et al., 2014). The integrated ATR-N CREATE therapeutic guidelines and memory reconsolidation protocols suggested in this chapter promote and are characterized by the following: a) safeness, comfort, and pleasure; b) positive emotions and cognitions; c) repetitive opportunities for mastering control and protection; d) relational security and social communication; e) self-acceptance and compassion; f) memory reconsolidation; and g) mind-body transformative integration. Overall, these qualities contribute to the capacity for imagining positive and different outcomes (Figure 5.6).

Adaptive Responding Establishing mastery and control through the art making Secure Remembrance Chronic Trauma An ATR-N Treatment Model (SR-5) •

Transformative Integration: Mentalizing and memory reconsolidation through art making

• •

• •

Creative Embodiment: Using the arts for observation, movement, and social learning by imitation and cognition.

Safety: Sensory grounding, relaxation and affect regulation skills (SR-1) Relationships: Trust and home (SR-2) Remembrance: Autobiographical trauma narrative processing, internal locus of control experiences and emotive expression. (SR-3) Reconnection to others: Exercising social and emotional planning and control. (SR-4) Resiliency & Relapse Prevention: Strategies to maintain safety, internal locus of control and affect regulation as well as social and familial relationships. (SR-5)

Empathic & Compassionate Associating: Through the making and observation of artmaking and the arts

Figure 5.6 Summary of the ATR-N Principles and Secure Remembrance

Relational Responding: Attuned Relationships

Expressive Communicating: Expressive arts – affect, emotion, imagination and cognition

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Lahad, S. (1993). Tracing coping resources through a story in six parts—The “BASIC PH” model. In S. Levinson (ed.), Psychology at school and the community during peaceful and emergency times (pp. 55–70). Tel-Aviv: Levinson-Hadar, (in Hebrew). Lane, R. D. (2008). Neural substrates of implicit and explicit emotional processes: A unifying framework for psychosomatic medicine. Psychosomatic Medicine, 70(2), 214–231. Lane, R. D., Ryan, L., Nadel, L., & Greenberg, L. (2014). Memory reconsolidation, emotional arousal, and the process of change in psychotherapy: New insights from brain science. The Behavioral and Brain Sciences. doi:http://dx.doi.org/10.1017/ S0140525X14000041 Lanius, R. A., Bluhm, R. L., Coupland, N. J., Hegadoren, K. M., Rowe, B., Théberge, J., . . . & Brimson, M. (2010a). Default mode network connectivity as a predictor of posttraumatic stress disorder symptom severity in acutely traumatized subjects. Acta Psychiatrica Scandinavica, 121(1), 33–40. Lanius, R. A., Bluhm, R. L., & Frewen, P. A. (2011). How understanding the neurobiology of complex post-traumatic stress disorder can inform clinical practice: A social cognitive and affective neuroscience approach. Acta Psychiatrica Scandinavica, 124, 331–348. Lanius, R. A., Hopper, J. W., & Menon, R. S. (2003). Individual differences in a husband and wife who developed PTSD after a motor vehicle accident: A functional MRI case study. American Journal of Psychiatry, 160(4), 667–669. Lanius, R. A., Vermetten, E., Loewenstein, R. J., Brand, B., Schmahl, C., Bremner, J., & Spiegel, D. (2010b). Emotion modulation in PTSD: Clinical and neurobiological evidence for a dissociative subtype. The American Journal of Psychiatry, 167(6), 640–647. LeDoux, J. E. (2003). The emotional brain, fear and the amygdala. Cellular and Molecular Neurobiology, 23(4/5), 727–738. Linehan, M. M. (1993a). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. Linehan, M. M. (1993b). Dialectical behavioral therapy: A cognitive behavioral approach to parasuicide. Journal of Personality Disorder, 11(4), 328–333. Linley, P.A., & Joseph, S. (2004). Positive change following trauma and adversity: A review. Journal of Traumatic Stress, 17(1), 11–21. Litz, B. T., & Gray, M. J. (2002). Emotional numbing in post-traumatic stress disorder: Current and future research directions. Australian and New Zealand Journal of Psychiatry, 36(2), 198–204. Lonergan, M. H., Olivera-Figueroa, L. A., Pitman, R. K., & Brunet, A. (2013). Propranolol’s effects on the consolidation and reconsolidation of long-term emotional memory in healthy participants: A meta-analysis. Journal of Psychiatry & Neuroscience, 38(4), 222–31. Lyubomirsky, S., King, L., & Diener, E. (2005). The benefits of frequent positive affect: Does happiness lead to success? Psychological Bulletin, 131(6), 803–855. doi:10.1037/ 0033-2909.131.6.803 Maddi, S. R. (2006). Hardiness: The courage to grow from stresses. The Journal of Positive Psychology, 1(3), 160–168. Malchiodi, C. A., & Crenshaw, D. A. (Eds.). (2013). Creative arts and play therapy for attachment problems. New York: Guilford. Markowitz, J. C., Milrod, B., Bleiberg, K., & Marshall, R. D. (2009). Interpersonal factors in understanding and treating post-traumatic stress disorder. Journal of Psychiatric Practice, 15(2), 133–140.

Secure Resiliency 135 McEwen, B. S. (2007). Physiology and neurobiology of stress and adaptation: Central role of the brain. Physiological Reviews, 87(3), 873–904. McEwen, B. S. (2012). Brain on stress: How the social environment gets under the skin. Proceedings of the National Academy of Sciences, 17180–17185. McGaugh, J. L., & Roozendaal, B. (2002). Role of adrenal stress hormones in forming lasting memories in the brain. Current Opinion in Neurobiology, 12(2), 205–210. Meekums, B. (1999). A creative model for recovery from child sexual abuse trauma. The Arts in Psychotherapy, 26(4), 247–259. Ming, G. L., & Song, H. (2011). Adult neurogenesis in the mammalian brain: Significant answers and significant questions. Neuron, 70(4), 687–702. Missirlian, T. M., Toukmanian, S. G., Warwar, S. H., & Greenberg, L. S. (2005). Emotional arousal, client perceptual processing, and the working alliance in experiential psychotherapy for depression. Journal of Consulting and Clinical Psychology, 73(5), 861–71. doi:10.1037/0022-006X.73.5.861 Moon, C. H. (2001). Studio art therapy: Cultivating the artist identity in the art therapist. London: Jessica Kingsley. Mukamel, R., Ekstrom, A.D., Kaplan, J., Iacoboni, M., & Fried, I. (2010). Single-neuron responses in humans during execution and observation of actions. Current Biology 20, 750–756. Nader, K., Schafe, G. E., & LeDoux, J. E. (2000). The labile nature of consolidation theory. Biological Psychiatry, 76(4), 274–80. Neff, K., D., Kirkpatrick, K. L., & Rude, S. S. (2007). Self-compassion and adaptive psychological functioning. Journal of Research in Personality, 41, (1) 139–154. doi:10. 1016/j.jrp.2006.03.004 Panksepp, J., & Burgdorf, J. (2006). The neurobiology of positive emotions. Neuroscience and Biobehavioral Reviews, 30(2), 173–187. Pearson, D. G., Ross, F. C., & Webster, V. L. (2012). The importance of context: Evidence that contextual representations increase intrusive memories. Journal of Behavior Therapy and Experimental Psychiatry, 43(1), 573–580. Perry, B. D. (2006). Applying principles of neurodevelopment to clinical work with maltreated and traumatized children. The neurosequential model of therapeutics. In N. Boyd Webb. Working with child abuse in welfare. New York: Guildford Press. Perry, B. D., Pollard, R. A., Blakely, T. L., Baker, W. L., & Vigilante, D. (1995). Childhood trauma, the neurobiology of adaptation and “use-dependent” development of the brain: How “states” become “traits.” Infant Mental Health Journal, 16(4), 271–291. Pessoa, L., & Adolphs, R. (2010). Emotion processing and the amygdala: from a “low road” to “many roads” of evaluating biological significance. Nature Reviews Neuroscience, 11(11), 773–783 Peterson, C., Ruch, W., Beerman, U., Park, N., & Seligman, M. E. P. (2007). Strengths of character, orientations to happiness, and life satisfaction. Journal of Positive Psychology, 2(3), 149–156. doi:10.1080/17439760701228938 Phelps, E. A., & LeDoux, J. E. (2005). Contributions of the amygdala to emotions processing; From Animal models to human behavior. Neuron, 48(2),175–187 Pifalo, T. (2002). Pulling out the thorns: Art therapy with sexually abused children and adolescents. Art Therapy: Journal of the American Art Therapy Association, 19(1), 12–22. Porges, S. W. (2001). The polyvagal theory: Phylogenetic substrates of a social nervous system. International Journal of Psychophysiology, 42(2), 123–146. doi:10.1016/S01678760(01)00162-3

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Secure Resiliency 137 Seligman, M. P., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American Psychologist, 55(1), 5–14. Shahar, G., Elad-Strenger, J., & Henrich, C. C. (2012). Risky resilience and resilient risk: The key role of intentionality in an emerging dialectics. Journal of Social & Clinical Psychology, 31(6), 618–640. Siegel, D. J. (2006). An interpersonal neurobiology approach to psychotherapy: Awareness, mirror neurons, and neural plasticity in the development of well-being. Psychiatric Annals, 36(4), 248–256. Singer, J. A. (2004). Narrative identity and meaning-making across the adult lifespan: An introduction. Journal of Personality, 72(3), 437–460. Singer, J. A., Blagov, P., Berry, M., & Oost, K. M. (2013). Self-defining memories, scripts, and the life story: Narrative identity in personality and psychotherapy. Journal of Personality, 81(6), 569–582. Skelton, K., Ressler, K. J., Norrholm, S. D., Jovanovic, T., & Bradley-Davino, B. (2012). PTSD and gene variants: New pathways and new thinking. Neuropharmacology, 62(2), 628–637. Spreng, R., & Grady, C. L. (2010). Patterns of brain activity supporting autobiographical memory, prospection, and theory of mind, and their relationship to the default mode network. Journal of Cognitive Neuroscience, 22(6), 1112–1123. Sterling, P., & Eyer, J. (1988). Allostasis: A new paradigm to explain arousal pathology. In S. Fisher & J. T. Reason, Handbook of life stress, cognition, and health (pp.629–640). Oxford, England: John Wiley. St. Jacques, P. L. (2012). Functional neuroimaging of autobiographical memory. In D. Berntsen & D. C. Rubin (Eds.), Understanding autobiographical memory: Theories and approaches (pp. 114–138). Cambridge, MA: Cambridge University Press. Summerfield, J. J., Hassabis, D., & Maguire, E. A. (2009). Cortical midline involvement in autobiographical memory. Neuroimage, 44(3), 1188–1200. Sutherland, K., & Bryant, R. A. (2005). Self-defining memories in post-traumatic stress disorder. British Journal of Clinical Psychology, 44(4), 591–598. doi:10.1348/014466505 X64081 Talwar, S. (2007). Accessing traumatic memory through art-making: An art therapy trauma protocol (ATTP). The Arts in Psychotherapy, 34(1), 22–35. Tedeschi, R. G., & Calhoun, L. G. (2004). Post-traumatic growth: Conceptual foundations and empirical evidence. Psychological Inquiry, 15(1), 1–18. Timmann, D., & Daum, I. (2007). Cerebellar contributions to cognitive functions: A progress report after two decades of research. Cerebellum, 6(3), 159–162. Tronson, N. C., & Taylor, J. R. (2007). Molecular mechanisms of memory reconsolidation. Nature Reviews Neuroscience, 8(4), 262–275. Tsai, J., El-Gabalawy, R., Sledge, W. H., Southwick, S. M., & Pietrzak, R. H. (2015). Posttraumatic growth among veterans in the USA: Results from the National Health and Resilience in Veterans Study. Psychological Medicine, 45(1), 165–179. doi:10.1017/ S0033291714001202 Tugade, M. M., & Fredrickson, B. L. (2007). Regulation of positive emotions: Emotion regulation strategies that promote resilience. Journal of Happiness Studies, 8(3), 311–333. Vance, R., & Wahlin, K. (2008). Memory and art. In N. Hass-Cohen & R. Carr (Eds.), Art therapy and clinical neuroscience (pp. 159–173). London, United Kingdom: Jessica Kingsley.

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6

Neuroscience and Art Therapy with Severely Traumatized Children The Art is the Evidence P. Gussie Klorer

I had not heard him enter the waiting room, but I anticipated that 12-year-old Jack (a pseudonym*1) would be hiding either under the beanbag chair or behind the door in my waiting room when I went in to pick him up at exactly 2:00 p.m., his regularly scheduled appointment time. It was a ritual repeated every week, reminiscent of a much younger child playing peek-a-boo. I found Jack, and as we walked into the inner office he said: “I didn’t want to come here today. They made me come.” I caught his eyes fleetingly, smiled, and told him I was happy to see him. Before sitting down he took a clock off the shelf and placed it on the table facing his chair so that he could monitor the time. He claimed this attention was so I didn’t get a single extra minute out of him, but I believed he wanted to feel a sense of control. Jack’s history was not unlike many children in state custody. The abuse and long-term neglect during his crucial developmental years left him with few inner resources. Jack was four and his brothers were two and three when they were found abandoned in an impoverished home, untended for days. Jack attempted to change his brothers’ diapers and gave them water and Cheerios. The children were put in separate foster homes, and ultimately his brothers were adopted by a family member who severed all contact with Jack. Jack spent his childhood in foster homes, abusive environments, and residential treatment centers. He had poor social skills, no manners, terrible hygiene, and avoided eye contact. When he perceived an injustice, his behavior escalated into physical aggression. Jack was referred to art therapy because he was not making progress in his verbal processing group or individual therapy provided by his residential treatment program. Although there were varied goals in therapy, the most important initial treatment goal was to form a therapeutic relationship based upon safety and trust. Jack’s first picture in art therapy was one he had painted before, a lone wolf (Figure 6.1). He repeatedly painted this image during the nine years I worked with him. Jack intended the wolf to look angry and menacing. As an unconscious self-portrait, it showed Jack’s ability to lash out offensively and push people away, yet the wolf appeared to be young, defensive, and scared. This painting coincided with other drawings Jack did, such as an aggressive knife–wielding male figure, facing backward so that he could not see

DOI: 10.4324/9781003196242-6

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Figure 6.1 Jack, age 12. Painting of a wolf

Figure 6.2 Jack, age 13. Drawing of an Indian

Neuroscience and Art Therapy 141 (Figure 6.2). The lack of facial features in this figure, preventing genuine contact with others, echoed Jack’s avoidant approach to all relationships and was metaphorically repeated every time he hid in my waiting room. I continued to see Jack weekly for the next several years. To supplement our work, at age 14 he was referred to a trauma focused cognitive-behavioral therapy (TF-CBT) experimental trial, which was not effective. Recent developments in evidence-based practice (EBP) research recognize the difficulty for children like Jack to assimilate into a trauma protocol that requires them to provide a narrative when there is not a discrete traumatic event, they have incomplete recall of what happened, or their attachment issues are complex (Amaya-Jackson & deRosa, 2007). Whereas the 1990s and early 2000s were dominated by the favorability of cognitive-behavioral treatment manual-type approaches as the desired treatment protocol for trauma, Johnson (2009) notes that cognitivebehavioral, evidenced-based practice is now being overtaken by the neuroscience paradigm. Neuroscience offers a new understanding of the impact of early trauma on brain development, requiring adjustments to treatment conceptualization in EBPs. This chapter will focus on therapy with severely maltreated children who have been abused and neglected at an early age by their principle attachment figures. The very person upon whom the child relied for basic needs, such as holding and feeding, was the person who hurt and neglected the child. This population can include children whose behaviors suggest severe disturbance even if the reported abuse does not seem severe, because the extent of what these children have experienced can be completely unknown (Haugaard, 2004). This is a population for whom there are no easy answers or cookbook approaches. I will focus on case examples couched in neuroscience theory, demonstrating how in EBP, the art produced in art therapy is the evidence. The term evidence-based practice (EBP) is often misunderstood. The American Psychological Association Presidential Task Force on Evidence-Based Practice defines the term as “the integration of the best available research with clinical expertise in the context of patient characteristics and preferences” (American Psychological Association, 2006: 273). EBP is not necessarily equivalent to randomized controlled trials or brief, manualized approaches. Clinical expertise is an important component of this broad definition, as is current research. A trauma narrative, as would be expected in a TF-CBT approach to therapy, does not work for a child who cannot tolerate the memory. Treatment interventions that bypass the severely maltreated child’s habitual or defensive modes of response are needed, and these kinds of interventions are often expressively based. The goal of expressive therapy is to support the client’s coping skills at his or her emotional-developmental level, and to use art to help the child express that which is impossible to verbalize. At a later developmental stage when the child is more able to tolerate the knowledge and implications of parental rage (typically late adolescence or possibly not until adulthood), it is possible to work more directly with the trauma, both through art and cognitive-behavioral approaches. The clinical implication is that pressing too hard for verbal therapy

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with a child who has severe parental abuse issues can be counterproductive and counter therapeutic (Klorer, 2005, 2008). Best practice in working with this population is a neuroscience approach that takes into account current research about brain functioning, traumatic responses, attachment issues, and accessing therapeutic issues through expressive means independent of the child’s ability or willingness to verbalize (Chapman, 2002, 2014; Klorer, 2005, 2008). Best practice utilizes cognitive therapy techniques when it is developmentally appropriate for alleviating symptoms and reducing anxiety. As opposed to a manual approach, best practice requires individualizing treatment and developing a genuine therapeutic relationship over a longer period of time than a 12–16 week protocol such as TF-CBT. It entails following the child or adolescent’s path of creative expression, trusting the importance of safety and relationship building through the use of metaphor.

Neuroscience Contributions to Understanding Trauma Neuroscience research provides important information for therapists working with severely maltreated children. According to Schore (2001), this exciting research presents solid evidence for the observations that Bowlby (1969) made over forty years ago when developing ideas for object relations and attachment theory. Neuroscientists are discovering that severe maltreatment and a lack of significant attachment figures in the crucial early years lead to adverse brain development (Bremner, 2001; Chugani et al., 2002; De Bellis, 2001; De Bellis et al., 1999; Perry, 1997; Rutter & O’Connor, 2004). Recent studies examine how traumatic memories are stored in the brain. In particular, traumatic memories are stored in the right hemisphere, making verbal declarative memory of the trauma more difficult (Glaser, 2000; Rauch et al., 1996; Schiffer, 2000; Schiffer, Teicher, & Papanicolaou, 1995). These studies lay the groundwork for understanding why nonverbal, expressive therapies can be so much more effective than verbal therapies during work with severely maltreated children exhibiting attachment difficulties (Klorer, 2005, 2008). According to Jernberg (1979), work with abused children may not need to focus so much on the trauma itself, but rather on engaging children in situations that make them feel lovable, helping the caretaker or parent to recreate missed positive parent/infant interactions, and encouraging the child to abandon abuseevoking behaviors. Jernberg developed “Theraplay,” a therapeutic technique designed to repeat those games and interactions that normally occur in a mother or father’s relationship with a young child. In Theraplay, these early relational emotions are re-experienced in a healthier, more secure situation. Harvey (1990, 1991), a dance therapist who also works in a playful way with adoptive parents and children, suggests that expressive modalities can define and assist change in the development and construction of new attachment communication, vital for the child’s success in a foster care or pre-adoptive family. The therapist’s role is to provide the structure, safety, and boundaries necessary for the child to experiment with new roles and relationships. Actively

Neuroscience and Art Therapy 143 participating with the child and foster or adoptive parent, the therapist allows the child to choreograph scenarios that echo the child’s attachment dilemma. The goal of therapy is to provide the child with a new repertoire of positive experiences from which to draw. Early unmet needs for nurturance are often acted out in spontaneous play by children with severe abuse histories. Techniques like Theraplay actually encourage regression to an infant or toddler developmental stage, allowing the child to fulfill some of these unmet needs. For example, in her therapy session, Melissa, age four, continuously fed the baby dolls and would often plop the toy bottle in her own mouth. Concerned that the doll bottle was not sterilized and was used by many children, I bought Melissa a real baby bottle that I put her name on, filled with water, and kept in the refrigerator. Melissa developed and played out a feeding ritual. She would enter the therapy session and immediately retrieve her bottle, then crawl into my lap to be fed. After a few minutes of this pretend play, she would become a big girl again, putting fresh water into the bottle and returning it to the refrigerator to be cold and ready for her next session. Melissa had been neglected, and much of her early abuse included not being fed, or being forced to watch others eat while she had to perform chores that were inappropriate for a two or three year-old. Her compulsion to enact feeding rituals was understandable, and the intervention, although regressive, allowed her to experience feeding from a healthy perspective. Her repetition of the ritual suggests that it was reaching unmet needs. She abandoned the ritual after three months, at which time she returned to feeding baby dolls instead, assuming the role of nurturer rather than of one being nurtured. During the next few years of therapy, around age 13–14, Jack was too big to hide under the beanbag chair in the waiting room. His new hiding place was in the larger hallway leading to the office. He would open and shut the outer door so that I would think he had come in, and then he would stay in the hallway so that I had to pursue him further. Although our relationship was firmly established, he still wanted me to believe that he came only under coercion. In his residential treatment center, Jack engaged in fits of uncontrollable rage over the slightest perceived injustice. He was a large adolescent, and his aggressive outbursts were so intense they resulted in physical restraints requiring four adult men to contain him. His emotional instability challenged his teachers and caregivers, and his triggers for emotional upheaval were unpredictable. His psychiatrist frequently adjusted Jack’s medication. In art therapy, Jack began making pillows, those wonderful soft objects that comfort us in our beds at night. He made pillows of varying sizes and shapes for his bed. He entrusted me to hand sew the seams with him, one of us working on each side of the pillow in an intimate sharing of space. He was just beginning to learn to self-soothe, an important component of behavioral regulation. A further consideration with children who have been severely maltreated is the flawed attachment itself, which affects brain development. During the early years the human brain depends upon both genetic information and external stimulation for growth. During the first two years of life the basic circuits of the

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brain are being established (Balbernie, 2001; De Bellis, 2001; Schore, 2002). The child’s brain develops in what Perry (2001) terms a use-dependent fashion, meaning that the more any neural system is activated, the more likely it is to become permanent. For children born into an environment where external stimulation, such as holding and talking, is lacking, neuropathways devoted to language do not form, and the children will develop language slower than usual. Communication delays result because those parts of the brain were not stimulated at a crucial developmental time. Holding and talking to a child are crucial components of normal cognitive and emotional development. Schore (2002) describes the neurobiology of a secure attachment: early in the relationship the primary caretaker comforts the distressed baby by holding and feeding. In order to form a complete and healthy attachment, the mother must be able to create psychobiological attunement with the infant, developing what Schore defines as “affect synchrony” (p. 11). When the infant cries, the mother creates attunement by holding and rocking so that the child becomes synchronized with the mother’s rhythmic structure. This begins as an external regulator for the child, and neuropathways in the brain are stimulated each time this happens. With repetition, the neuropathways become permanent, and ultimately the child learns to self-regulate. When the maternal figure does not provide this comforting stimulation, the child suffers greatly. According to Schore, a lack of stimulation affects the development of the frontolimbic regions of the brain, especially the right cortical areas that are prospectively involved in affectregulating functions. Evidence shows that early relational trauma is expressed in right brain hemispheric deficits in the processing of social-emotional cues (Schore, 2002). Therefore, the child operates at a much lower socio-emotionaldevelopmental level than normal in terms of affect regulation and behavior management. We can assume by his history that Jack missed this early holding and stimulation from his mother. He did not learn to self-regulate, which is why external physical restraint was required to contain his anger. The Complexity of Attachment Issues Jack had unexplained scars, the source of which he could not remember. It was very clear in therapy that Jack needed to remember his mother as good. He longed for her. He could not remember her appearance, but he said he missed her all the time and he made excuses for her. He said that perhaps she was in an accident, and that is why she never came back. Jack said, “She was the best thing that ever happened to me.” He did not want to hear the facts of his case when they were presented by his social worker. He worried about his younger siblings and frequently asked to see them. Although his early abuse and trauma were important parts of Jack, trying to focus therapy on what happened at an earlier age would be counterproductive at this stage of treatment because he could not tolerate the memories, and he could not betray his need to protect his mother.

Neuroscience and Art Therapy 145 There are tremendous psychological complications for treatment when the perpetrator of maltreatment was the person upon whom the child must rely for meeting basic needs. This layer of complexity is reminiscent of Cairns’ (1966a, 1966b) experiments with putting a lamb and a vicious mongrel dog in a cage together. In situations where the dog abused the lamb, after separation the lamb sought the dog for companionship. When a child is removed from an abusive parent, there is often an overwhelming desire to be reunited, no matter how intense the abuse was. This habitual action response, described by van der Kolk (1989), reflects a longing for the original attachment figure and a loss of conscious memory of the trauma. Corwin and Olafson’s (1997) study of Jane Doe demonstrates how a child’s ability to recall events changes over time and is particularly impacted by the child’s desire to reconnect to the parent, even years after a seemingly good adjustment in a foster or adoptive home. Often we find that the child who could disclose enough detail to assist in substantiating abuse during the acute trauma stage (in Jack’s case, when the children were found alone in the house) will stop using words about the trauma during the treatment phase. Some children will “forget” that it was the parent who elicited the trauma or will simply deny the trauma. Workers in residential children’s homes can describe numerous examples of severely maltreated children who desperately want to return home. According to Fairbairn, there is a critical need to preserve and protect an image of a good parent, because if the parent is not good, there is a startling reality that the child could die (1941). In order to preserve the image of a loving parent, children who are victims of severe parental abuse and neglect have to deny that the abuse happened or justify it as being deserved. The child assimilates the qualities of the bad object and preserves the abusing parent as the good object, rather than risk losing the parent (Fairbairn, 1941; Seinfeld, 1989; St. Clair, 1986; van der Kolk, 1989). While these children verbally protect and defend the abuser, in art they sometimes depict deeper feelings that they cannot possibly articulate or understand. We often see family pictures reflective of chaos and anger: a child draws her mother with such aggression that she tears holes in the picture; a young boy draws his parents and then scribbles them out repeatedly. The art allows for expression of unconscious feelings that are too unbearably painful to articulate, but are contained within the metaphor of the picture. The art does not lie. In the two examples above, at the time the child made the artwork the child vigorously defended the abusive parent and could not tolerate that the parent was anything less than loving toward him or her. How does the art capture feelings that the client cannot access? These early memories of abuse and neglect, stored in the unconscious and kept at bay by coping skills and defenses, are like sleeping volcanoes. The hallmark of the traumatic response is physiologic hyperarousal to current stimuli reminiscent of the original trauma (Perry, 1995). Victims of trauma respond to contemporary stimuli as if they were back in the traumatic moment, with the same physiologic emergency response (van der Kolk, 1989). So when a child is asked to draw a picture that stimulates the original trauma (for example, a family picture), he or

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she is likely to immediately be propelled back to that physiologic hyperaroused state, and the artwork will reflect the chaos and feelings of that point in time rather than the usual defended self. This may explain why, in my own practice with abused and neglected children, the family drawing is the most often refused drawing in an art evaluation, or is drawn at a regressed developmental stage. Treatment Implications As Jack became more comfortable in his residential treatment center, he began making animal-shaped pillows for the staff. The pillows were a sought-after commodity; all the staff wanted one. Giving away his pillows was his safe way of being relational, and the staff responded to this childlike gesture in a nurturing way. He began to enjoy these safe relationships and started teasing with the staff, similar to his teasing me about not wanting to come to therapy. Recently in trauma cases there has been a paradigm shift away from conscious, explicit left-brain discourse to the nonverbal, body-based approaches utilizing the right brain (Chapman, 2014; Perry, 2009; Schore, 2012). These latter approaches rely less on verbalization and more on expressive output. Treatment should be targeted at the child’s emotional-developmental age, not chronological age. There should be an implicit understanding that later, perhaps not until adulthood, the client will be able to approach issues of severe parental maltreatment at a more sophisticated level of understanding than is currently possible. To paraphrase a residential children’s home’s director, children and adolescents are rarely capable of resolving intense issues of parental rejection or trauma in therapy; they just want to get through a day of school without anyone making fun of them (S. Veit, personal communication, May 2014). Perry (2001) suggests that children exposed to violence or trauma at young ages spend a large amount of time in a low-level state of fear, mediated by brainstem and midbrain areas, and their cognition is dominated by the subcortical and limbic areas. In a state of hypervigilence, they tend to focus on nonverbal clues and often misinterpret them, reacting impulsively without cognitively processing actual events. For example, when Jack perceived that someone looked at his shoes wrong, he assumed he was being criticized and pounced on the child, quickly escalating the interaction into a physical fight. Jack was always looking out for himself. This hypervigilence did not lead to sensitivity to others’ feelings, however. In fact, the opposite occurred. Jack would be the first to make fun of someone else’s shoes or to say “Your mama” to a child who also had maternal issues, so fights in his cottage and classroom were frequent. His lack of empathy harkens back to his early developmental losses. Using neuroscience research to inform his work, Perry (2009) developed the neurosequential model of therapeutics (NMT) to conceptualize treatment with severely maltreated children. He suggests conceptualizing the beginning of treatment as working with the brainstem, the area associated with selfregulation, attention, arousal, and impulsivity. At this stage he recommends patterned, repetitive, and sensory activities, such as music, movement, yoga, or

Neuroscience and Art Therapy 147 drumming. These activities are associated with preverbal neuro input to the brainstem, and the repetitions would provide the regulating input that would help to alleviate anxiety and impulsivity. Chapman (2014) compiled a variety of sensory-motor art techniques and games based upon neuroscience principles designed to facilitate cortical development. Her techniques provide the opportunity for relational exchanges between the child and therapist or child and caregiver that mimic early parent/ child interactions and facilitate right brain development, visual development, tactile development, gross and fine motor development, auditory development, vestibular development, and proprioceptive development. Whereas Chapman uses directives to lead clients to relational exchanges, children often develop these types of games on their own. Jack’s repeated desire to hide in the waiting room was his own invention and demonstrated that he was operating at a developmental stage much younger than his chronological age. “Finding” him always resulted in smiles, very similar to when a two-yearold hides and is found. One of the games Jack and other children like to play early in therapy is hiding jewels or animals in the sandtray and taking turns sifting through the sand to find them. Older children often invent games that seem age-inappropriate. They tend to repeat the game until they have worked through that earlier stage of development. The therapist does not have to search for these kinds of games; children invent what they need. Jack’s hide-and-seek game was relational. The importance of following the relational rituals a child invents cannot be overstated. Jack’s affectionate gesture of making pillows as gifts reflected a slightly later developmental progression in relationships, similar to kindergarten or elementary aged children making presents for their mothers. Children and adolescents gravitate toward materials and themes that resonate with their issues. Sewing is an unusual activity for a large adolescent male, and certainly not something I would have chosen for Jack. The activity began when he brought in a pair of pants and asked if I would help to mend them. I showed him how to thread a needle and sew. This progressed into his idea of making pillows. Through these relational experiences of making and giving pillows, Jack gained confidence in relationships. He started asking his caseworker for a foster family and began talking about adoption, indicating he was getting ready to relinquish the idealized image of his biological mother and possibly acknowledge that she was never going to come back and get him. At age 15 in art therapy he made his first sculpture of a bear family (Figure 6.3). As is often the case, at the time I did not realize the significance of this sculpture, but he would make similar sculptures three times over the next four years, which suggested that he was working through something important with this sculpture. The first version looked hauntingly un-nurturing because the characters lacked facial features. Although he yearned for a family, it was apparent that he really did not understand how families should work. The three bears faced outward, and without facial features they could not interact. He did not notice anything unusual about the bears and glazed the sculpture to finish it.

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Figure 6.3 Jack, age 15. First bear sculpture

According to Perry’s (2009) neurosequential model, “Once there is improvement in self-regulation, the therapeutic work can move to more relationalrelated problems (limbic) using more traditional play or arts therapies” (p. 252). It was not an accident that Jack’s artwork took on a more relational tone in content when he began exploring the relational aspects of his own life through practicing what it meant to be in relationship with staff. His developmental level had progressed beyond the most primitive brain stem levels; he was progressing on his behavioral level system in his treatment center, to the point that he was moved to a less restrictive unit. Jack made progress on his level system, although he still had many challenges. At age 15 Jack got his wish and moved into a foster home with a wonderful woman who considered teenaged boys her specialty. I could be the best therapist in the world, but nothing I did in 50 minutes per week compared to the fact that the foster mother wanted Jack and made a long-term commitment to his care. Jack did a lot of testing of this relationship. The foster mother learned early on that consequences devastated Jack and he was hypersensitive to rejection. If he got into trouble, he assumed that his foster mother no longer wanted him and he would become violent or run away. One of the difficulties in work with institutionalized children is the lack of consistency in caregivers. Foster homes are not usually long term, nor is consistency in therapists typical. Children in state custody lose therapists as frequently as they change placements, and they change social workers, schools,

Neuroscience and Art Therapy 149 psychiatrists, and house parents continually. Somehow through all of this I was one of the only long-term relationships in Jack’s life. Once I started working with Jack, my ability to follow him from residential treatment to a foster home, through two more hospitalizations, two more residential placements, another group home, and back to his foster mother, was partially my insistence and partially luck. Many children with attachment issues end up with multiple placements because the system does not value relationships. Others end up with multiple placements because the children actively push away the very people who are trying to love and help them (Hughes, 1997, 1998). Foster parents become frustrated by a child’s inability to bond, and thus a cycle of failed placements continues. Family therapy with the foster parent and child, even if it is not a pre-adoptive home, becomes a crucial intervention to safeguard the placement and break this pattern (Klorer, 2000). Family therapy with Jack and his foster mother was imperative in order for Jack to learn how to be in a family, and we alternated family and individual sessions. The most important treatment goal for Jack at age 15 was to form an attachment with his foster mother. In his individual sessions, Jack initiated making presents for his foster family. He made pillows for everyone, including a stuffed animal pillow with an imbedded squeaky toy for the family dog. He made an origami person for the college-aged daughter (Figure 6.4) and a doll for his foster brother (Figure 6.5). As was typical of his art, faces were devoid of features. We needed to build Jack to the point that he could look people in the eye and not be afraid of their faces. Jack had a number of explosive incidents during the next few years, several with police involvement, and he had to leave the foster home for hospitalizations. Twice he returned to residential treatment centers, but his foster parents genuinely cared about him and always took him back. Jack made his bear sculpture again at age 16 (Figure 6.6). He was still trying to understand what it meant to live in a family. His foster mother reported that he was most comfortable spending time alone in his room rather than interacting with others in the house. Yet he was reaching out to family members and expressing affection through his art. During this same time period he tried to “fire” me as his therapist several times, claiming that I tortured him. I teased him and told him I wanted to work with him until he was at least 21, and maybe even an old man. He would smile. In her neurodevelopmental art therapy model, Chapman (2014) identifies the “problem phase” as when the child is exploring nonverbal emotions through art and play. As Jack was becoming more secure in his attachment with his foster mother, he could experiment with pushing me away. The fact that I would not leave was another testament to the power of a secure attachment. Perry (2009) notes in his neurosequential model that “once fundamental dyadic relational skills have improved, the therapeutic techniques can be more verbal and insight oriented (cortical) using any variety of cognitive-behavioral or psychodynamic approach” (p. 252). This was evidenced by Jack’s ability in the following years to take advantage of verbal therapy, not possible until his neurodevelopmental functioning reached the cortex.

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Figure 6.4 Jack, age 15. Origami person made for his foster sister

Figure 6.5 Jack, age 16. Doll made for his foster brother

Figure 6.6 Jack, age 16. Second bear sculpture

Neuroscience and Art Therapy 151 At ages 17–18 Jack sat in the waiting room with his hooded sweatshirt pulled so far over his head that only the bottom third of his face showed. At 225 pounds he didn’t fit under the beanbag chair or behind the door anymore, and he felt foolish hiding in the hallway, but he still wanted me to find him. Jack still had difficulty making eye contact unless I asked him to, with the exception of when he was lying; then he looked directly into my eyes and smiled. Then we would both laugh knowingly. I thought he was adorable, and he knew it. Once he had told me that he had not had any problems in school that week, then he could start talking about the problems he had had in school. His foster mother continued to attend sessions and assisted him in behavior regulation. Cognitivebehavioral approaches were now more successful, so we utilized positive selftalk to de-escalate his anger before an outburst, relaxation techniques, and role playing for social problem solving. However, Jack’s primary treatment goals continued to focus on that which he had missed in his early developmental years: emotional regulation through attachment with a maternal figure. At age 19 Jack had a crucial turning point in his life when his foster mother discovered that in a fit of anger he had destroyed all of the family photos she had given him. Although she told him she understood why he did it, she wanted him to know it hurt her feelings. Perceiving this as another rejection, he became very angry, began yelling, threw some of his things in a bag, and said he was going back to

Figure 6.7 Jack, age 19. Third bear sculpture

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the group home to live. Although the foster mother thought he was going to bolt, she kept talking to him calmly. Finally he started crying, she started crying, and they hugged. She told him she loved him with all her heart. Through tears he said he wanted to stay. During the next few months Jack opened up in therapy as he never had before about painful recollections of his biological mother and other abusive people in his life. With the security of his foster mother’s love, he could finally face these feelings. Jack stopped hiding in my waiting room at about that same time. Later that year, Jack began making another bear sculpture. The sculpture took more than a month to complete, as he started and then abandoned it several times. The amazing thing about this sculpture, when it was finally finished, was that the bears had facial features (Figure 6.7). Jack finally understood what it was like to make a genuine connection with his foster mother. A secure attachment is a necessary ingredient to face early developmental trauma. In Jack’s case, the facial features, which for him represented the emotional center of the figure, could not be incorporated in the family figures until he had experienced such connections firsthand in a relationship and in the higher cortical function of the brain.

Summary: Neuroscience-Informed Approaches to Attachment Related Trauma A neuroscience approach to therapy with children severely traumatized by their principle attachment figures takes into account the psychological and physiological effects of abuse. This approach entails working at the child’s socioemotional level rather than chronological age (Perry, 2009), recognizing that the child may be functioning at a much lower developmental level than anticipated. Early relational games and interactions, some that might appear on the surface to be too young for the client, may actually hold his or her interest for quite a while. The therapist will want to provide opportunities for the child to experiment with new modes of interactive responses with the therapist and primary support group. Aligning therapeutic support with the treatment center, foster parent, or pre-adoptive family is imperative, as those relationships can be where the most important work happens. Helping caregivers to understand the meaning behind the behavior can sometimes save a placement. Although it is beyond the scope of this chapter to discuss medication regimens, frequent medication evaluation and adjustments may also be a necessary component of treatment. One should postpone cognitive-based therapies in favor of expressive and relational work until the child is able to form an attachment (Perry, 2009). Later, cognitive approaches for symptom reduction and acquisition of coping skills may be used. Using expressive methods in a relational way enables the child or adolescent to make emotional connections. The child will create imagery reflective of his or her relationships. Although the examples in this chapter focused on art, expressive

Neuroscience and Art Therapy 153 nonverbal work happens in many expressive therapy modalities including movement, play, poetry, art, sandtray, and drama. Directed approaches can assist clients in furthering their developmental progression (Chapman, 2014). However, one does not always need to provide directives to achieve desired outcomes. The most powerful work in art therapy often stems from non-directive, client-centered work. When provided with psychological safety in the art room and a trusting relationship with a therapist, children and adolescents find their own paths. It is an idiosyncratic process, in that what is an important symbol for one client is irrelevant for another. A lack of facial features was an important symbol for Jack, but one could not generalize this to another client. For the same reason that artwork alone cannot be used to diagnose sexual or physical abuse, there is no defined set of graphic indicators that will indicate success of treatment. Rather, the therapist has to track the progress of the client’s own imagery in comparison to changes in behaviors. Jack’s art reflected his attachment issues, although we did not talk about that interpretation directly. We talked about current behavior and social interactions, and we lived the attachment issues through a genuine relationship. To summarize, Jack’s first attempts in art were well defended and his beginning art reflected his fear of closeness (Figures 6.1 and 6.2). As he began to trust his staff, he began making them pillow animals. His art became more relational, as if he were in the practicing phases of attachment/separation/ individuation. He practiced being in relationships with his caretakers. At the same time, he invited me to assist him in sewing, which brought us into an intimate, shared space. When he moved to a foster home, he continued to use art relationally. His fear of closeness was apparent in the lack of facial features on the people and animals that he made as gifts (Figures 6.3, 6.4, 6.5, and 6.6). As he realized that he had found a forever family and he engaged in a genuine familial relationship, Jack’s art changed. His final sculpture (Figure 6.7) demonstrated this relational progression. At termination, Jack understood what it meant to be in a family. The art is the evidence. Expressive therapy provided an avenue for Jack to explore themes related to his issues. It was the therapeutic relationship with me and his foster family relationships, however, that were the most important. One should keep in mind that, in a meta-analysis of hundreds of psychological studies of therapeutic effectiveness, by far the most important factor of successful treatment is the alliance between therapist and client (Norcross & Lambert, 2006) and in this case foster mother and child. At age 21, Jack and I terminated therapy. He signed release forms so that I could photograph his artwork and possibly share his story someday. He took all the artwork that had been left in the office over the nine years of our work together, and he moved into a semi-independent living program for adults. Although Jack still has many struggles, at the time of this writing he sees his foster family at least once a week.

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Note 1. Although details of this case have been changed to protect confidentiality, the essence of the case and the artwork are real.

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Neuroscience and Art Therapy 155 Harvey, S. (1991). Creating a family: An integrated expressive approach to adoption. The Arts in Psychotherapy, 18(3), 213–222. Retrieved from: http://dx.doi.org/ 10.1016/0197-4556(91)90115-Q Haugaard, J. (2004). Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: Introduction. Child Maltreatment, 9(2), 123–130. doi:10.1177/1077559504264305 Hughes, D. (1997). Facilitating developmental attachment. Northvale, NJ: Jason Aronson. Hughes, D. (1998). Building the bonds of attachment. Northvale, NJ: Jason Aronson. Jernberg, A. (1979). Theraplay: A new treatment using structured play for problem children and their families. San Francisco: Jossey-Bass. Johnson, D. R. (2009). Commentary: Examining underlying paradigms in the creative arts therapies of trauma. The Arts in Psychotherapy, 36(2), 114–120. Retrieved from: http://dx.doi.org/10.1016/j.aip.2009.01.011 Klorer, P. G. (2000). Expressive therapy with troubled children. Northvale, NJ: Jason Aronson. Klorer, P. G. (2005). Expressive therapy with severely maltreated children: Neuroscience contributions. Art Therapy: Journal of the American Art Therapy Association, 22(4), 213–220. doi: 10.1080/07421656.2005.10129523 Klorer, P. G. (2008). Expressive therapy for severe maltreatment and attachment disorders: A neuroscience framework. In C. Malchiodi (Ed.), Creative interventions with traumatized children. New York: Guilford Press. Norcross, J., & Lambert, M. (2006). The therapy relationship. In J. Norcross, L. Beutler & R. Levant (Eds.), Evidence-Based Practices in Mental Health (pp. 208–218). Washington, DC: American Psychological Association. Perry, B. (1995). Childhood trauma, the neurobiology of adaptation, and “use-dependent” development of the brain: How “states” become “traits.” Infant Mental Health Journal, 16(4), 271–291. Perry, B. (1997). Incubated in terror: Neurodevelopmental factors in the “Cycle of Violence.” In J. Osofsky (Ed.), Children in a violent society (pp. 124–148). New York: Guilford. Perry, B. (2001). Violence and childhood: How persisting fear can alter the developing child’s brain. (October 25, 2001). Retrieved from: www.ChildTrauma.org Perry, B. (2009). Examining child maltreatment through a neurodevelopmental lens: clinical applications of the neurosequential model of therapeutics. Journal of Loss & Trauma, 14(4), 240–255. doi: 10.1080/15325020903004350 Rauch, S., van der Kolk, B., Fisler, R., Alpert, N., Orr, S., Savage, C., . . . & Pittman, R. (1996). A symptom provocation study of postraumatic stress disorder using positron emission tomography and script-driven imagery. Archives of General Psychiatry, 53(5), 380–387. doi: 10.1001/archpsyc.1996.01830050014003 Rutter, M., & O’Connor, T. (2004). Are there biological programming effects for psychological development? Findings from a study of Romanian orphans. Developmental Psychology, 40(1), 81–94. doi: 10.1037/0012-1649.40.1.81 Schiffer, F. (2000). Can the different cerebral hemispheres have distinct personalities? Evidence and its implications for theory and treatment of PTSD and other disorders. Journal of Trauma and Dissociation, 1(2), 83–104. Schiffer, F., Teicher, M., & Papanicolaou, A. (1995). Evoked potential evidence for right brain activity during the recall of traumatic memories. Journal of Neuropsychiatry and Clinical Neurosciences, 7(2), 169–175.

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Schore, A. (2001). The effects of a secure attachment relationship on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22(1/2), 7–66. doi: 10.1002/1097-0355(200101 Schore, A. (2002). Dysregulation of the right brain: A fundamental mechanism of traumatic attachment and the psychopathogenesis of post-traumatic stress disorder. Australian and New Zealand Journal of Psychiatry, 36(1), 9–30. Schore, A. (2012). The science of the art of psychotherapy. New York:W.W. Norton. Seinfeld, J. (1989). Therapy with severely abused child: An object-relations perspective. Clinical Social Work Journal, 17(1), 40–49. St. Clair, M. (1986). Object Relations and Self Psychology: An Introduction. Belmont, CA: Brooks/Cole Publishing. van der Kolk, B. (1989). The compulsion to repeat the trauma. Psychiatric Clinics of North America, 12(2), 389–411.

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Practical Applications of Neuroscience in Art Therapy A Holistic Approach to Treating Trauma in Children Christopher M. Belkofer and Emily Nolan

When working with children who have experienced trauma it is common for relatively small stimuli such as perceived rejection, an authority figure saying “no,” or a redirection of behavior to result in outbursts of defiance, anger, sadness, despair, and often aggression. These extreme reactions can be described as low input–high output responses. A mild stimulus (low input) often evokes an extreme response (high output). Encountering such “meltdowns” proposes a series of challenges and complexities for the therapist, support staff, and/or primary caregiver. Moreover, as a result of their neurodevelopment children, traumatized or not, lack the verbal processing skills necessary to discuss their feelings and emotions (Siegel & Bryson, 2012). This chapter explores how the practice of art therapy has unique characteristics that can address these challenges. In the following pages we will explore how process-oriented approaches to treatment may help clients practice self-regulation by increasing their awareness of their own bodies (Hass-Cohen, 2008). Through the exploration of the physical properties of art media art therapy can target the underlying components of trauma in a way that language cannot. Neuroscience research shows that the high output responses often seen in children who have experienced severe trauma are related to levels of arousal and dysregulated systems of the brain (Glaser, 2000; Klorer, 2005; Perry, 2009). Trauma in essence wires one’s emotional system in a heightened way that is characteristically primed to be highly reactive. Repeated exposure to real or perceived threats, such as those that are associated with psychological and physical trauma, can result in changes in neurophysiology such as variations in hormones, breathing patterns, and baseline levels of arousal (Siegel, 1999). As a result of these chronic elevated states clients typically become mentally fatigued. Chronic anxiety can lead to depression because the bodily system breaks down and as a result shuts down.

DOI: 10.4324/9781003196242-7

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Trauma and the Body In many ways, people who have experienced trauma often struggle within their own bodies (van der Kolk, 2006). In addition to invasive thoughts they may also experience numerous aches, pains, and muscle tension, as well as sleep disorders. The lingering effects of the trauma become so painful that clients may feel it is better to not be aware of their bodies at all. As trauma survivors lose more and more touch with their bodies and their own inner selves, they grow increasingly distant from a connection with their own senses of self, leading to the feeling that they exist outside of their own body. To conceptualize this image, imagine that a person observes herself on the opposite shore of a river. What she sees is disconnected from what she feels. The self is ruptured by the ripples of trauma. Our perception of our reality and our own felt sense of the world is influenced by our neurophysiology (Siegel, 1999). Variations in the systems of the brain and other related parts of the body influence our perception and our mood, as well as our thoughts and feelings. The communication between our cells, the flow of blood and oxygen, and the secretion of hormones directly constitute how we experience our realities. Trauma disrupts these bodily systems, which correlates with a rupture in how people experience the world. This estrangement in how a person feels in and about the world impacts the self. To understand how trauma disrupts the mind—or, if we prefer, the self—we must also appreciate how trauma impacts the body. Scientists and researchers are garnering evidence that the impacts of psychological trauma from verbal abuse and emotional neglect last far beyond the duration of the event (Glaser, 2000). Researchers have shown that early life trauma leads not only to long-term mental health problems well into adulthood, such as depression and suicidal thoughts, but also diseases including cancer and diabetes (Anda et al., 2006). Although a full review of the literature on the impact of psychological trauma on the body and the mind is beyond the scope of this chapter, the arching implication of these findings for mental health is that there is a need for greater understanding that the development of psychiatric symptoms are related to “stress-induced changes in neurobiology” (Bremner & Vermetten, 2001: 481). Changes in the neurobiology that make up the mind are also changes in the body. Although it was once conceptualized that the mind is split from the body, current neuroscience-informed approaches to mental health have helped to bridge the mind/body divide (Damasio, 1994, 1999). Traditional models of mental health often separate cognition from the body, but we now have a greater understanding of how the body informs and influences our thoughts and higherorder cognitive functioning (Damasio, 1999). In many ways the contemporary frameworks for understanding the brain return mental health clinicians to considerations of the body. In the early part of the twentieth century, Adler’s theory of holism posited that there is no separation between the brain and the body (as cited in Mosak & Maniacci, 1999). Similar to Freud’s theories of the unconscious, a vivid reality of chemical reactions and intersecting systems have been identified as major parts in an ongoing play that exists within our brains

Practical Applications of Neuroscience 159 and outside our awareness. This is now referred to as implicit communication (Siegel, 1999). Damasio (1999) asserted that language is an interpretation of concepts already known within the body. Bollas (1987) referred to this idea as the “unthought known.” Moon (2010) noted that the work of art therapy is in the doing and nonverbal interchange. The verbal exchange about the art-making is the “icing on the cake” of the therapy. These advancements for understanding the brain have widespread applications for mental health as well as understanding interpersonal relationships. Clinical neuroscience and interpersonal neurobiology have built upon seminal attachment theory (Schore, 2001) to work toward addressing mental health as an interpersonally influenced mind/body holistic experience. Relationships can change the brain (Siegel, 1999). We understand how the relational bond between mother and child, or client and therapist, for example, impacts the development of the brain at structural levels (Chapman, 2014; Kravits, 2008). This era of increased appreciation for the neuroplasticity of the brain has led to a paradigm shift in how human relationships are conceptualized; for example, Siegel’s (1999) assertion that interpersonal connections throughout one’s life impact the systems and the structures of one’s brain. Cozolino (2002), Damasio (1994, 1999), Perry (1996), Schore (1994, 2001), Siegel and Bryson (2012), van der Kolk (2003, 2006), and others have helped to redefine our understanding of the neuroscience of psychotherapy and ushered in a revolution in mental health. What we do and with whom we do it with impacts the structures of the brain. Relationships shape the brain. These authors cover a vast range of topics, research, theories, and brain mechanisms that are far beyond the scope of this chapter. For the sake of simplicity and with a potential for reduction in mind, the collective influence of these shifts as pertinent to our writing can be broadly summarized as follows: •

• • •

a greater understanding and emphasis on how interpersonal relationships directly influence the development and performance of structures and systems within the brain; our thoughts, feelings, and behaviors are made up of dynamic processes that directly relate to the whole self; traumatic memories are difficult to access and process exclusively with language; and mental health disorders associated with trauma relate directly to physiological processes such as levels of hyper- and hypo-arousal.

The implication of these influences is that effective mental health models no longer conceptualize the brain as distinct from the body. The brain and the body “are intimately linked together” in the formation of the mind (Newberg & d’Aquili, 2000: 54). Newberg and d’Aquili (2000) clarify: Perhaps the easiest way to understand the relationship between the mind and the brain is to regard the brain as the structure that performs all of the

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The implications of these assertions have widespread applications for art therapy. It is not surprising that a field that was once ambivalent toward scientific paradigms (Kaplan, 2000) has enthusiastically looked toward neuroscience for greater understanding and at times legitimization (Johnson, 2009). In addition to the development of brain-based art therapy clinical models (Buk, 2009; Chapman, 2014; Collie, Backos, Malchiodi, & Spiegel, 2006; HassCohen, 2008) and exploratory brain imaging studies (Belkofer & Konopka, 2008; Belkofer, Vaughn Van Hecke, & Konopka, 2014; Kruk, Aravich, Deaver, & deBeus, 2014) that consider how media impacts the brain, an entire special issue of Art Therapy: Journal of the American Art Therapy Association was dedicated to the topic of art therapy and neuroscience (Kapitan, 2014). Johnson (2009) asserted that “the fact that the brain is involved is not evidence that the creative arts therapies are effective” and that applications of neuroscience in art therapy remain primarily “metaphorical” (pp. 116–117). These observations do not take away from the significant advancements that have led us past a conceptualization of art therapy as a right-brained profession and toward an increasing appreciation for the fact that art-making takes place all over the brain. The emphasis of this chapter is on how the aforementioned brain-based knowledge has informed our work as art therapists. We hope to illustrate through two case vignettes how the therapeutic use of the visual arts is an effective means for working with children who either can not or will not express themselves in traditional verbal narratives. To illustrate this we build from a foundational notion that all arts involve the body (Kossak, 2009.) Although this is not necessarily a revolutionary concept or even a new idea, bodily elements of the arts remain largely understated in comparison to the emphasis on cognitive processing. One could argue that an overemphasis on the mind (thinking and explaining) as opposed to the body (feeling and experiencing) has thrown mental health in general out of balance (Belkofer, 2014). For our purposes, we assert that although targeting the body has been a long-standing feature of expressive therapies such as dance movement therapy, drama therapy, and music therapy (Pearson & Wilson, 2009), the bodily characteristics of art therapy remain less explicit. We do not intend to diminish the significant emphasis on the physical elements of art-based approaches to art therapy (McNiff, 1992; Moon, 2009; B. L.Moon & Belkofer, 2014), yet traditionally these theories have overtly attempted to differentiate art therapy from traditional scientific models. Regardless of these differences, contemporary views of art therapy are no longer bound to the old models of “art psychotherapy” (Naumburg, 1987) versus “art as therapy” (Cane, 1983; Kramer, 1958), but rather view the work as existing on a continuum. The ability of art therapists

Practical Applications of Neuroscience 161 to work from a variety of approaches as determined by the needs of the client as well as the suitability of the setting is a basic expectation of art therapy training today. Helping to provide a conceptualization for this agility has been Lusebrink’s (2004, 2010) neuroscience-informed exploration of the Expressive Therapies Continuum (ETC). Lusebrink (2010) hypothesized that multiple regions and systems of the brain are at play during different levels mapped out by the ETC. The ETC categorizes a person’s responses to media on three levels that reflect variations in responses: Kinesthetic/Sensory (K/S), Perceptual/Affective (P/A), and Cognitive/Symbolic (C/Sy). Lusebrink (2010) theorized that each level of the continuum utilizes different elements of the brain. The K/S level, for example, involves brain functioning associated with movement and evolutionarily lower order brain functioning. By contrast, working on the C/Sy level entails a higher level of cognitive functioning reliant upon more advanced thought processes such as abstraction, metaphor, and “concept formation” (Lusebrink, 2010: 171). Although art therapy is not necessarily sequential or bound to one level or another, art therapists can look the ETC to appreciate the range of dynamic brain structures and processes broadly associated with the therapeutic applications of the creation of visual imagery. More empirical support is needed, but the varied responses of art-making afforded by the ETC model are well suited for conceptualizing a rationale for how divergent ways of working as an art therapist correspond to divergent processes within the brain. The action-oriented use of the body and perceptual and sensory processing associated with the Expressive Therapies Continuum aligns art therapy with conceptual models of neuroscience-informed approaches to trauma that emphasize learning how to feel feelings in a safe way and also the practice of self-regulation (Perry, 2009; van der Kolk, 2006). The bodily awareness afforded by the K/S and P/A levels of the continuum is a foundational step toward effectively working with clients who have experienced complex trauma to conceptualize their emotions in a metaphoric and insightful way. A solid rationale that is based upon empirical research for the nonverbal, kinesthetic, and sensory elements of art therapy is not only helpful to the profession but also helpful for art therapy clients. The neuroscience-informed ETC model allows for approaches that are clinically grounded but inclusive of diverse ways of practicing art therapy as well as the diverse ways of knowing that our clients exhibit. As noted by Pearson and Wilson (2009), “an inclusive emotional healing process offers combined cognitive, somatic, kinesthetic and intrapersonal reconnection with sources of past and present experiences” (p. 49). In our own art therapy work we have identified the importance of including how our clients experience the world with our own clinical agenda.

Volcanoes and Ice Cream Cones: Christopher’s Case Vignette I, Christopher (first author), previously worked as an art therapist at a residential treatment center for troubled youth. One evening a young girl, Kristy

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(pseudonym), was on the way to a movie group, a standard part of our evening programming for the residents. To go to the movie group, she had to pass through the gym. As excited children often do, she entered the gym without stopping at the door, a standard procedure. She was directed to walk through the gym again. Instantly becoming upset and refusing, she became verbally aggressive to staff, which quickly escalated into physical aggression. This required the staff to place her in a therapeutic hold, which led to her being held on the ground of the gym floor. There she attempted to bang her head on the hard tile, screamed, and cried. This behavior lasted for 45 minutes; stages of emotions would subside only to return again with reattempted head banging (which staff prevented with a pillow, a mat, and therapeutic holds). Kristy had a history of abuse. Touch—even if designed to be nurturing and caring—was confusing, painful, and frightening from her perspective. After her intense emotions subsided and she returned to the unit, I met Kristy in my office. I brought paper and oil pastels and gave them to her with no instructions. “Wow,” I said. “I was really worried about you earlier.” I picked up the pastels and began a scribble drawing. “That was pretty scary.” I breathed in and sighed. She picked up the oil pastels and started a drawing. “What do you think about when that happens?” I asked. “Nothing” she said. “I actually don’t even remember it happening.” “I wonder how that feels.” “Like this,” she said, showing me her drawing. “When I get angry I feel like a volcano.” “I see,” I said. “Volcanoes are powerful. I wonder if there is something you can do to stop the volcano from exploding.” “I don’t know,” she said. “When I feel like a volcano, sometimes I breathe like this,” I said, taking a big breath. “Can you breathe like this too?” I asked. “Oh, you mean like in yoga!” “Yes, like in yoga,” I said. Together we breathed. After taking a few deep breaths, Kristy turned her picture over and drew a pink bubbly cloud at what once was the base of the volcano. “I like the colors there,” I said. “This is an ice cream cone,” she replied. “Even though I can be like a volcano, I am a sweet girl too.” “Yes, you are,” I said. “Can I go back to my room now?” she asked, letting me know she was finished. “I think so,” I said. “But first, what can you do next time when you feel like a volcano?” “Breathe,” she said, exaggeratedly drawing the word out. “How are you going to be the rest of the night?” I asked. “I don’t want to hear that you turned into a volcano again. Can you be an ice cream cone?” “Yes, I can be an ice cream cone,” Kristy said.

Practical Applications of Neuroscience 163 This vignette offers an example of how a minor redirection from staff (being told to walk though the gym as opposed to running) triggered a powerful emotional and physical response. When asked later, the client did not remember an almost hour-long regression into crying, kicking, and self-harming. The small stimulus led her to relive her previous trauma in the moment. Luckily, Kristy was supported by trained professionals who were able to identify this regression as a product of her PTSD. As part of the treatment team, I was able to use art therapy to help assess her current psychological state. Through the use of visual imagery we were able to identify a means of communication. This communication, which occurred primarily through visual imagery, inherently involves the brain. For example, the experience of the color of the images as well as the process of recognizing one object as a volcano and another as an ice cream are reliant upon structures, cells and synaptic transmission of the visual system (for more detailed descriptions of how visual art is processed in the brain, see Livingstone, 2002; Lusebrink, 2004; Zeki, 1999). In the language of art we found the metaphor of the ice cream cone and the volcano. Yet, the language of visual art references “the grammar of the brain” (Belkofer & Konopka, 2008: 57). Ice cream cones are cool and sweet. Volcanoes are hot and explosive. Through the sensory characteristics of the visual objects Kristy created on the page, she was able to describe the sensory characteristics of her self. It is the sensory nature of artistic expression that helps the client and the therapist bridge the limitations of language and communicates concepts that would be difficult to express otherwise. Although our entire encounter lasted no more than 10 minutes the metaphor of the imagery gave Kristy a reference for expressing and understanding herself and her behaviors that extended beyond the time of our meeting. This reference was visual and bodily. She could see the volcano in her head and feel the molten lava boil in her stomach. For the remainder of the evening I was able to check up with her while she was on the unit with the simple question/prompt: “Ice cream cone or volcano?” In future encounters I was able to assess her affect through the same imagery. In this vignette I made art alongside my client. We both had pieces of paper and oil pastels. As I scribbled, she scribbled. Through these motions there was a sense of synchronicity that occurred. As I made a mark, she made a mark. In this synchronized kinesthetic action a rhythm emerged. In this rhythm of shared visual art-making it is possible that Kristy and I reached a state of interpersonal connection called “therapeutic attunement” (Kossak, 2009: 14). This sensorybased exchange of energy need not be conceptualized as made up of some kind of abstract cosmic “stuff” that floats all around us. Rather, as conceptualized by Siegel (1999) the shared energy was a resonance occurring in our brain and our minds. As noted by Hass-Cohen (2008), art therapy can promote an interpersonal resonance related to “expressing, experiencing and learning how to regulate affects . . . through sensory integration activities and kinesthetic movement associated with art therapy activities” (p. 35). One way to conceptualize this connection is through the act of entrainment, which is “a felt inner sense of deep shared connectivity or merging in the

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moment” (Kossak, 2009: 16). The therapeutic use of the arts (as in art therapy, dance/movement therapy, poetry therapy, drama therapy, and music therapy) helps therapists tune in to the inner reality of their clients through creative expression, improvisation, movement, and rhythm (Kossak, 2009) The felt sense of interpersonal connection associated with entrainment involves dynamic changes in the brain and other parts of the body. The “bodily resonances” (Freedberg & Gallese, 2007: 197) often associated with witnessing and marking art may be associated with the activation of cells identified by team of Italian researchers (Gallese, Fadiga, Fogassi, Fogassi, & & Rizzolatti, Rizzolati, 1996) called mirror neurons. Art therapists have explored the role of these cells, which are found in the motor cortex of the brain, as playing an important role in the bodily experience of empathy and the felt aesthetic responses associated with the therapeutic applications of the arts (Belkofer, 2014; Buk, 2009; Franklin, 2010). The act of shared art-making affords opportunities for strong personal interconnections (B. L. Moon, 2010). Working side-by-side or on the same art piece opens up a door for entrainment. Where my mark making resulted in nonobjective imagery, my client’s work referenced the imagery of volcanoes and ice cream cones. I did not provide a directive for Kristy to draw a specific object or image. According to Arnheim (2004), “It turns out that every visual object is an eminently dynamic affair” (p. 412). Related art media, such as paint, clay, pastels, and so on are also dynamic. As noted by Seiden (2001), “The art therapist, in approaching materials, must first accept the significance of the nonliving object . . . They each have properties which are evocative” (p. 20). The physical and metaphorical qualities of media play a vital role when working with children who have experienced trauma; it is essential for the therapist to understand the inherent physical qualities of diverse media. In this approach one can think of materials as having personalities, which clients are attracted to or repelled from. The personalities of the media are made up physical characteristics such as being fluid, resistant, hard, delayed, immediate, and so forth. These physical and symbolic qualities, which impact the maker and also influence the art on multiple levels, (C. H. Moon, 2009) inherently involve the brain. The Story of Nate: Emily’s Case Vignette Much like Christopher’s experience with Kristy, I, Emily (second author), also had a revelatory experience when working with a young boy named Nate (pseudonym) who opened my eyes to the integrative potential of art therapy. Nate began therapy after having been severely sexually abused by an older adopted sibling in his foster home. The sexual abuse occurred on a nearly daily basis from the age of 6 weeks to eight-years-old. The following vignette shows how Nate was able to use his art-making to develop his own nonverbal method of self-soothing. When Nate first began therapy with me, it took a long time to build trust between us. For the first three years of therapy, he would only play board games.

Practical Applications of Neuroscience 165 Art did not seem important or interesting to him. As Nate slowly began to show signs of trusting me, he would experiment with the art materials that I provided for him. Nate was nonverbal. I think he would listen to me talk, but he hardly ever answered with words, and he rarely made eye contact. I relied on reports from his adoptive mother and teachers, and I attempted to interpret his behaviors and actions to understand his experience. Nate used the media and materials in the art therapy studio in a way that was uniquely therapeutic for him. I typically did not give him directives. I purposefully gave him limited choices, and once he discovered what materials felt good to work with, he continued to experiment with that medium. In my mind, this was my way of addressing Nate’s complex feelings related to control and his perception of authority figures. Having experienced sexual abuse— something outside of his control—he often engaged in power struggles with important adults in his life. Art therapy offered Nate a different experience: a new way to rework his previous emotional and behavioral patterns that resulted from feeling powerless. After nearly four years in session, Nate had developed a regular routine in the art therapy studio. He would gather his own paints and brushes, begin painting, and make significant progress on several pieces during each session. I noticed that he worked in a very kinesthetic way, building up the surface of the canvas with paint to create peaks and texture. He worked on one painting, over and over, for almost three years (Figure 7.1). Most weeks he simply added a new layer to continue building the texture of the surface. I told him that the spikey

Figure 7.1 Client Process Painting Color version available at http://www.routledge.com/9781032050539

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Figure 7.2 Therapist's Response Image Color version available at http://www.routledge.com/9781032050539

peaks reminded me of armor that could be used to protect him, perhaps similar to his outbursts of angry, defensive behavior at home with his mom and at school with his teachers. He listened intently and made eye contact as I shared my own response drawing of a figure with spikes on him (Figure 7.2). Our work continued this way; Nate used the materials in the studio to paint, and I made connections to how his art-making behaviors might relate to what had happened to him and how these experiences were affecting him currently. At one point I asked him to do an experiential task that I often asked other clients to do close to the beginning of treatment. I asked him to write a list of emotions down on paper. I usually expect that a typical emotionally regulated child in his age range can name at least six. Nate had difficulty naming any emotion words, so I helped him with a few. When I asked him to try and conjure up each feeling within himself and imagine it was traveling down his arm and onto the paper as an extension of the emotion, he used all the colors and scribbled them together. He covered the entire paper and not one mark or color stood out from the others. At first I was frustrated that he didn’t seem to be following my directions. I took a minute to think about what he was really communicating to me through

Practical Applications of Neuroscience 167 his art actions. Then it dawned on me that this was a kinesthetic and sensory way of working. Nate was practicing his ability to self-soothe, not only with the paint and his paintings, but also with the scribble drawings. I also wondered if he was not able to differentiate his emotions. I hypothesized that when a feeling arose, he might often be feeling a complicated, mixed-up jumble of emotions. If this were true, I imagined it would be very hard for Nate to discern what he was feeling, except for the overall sense that it was bad. Did every emotional state just feel the same? In our next session I asked Nate about it to test out my hypothesis. He nodded “yes” when I suggested that “he felt it all at once,” and “the feelings were all over his body.” Nate continued his regular routine of painting, but I noticed that he began to leave time at the end of each session to organize the art room. He would pull out materials, like stamps and other cans of odds and ends, and put them in order. Over the next few months, I noticed that although he continued to work on his paintings and organize materials in the studio, he also began new paintings in which forms were beginning to emerge. He started to use modeling paste to paint waves and a beach. His paintings incorporated sculptural elements such as threedimensional shapes. Nate also started to paint egg case palettes. He mixed colors and painted each color in a rainbow succession. He seemed to be organizing the palettes (Figure 7.3), one color in each well where each color of the rainbow should go. He took a break from the paintings and each week he would paint the palettes. I wondered if Nate’s pattern of creating the egg cases meant that he had increased his ability to differentiate some of his emotions. I could see he was beginning to self-organize, and then my clinical understanding was confirmed.

Figure 7.3 Egg Crate Palette Color version available at http://www.routledge.com/9781032050539

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At one session in particular, Nate’s mother came in exasperated, reporting that he had stolen a movie and money from his aunt. Stealing was not uncommon behavior for Nate. As a result of the complex trauma he had endured and his resulting attention deficit and hyperactivity symptoms, Nate struggled with impulse control. Because we had been working on a foundation of understanding and articulating emotions, I used a direct verbal approach to address the emotions underneath the stealing behaviors. While Nate was painting, I asked him a number of questions about his feelings, his thoughts, and the circumstances that had led up to the act of stealing. Nate eventually revealed that he had been anxious about a missing homework assignment at school right before he went to his aunt’s house. With troubling feelings of anxiety swirling through his body, Nate swiped the movie and the money. I asked Nate to go home that week and think about where he felt anxiety in his body, and proposed that next week we could develop a plan to prevent the stealing behavior when he felt the impulse. When Nate returned the following week, he told me that he felt the anxiety in his stomach. He acknowledged that there was usually something that precipitated his feeling anxious. When the anxiety hit, Nate felt desperate to alleviate the uncomfortable, tight, and swirling feeling in his stomach. His first resort was to steal something, but he would immediately feel guilty and ashamed. It was a painful cycle: One bad feeling led to an action that led back to a bad feeling. However, Nate was now able to understand his emotions better, and he created a plan for when this feeling emerged in his stomach again. Instead of immediately acting on his impulse to soothe his bad feelings, he could talk to his trusted sister or he could make art, and, Nate has refrained from stealing. When children feel upset, caregivers validating their feelings can help the children practice self-regulating their emotions (Siegel & Bryson, 2012). Validation can be difficult for parents and caregivers, especially if the child is annoying or frustrating the adult with the behavior. Children also learn to tolerate the ambiguity that life often brings; they learn that many times there are no precise right answers. The process of self-regulation needs to be learned and practiced, by both the child and the caregiver. Art therapy can be an effective way for children to learn about their bodies and their brains through sensory, perceptual, action-oriented means that aid self-regulation. In the case examples above, both clients were able to use art therapy to communicate, understand their bodily sensations, and develop positive plans of action when they felt stressed.

Summary In this chapter we have reviewed how the negative bodily impacts of psychological trauma can disrupt individuals’ abilities to connect with their own emotions (van der Kolk, 2006). This loss of bodily awareness can be associated with a loss of a sense of the self. As a result of this disconnection, clients suffering from trauma often become removed from their own internal realities. As they

Practical Applications of Neuroscience 169 lose touch with their emotions they have a harder time connecting to the world and the people around them in vibrant and positive ways. The cumulative effect of these impacts may render verbal and insight-based approaches ineffective. Clients first “need to learn that it is safe to have feelings and sensations” (van der Kolk, 2006: 287). The goal of treatment shifts to a more experiential base aimed at emotional regulation of the body. Without these basic building blocks clients can become trapped in a reactionary state of helplessness. Unable to organize their emotions they live in a chronic state of “physical immobilization” (van der Kolk, 2006: 283). They become trapped in a body that erupts like a volcano or feel like an undifferentiated mix of colors. According to van der Kolk (2006): If past experience is embodied in current physiological states and action tendencies and the trauma is reenacted in breath, gestures, sensory perceptions, movement, emotion and thought, therapy may be most effective if it facilitates self-awareness and self-regulation. Once patients become aware of their sensations and action tendencies they can set about discovering new ways of orienting themselves to their surroundings and exploring novel ways of engaging with potential sources of mastery and pleasure. (p. 289) Art therapy aligns with van der Kolk’s descriptions of “effective” treatment of PTSD because of the inherent sensory and bodily oriented qualities of the profession. Research on the impact of trauma has placed the body and the nonverbal somatic phenomenological responses of clients at the center of therapeutic treatment. The arts excel in their ability to tap into feelings and sensations. Art therapy, like all of the creative arts, adds “a unique dimension to psychotherapy and counseling . . . not always found in strictly verbal therapies, including, but not limited to, (1) self-expression, (2) active participation, (3) imagination, and (4) mind-body connections” (Malchiodi, 2006: 8–9). These characteristics are consistent with current understandings of how trauma is stored in the brain and the body, impacting levels of hyper-arousal and capacities for self-regulation. If we conceptualize art therapy as a sensory and perceptual approach to the therapeutic process, visual imagery as well as the media used to create it can be conceptualized as living factors within the traditional therapeutic dyad. Visual art is alive in the visual system (Zeki & Lamb, 1994), and the sensations and perceptions it evokes in the body are not bound to verbal interpretations of the work. Understanding the connection between art therapy and brain processing need not be reductionist if we emphasize that the phenomenological experience of visual art is a mixture of both experience dependent perception and what Arnheim (2004) referred to as the metrics of art: What are reds and oranges meeting on a canvas? Wavelengths of 700 and 610 mill microns . . . Although useful for practical and scientific purposes,

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When an art therapist engages with the metaphorical and sensory qualities of an image (“The black squiggly line in top corner seems aggressive and lonely to me,” for example) he or she is engaging with a complex system within the brain, that perceives the qualities of this form and assigns it meaning. Thus, like a word that is assigned narratives and emotional significance, objects, shapes, colors, and forms, are loaded with evocative features. The results of these impacts have substantial therapeutic potential. The sensual nature of the media and the content of the image are both factors in treatment that shape the course of therapy (Moon, 2010). The qualities of the media and the image, the complex understanding of the client and how or what he or she communicates, and the relationship with the client all influence the therapeutic process. This chapter outlined one way that the authors work from a practical neuro-informed art therapy perspective and process with their young clients.

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Malchiodi, C. A. (2006). Expressive therapies: History, theory, and practice. In C. A. Malchiodi (Ed.), Expressive therapies (pp. 1–15). New York: Guilford Press. McNiff, S. (1992). Art as medicine: Creating a therapy of the imagination. Boston, MA: Shambhala. Moon, B. L. (2009). Existential art therapy: The canvas mirror (3rd ed.). Springfield, IL: Charles C Thomas. Moon, B. L. (2010). Art-based group therapy: Theory and practice. Springfield, IL: Charles C Thomas. Moon, B. L., & Belkofer, C. (2014). Artist, therapist, and teacher: Selected writings by Bruce L. Moon. Springfield, IL: Charles C Thomas. Moon, C. H. (2009). Materials and media in art therapy: Critical understandings of diverse artistic vocabularies. New York: Routledge. Mosak, H., & Maniacci, M. (1999). Primer of Adlerian psychology: The analyticbehavioural-cognitive psychology of Alfred Adler. New York: Routledge. Naumburg, M. (1987). Dynamically oriented art therapy: Its principals and practice. Chicago, IL: Magnolia Street. Newberg, A. B., & d’Aquili, E. G. (2000). The creative brain/the creative mind. Zygon, 35(1), 53–68. Pearson, M., & Wilson, H. (2009). Using expressive arts to work with mind, body and emotions: Theory and practice. London, England: Jessica Kingsley. Perry, B. D. (1996). Maltreated children: Experience, brain development and the next generation. New York: W.W. Norton. Perry, B. D. (2009). Examining child maltreatment through a neurodevelopmental lens: Clinical applications of the neurosequential model of therapeutics. Journal of Loss and Trauma, 14(240), 240–255. Schore, A. N. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. Hillsdale, NJ: Erlbaum. Schore, A. N. (2001). Effects of secure attachment relationships on right brain development, affect regulation, and infant mental health. Infant Mental Health Journal, 22(1–2), 7–66. Seiden, D. (2001). Mind over matter: The use of materials in art, education, and therapy. Chicago, IL: Magnolia Street. Siegel, D. J. (1999). The developing mind: How relationships and the brain interact to shape who we are. New York: Guilford Press. Siegel, D., & Bryson, T. (2012). The whole brain child: 12 revolutionary strategies to nurture your child’s developing mind. New York: Bantam. van der Kolk, B. A. (2003). The neurobiology of childhood trauma and abuse.Child and Adolescent Psychiatric Clinics of North America, 12(2), 293–317. van der Kolk, B. A. (2006). Clinical implications of neuroscience research in PTSD. Annals of the New York Academy of Sciences, 1071(1), 277–293. Zeki, S., & Lamb, M. (1994). The neurology of kinetic art. Brain, 117(3), 607–636. Zeki, S. (1999). Inner vision: An exploration of art and the brain. New York: Oxford University Press.

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A Body-Based Bilateral Art Protocol for Reprocessing Trauma Tally Tripp

Neuroscience researchers widely accept that vivid, unprocessed traumatic memories are stored predominately in the right hemisphere of the brain, where they lack narrative organization and cognitive perspective (LeDoux, 1996; Schore, 2009, 2012). Preverbal, implicit memories of trauma appear to be held in fragments and manifested in physical sensations and habitual action patterns that are segregated from ordinary narrative memory and disconnected from the self (Chu, 1998; van der Kolk & Fisler, 1995). Flashbacks, intrusive thoughts and images, and unbidden body sensations are reminders of past traumas that are experienced as if they were happening in the present, largely inaccessible to conscious recall or control (Caruth, 1995; Chu, 1998). For clients with post-traumatic stress disorder (PTSD), these emotional memories are often overwhelming and can be so powerful that the person loses contact with present reality. Ford (2009) asserts that when extreme trauma occurs in early childhood, there is an automatic shift from a learning brain that is open and able to explore the environment to a survival brain focused on defending against potential danger and threat. Cognitive functioning and the ability to evaluate or categorize experience can be greatly impaired by traumatic stress. Trauma survivors are fundamentally stuck in defensive response patterns that are manifested in a variety of post- traumatic symptoms such as avoidance, numbing, dissociation, flashbacks, intrusive thoughts, hyperarousal, negative or distorted self-beliefs, and/or chronic states of dysregulation. These extreme behaviors may have been adaptive during a past traumatic event, but are generally considered maladaptive in a present, nonthreatening context. Motivated by a faulty alarm system that triggers autonomic survival defenses, traumatized clients may respond to external stimuli as if the past were present. Trapped in a state of hyper- or hypo-arousal, the trauma survivor will not be able to process information effectively or learn from experience (Ogden, Minton, & Pain, 2006; Ford, 2009). The goal of trauma therapy is to move the survivor away from being held captive by the unspeakable past and to engage more fully in the present (van der Kolk, 2014). To do this, clients and therapists need to develop tools for regaining control over dysregulated responses. This is no easy task. Emotional memory is strong, vivid, and long lasting. LeDoux (1996) suggests that trauma

DOI: 10.4324/9781003196242-8

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may bias the brain in such a way that the lower, limbic regions predominate over the higher cortical ones, with emotional learning taking precedence over cognitive insight. Furthermore, neuroimaging studies of individuals with PTSD demonstrate that the cognitive parts of the brain, responsible for language, analysis, and context, are essentially shut down during trauma recall (van der Kolk, 2006). For healing to occur, traumatic memories need to be transformed, contextualized, and given meaning, but words alone may be inadequate for addressing the negative imprint of trauma that is lodged in the emotional, right brain (van der Kolk, 2006, 2014). It follows that trauma may best be identified, desensitized, and resolved through some of the newer nonverbal, experiential, and body-based therapies. Yoga, Eye Movement Desensitization and Reprocessing (EMDR), body-based therapies, neurofeedback, and mindfulness meditation are among the recommended practices now utilized to keep the mind, brain, and body fully engaged in the present rather than trapped in the traumatic past. Art therapy, or the creation of art work in the company of an art therapist, is increasingly recognized as a valuable tool for treating trauma-related disorders (Avrahmi, 2006; Crenshaw, 2006; Gantt & Tinnin, 2009; Johnson, 1987; Talwar, 2007; Tripp, 2007). Because art-making engages both mind and body, an individual in art therapy can rapidly access implicitly stored traumatic memory and remain mindfully focused in the present. The art therapy process engages multiple senses and provides a unique vehicle for expression where words and language can fall short. Art therapy utilizes both hemispheres of the brain, pairing the unconscious, emotional right-brain sensations with rational, verbal left-brain thought processes (Chapman, 2014). Expression through art can facilitate a shift of traumatic material from implicit to explicit memory. Ultimately, the creation of a coherent pictorial narrative of the trauma may be required for symbolic processing and trauma resolution to occur (Collie, Backos, Malchiodi, & Spiegel, 2006). This chapter will describe an original somatically-informed bilateral art therapy protocol for trauma treatment that can be effective for both single incident and complex trauma. Drawing from the theories of art therapy, sensorimotor psychotherapy EMDR, and interpersonal neuroscience, this unique traumainformed protocol accesses traumatic memory and facilitates resolution using sensorimotor processes and bilateral stimulation. This is an adaptation of the author’s previous bilateral art therapy trauma processing tool (Tripp, 2007) with the major addition being the focus on the body. The newer trauma treatments are based on the idea that verbally telling the story is not, in and of itself, enough. In this protocol, the therapist helps the client tune into the sensorimotor processes that accompany the traumatic memory and create artworks that reflect shifts in somatic states leading to resolution. Client and therapist work in a collaborative and interactive manner, trusting the knowledge of the body and articulating the story through simple drawings. This here-and-now focus improves the client’s ability to manage dissociation and regulate states of hyper- and hypo-arousal.

A Body-Based Bilateral Art Protocol 175 Because this protocol facilitates access to a client’s creative strengths and inherent healing potential, positive results can occur quickly and often dramatically (Tripp, 2007, 2012). At the end of the session, clients are likely to feel more grounded in their bodies and are able to recognize the trauma is over; the past is past.

Managing Traumatic Stress Psychological trauma, according to Herman (1992), is an affliction of the powerless. The most devastating aspect of trauma may not be the traumatic event itself, but the resultant feeling of powerlessness that ensues when the individual is rendered helpless to do anything to manage its negative effects. Unlike mental illness or disease, traumatic stress comes from emotional and physiological responses to actual events, incidents, experiences, and interactions. Trauma disrupts the biological, psychological, and social equilibrium of the individual, and the resulting range of symptoms seem to be “disconnected from their source . . . [taking] on a life of their own” (Herman, 1992: 34). Trauma survivors have been described as “feeling too much, or feeling too little” (van der Kolk, 1994). According to Herman (1992), people with trauma disorders act “as if their nervous systems have been disconnected from the present” (p. 35). Because trauma has a timeless quality, survivors regularly feel and act as if the past and present were the same, responding intensely, as if they were being traumatized all over again (Scaer, 2005). Somatic remnants of past trauma can include destabilizing symptoms such as intrusive thoughts, images and body sensations, physical pain, difficulty modulating arousal, unbidden movement, and a variety of autonomic responses such as rapid heat rate, constricted breathing, and muscle tension (Fisher & Ogden, 2009). Further symptoms related to numbing and avoidance might include a sense of disconnection from the body, feelings of depersonalization and derealization, amnesia and dissociation, and persistent relational and attachment problems (Fisher & Ogden, 2009; Ford, Courtois, Steele, Hart, & Nijenhuis, 2005). Emotions, including feelings of overwhelming fear, anxiety, anger, shame, betrayal, and hopelessness, may render a trauma survivor powerless and seemingly frozen with what van der Kolk (1996a) has aptly termed “speechless terror.” This complex range of psychological and physical symptoms can be confusing and extremely challenging for both client and therapist to manage. Interpersonal neurobiology, as espoused by Siegel (1999, 2001, 2003), conceptualizes the interrelationship between the mind, brain, and interpersonal relationships throughout the life span. In a healthy person, flexible, adaptive, and coherent narratives, the product of integration between left and right hemispheric processes, are the foundation for secure attachment (Siegel, 2001). Unresolved trauma, however, can impair the brain’s integration and representational processes, resulting in an array of symptoms including heightened emotion and lack of self-reflection (Siegel, 2003).

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A whole brain approach to trauma treatment requires activation of both left (exploratory, linguistic, logical) and right (emotional, body-based, social) hemispheres of the brain. It is posited that neural integration and collaborative interhemispheric function can be enhanced through therapies that activate both sides of the brain for resolving traumatic states (Shapiro, 2001; Siegel, 2003). Siegel suggests that the core of effective therapy is not the verbalization of feelings, but the contingent communication between patient and therapist and the ensuing creation of a sense of safety. Likewise, van der Kolk (2002, 2006) states that the goal of trauma treatment is to find therapeutic techniques that desensitize clients without fully engaging them in a verbal reliving of their experiences. Art therapy does not rely on verbalization for accessing or processing traumatic memory. Difficult feelings can be contained and expressed within the artwork using symbols as natural metaphors for experiences. The multisensory focus in art therapy provides a safe, creative environment in which the client can be mindfully engaged in the present moment. Through the manipulation of art materials, the client can practice regulation of a range of cognitive, emotional, and physiological responses. Exploration of materials provides an avenue for working through issues while discovering new strengths, insights and resources. For these reasons, art therapy can be considered a treatment of choice for trauma-related disorders.

Art Therapy and Trauma Treatment Art therapy is a promising therapeutic treatment for working with children as well as adults who have experienced trauma (Goodman, Chapman, & Gantt, 2009; Johnson, Lahad, & Gray, 2009). While art therapy is historically rooted in psychoanalytic thinking, more recently the expressive therapies have been associated with the cognitive-behavioral therapies that are especially useful for treating trauma-related disorders (Johnson et al., 2009). It can be argued that creating art in therapy is a form of imaginal exposure, since the art itself is most often an equivalent of some aspect of a traumatic event (Johnson et al., 2009). Recent findings in neuroscience demonstrate that traumatic memories are stored in the right-brain, largely unavailable to verbal recall (Schore, 2009, 2011, 2012). Art-based interventions can facilitate connection to implicit, traumatic memory and create a bridge from unconscious states to conscious awareness (Talwar, 2007; Tripp, 2007). Furthermore, art products externalize the individual’s inner thoughts and feelings, rendering them in tangible, visual form, making them difficult to avoid or deny. An image will often express the un-censored “rightbrain truths” that lack the defensive armor of left-brain explanation or interpretation (McNamee, 2004).

Trauma and Memory: It’s not about the Story Traumatic memory is different from ordinary memory (Chu, 1998; Rothschild, 2000; van der Kolk, 2006). Unlike ordinary or explicit memory, which is encoded

A Body-Based Bilateral Art Protocol 177 consciously and available for verbal recall, traumatic memory is emotional, largely unconscious and procedural, like a feeling without any corresponding story. Unresolved trauma appears to be stored separately from other memory networks and tends to be “inflexible, nonnarrative, and disconnected from ordinary experience” (Chu, 1998: 57). According to Siegel (2007), impairment in neural integration is at the heart of unresolved trauma. It is presumed that this lack of integration may underlie the trauma survivors’ confusion and chaos that accompanies the intrusive imagery, unbidden body sensations, and behavioral enactments (Chu, 1998; van der Kolk & Fisler, 1995). Because traumatic memory is unassimilated, to a large extent it retains its original, indelible force (LeDoux, 1996). Trauma survivors are often simultaneously experiencing a confusing multitude of thoughts, feelings, body sensations, and perceptions that leave the system overwhelmed and the survivor without words to tell the story or convey the feeling of what happened (Damasio, 1999). Individuals who have been exposed to ongoing developmental or interpersonal trauma can perceive relationships as dangerous; subsequently, such individuals may avoid interaction and become immobilized or frozen in fear. Porges (2011) coined the term “neuroception” to describe the way humans are constantly attending to nonverbal cues from others, assessing tone of voice and the activity of facial muscles, expressions, and eye contact, to determine if the environment is “safe, dangerous or life-threatening” (p. 13). He suggests that playful activity, which is reciprocal and mobilizing, can help a person remain present and activate the social-engagement system. Similarly, in order to be active and regain a sense of safety, van der Kolk recommends trauma survivors engage in “. . . challenges that can help them deal with issues of passivity and helplessness: play and exploration, artistic and creative pursuits, and some form of involvement with others” (1996b: 18). Art therapy is a dynamic, active, present-focused treatment that, in the company of the art therapist, can be experienced as both powerful and enjoyable. Making art can facilitate rapid access to the core imprint of trauma because traumatic memory is primarily stored in nonverbal, sensory modes. The traumasensitive art therapist can provide the necessary ego support to facilitate a client’s creative expression and witness the unfolding trauma narrative as it is transformed into artistic form. Implicit in the art therapy process is a co-creation of a representation of the problem and a means to adaptive resolution, making this strengths-based, experiential approach uniquely well suited for working with traumatic material.

The Body in Trauma Treatment The instinctual trauma response—to fight or flee—ensures survival in the animal kingdom (Gantt & Tinnin, 2009; Scaer, 2001). But for many victims of abuse and neglect, the fight/flight system may have been thwarted due to lack of control or power, leaving the person with no choice other than to freeze or submit. Levine (1997) suggests that when a person is unable to activate resources

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and complete the appropriate response to an external threat, energy gets stuck in the body, and the nervous system responds with a high degree of arousal and a state of chronic dysregulation. Scaer (2001) posits that this inhibited discharge of sensorimotor energy results in changes in the brain that trigger states of distress including symptoms of PTSD and dissociation. Scaer describes traumatic stress as a corruption of memory where procedural memories learned from past traumas are enacted through somatic symptoms in the present (Scaer, 2005, 2007). Somatic memories can be expressed through various body-based symptoms such as gastrointestinal disturbances, sleep problems, compromised immune system, migraines, activation or tension in the muscles, chronic stress, or panic. Rothschild (2000) believes that the goal of therapy is to facilitate the understanding of these body sensations, which must be felt, described, and narrated, in order to clarify the connection between body sensation and past trauma. It is now widely accepted that effective treatment of PTSD must involve focused attention to the body and related somatic states. Awareness, rather than avoidance of one’s internal states, allows feelings to be known and sensorimotor experiences to be assimilated. Sensorimotor psychotherapy helps clients to somatically reorganize their overwhelming and dysregulated bodybased symptoms through co-created therapeutic engagement referred to as “experiments” (Ogden et al., 2006). Inviting clients to physically stand up, push away, reach out, or practice saying “No” can transform traumatic memory by working with the body’s natural action tendencies, which may have been blocked or frozen at the time of the event. The goal is to facilitate the body’s completion of the action that may have been thwarted and to find a new or acceptable resolution to the story.

Art and the Creation of a Trauma Narrative For trauma survivors, finding a strong voice is, at best, a complicated task. Trauma arouses overwhelming emotional states that can interfere with the appraisal and processing of experience, ultimately impeding the meaningmaking and narrative processes (Fosha, 2003). Fear and shame may render the individual unable to access emotional resources, relying instead on defenses such as avoidance, numbing, or denial (Fosha, 2003). Survivors may feel that verbally expressing the unspeakable terror is impossible, and, to further complicate matters, may have been urged explicitly or implicitly to remain silent about their abuse, trauma, and neglect. Art therapy, by focusing on images about the trauma rather than the words, can help survivors connect their experiences back to the implicit story (Gantt & Tinnin, 2009). An advantage of art therapy is that it provides a means of “telling without talking” (Cohen & Cox, 1995: xix) that may circumvent some of the fear and shame, as well as deal with the problems of alexithymia. Hass-Cohen (2008) outlines an art therapy relational-neuroscience (ATR-N) model that describes how the sensory elements of art-making can create an

A Body-Based Bilateral Art Protocol 179 “integrated and attuned state of mind” (p. 305). She suggests that the positive aspects of art-making can counter the avoidant feelings and fear that can be problematic in trauma work. McNamee (2004) uses an annotated scribble drawing as a right-brain intervention where images are developed and later explored through left-brain verbal discussion of the metaphor. In their intensive trauma therapy (ITT) model, Gantt and Tinnin (2007, 2009) ask clients to create a “graphic narrative”, which is essentially a structured recounting of the trauma story based on the Initial Traume Response (ITR). Their approach helps restore the right to left brain connection by opening “a dialogue between the verbal and nonverbal minds” (Gantt & Tinnin, 2009: 150). Rankin and Taucher (2003) also suggest a structured, task-oriented approach for trauma-informed art therapy in which treatment focuses on one task at a time and builds on the client’s sense of control and mastery.

Eye Movement Desensitization and Reprocessing (EMDR) In 1987, while taking a walk in the park, psychologist Francine Shapiro observed that as she pictured an upsetting issue, her eyes spontaneously began to move back and forth diagonally in her head, and the negative charge of the distress was greatly reduced (Shapiro, 2001). After experimenting with this reaction she developed a basic protocol: ask clients to think of a disturbing memory, situation, or belief, and then instruct them to follow her fingers across a focal plane in lateral eye movements. The response was overwhelmingly positive that anxiety and distress could be reduced through this process, and EMDR was born out of this experience. Shapiro’s model of Adaptive Information Processing (AIP) posits that the bilateral stimulation in EMDR accesses the negatively stored traumatic memory and moves that disturbing information along the neural pathways until adaptive resolution is found. Inherent in this model is the belief that trauma can disrupt the brain’s natural information processing tendency toward health. EMDR targets these blocks to healing and, in a sense, digests or metabolizes them, so that ultimately more positive, flexible images, emotions, and cognitions will emerge (Shapiro, 2001).

Bilateral Processes in Trauma Therapy The word “bilateral” simply means relating to or involving two sides. For the purposes of this chapter, bilateral refers to the two sides of the body and, consequently, the two hemispheres of the brain. Bilateral stimulation can be produced by stimulating the body/brain through activities such as walking, running, dancing, drumming, or rocking as well as through making art that involves using both hands and both sides of the brain. Most runners, drummers, dancers and artists will attest that these activities can lead to positive feelings and a sense of well-being. Bilateral activation can be initiated in therapy using specific equipment (designed for EMDR) such as a light bar to track eye movement, tappers that produce alternating vibration, or headphones that

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deliver bilateral tones. Therapists can also readily induce bilateral stimulation by moving their fingers across the client’s field of vision in side-to-side horizontal strokes, or by literally tapping alternate sides of the body (typically by gently touching the hands, knees, or feet). In trauma treatment, bilateral stimulation appears to be an effective tool that can enhance communication across both left and right hemispheres of the brain, which may improve the integration between logical thought and expressive feeling (Shapiro, 2001). In the language of neuroscience, the limbic system and specifically the right hemisphere, which is overactive when encountering or remembering a traumatic situation or event, can be down regulated by the bilateral stimulation, eventually bringing cognition back on line through activation of the left hemisphere of the prefrontal cortex (PFC). When the heightened state of reactivity in the emotional brain is reduced, the thinking brain in the PFC is more readily able to access self-reflection. It is hypothesized that bilateral stimulation activates the frontal lobes, which increases interhemispheric interaction and retrieval of episodic memory (Christman, Propper, & Brown, 2006). Another hypothesis related to the mechanism in bilateral activity that leads to healing trauma is that it produces a calming effect (similar to a human heart beat or the rhythm of the breath), thereby increasing the parasympathetic and relaxation response. Stickgold (2002) theorizes that the alternating bilateral stimulation in EMDR produces a fundamental change in the brain circuitry that is similar to REM sleep where memories are processed and integrated as if in a dream. He posits that the re-orienting of attention integral in the bilateral stimulation creates a shift in brain activation that facilitates a memoryprocessing mode (Stickgold, 2002). It has also been suggested that the dual attention focus (being both focused on the disturbing memory and the bilateral movement at the same time) interferes with working memory, perturbing the old neural connections and creating new, adaptive associations that transmute the memory of trauma (Gunter & Bodner, 2009; Solomon & Shapiro, 2008). Dual attention also encourages the client to assume the role of the observer, watching his or her trauma from a distance, so as not to overly identify with the emotion but simply notice it as a passing thought or feeling (Lee, 2008; Solomon & Shapiro, 2008). It appears that as the memory is taxed by the dual focus, emotions become less vivid and thus less disturbing (Gunter & Bodner, 2009; Solomon & Shapiro, 2008).

Bilateral Art Therapy Approaches In the past decade, there has been increased interest in approaches that purposefully integrate art-making with some form of bilateral stimulation for the treatment of trauma-related disorders (Chapman, Morbiato, Ladakakos, Schreier, & Knudson, 2001; Talwar, 2007; Tripp, 2007). McNamee (2006) described a bilateral art protocol that she has applied in various settings using both dominant and non-dominant hands, engaging responses from left and right

A Body-Based Bilateral Art Protocol 181 hemispheres of the brain for the purpose of integration and balance. She invites the client to respond with opposite hands to conflicting images drawn on two sides of a page to “facilitate the integration of both positive and negative thoughts and to strengthen the client’s belief in the positive thought” (2006: 7). Chapman et al. (2001) and Chapman (2014) developed a drawing treatment tool for incident-specific medical trauma with pediatric patients. Her intervention activates left and right hemispheres of the brain along visual and verbal neural pathways to create a “graphic narrative” that is then translated into a verbal narrative. She noted that affective expression is often followed by a rapid shift to language and cognition, which assists the child in maintaining control over the traumatic material. Talwar (2007) incorporated physical movement in her art therapy trauma protocol (ATTP), asking clients to move from a table to a wall to paint in a process painting style, thus activating physical movement with art-making. In this setting, art-making involves analytical tasks such as choosing paint colors while also engaging visual, spatial, emotional, and sensory processes. In Tripp’s (2007) method, art therapy was integrated into the standard EMDR protocol leading to transformation of traumatic memory by incorporating alternating bilateral stimulation with expression through a series of drawings. She hypothesized that bilateral stimulation facilitated access to affective material while concurrent art-making kept the client relaxed and moving through the distressing memory networks. Likewise, Kolodny integrated bilateral activation while working with clients processing traumatic material (Tripp & Kolodny, 2013, 2014). Using a disturbing image as the focus of the session, the client is instructed to draw alongside that image with bilateral strokes until there is a noted shift in the memory and new insights are gained (Kolodny, personal communication, June 8, 2014). Tobin (2006) suggested that art therapy and EMDR share some fundamental properties including the idea that we “stay with” the image and, rather than interpret it, letting the image transform itself and do the work of healing. A cognitive-behavioral informed trauma approach was developed by Lahad and colleagues (Lahad, Farhi, Leykin, & Kaplansky, 2010) in which a client uses an assortment of therapeutic cards to practice reducing stress and to control physiological arousal when confronted with a negative or threatening stimulus. The client re-narrates the traumatic event using the cards, essentially playing with the possibilities, until control is gained over the story. The movement between stressful and more resourced cards is also a bilateral process.

A Bilateral Art Therapy for Reprocessing Trauma Trauma has a profound effect on the body, brain, and nervous system. Implicit, bodily-based memories of trauma are acute reminders of the traumatic experience itself and can be overwhelming, resulting in physiological distress and a range of psychological symptoms. Clients suffering from unresolved traumas often experience dysregulated body sensations accompanied by a cascade of strong emotions and physical sensations that they may be ill-equipped to manage

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(Ogden et al., 2006). Neuroimaging studies (Rausch et al., 1996) demonstrate that during trauma there is an increased activation in the amygdala, the area responsible for initiating emotional response to incoming stimuli, with a concomitant decreased activation of the medial prefrontal cortex and Broca’s area, the areas responsible for executive functioning and speech. These findings have significant implications for trauma-informed treatment and suggest that the traditional “top-down” approaches that are reliant on language and verbalization may not be adequate for the resolution of trauma. In recent years, there has been an upsurge in the experiential and body-based therapies that enter the system from the “bottom-up” to address the client’s present moment experience. Focusing mindfully on the body and related sensation can help a client learn to observe and monitor his or her internal state, which ultimately will lead to an activation of the medial prefrontal cortex and increase the capacity for selfreflection and introspection. In the author’s original paper describing a case integrating art therapy and EMDR (Tripp, 2007), the art-making provided a means to track the client’s traumatic memory as it was reprocessed, and facilitated the expression of new, more adaptive cognitions. The recent modification of this protocol shifts the focus away from the story, targeting instead the client’s somatic memory and associated emotions. Using bilateral stimulation, the client is invited to notice bodily sensations and attend to the corresponding thoughts and feelings that arise. Through marks made on simple body outline templates, the client and therapist gradually develop a trauma narrative, broken down into manageable segments. The process of creating a visual trauma narrative based on the body helps the client to manage affect and contain the potentially overwhelming traumatic material while telling the story. Somatically-informed bilateral art therapy engages both hemispheres of the brain and activates adaptive processing for the resolution of traumatic stress. When working with attachment wounds and early trauma, words or language may not be readily available, so talking about a trauma or even determining a focus for the session can be difficult. Because the body naturally holds the implicit memory of the trauma, a “bottom-up” approach can effectively access disturbance and effect change. With guidance from an attuned therapist, the client will become curious about body sensations and begin to notice how the body holds trauma, which will help with mindfulness, cognition, and affect regulation. As with any trauma-sensitive treatment, trauma processing follows phase one assessment and adequate provision for safety and stabilization (Herman, 1992). Resourcing, creating a safe or healing space, building or imagining a container, and maintaining a solid therapeutic rapport are foundational tools that should be in place before beginning any trauma processing. This trauma processing protocol begins by inviting the client to mindfully scan the body noticing any feelings of stress, tension, or discomfort, and drawing such feelings using lines, shapes and colors on a provided body outline template. The client is asked to identify the corresponding negative self-beliefs that come

A Body-Based Bilateral Art Protocol 183 to mind when focusing on the body as well as any desired positive beliefs that might contrast with the negative ones. For example, a negative belief might be “I am powerless” while a positive belief could be “I can have some control.” Unlike EMDR, it is not necessary to have a specific target traumatic memory to focus on with this protocol; the underlying dysfunctional belief or memory will become apparent while moving through the body. Once the client has produced an initial drawing and corresponding negative belief, he or she is asked to focus on that image and those beliefs while bilateral stimulation is initiated using tapping, tones or eye movements. After a few brief sets of alternating bilateral stimulation the client is directed to refocus attention to the body and, using the body outline template, express anything that has shifted somatically, cognitively or emotionally in a drawing. In a single session, a series of four to eight drawings may be produced that will essentially map out the experience. The goal is to track sensations in the body and any co-occurring shifts in awareness, emotion or cognition, thus facilitating the brain’s discovery of new neural connections for reprocessing the traumatic memory. The session ends with a final body scan and wrap up, checking for new adaptive information and highlighting any positive beliefs that may have been gained through the process. Finally, the therapist and client can examine the series of pictures together and engage in a left-brain analysis of the images and associated information. This protocol teaches the client to track the somatic indicators in the body, noting the rise and fall of stress as it moves through the nervous system. The client describes any shifts in state or other responses through simple drawings, keeping verbalization to a minimum. This also provides a nonthreatening way to access new cognition, which is likely to become available during processing. The client is encouraged to “just notice” the body and mind’s natural tendency toward healing. Most often the session will end with the client feeling newly aware of internal strengths, choices, and resources. This approach is systematic and focused on the present moment, with attention on the body rather than on the narrative. An important feature of this protocol is that by not focusing on the story, emotion is titrated and the experience is apportioned into manageable bits of information. Keeping the client within a “window of tolerance” (Ogden et al., 2006; Siegel, 1999; Siegel, 2007), the process encourages mindful awareness of shifts in cognition, emotion, and/or somatic states. Traumatic memories can be processed systematically through the body drawings without flooding or overwhelming the client. This experiential approach provides an opportunity to rework a traumatic memory in a resourced way and to find new solutions to old problems. Staying resourced while working with the experience can be particularly important for a trauma client who has repeatedly been disempowered by others. The following case describes a session where the body-based bilateral art therapy protocol was successful in accessing and channeling negative emotions and accessing a more adaptive resolution.

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Clinical Vignette: Freedom from the Weight Kathy (a pseudonym), is a 46-year-old professional female who came to me for an art therapy consultation on the recommendation of her internist. Kathy reported feeling anxious and depressed, with symptoms of binge eating, low energy, and social withdrawal. In the week prior to our session, Kathy and her family had flown across the country to visit their 17-year-old son, Tim, who had dropped out of high school and begun working on the west coast in a menial job. Kathy reported being quite concerned about the welfare of her son, while at the same time feeling angry that he had abandoned his education and was not following a more conventional path. Kathy’s husband, Pete, had also been in a state of transition; after 20 years in an established business, he decided to return to school to make a significant career change. This decision took time away from the family and also added to their financial stress. Kathy has an advanced degree and works from home in her own business. She is successful but admits that it is stressful being the chief breadwinner as well as often the sole available parent for taking care of home life. The 15-year-old daughter is a straight “A” student and reportedly doing well, although she tends to be shy and often requires extra support from her mother with whom she is very close. In the language of trauma, the focus of this session is a small t trauma (as opposed to a big T, a major traumatic incident or life-threatening event) but one that I suspected might be connected to the somatic symptoms of binge eating and low energy, and possibly also to other small t traumatic events. I invited Kathy to start the session with a body scan, instructing her to “just notice” any areas of tension or stress and any associated sensations, thoughts, or feelings that came to mind as she scanned the body head to toe. I gave her a body outline drawing and invited her to depict anything she noticed using lines, shapes, and colors (see Figure 8.1). The first body drawing indicates Kathy’s initial awareness of tension in her body. She drew a series of red marks on the left side depicting areas where she felt achy and uncomfortable following a long cross-country trip. She also drew a prominent red circle in the abdomen, stating, “This is where I feel fat!” She went on to describe feelings of discomfort about her body image and weight gain over the last year. When I asked Kathy to describe a negative self-belief that matched the body drawing, she identified, “I am fat,” focusing on seeing herself as “disgusting and gluttonous.” I felt we needed to step back and look at the meaning of fat as a negative belief, so I suggested we rework that negative judgment to reflect a more internal self-referencing statement. Kathy was then able to look deeper at the meaning of her excess weight and reflect on how she felt about herself. She stated the weight brought up a feeling of heaviness, and a feeling of being “weighted down or burdened.” This, in turn, brought up the emotion “helplessness” which better described her self-state, referring to an internal belief. The new negative cognition she proposed was this: “I am burdened; I am helpless.” The corresponding positive belief that she identified wishing to feel was this: “I am not

A Body-Based Bilateral Art Protocol 185 burdened; I am strong.” When I asked Kathy what emotions she was noticing she immediately stated, “anger.” We then began bilateral stimulation. I gave Kathy a choice of techniques including tapping her own body by alternately tapping her knees or crossing arms over the chest. I also offered to show her how I could move my finger across the focal plane at her eye level, inducing a back-and-forth rhythm where she could track my fingers. She chose the eye movements. I gently moved my finger across her focal plane about 10–12 times, paused, asked her to take in and release a deep breath, and then to report any observations, feelings, or shifts in awareness or sensation. The process of inducing bilateral stimulation and then asking for response essentially mirrors the reprocessing phase of the EMDR standard protocol. I reminded Kathy that there was no expected outcome, inviting her to simply focus mindfully and bring an attitude of curiosity and openness to whatever came up. Any images, thoughts, or associations reported are akin to dream fragments, so I encouraged her to simply state them, as she felt comfortable. I also did not ask questions about the reported details, nor did I inquire about meaning or context, so as to keep the verbalization minimal and avoid judgment.

Figure 8.1 “I am burdened; I am helpless” Color version available at http://www.routledge.com/9781032050539

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After a few sets of alternating bilateral stimulation (ABS), Kathy stated she detected a shift in her body; she was aware of a sensation in her uterus and a weight pressing down upon her shoulders. She seemed surprised as she reported a vivid memory of being pregnant with her son. Taking the body scan template, she chose a green marker and drew arrows pointing to the shoulders and a circle over the uterus. I observed that she had shifted from a warm, red color to a cooler, green one, and she acknowledged that she noticed a new, tingly sensation in her uterus and that the heaviness in her stomach had vanished. She also noted the left foot still held the pain from hiking the previous weekend (see Figure 8.2). Again, without analyzing the image in any way, I directed Kathy to refocus her attention to the sensations in her uterus along with the memory of being pregnant and the weight on her shoulders. After several sets of ABS Kathy reported that she found herself thinking more about her son on the west coast. Indeed, I noticed there was stress evident in Kathy’s face, marked by a slight perspiration and reddening as well as some tension in her jaw. I also noticed her breathing had become increasingly shallow. I invited Kathy to show me on the body outline what she noticed in her body (see Figure 8.3). This drawing shows the green feeling in the uterus moved into a tight ball into the heart and throat area. Additionally, the weight on the shoulders moved

Figure 8.2 “Noticing sensation in uterus and tension in shoulders” Color version available at http://www.routledge.com/9781032050539

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Figure 8.3 “Emotions moving to heart and head” Color version available at http://www.routledge.com/9781032050539

into the face, as depicted by arrows from both shoulders going into the head, giving an overall impression of eyes crying. Kathy noted a blue feeling of constriction in the neck and jaw as well as slight tingling in the hands, an indicator of some activation in response to the emotion. The blue color is cool and not heavily shaded, suggesting the feelings are not strong. It is interesting to note the focus of the image is on the face. The picture seems to track movement up the body and into the face and hands where expression and action can happen. Also, during this set of bilateral stimulation, I noticed more actual emotion in her face, suggesting somatic indicators of unprocessed feeling. With Kathy notably more flushed and eyes watering, we continued the ABS for several minutes, allowing the feeling to process through the body. After a few minutes, Kathy seemed to have ridden this wave of emotion; her body appeared more relaxed. I noticed her breathing was again deeper and more rhythmic. She paused and stated: “I am feeling love and rage for him all at the same time . . . this is a complex feeling; it’s so mixed!” I asked her to focus on that sensation and draw what she noticed in her body in the next outline (see Figure 8.4). This picture focuses even less on the lower body and brings more attention to the face, which conveys a mix of emotions. Heavy red dots surround the mouth

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Figure 8.4 “Noticing a mix of anger and sadness” Color version available at http://www.routledge.com/9781032050539

area and cross the forehead while faint blue tears flow from the eyes. The resulting image appears a little frightening, almost like a crying clown with an exaggerated mouth. As the rest of the body is largely empty, the emphasis on the emotion in the face is more obvious. Kathy also indicated that she was aware of a pain in her right hip that she had not been aware of when we started. She stated it had first given her problems a few days before when she had gone on a day hike with her son along a rugged, west coast beach. She had chosen not to share that she had been in any physical pain with her son because she did not want to “ruin the hike.” She bore the burden silently. This pain, like the pain previously identified in her foot and the pressure she had noticed in her shoulders, is another body-based metaphor for carrying a burden that we were able to explore later in the session. Stepping back for a moment and engaging with the image, Kathy said about her son, “I feel I want to hug him, but I also want to strangle him.” After stating this truth, she exhaled deeply and sighed a visible sigh of relief. It seemed she had finally found her voice and given herself permission to express her deeply conflicted feelings. She then commented: “I feel lighter now. Somehow I feel I have more strength. It’s like I could just lift him up in the air and throw him

A Body-Based Bilateral Art Protocol 189 off me.” I invited Kathy to draw this concept on the final body outline (see Figure 8.5). Kathy quickly picked up the blue marker and defined “space” around her upper body with a sort of blue shield that protects the upper torso. The body is now empty and light, which she called a “freeing feeling.” She then drew a long, light blue stick figure on top of the body outline to represent her son Tim who seems to be flying off her shoulders and literally going off the top of the page. She laughed and stated, “It IS un-burdening to draw this!” Smiling and visibly relieved, she laughed and said, “I feel so much more relaxed now!” The sensation of release was also evident in her body, and together we raised our arms over our heads, physically moving to enact and reinforce the feeling of release and actively express letting go through the physical body. As we looked over the series of images together, Kathy told me about her difficult pregnancy with Tim and the feeling of having been largely alone and unsupported by her husband at that time. Kathy had suffered from post partum depression, which was exacerbated by the fact that Tim was a colicky infant who was difficult to soothe. Discussing her recent weight gain, it was interesting to note that she had gained most of this weight during Tim’s last year at home, a stressful time for the entire family. She made a cognitive connection between the weight gain of pregnancy and the heavy burden of being a mom to a young adult in transition.

Figure 8.5 “Feeling free” Color version available at http://www.routledge.com/9781032050539

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Kathy was pleased to observe the progression of her images that recorded the movement of feeling through her body. She could see how anger had naturally flowed upward through the body from stomach to uterus to chest, heart, shoulders, hands, and face until it finally left the body altogether. In one brief session a lot of emotion was expressed and released with minimal verbalization. “This was an incredibly freeing process,” she stated. Then, with a green marker and a twinkle in her eye, she drew another stick figure overhead, adding, “This is my husband; he can give me some space, too!” To close the session, the positive self-belief (in this case “I am not burdened”) is paired with short sets of bilateral stimulation. Kathy felt the words not burdened “perfectly” described her current state. As the session ended Kathy stated she was feeling “strong and free.” I noted that she had shifted to her original desired positive beliefs. She stated her level of distress was significantly diminished and, when we checked in the following week, she had continued to feel empowered in her interactions with family and friends. Her burden had been lifted. Discussion This somatically-informed bilateral art therapy protocol begins with a nonspecific target, entering in through the body and focusing on a present moment state. In the session, it quickly became evident that Kathy’s identified small t trauma, her son’s leaving home in an undesirable way, brought up unconscious associations to an earlier traumatic experience, her postpartum depression. Somatic symptoms related to weight, burden, and helplessness were understood as indicators of a long held, unresolved trauma responses. Accessing and depicting these sensations as they moved through the body facilitated Kathy’s expression of feelings related to her role as wife and mother. The images reflect the surge of strong emotion moving from being overwhelmed with a burden to lifting that burden and feeling relief. Through this process Kathy found a way to gain control and shift her perspective. When she left the session feeling free and un-burdened, there was no longer a feeling of being stuck with the traumatic sensation of heaviness. Through mindful tracking of body sensations, this protocol accesses the right brain where the emotions, images, and sensations are stored. The client is not asked questions that interrupt the process, and there is little focus on words or interpretation. Rather, the focus is on the present moment, staying with the images and body sensations, and seeing what naturally happens or needs to happen. The art-making directly connects with observed shifts in the body as well as associated emotion, perception, and cognition. Use of color, variation in line pressure, and choice of patterns and shapes can express many subtleties that may be unconscious and may be related to raw emotion. Left-brain analysis follows when client and therapist stand back and look at the series of responses. This protocol is an integration of many years’ experience working with complex trauma, integrating the best practices in trauma treatment including

A Body-Based Bilateral Art Protocol 191 art therapy, EMDR, and sensorimotor psychotherapy. It expands on previous bilateral art therapy protocols in that it actively tracks the somatic indicators of stress and brings awareness of bodily sensation into the therapy session. Art therapists can naturally engage their clients in bilateral processes and are encouraged to appreciate the wisdom of the body in trauma recovery.

References Avrahmi, D. (2006). Visual art therapy’s unique contribution in the treatment of posttraumatic stress disorders. Journal of Trauma and Dissociation, 6(4), 5–38. Caruth, C. (1995). Trauma: Explorations in memory. Baltimore, MD: John Hopkins University Press. Chapman, L. (2014). Neurobiologically informed trauma therapy with children and adolescents: Understanding mechanisms of change. New York: W. W. Norton. Chapman, L., Moranito, D., Ladakakos, C., & Schreier, H. (2001). The effectiveness of art therapy interventions in reducing post-traumatic stress disorder (PTSD) symptoms in pediatric trauma patients. Art Therapy: Journal of the American Art Therapy Association, 18(2), 100–104. Christman, S., Propper, R., & Brown, T. (2006). Increased interhemispheric interaction is associated with earlier offset of childhood amnesia. Neuropsychology, 20(3), 336–345. Chu, J. (1998). Rebuilding shattered lives: The responsible treatment of post-traumatic dissociative disorders. New York: John Wiley. Cohen, B.M. & Cox, C.T. (1995). Telling without talking: Art as a window into the world of multiple personality. New York: W. W. Norton. Collie, K., Backos, A., Malchiodi, C., & Spiegel, D. (2006). Art therapy for combat-related PTSD: Recommendations for research and practice. Art Therapy, 23(4), 157–164. Crenshaw, D. (2006). Neuroscience and trauma treatment: Implications for creative arts therapists. In L. Carey (Ed.), Expressive and creative arts methods for trauma survivors (pp. 21–38). Philadelphia: Jessica Kingsley. Damasio, A. (1999). The feeling of what happens: Body and emotion in the making of consciousness. New York: Harcourt Brace. Fisher, J., & Ogden, P. (2009). Sensorimotor psychotherapy. In C. Courtois and J. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide (pp. 312–328). New York: W. W. Norton. Ford, J. (2009). Neurobiological and developmental research: Clinical implications. In C. Courtois and J. Ford (Eds.), Treating complex traumatic stress disorders: An evidence-based guide (pp. 31–58). New York: W. W. Norton. Ford, J. D., Courtois, C. A., Steele, K., Hart, O., & Nijenhuis, E. R. (2005). Treatment of complex postratumatic self –dysregulation. Journal of Traumatic Stress, 18(5), 437–443. Fosha, D. (2003). Dyadic regulation and experiential work with emotion and relatedness in trauma and disorganized attachment. In M. F. Solomon & D. J. Siegel (Eds.), Healing trauma: Attachment, mind, body, and brain (pp. 221–282). New York: W. W. Norton. Gantt, L., & Tinnin, L. W. (2007). Intensive trauma therapy of PTSD and dissociation: An outcome study. The Arts in Psychotherapy, 34(1), 69–80. Gantt, L., & Tinnin, L. W. (2009). Support for a neurobiological view of trauma with implications for art therapy. The Arts in Psychotherapy, 36(3), 148–153. Goodman, R. F., Chapman, L. M., & Gantt, L. (2009). Creative arts therapies for children. In E. B. Foa, T. M. Keane, M. J. Friedman, & J. A. Cohen (Eds.), Effective treatments

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A Body-Based Bilateral Art Protocol 193 M. Solomon (Eds.), The healing power of emotion: Affective neuroscience, development & clinical practice (pp.112–144). New York: W. W. Norton. Schore, A. N. (2011). Attachment trauma and the developing right brain: Origins of pathological dissociation. In P. Dell & J. O’Neill (Eds.), Dissociation and the dissociative disorders: DSM-V and beyond. (pp. 107–141). New York: Routledge, Taylor & Francis. Schore, A. N. (2012). The science of the art of psychotherapy. New York: W.W. Norton. Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures. New York: Guilford Press. Siegel, D. J. (1999).The developing mind: Toward a neurobiology of interpersonal experience. New York: Guilford Press. Siegel, D. J. (2001). Toward an interpersonal neurobiology of the developing mind: Attachment, “mindsight” and neural integration. Infant Mental Health Journal, 22(1–2), 67–94. Siegel D. J. (2003). An interpersonal neurobiology of psychotherapy: The developing mind and the resolution of trauma. In M. F. Solomon & D. J. Siegel (Eds.), Healing trauma: Attachment, mind, body, and brain (pp. 1–56). New York: W. W. Norton. Siegel, D. J. (2007).The mindful brain: Reflection and attunement in the cultivation of wellbeing. New York: W. W. Norton. Solomon, R. M., & Shapiro, F. (2008). EMDR and the adaptive information processing model: Potential mechanisms of change. Journal of EMDR Practice and Research, 2(4), 315–325. Stickgold, R. (2002). EMDR: A putative neurobiological mechanism of action. Journal of Clinical Psychology, 58(1), 61–75. Talwar, S. (2007). Accessing traumatic memory through art making: An art therapy trauma protocol (ATTP). The Arts in Psychotherapy, 34(1), 22–35. doi:10.1016/j.aip. 2006.09.001 Tobin, B. (2006). Art therapy meets EMDR: Processing the paper-based image with eye movement. Canadian Art Therapy Association Journal, 19(2), 27–38. Tripp, T. (2007). A short-term approach to processing trauma: Art therapy and bilateral stimulation. Art Therapy: Journal of the American Art Therapy Association, 24(4), 176–183. Tripp, T. (2012). Bilateral transformation of trauma: Integrating EMDR and art therapy. Paper presented at the Expressive Therapies Summit, New York. Tripp, T., & Kolodny, P. (2013). Integrating EMDR and art therapy for bilateral transformation of trauma. Workshop presented at the Expressive Therapies Summit. New York. Tripp, T., & Kolodny, P. (2014). Change the Brain: Using bilateral methods to reduce anxiety and relieve traumatic stress. Workshop presented at the Expressive Therapies Summit, New York. van der Kolk, B. A. (1994). The body keeps the score: Memory and the evolving psychobiology of PTSD. Harvard Review of Psychiatry, 1(5), 253–265. van der Kolk, B. A. (1996a). The complexity of adaptation to trauma: Self-regulation, stimulus discrimination, and characterological development. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth, (Eds.), Traumatic Stress: The overwhelming experience on mind, body, and society (pp.182–213). New York: Guilford Press. van der Kolk, B. A. (1996b). The body keeps the score: Approaches to the psychobiology of post-traumatic stress disorder. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The overwhelming experience on mind, body, and society (pp. 214–241). New York: Guilford Press.

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van der Kolk, B. A. (2002). Beyond the talking cure: Somatic experience and subcortical imprints in the treatment of trauma. In F. Shapiro (Ed.), EMDR as an integrative psychotherapy approach: Experts of diverse orientations explore the paradigm prism. (pp. 57–83). Washington, DC: American Psychological Association. van der Kolk, B. A. (2006). Post-traumatic stress disorder and the nature of trauma. In M. Solomon and D. Siegel (Eds.), Healing trauma: Attachment, mind, body and brain (pp. 168–195). New York: W.W. Norton. van der Kolk, B. A. (2014). The body keeps the score: Brain, mind and body in the healing of trauma. New York: Viking Penguin. van der Kolk, B. A., & Fisler, R. (1995). Dissociation and the fragmentary nature of traumatic memories: Background and experimental evidence. Journal of Traumatic Stress, 8(4), 505–525.

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Medical Art Therapy Applied to the Trauma Experienced by those Diagnosed with Parkinson’s Disease Deborah Elkis-Abuhoff and Morgan Gaydos

Advancements in the field of neuroscience, specifically in treatment of neurodegenerative diseases such as Parkinson’s disease, have supported recognition that psychological trauma may cause physiological effects. Emotional and behavioral responses to trauma have been found to directly affect sensory information, memory, and motor impulses within the brain (Högberg, Nardo, Hällstrom, Hällström, & Pagani, 2011). Complementary treatment, such as kinesthetic art therapy through clay manipulation, has been found to provide emotional support to individuals suffering from trauma and holds potential for the activation of brain stimulation through sensory and tactile experiences.

What is Parkinson’s Disease? Caused by a lack of dopamine-producing cells within the brain, Parkinson’s disease (PD) is characterized as a neurodegenerative disorder that is both chronic and progressive in nature. PD affects approximately seven to ten million people worldwide (Parkinson’s Disease Foundation, 2014a). As many as one million individuals per year may be diagnosed with PD within the United States, affecting males one and a half times more than females (Parkinson’s Disease Foundation, 2014a). PD is the second most common neurodegenerative disorder among individuals, falling short to Alzheimer’s disease (Yoritaka et al., 2013). Because it is a progressive disorder, the risk of developing PD increases with age, but the disease may also occur in the early years of middle adulthood. Neurodegenerative disorders are defined as a loss of functioning neurons within the brain, a loss which affects the body’s ability to respond and perform at healthy levels. Therefore, a variety of physical symptoms, commonly referred to as motor symptoms, as well as cognitive symptoms, arise during the course of PD. Many physicians rely on specific motor features to clinically diagnosis the disease (Shulman, De Jager, & Feany, 2011); difficulty controlling muscle movement, rigidity in limbs, physical instability related to balance, tremors, bradykinesia, freezing gait, changes in affect, and fatigue are among the most

DOI: 10.4324/9781003196242-9

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notable motor deficiencies (Chen et al., 2013; Elkis-Abuhoff, Goldblatt, Gaydos, & Convery, 2013a; Zwartjes et al., 2010). Tremors, classified as rhythmic and involuntary movements that can affect any limb or body part, are the most recognized motor symptom of PD (Helmich, Toni, Deuschl, & Bloem, 2013). These motor symptoms can result in delayed movements during daily activities and are seen as changes in posture and postural control, such as shuffling and leaning forward (Figure 9.1). As the disease progresses, motor symptoms increase in severity and frequency. Along with motor symptoms, cognitive symptoms appear, such as a decrease in attention span, problem solving, and the ability to plan ahead. These are believed to be caused by the damaged neurons within the left hemisphere of the brain (Bogdanova & Cronin-Golomb, 2012). Furthermore, psychological symptoms such as depression, phobia, stress/anxiety, and obsessive-compulsive tendencies have been reported in individuals diagnosed with PD (Chen et al., 2013; Elkis-Abuhoff, et al., 2013a; Yoritaka et al., 2013). These debilitating cognitive features, also including sleep disturbances, contribute to the level of

Figure 9.1 Illustration of the changes in posture and postural control Color version available at http://www.routledge.com/9781032050539

Medical Art Therapy Applied to Trauma 197 disability and trauma in the life of an individual diagnosed with PD (Brichta, Greengard, & Flajolet, 2013). The trauma one experiences starts with the diagnosis, although little research has examined the emotional effects upon receiving a medical diagnosis (Thompson et al., 2009). Individuals often experience an extensive range of emotions when presented with the PD diagnosis. These emotions can range from shock to anger to frustration with needing to adjust to the diagnosis (Parkinson’s Disease Foundation, 2014c). Patients diagnosed with PD can become traumatized when having to acknowledge lifestyle changes, such as negotiating within the environment, risk of falling, freezing gait, a need for increased dependency. In addition to the trauma directly relating to symptomology, the traumatization of having the disease adds to the overall experience of trauma and effects neurological functioning, increases the physical deficits, and can leave a person with PD feeling dysregulated (Naff, 2014). Despite many medical and therapeutic treatment interventions, there is currently no cure for PD. Research efforts to determine that exact cause of the disease have included theories about environmental factors and genetic mutations (Parkinson’s Disease Foundation, 2014b). Researchers continue to study the causes, symptoms, and development of PD and the effects on brain functioning. To better understand the physical and cognitive symptoms associated with the disease, it is important to examine the neurological changes within the brain that classify PD as a neurodegenerative disorder.

Changes in the Brain During the Course of PD Neurologically, PD is generally characterized as a disorder that significantly affects the central nervous system, consisting of the brain and spinal cord. The basal ganglia, comprised of the substantia nigra structure of the brain, facilitates physical movement (Figure 9.2). This region of the brain absorbs most of the damage during the disease’s development and progression. PD is the most common disease of the basal ganglia; the dopaminergic neurons of the substantia nigra gradually deplete (Rothwell, 2011). These neurons are important because they produce the neurotransmitter dopamine, and play an important role in the structure and function of the brain. Interactions between the dopaminergic neurons, the main source of dopamine, and glutamatergic neurotransmission, considered to be the most prominent neurotransmitter, are needed for the basal ganglia to function and communicate at a healthy level (Petzinger et al., 2010). In the brain of an individual diagnosed with PD, neurological deficits occur during the nuclei dysfunction of the basal ganglia, restricting the body’s ability to execute physical movements (Shulman, De Jager, & Feany, 2011). Figure 9.3 is an artist’s representation of a positron emission tomography (PET) scan, which depicts the comparison of dopaminergic neurons, shown in red, within the brain of a PD individual versus a non-PD individual. Changes in modulatory pathways within the brain, including the expression levels of neurotransmitter receptors, continue to alter and deplete dopaminergic neurons as PD progresses (Brichta, Greengard, & Flajolet, 2013).

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Figure 9.2 Basal ganglia and additional structures Color version available at http://www.routledge.com/9781032050539

Figure 9.3 Artist’s depiction of the comparison between a normal and Parkinson’s diseased PET scan Color version available at http://www.routledge.com/9781032050539

Medical Art Therapy Applied to Trauma 199 Theories about the depletion of cells within the brain point out proteasomal and lysosomal system dysfunction. A healthy proteasomal system discards unwanted or damaged proteins to help better regulate the concentration of proteins, whereas the lysosomal system breaks down proteins for homeostatic purposes. Dysfunctions in these two systems, such as the body’s inability to disregard and exterminate unnecessary or damaged protein cells and enzymes that can lead to neurodegenerative disorders, reduced mitochondrial activity, and gene mutations can all result in the depletion of cells. (Obeso et al., 2010). Dopamine cell depletion within the brain results in motor symptoms such as rigidity, slowness of movement, and tremors, as well as the body’s ability to respond and react to mental commands. Current medical research has suggested that deficits within the basal ganglia can also be associated with memory loss and a decrease in maintaining and forming new habits, which are portrayed through the cognitive impairments of PD (Foerde & Shohamy, 2011). Specific types of memory, such as prospective memory, are believed to be impaired more than others, due to the damage within the brain (Kliegela, Altgassena, Heringa, & Rose, 2011). Prospective memory is characterized as the form of memory that allows for performing a specific task at a specific time, such as taking medication (Kliegela, Altgassena, Heringa, & Rose, 2011). Cognitive impairments related to memory can also include feeling distracted and disorganized, difficulty making choices, and a delay when searching for the right words to communicate a thought or feeling (Parkinson’s Disease Foundation, 2014b). Since both physical and cognitive deficits stem from the effects of PD on the brain, researchers question which methods are most effective in attempting to restore varying levels of brain functioning, thus improving symptomology and quality of life.

Medical Methods and Treatment of the PD Brain Symptomatic therapies, such as dopamine replacement therapy (DRT) and dopamine agonists, can improve brain functioning by activating dopamine receptors, to some degree (Obeso et al., 2010; Vedam-Mai et al., 2014). These medications target the motor symptoms of PD caused by the loss of dopaminergic cells within the substantia nigra region of the brain. DRT medications have been used to improve motor symptoms for the past few decades and directly target dopamine-producing cells (Shulman et al., 2011). Medications used for DRT, such as levodopa, have been found to improve cognition and attention performance in individuals diagnosed with PD by increasing the dopamine chemical within the body (Moustafa & Gluck, 2010). Dopamine agonists are medications that mimic the effects of dopamine within the brain, not produce it, and can be used alongside a DRT medication. Although the use of PD medication has its benefits, medical treatment interventions are not believed to slow the progression of PD, but rather are used to alleviate the severity of symptoms (Mehanna & Lai, 2013).

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As with many chemical interventions, medications used to treat PD can have side effects. Possible side effects for dopamine agonists include compulsive behaviors, confusion, paranoia, and hallucinations (Evans & Sung, 2013). An additional disadvantage to PD medications lies in a patient’s tendency to experience motor complications, most commonly levodopa-induced dyskinesias, during the peak of a dose or while the medication is wearing off (Mehanna & Lai, 2013). As PD medications wear off, a patient may experience a decrease in mobility and an increase in the severity of motor symptoms before the next scheduled dose (Evans & Sung, 2013). Such side effects can lead to a defeated state of mind and possible resistance to medication. Deep brain stimulation (DBS), considered to be the most invasive treatment available, is a surgical procedure that has been found to reduce common PD symptoms and the need for medication (Nilsson et al., 2013). DBS is typically offered to individuals whose PD medications have failed to provide relief and improvement of the disease (Péron et al., 2010). Simply stated, DBS provides electrical impulses to a target area of the brain. DBS involves implanted electrodes, connected to an impulse generator within specific regions of the brain, to help modulate neural signaling and increase overall blood flow (Okun, 2012). The electrical currents can vary in voltage, frequency, and duration, as can the size and shape of the parameter needed to stimulate the specific region of the brain (Mehanna & Lai, 2013). Seen as an asset in the field of neurology, DBS is also considered as an important treatment option for individuals with neuropsychiatric diagnoses or features (Delaloye & Holtzheimer, 2014). DBS has been found to aid in targeting psychological features, such as depression and obsessive-compulsion; although DBS has used in research studies focusing on mental health, it can be applied to the psychological factors present within the PD diagnosis (Delaloye & Holtzheimer, 2014). DBS is also believed, through voice and speech modulation, to improve emotional impairments resulting from the course of PD, such as impaired facial or emotional expression (Péron et al., 2010). The neurological side effects of receiving DBS include memory deficits, cognitive impairments, difficulties with speech, and sensory disturbances, with the most common side effect being a decrease in verbal fluency (Okun, 2012). Contrary to research findings that state DBS can help with psychological factors, some cases have shown that individuals receiving DBS actually experience psychological side effects, such as mania, liability, and even depression (Okun, 2012). Although DBS and medication both may greatly improve the overall symptomology of PD, as the medical field continues to progress in treatment interventions, ever-growing interest in holistic approaches and complementary therapies such as art therapy has led to improvements in patient treatment by stimulating the brain through noninvasive, creative engagement. This development can provide insight into how the brain can be activated and engaged without solely relying on medical intervention.

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Art Therapy and the Brain A connection between art therapy and neuroscience may be examined by briefly analyzing the roles of the left and right hemispheres of the brain. The two hemispheres of the brain have often been designated as providing different characteristics to a person, hence phrases such as “are you left- or right-brained?” The right hemisphere is commonly associated with creativity, visual imagery, visual-spatial information and memory, and color distinction (Lusebrink, 2004). Current research has also indicated that, when provided with multisensory stimuli, neural responses within the right hemisphere of the brain may be associated with behavioral effects (Hoefer et al., 2013). The left hemisphere of the brain is often associated with problem solving, language, and interpreting information (McNamee, 2004). Contrary to the notion that the two brain hemispheres act separately, both the right and left hemisphere become activated during the art-making process (Malchiodi, 2012). The right hemisphere is activated during the creativity stage; the left hemisphere responds to the creative process, adding meaning to the visual representation (McNamee, 2004). The relationship between art therapy and neuroscience is strengthened as current researchers examine not only the hemispheric engagement within the brain, but also changes in brain activity that occur during the process of creating art. Art therapy researchers have begun to examine the direct effects of art therapy and brain activity by utilizing measures related to brainwave activity, such as an Electroencephalograph (EEG) and Quantitative Electroencephalography (qEEG) (Belkofer & Konopka, 2008; Kruk, Aravich, Deaver, & deBeus, 2014). These tests record electrical activity within the brain and can monitor different frequency bands when electrodes are placed on an individual’s scalp. The most dominant frequency band in the brain, alpha, is the most studied within neuroscience and has been associated with visual skills, artistic skills, and artistic interest (Belkofer, Van Hecke, & Konopka, 2014). Utilizing the qEEG, Kruk, et al., (2014) found that brain activity increased during the process of art-making; comparing the recorded brain activity to that of a participant’s resting state supported this. Belkofer and Konopka (2008) found similar results, concluding that brain activity immediately following a drawing session differed significantly from brain activity during a participant’s resting state. Results of qEEG use propose that different mediums of art may generate different levels of brain stimulation, as seen in the electrical activity within the frontoparietal region of the brain (Kruk, et al., 2014). From a neurological viewpoint, these data lend credence to the theory that creating art encompasses a natural relationship between the brain and artistic imagery. Researchers in art therapy and neuroscience have examined visual expression in relation to brain functioning and have found that images can influence a participant’s emotions, thoughts, memories, and physiological reactions during art-making (Lusebrink, 2004; Malchiodi, 2011; Talwar, 2007). Visual imagery can lead an individual to understand experiences, release inner conflicts, and maintain or reconstruct a positive identity by simply engaging in the art

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therapy process (Stuckey & Nobel, 2010). Art therapists use various intervention strategies to engage a patient in the creative process; an effective technique commonly used is hands-on art media. Through tactile stimulation, an art therapist can further engage various regions of the participant’s brain, thus applying art therapy to the treatment of a wide variety of neurological disorders.

Art Therapy within the Treatment of PD: A Kinesthetic Experience Art therapists use the creative process to address traumatic emotional responses to the PD diagnosis by engaging the patient with direct media experiences. Art media can stimulate parts of the brain through sensory and tactile engagement, incorporating motor activity and functioning (Lusebrink, 2004). Immersion in the art-making process provides a kinesthetic, tactile, and sensory experience that holds great benefits for an individual with neurological disorders. The emotional and physical reaction within the art-making process naturally stimulates brain cells and strengthens brain activity through the art media (Ri, Jeong, & Jung, 2014). A kinesthetic experience (through motor activity) and a sensory experience (through the use of tactile art materials) both can be naturally self-soothing and can induce relaxation through repetitive movements and touch (Malchiodi, 2012). Lusebrink (2010) suggests that sensory and kinesthetic art experiences can promote positive physical, emotional, and adaptive reactions within the body. Neurological disorders in general often have significant emotional and physical effects on the body through traumatic experiences, such as experiencing changes in lifestyle, physiology, quality of life, and the ability to cope with initial diagnosis through the progression of the disease. From a neurodevelopmental approach, the right hemisphere of the brain is believed to store traumatic memories; using tactile art media for optimum stimulation can activate the right hemisphere of the brain and release emotional responses associated with the trauma (Monti et al., 2006). Use of tactile art materials, such as clay, illustrates how kinesthetic engagement can stimulate the brain of an individual diagnosed with PD through a cathartic release of emotional responses to take place, even in the midst of trauma. Increasingly, clay has been used within art therapy intervention for patients diagnosed with PD. Yaretzky, Levinson, and Kimchi (1996) found clay manipulation to be a soothing factor and a sensorimotor solution during rehabilitation of patients diagnosed with PD. Recent work further suggests using clay as a therapeutic tool for targeting physical discomfort related to PD symptoms and the resultant changes in lifestyle. The use of clay, also known to address emotional stress and trauma brought on by PD diagnosis and disease progression, can instill and promote emotional expression. Trauma impedes expression, whereas art allows emotions to surface and flow in a safe setting. Specifically with the use of clay, art therapy can support patients experiencing trauma, aid them in finding their voice, and allow them to process their emotional distress through creative exploration and the strength of the therapeutic art (Elkis-Abuhoff et al., 2013a;

Medical Art Therapy Applied to Trauma 203 Goldblatt, Elkis-Abuhoff, Gaydos, & Napoli, 2010; Elkis-Abuhoff, Goldblatt, Gaydos, & Corrato, 2008; Kimport & Robbins, 2012). The use of clay has been associated with tactile communication, as a way to provide a nonverbal outlet of self-expression (Kimport & Robbins, 2012). The tactile and malleable properties of clay allow for active engagement through direct touch and manipulation. Patients diagnosed with PD find a soft and pliable art material, which can easily form to any hand or grip, to be inviting, engaging, and encouraging (Elkis-Abuhoff et al., 2013a). By manipulating clay, patients with PD can move past physical symptoms often known to limit functioning, such as rigidity and tremors, and actively engage and communicate through a pliable and forgiving medium. For those in distress and with physical limitations, the physical engagement of grasping, pulling, and integrating the clay allows for a successful and therapeutic outcome. The use of clay as tactile engagement can provide a relaxing and cathartic experience, allowing patients diagnosed with PD to transform a ball of clay into a meaningful symbol (Kimport & Robbins, 2012). It is proposed that the art therapy process serves as a noninvasive experience that can relieve tension, promote feelings of wellness, and decrease emotional and physiological traumatic responses. The engagement of art therapy through the use of clay manipulation with persons diagnosed with PD was explored in several studies (Elkis-Abuhoff et al., 2013a; Elkis-Abuhoff et al., 2008; Goldblatt et al., 2010). Through three phases of research, participants had the opportunity to intimately engage with manipulation of a clay-like media (dough, Model Magic (c), or self drying clay). Researchers explored if those diagnosed with PD would enjoy the clay manipulation experience. A pre-post assessment—the Brief Symptom Inventory (BSI, Derogatis, 1993)—explores the effects of emotional symptomology for those diagnosed with PD. The BSI, a 53-item psychological screening, provides an overview of patient’s symptomology and its intensity within a specific time period, which is always within the past week. The BSI is rated on a five-point Likert scale and has nine dimensions: Somatization (SOM), Depression (DEP), Obsessive-Compulsive (O-C), Interpersonal Sensitivity (I-S), Phobic Anxiety (PHOB), Anxiety (ANX), Hostility (HOS), Paranoid Ideation (PAR), and Psychoticism (PSY). During the initial phase, participants were given the opportunity to engage with a ball of modeling dough the size of a racquetball. Each participant was instructed to squeeze the ball in each hand, pull it apart into pieces, and then reintegrate the material into something other than the original ball. The outcome of this phase revealed a significant change between pre- and post-assessment, showing a decrease in overall emotional symptomology for participants post-engagement in the clay manipulation experience (ElkisAbuhoff et al., 2008). Phase II (Goldblatt et al., 2010) continued to explore the specific subscales of the BSI and extrapolates the outcomes for each subscale. The researchers found that three specific subscales produced significant outcomes: Obsessive-Compulsive thinking (O-C), Phobia (PHOB), and Depression (DEP) as developed by

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Figure 9.4 BSI Pre- (top) and post (bottom) outcomes; below the line is within normal range

Derogatis (1993). Not only were these three subscales decreased, but also overall they were reduced to within the normal adult range. Figure 9.4 presents an example of an 80-year-old female participant diagnosed with PD on her subscales pre- and post- clay manipulation. Finally, the third phase (Elkis-Abuhoff et al., 2013a) consisted of a six-week group art therapy program. The group comprised patients with PD and was facilitated by both an art therapist and a psychologist. Each week participants explored a different session topic, including living with PD, anxiety and fears, relationships, getting old/aging, emotions/control, and goal setting, partnered with a clay manipulation experience. Verbal processing was incorporated to engage the participant with the topic of the week and to discuss the outcome after the manipulation was completed. Participants were assessed throughout the program with a pre/post modified version of the BSI, based on the three subscales of obsessive-compulsive thinking (O-C), Phobia (PHOB), and Depression (DEP, Derogatis, 1993) and the Perceived Stress Scale (PSS, Cohen, Kamarck, & Mermelstein, Mermeistein, 1983). Once again the areas of obsessive-compulsive

Medical Art Therapy Applied to Trauma 205 thinking, phobia, and depression were reduced, as was perceived stress. The verbal therapy created group cohesiveness and an open forum for the participants to share and support each other. However, it was the clay manipulation process that participants enjoyed most and had the greatest impact on affect and activity as represented in the outcomes of Figure 9.5, which gives an example of the expressive processes of one participant. In all three phases the participants were asked to become familiar with the clay medium through tactile engagement. In a paper presentation at the Expressive Therapies Summit, the researchers reported that they observed substantial changes in participants in all phases of the research (Elkis-Abuhoff, Goldblatt, Gaydos, & Convery, 2013b). The engagement in modeling clay allowed the participants to intimately use both fine and gross motor skills and to experience a sense of control of their environment. The manipulation of the clay material created an alternative to often seen PD symptoms such as hand tremor and “pill rolling.” One participant, for example, entered the room visibly hunched over, eyes glazed, with a flat affect and a shuffling gait. Through a slow and patient introduction to and eventual manipulation of the clay material, his affect began to lift. He became visibly more focused, and his eyes appeared to be clear. In a short time, his speech was coherent, and he was able to participate in a

Figure 9.5 Example of artwork created from a ball of clay Color version available at http://www.routledge.com/9781032050539

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conversation. After engaging with the clay he left the room, had a smile on his face and a much steadier gait. When he saw his wife, his first words were “I’m hungry; what are we going to have for lunch?” His wife, extremely surprised by his presentation, stronger and clearer than usual, reported that this was not his normal presentation since his PD diagnosis. The researchers observed that many neurological symptoms related to PD decreased during and immediately after the engagement with the manipulative clay material. There was a noticeable change in presentation, leading to better posture and speech and a decrease in tremors. The increased tactile stimulation in the fingers, leading to greater neurotransmitter firings or communication, could be related to the participants’ ability to focus on their symptomology and their emotional needs with better clarity. Continuing forward, research that evaluates the neurological responses of the tactile stimulation may lead to the improved functioning of those diagnosed with PD. The researchers observed that many neurological symptoms related to PD decreased during and immediately after the engagement with the manipulative clay material. There was a noticeable change in presentation, leading to better posture and speech and a decrease in tremors. Participants were able to hold and manipulate the clay with ease, their hands cradling the clay despite the presence of rigidity. Manipulating the clay at their own pace, participants were observed as having more dexterity toward the end of the art therapy process. On a neurological level, the increased tactile stimulation in the fingers and palms through direct touch suggests an increase in neurotransmitter firings, sensation in nerves, and overall brain activity. Despite the decrease in brain activity caused by the progression of PD, it is suggested that the art therapy process allows for both the right and left hemispheres of the brain to become activated, which contributed to the positive experiences observed in the participants. The increased stimulation within the brain resulted in participants’ ability to focus on their symptomology and process their emotional needs with increased clarity. Through tactile stimulation, for instance natural motor reflexes through the strong sense of touch, it was observed that many participants improved in functioning and relaxed enough to work through their symptoms. The results of this investigation suggest that physical engagement of the modeling clay manipulation can connect patients tactilely to the world, providing what patients often perceive as regaining a “grip on the world.” The outcomes of this research support that neurological stimulation in the brain of patients with PD allows for improved physical symptomology and the ability to address the emotional stresses of living with the disease. The outcome of this research supports that engagement in art therapy through the monitoring of specific brainwaves, as previously seen within the qEEG applications, affects brain functioning (Belkofer et al., 2014; Belkofer & Konopka, 2008; Kruk et al., 2014). As a result this could target and improve the physical and emotional symptomology for those diagnosed with PD.

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Conclusion Art therapy, specifically through clay manipulation, has been shown to provide support to the psychological and physiological traumas experienced during the course of a neurodegenerative illness such as Parkinson’s disease. Empirical studies of PD and art therapy have shown a decrease in depression, obsessivecompulsive thinking, and phobia, as well as observable changes in behaviors such as posture, affect, increased speech, and reduced tremors (Elkis-Abuhoff et al., 2013b; Goldblatt et al., 2010; Elkis-Abuhoff et al., 2008). As further insights into brain functioning occur, a more defined and structured approach to art therapy can address patients with trauma related to medical illness through tactile stimulation and kinesthetic experiences. Understanding the advancements of brain functioning as it applies to neuroscience provides insight into the traumatic experiences of medical illness. Being able to record and map changes in brain activity helps clinicians to establish effective and alternative methods of treatment. This capability leads to a better understanding of what exactly happens within the brain and how psychological and physiological symptoms can stem from changes in brain activity.

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Elkis-Abuhoff, D. L., Goldblatt, R. B., Gaydos, M., & Convery, C. (2013b). Clay manipulation with those diagnosed with Parkinson’s disease. Paper presented at the annual Expressive Therapies Summit, New York, NY. Elkis-Abuhoff, D. L., Goldblatt, R. B., Gaydos, M., & Corrato, S. (2008). The effects of clay manipulation on somatic dysfunction and emotional distress in patients with Parkinson’s disease. Art Therapy: The Journal of the American Art Therapy Association, 25(3), 122–128. Evans, A. H., & Sung, S. (2013). Therapeutic progress in Parkinson’s disease. Modern Medicine, 38(3), 29–31. Foerde, K., & Shohamy, D. (2011). The role of the basal ganglia in learning and memory: Insight from Parkinson’s disease. Neurobiology of Learning and Memory, 96(4), 624–636. Goldblatt, R., Elkis-Abuhoff, D., Gaydos, M., & Napoli, A. (2010). Understanding the clinical benefits of modeling clay exploration with patients diagnosed with Parkinson’s disease. Art &Health: An International Journal of Research, Policy and Practice, 2(2), 140–148 9p. doi:10.1080/17533010903495405 Helmich, R. C., Toni, I., Deuschl, G., & Bloem, B. R. (2013). The pathophysiology of essential tremor and Parkinson’s tremor. Current Neurology and Neuroscience Reports, 13(9), 1–10. Hoefer, M., Tyll, S., Kanowski, M., Brosch, M., Schoenfeld, M. A., Heinze, H. J., & Noesselt, T. (2013). Tactile stimulation and hemispheric asymmetries modulate auditory perception and neural responses in primary auditory cortex. NeuroImage, 79, 371–382. doi:10.1016/j.neuroimage.2013.04.119 Högberg, G., Nardo, D., Hällström, T., & Pagani, M. (2011). Affective psychotherapy in post-traumatic reactions guided by affective neuroscience: Memory reconsolidation and play. Psychology Research and Behavior Management, 4, 87–96. doi: 10.2147/ PRBM.S10380 Kimport, E. R., & Robbins, S. J. (2012). Efficacy of creative clay work for reducing negative mood: A randomized controlled trial. Art Therapy: Journal of the American Art Therapy Association, 29(2), 74–79. Kliegela, M., Altgassena, M., Heringa, A., & Rose, N. S. (2011). A process-model based approach to prospective memory impairment in Parkinson’s disease. Neuropsychologia, 49(8), 2166–2177. doi:10.1016/j.neuropsychologia.2011.01.024 Kruk, K. A., Aravich, P. F., Deaver, S. P., & deBeus, R. (2014). Comparison of brain activity during drawing and clay sculpting. Art Therapy: Journal of the American Art Therapy Association, 31(2), 52–60. Lusebrink, V. B. (2004). Art therapy and the brain: An attempt to understand the underlying processes of art expression in therapy. Art Therapy: Journal of the American Art Therapy Association, 21(3), 125–135. Lusebrink, V. B. (2010). Assessment and Therapeutic Application of the Expressive Therapies Continuum: Implications for Brain Structures and Functions. Art Therapy: Journal of the American Art Therapy Association, 27(4), 168–177. Malchiodi, C. A. (Ed.). (2012). Handbook of art therapy (2nd ed.). New York: Guilford Press. McNamee, C. M. (2004). Using both sides of the brain: Experiences that integrate art and talk therapy through scribble drawings. Art Therapy: Journal of the American Art Therapy Association, 21(3), 136–142. Mehanna, R., & Lai, E. C. (2013). Deep brain stimulation in Parkinson’s disease. Translational Neurodegeneration, 2(22), 1–10.

Medical Art Therapy Applied to Trauma 209 Monti, D. A., Peterson, C., Kunkel, E. J. S., Hauck, W. W., Pequignot, E., Rhodes, L. & Brainard, G. C. (2006). A randomized, controlled trial of mindfulness-based art therapy (MBAT) for women with cancer. Psycho-Oncology, 15(5), 363–373, DOI:10.1002/ pon.988 Moustafa, A. A., & Gluck, M. A. (2010). A Neurocomputational model of dopamine and prefrontal–striatal interactions during multicue category learning by Parkinson patients.Journal of Cognitive Neuroscience, 23(1), 151–167. Naff, K. (2014). A framework for treating cumulative trauma with art therapy. Art Therapy: Journal of the American Art Therapy Association, 31(2), 79–86. Nilsson, M. H., Patel, M., Rehncrona, S., Magnusson, M., & Fransson, P. A. (2013). Subthalamic deep brain stimulation improves smooth pursuit and saccade performance in patients with Parkinson’s disease. Journal of NeuroEngineering and Rehabilitation, 10(33), 1–12. Obeso, J. A., Rodriguez-Oroz, M. C., Goetz, C. G., Marin, C., Kordower, J. H., Rodriguez, M., & Halliday, G. (2010). Missing pieces in the Parkinson’s disease puzzle. Nature Medicine, 16(6), 653–661. Okun, M. S. (2012). Deep Brain Stimulation for Parkinson’s Disease. The New England Journal of Medicine, 367(16), 1529–1538. Parkinson’s Disease Foundation. (2014a). Statistics on Parkinson’s. Retrieved from www.pdf.org/en/parkinson_statistics. Parkinson’s Disease Foundation. (2014b). Causes. Retrieved from www.pdf.org/en/ causes. Parkinson’s Disease Foundation. (2014c). Coping with a diagnosis. Retrieved from www.pdf.org/en/newly_diagnosed_pd. Péron, J., Grandjean, D., Le Jeune, F., Sauleau, P., Haegelen, C., Drapier, D., & Vérin, M. (2010). Recognition of emotional prosody is altered after subthalamic nucleus deep brain stimulation in Parkinson’s disease. Neuropsychologia, 48(4), 1053–1062. doi:10. 1016/j.neuropsychologia.2009.12.003 Petzinger, G. M., Fisher, B. E., Van Leeuwen, J. E., Vukovic, M., Akopian, G., Meshul, C. K., Jakowec, M. W. (2010). Enhancing neuroplasticity in the basal ganglia: The role of exercise in Parkinson’s disease. Movement Disorders, 25(1), S141-S145. Ri, K. Y., Jeong, K. Y., & Jung, K. H. (2014). Effect of art therapy program on the physical, emotional, cognitive functions of the Korean elderly with Dementia. Life Science Journal, 11(7s). 489–493. Rothwell, J. C. (2011). The moor functions of the basal ganglia. Journal of Integrative Neuroscience, 10(3), 303–315. Shulman, J. M., De Jager, P. L., & Feany, M. B. (2011). Parkinson’s disease: Genetics and pathogenesis. Annual Review of Pathology: Mechanisms of Disease, 6, 193–222. doi:10.1146/annurev-pathol-011110-130242 Stuckey, H. L., & Nobel, J. (2010). The connection between art, healing, and public health: A review of current literature. American Journal of Public Health, 100(2), 254–263. Talwar, S. (2007). Accessing traumatic memory through art making: An art therapy trauma protocol (ATTP). The Arts in Psychotherapy, 34(1), 22–35. doi:10.1016/j.aip. 2006.09.001 Thompson, R., Isaac, C.L., Rowse, G., Tooth, C.L., & Reuber, M. (2009). What is it like to receive a diagnosis. Epilepsy & Behavior, 14(3), 508–515. doi:10.1016/j.yebeh.2008. 12.014

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Vedam-Mai, V., Gardner, B., Okun, M. S., Siebzehnrubl, F. A., Kam, M., Aponso, P., & Curtis, M. A. (2014). Increased precursor cell proliferation after deep brain stimulation for Parkinson’s disease: A human study. PloS one, 9(3), e88770 Yaretzky, A., Levinson, M., & Kimchi, O. L. (1996). Clay as a therapeutic tool in group processing with the elderly. American Journal Of Art Therapy, 34(3), 75–82. Yoritaka, A., Shimo, Y., Takanashi, M., Fukae, J., Hatano, T., Nakahara, T., & Hattori, N. (2013). Motor and non-motor symptoms of 1453 patients with Parkinson’s disease: Prevalence and risks. Parkinsonism and Related Disorders, 19(8), 725–731. doi:10.1016/ j.parkreldis.2013.04.001 Zwartjes, D. G. M., Heida, T., van Vugt, J. P. P., Geelen, J. A. G., & Veltink, P. H. (2010).Ambulatory monitoring of activities and motor symptoms in Parkinson’s disease. EEE Transactions on biomedical engineering, 57(11), 2778–2786.

Conclusion Juliet L. King with Kerry Kruk

It is very clear to me as someone who has been an art therapist for over 50 years that the time has come for art therapists to collaborate with those in other professions in order to help others to heal. Survivors of trauma in particular need as many different avenues of expression as possible, since their pain is so persistent and so difficult to treat. Through art they can accomplish ‘telling without talking’ (Cohen & Cox, 1995), which allows memories encoded in images to be accessed, expressed, looked at, and eventually detoxified—using any of the many creative approaches described in this book. Judith Rubin, art therapist Although I (Juliet) was elated when approached by Routledge to write a book on art therapy and neuroscience, it was important for me to be honest in my limitations of experience with the subject. I suggested that an edited text would be more appropriate for that stage in my learning process. When I asked the authors if they would be interested in contributing, I was overwhelmed and honored that they would trust me with the dissemination of their meaningful work. What happened next was what I consider to be a form of metaphorical participatory action research: The seasoned art therapists, who have integrated an ongoing intention and in-depth understanding of neuroscience in their theory and practice, all proposed submissions that focused on their work with people who have been traumatized. This speaks to the relevance of trauma in clinical treatment, and also to the natural amalgam that occurs between art therapy and neuroscience when addressing the complexities of biology, physiology, and neurology in the provision of patient-driven, whole-person care. The authors in this book show how to translate theory into technique when working with patients, which is often a parallel process. This process is as important in the development of the profession as defining the “basics” of what art therapy actually is (Rubin, 2001). Clinical practice is where we truly learn about the needs of the people we work with, and it is often within these relationships that research ideas and questions develop. All clinicians are researchers, and we all have different strengths, which is why it is so important to work together to determine what makes therapeutic change (L. Konopka,

DOI: 10.4324/9781003196242-10

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personal communication, June 23, 2014). As Jung (1963) reminds us, therapy begins with the investigation of the whole story of the person and the task of the therapist is to understand the patient experience through the story that is told, not the symptoms alone. The narrative provided by the patient is key to unlocking healing potential, and science has much to offer in this process. “Science . . . offers a means to establish proof of worth. More important, it offers the prospect of revealing the secrets of art and art-making and, as a consequence, of developing a true theory of art therapy” (Kaplan, 2000: 17). Gathering qualitative data through observation and experience in practice informs structured inquiry and assists in creating a theory of practical and clinical reasoning that can be applied and eventually tested. The protocols and instruments resultant of observation are then used to develop objective measures that help us distinguish and categorize the result of healing through creativity, revitalized attachment patterns, and the use of media in the evocation of expression and therapeutic relationship. Art therapists are not limited to one type of research approach, but rather should be encouraged to critically examine their worldview, paradigmatic assumptions about the topics they want to study, and select appropriate methods (N. Gerber, personal communication, August 6, 2015). The ways of conducting research in art therapy are “as broad and rich as the profession itself” (Deaver, 2011: 24). Art therapists have developed specific protocols to test the efficacy of art therapy and treatment interventions with various traumatized populations (Chapman et al., 2001, 2014; Hass-Cohen, 2008; Hass-Cohen & Clyde Findlay, 2009, 2015; Malchiodi, in press; McNamee, 2004, 2006; Talwar, 2007; Tripp, 2007), and the bulk of art therapy research with patients who have experienced trauma is supported with neuroscientific findings that recognize the importance of arts-based strategies that do not rely solely on language for processing (Collie, Backos, Malchiodi, & Spiegel, 2006; Malchiodi, 2006; Moon, 2009). Art therapists continue to refine existing treatment approaches in the expansion and applications of previously used methods. For example, Malchiodi (2012) has explained how trauma-informed expressive arts therapy approaches are based on the idea that art expression is helpful in reconnecting implicit (sensory) and explicit (declarative) memories of trauma and has further developed a TraumaInformed Art Therapy® and Trauma-Informed Expressive Arts Therapy® approach (in press), the components of which 1) demonstrate that neurodevelopment and neurobiology inform the application of expressive arts and play therapy to trauma-informed intervention; 2) focus on supporting self-regulation and stress reduction; 3) help identify and ameliorate the body’s experience of distress; 4) establish and support a sense of safety and positive attachment; 5) support strengths and enhance resilience; 6) respect the individual’s preferences for self-expression, particularly of the trauma narrative; and 7) identify expressive arts and play as meaning-making experiences. Art therapists have great capacity to expand upon the thoughtful protocols, and documented success has been disseminated in the literature thus far. Through a practical and expansive lens, a neuroscientific approach to work with

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traumatized patients has demonstrated that art therapy: 1) facilitates the organization and integration of traumatic memories; 2) reactivates positive emotions and serves as a vehicle for exposure and externalization of difficult content; 3) reduces heightened arousal responses; 4) enhances emotional selfefficacy and maintains a space for the exploration of self perception and psychic integration; and 5) enhances the development of identity (King, 2015). Tripp (Chapter 8), and Hass-Cohen (Chapter 5), offer specific protocols that address the impact of trauma on somatic and neurobiologically compromised human attachment systems and how this impacts the emotional processing of traumatic memories. While all of the authors underscore the importance of the relationship as integral in the healing process, Belkofer and Nolan (Chapter 7) detail how the brain itself is changed by discussing the interpersonal neurobiological experience that occurs in relationships. Building on previous knowledge (HassCohen, 2008) that suggests research in neuroscience can be used to develop the mind-body connection that is represented in the creation of art in art therapy. Hass-Cohen (Chapter 5) includes, among other processes, the role of the Mirror Neuron System (MNS) as it relates to the use of art materials and the intersubjectivity of the therapeutic relationship. The seminal work of leaders in the field of interpersonal neurobiology such as Daniel Siegel and neurodevelopmental psychoanalyst Allan Schore are well represented throughout this text, along with psychiatrists Bruce Perry and of course Bessel van der Kolk, as the contributing authors help us stay focused on the importance of “the subjective experience of our minds, not the functional anatomy of the brain” (Siegel, 1999), (Chapter 4, p. 28) when addressing the many ways that trauma impacts brain development, attachment, and the ongoing neurobiological consequences therein. The theory and research of these leaders helps the authors to understand and articulate the tenets of art therapy as potentially correlated with, for example, bottom-up and top-down information processing, left and right hemispheric functioning, and limbic system and frontal lobe communication in the self regulatory and expressive properties afforded by the nonverbal and symbolic communication that occurs throughout the creative process. Somewhere, something incredible is waiting to be known. Carl Sagan There are many ways of knowing and understanding, and many of these ways need to be objectified so that they can be reproduced and applied with the evidence that defines them. It is easy to make courageous assumptions about what we observe and see in clinical practice as absolute truth that is generalizable across clinical populations. As Belkofer (2012) astutely states: “Absorbing neuroscience theory as a rationale is one thing, but claiming conclusive activation of identifiable systems of the brain is something different entirely” (p. 38). The technologies and tools that are available help us make important distinctions between intuited knowledge and scientific fact. The 1990s were the decade of the brain, aptly named due to the amount of studies exploring the

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intricate connection between the brain and the experience of the individual. Much work was done to map the brain according to function and dysfunction. Additionally, various principles were learned and explored that have had profound influence on a variety of fields. Neuroplasticity became a staple in the literature and impacted theories of learning, adaptation, understanding the meaning of emotions, and exploring treatment options (Doidge, 2007). Because of neuroplasticity we can redefine our relationship with science in the creation of something new and integrate the disciplines of art therapy and neuroscience without prejudice. Exciting research has been conducted on the impact of trauma to peer into possible methods for reducing the negative impact of implicit memories by incorporating plasticity into neural training for patients who have a diagnosis of PTSD (Bremner, 2007; Hull, 2002). To explore implications for PTSD and brain injury, a meta-analysis was conducted that yields important data on the brain functions related to trauma memory and the reexperiencing of these often intrusive events (Sartory et al., 2013). Imaging technology has given rise to a new field of exploration about how the brain is affected by a wide variety of experiences, how individuals’ brains are influenced by their environments and activities, and how specific training and therapy may influence, positively change, or ameliorate otherwise debilitating damage. Currently, the field of art therapy has seen an increase in research regarding the fundamental principles of the impact of art creation on brain processes, as well as research focused on neurological perspectives. This information is vital to not only understand the functionality and science of therapy and art therapy, but to demonstrate the impact that therapy has to change and influence the overall experience and perceptions of an individual. Quantitative Electroencephalography (qEEG) technology has been demonstrated to be an effective method for recording activity under various conditions, specifically conditions involving art creation. qEEG has been utilized in a few studies within the field of art therapy and is used regularly in practice in treating neurological or mental disorders. This technology allows researchers to measure brain wave activity in a variety of different conditions—control and experimental—and data is compiled from recording sites on a subject’s whole brain into an image or maps. These maps are useful for understanding the phenomenon of the experimental conditions versus brain activity under control conditions. There have been a few studies in the art therapy literature that have shown some preliminary results while utilizing qEEG technology for measuring brain wave activity in response to art-making (Belkofer & Konopka, 2008; Belkofer, Van Hecke, & Konopka, 2014; Kruk, Aravich, Deaver, & deBeus, 2014). Belkofer and Konopka (2008) conducted a study on an artist by measuring brain wave activity before and after an hour-long period of art-making. They found a shift in brain wave activity as a result of the drawing and painting period in which there was increased higher brainwave function in the occipital, parietal, and temporal lobes. The left hemisphere showed a pattern of higher activations as beta activity was increased in the left medial temporal, left frontal, and left

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prefrontal lobes. While these empirical results are important, we still lack direct implication for art therapy. The researchers (2014) have continued to utilize qEEG technology in a study involving several participants, which elicited significant results that supported their previous research: Belkofer et al., (2014) measured residual effects of a drawing activity on brain activity. Results of the recordings demonstrated statistically significant differences in alpha-wave activity in the left posterior temporal, parietal, and occipital regions. Participants included artists and non-artists, and among the non-artists, there were statistically significant differences in alpha-wave activity in the right parietal and right prefrontal areas. There were no significant findings between the groups. Alpha-wave activity has been defined in attentional work as typically related to states of being awake and relaxed and is linked to inhibition of incoming sensory information. That is, where the alpha-wave activity is increased, or synchronized, those areas are working to suppress processing, while in other areas where there is a decrease, or desynchronization of alpha-wave activity, a higher degree of information processing is occurring (Toscani, Marzi, Righi, Viggiano, & Baldassi, 2010). The (2014) study of Belkofer, et al. also supports previous research in the difference between the artist’s and non-artist’s brain, that due to lack of training and experiences in art creation, the non-artist has to “work harder” and employ higher executive functioning in judgment and awareness, as reflected by activation patterns in the right prefrontal areas (Solso, 2000). Solso (2000) compared fMRIs of a portrait artist to a non-artist while completing portrait drawings and found that for both individuals, there was activation in the right posterior parietal lobe. He found that there were significant differences as well. While there was activation noted in the parietal lobe for the artist, it was significantly less than in the non-artist; further, the non-artist exhibited higher activation in the right middle frontal cortex. Solso (2000) explained the idea of repetition and adaptability in that “Experts from a wide range of areas, such as mathematics, music, photography, poetry, architecture and so on, may exhibit specialized patterns of cerebral activity related to their expertise” (Solso 2000: 83). Moreover, these specialized patterns may have developed due to efficiency—the brain adapting to repeated experiences and functions. There have been other fMRI studies (Harrington, Farias, & Davis, 2009; Harrington, Farias, Davis, & Buonocore, 2007; Makuuchi, Kaminaga, & Sugishita, 2003; Yuan & Brown, 2014) that have specifically explored the process of drawing. These studies elicited vital information about activation in both parietal lobes, throughout frontal, parietal, and temporal structures. It was shown that processes of recognition and naming are succinctly different from drawing and incorporate left lobe processing as well, along with an illuminated occipito-parietal stream that involves the sensorimotor cortex. These studies indicate that drawing involves motor skills, sensorimotor processing, recognition, and spatial processing that are special to the occurrence of drawing and significantly different from copying, writing, and naming/recognizing tasks. Ultimately, drawing and creating imagery elicits greater right hemisphere

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activation than the latter tasks, but involves variations in the pathways of processing from occipital–parietal, temporal, and frontal lobes. This information provides opportunity to consider additional qEEG mapping that will further distinguish between the cortical patterns of making art and other types of mental processes. Kruk et al. (2014) conducted a qEEG study comparing brain activity under different conditions of art-making in order to explore the shift from one kind of art-making, drawing, to another, clay sculpting. The methodology focused on specific art media in an effort to demonstrate that brain activity elicited by different art-making tasks can illustrate the shifts that are theorized in the Expressive Therapies Continuum theory (Lusebrink, 1990). Kruk et al. (2014) found that there were some significant differences between the two art-making conditions, that the art-making conditions were significantly different than the baseline conditions, and that art-making, in general, involves the right parietal lobe. Results included that a pattern of alpha-wave activity, a general decrease, supports the results in Belkofer, Van Hecke, and Konopka’s study (2014). More specifically, this research illustrated a frontoparietal network involved in artmaking that has also been found in previous work (Belkofer & Konopka, 2008; Solso, 2000; Yuan & Brown, 2014) and leads to ideas about how we might test the properties of media that would provide information for the art therapist in the implementation of protocols that treat specific areas of the brain. Specific to art therapy, Musha, Kimura, Kaneko, Nishida, and Sekine (2000) explored the effectiveness of art therapy as elicited through an EEG study in which the researchers had developed a method to analyze anger, sadness, joy, and relaxation through identifying specific EEG profiles (Emotion Spectrum Analysis Method). Researchers found that over a one-year period of art therapy treatment, participants diagnosed with dementia experienced an elevation in joy and some improvement in Mini-Mental Status Exam scores. These are significant results incorporating theories of neuroplasticity and the effectiveness of art therapy to bring about positive change in cognition. Moreover, the effect of art therapy is demonstrated with quantitative results. This research is important to expand and replicate in order to establish art therapy as an evidence-based best practice for dementia and other neurological disorders. What has been established through these studies is the effectiveness of a methodology using qEEG to research art-making, art materials, and art processes. Highly structured and controlled studies involving participants with a variety of diagnoses and functional impairments along with participants with limited impairments will move art therapy research forward to quantify effects, provide real results to demonstrate the effectiveness or, at the very least, the impact of art therapy on individuals. We have yet to discover an ideal methodology for examining therapy; furthermore, many art therapists have the concern that although it is useful, accessing this type of technology in their work is difficult. This speaks to the importance of collaborating with practitioners who are experienced with using the tools and understanding the data.

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Obtaining additional integrative psychotherapy training such as Eye Movement Desensitization and Reprocessing (EMDR) and combining research efforts with neurofeedback (brainwave feedback) clinicians and biofeedback practitioners are accessible methods of enhancing one’s own practice and therapeutic skills. For example, see Tripp’s work (Chapter 8). Neurofeedback has been developed to effectively train the brain to elicit increasingly normal activation, alert-arousal states, and to bring about symptom amelioration in ADHD (Baydala & Wikman, 2001; Fuchs, Birbaumer, Lutzenberger, Gruzelier, & Kaiser, 2003; Lubar, Swartwood, Swartwood, & O’Donnell, 1995; Null, 2013). If qEEG can map the activation of art media and techniques when used, as proposed in Kruk et al. (2014), more and expanded similar research can inform a developing theory that art therapy interventions can bring about “training” much like neurofeedback to re-engage various cognitive patterns to ameliorate symptoms within trauma disorders, depression, and other neurological and psychological disorders. Integrating psychotherapy theories and techniques also lends itself to collaborative research, such as the use of art therapy to help clients understand and verbalize the changes they experience during neurofeedback training and the study of graphic productions that may track neurological changes during neurofeedback training. For example, in 2000, I (Juliet) conducted a preliminary study of how neurofeedback could elicit changes in the artwork of children diagnosed with ADHD pre- and post-6 months of training and whether or not these changes could be correlated with specific behavioral change. I used the Brief Art Therapy Screening Evaluation (BATSE), Gerber, 1996) as data collection of the dependent variable (the artwork), and the neurofeedback was the independent variable for 15 subjects ranging in age from 6–15 years old. The artwork was blind rated by art therapists, and although there were many interesting outcomes, the most statistically significant was a decreased impulsivity in graphic indicators when correlated with a decrease in behavioral symptoms of the same. This preliminary data is useful for additional research that seeks to validate both art therapy and neurofeedback treatment and raises questions regarding the brain wave activity related to normative and compromised brain states that accompany various diagnoses. I am sure the authors in this text will attest that collaborating with neuroscientists has been a fluid endeavor. It has been my experience that the more I advocate for the profession with a collaborative and science-minded explanation of its benefits, the easier it has been to connect and expand existing networks of possibility. For example, Dr. Jane Yip, neuroscientist, and Kandi Jamieson, then art teacher and now master’s art therapy candidate, approached me with their work in treating people with autism. They hoped to produce a more specific protocol to test what they were observing in the art lessons that Ms. Jamieson had been providing for one of their beloved patients. The scientist and artist were overwhelmed with the improved symptoms of the 13-year-old patient after individual lessons, and consistent qEEG mirrored these improvements. Through this case study, a glimpse was obtained of the positive outcomes of art lessons,

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and the results were traced from normative qEEG profiles, the comparison of which showed improvement in brain circuitry and coherence and an amelioration of the neuro-marker in autism. Concomitantly, episodes of the patient’s maladaptive behavior reduced to give way to a calmer, more socially cooperative individual. The qEEG study provided the empirical evidence of the improved functioning of the case study subject, paving the way for the development of a more specific research design. There are a variety of ethical considerations and limitations due to the subjective factors of therapy: the difficulty inherent in knowing when and how to measure a therapeutic intervention and the risks in involving individuals seeking services for potentially sensitive and difficult issues. With an impetus toward providing evidence-based best practice methods in mental health services, it is vital for art therapists to find ways to incorporate imaging or other neurological sampling in order to promote quantitative results that can be replicated in further and expanded studies. As the brain is constantly processing, regulating, receiving, and organizing information, it is important to consider the diversity of subtleties that can impact a study of brain activity. There is no way to completely isolate an experience from other stimuli since human subjects cannot turn on and off when they think, judge, experience, remember, and perceive experiences in their lives. Patients are an N=1; humans are emotional creatures where emotions and cognitions vacillate throughout the day. With this reality, it is difficult to control for subjective experience. It is important for the prospective art therapist researcher to consider such details. The contributors to this text have provided theoretical and practical applications of how they have integrated neuroscience in their work with patients who have trauma, applications which can be developed into formal research protocols that use methods to test their efficacy. Art therapy practitioners integrate neuroscience in many ways and with a natural synthesis. Those that work responsibly are sure to consult with the experts in the development of their theories of practice with a wide range of populations. For example, art therapist Nicole Willcox responded to a call for help from the community of the Sandy Hook Tragedy in Newton, CT. As founding director of Emerald Sketch, she consulted with art therapists Linda Chapman and Noah Hass-Cohen in the development of a psychoeducation and psychodynamic art therapy approach that helped participants understand the neurobiological impacts of mind-body trauma as they engaged in tasks that fostered individual and community healing. Professor Eileen Misluk, drawing from years of experience treating those with eating disorders, has sensitively combined art therapy theory with neuroscience research on Anorexia Nervosa and traumatic experiences that contribute to the disease, the ETC, and creativity in the development of the “Nourishment Hypothesis,” which is based in how hunger is conceptualized on a biological and hormonal level and how the process of art therapy can address these systems. At the 2015 conference of the American Art Therapy Association, Lauren Smith provided the membership with an in-depth fiber-based narrative art therapy intervention (F-NAT), presented from a theoretical neurobiological as well as

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sociocultural framework, that sought to identify the origins and outcomes of specific sociocultural phenomena where fiber and narrative are uniquely paired in the efforts to confront expansive political, cultural, and psychological traumas. These examples support the quintessential knowledge that art therapy is a brainbased profession and that the ways of conceptualizing treatment and research are as expansive and limitless as the mind itself (King, 2015). The resistance to quantifying aspects of psychotherapy, thus the therapeutic relationship, has not been uncommon in most theoretical approaches, an attitude that has been rapidly changing with the increasingly understood and utilized concepts of neuroplasticity. Developments in evidence-based practice (EBP) provide crucial approaches toward facilitating health and wellness but do not always capture the complexities involved in the therapist-patient exchange and the ongoing amelioration of symptoms. Doctoral psychology training that is rooted in existential and humanistic theory has significantly decreased in educational programs across the United States (Row & Stone, 2011) in favor of theoretical training that is proven to be effective with more empirically-based treatment. I (Juliet) see that we need both, in that cognitive strategies and medications are important in symptom management but often serve as floating devices of coping and do not address the deeper work of deciphering the personal meaning of one’s experiences. Discussing the potentials for art therapy program implementation, Dr. Marion Couch, Chair of the Department of Otolaryngology-Head and Neck surgery at Indiana University School of Medicine, said that “. . . unfortunately we can’t heal everyone with steel . . . we need more heart.” Dr. Couch was referring to her facial paralysis patients and the secondary depression, low selfesteem, and concerns of identity that often accompany these medical traumas. She was also alluding to healthcare in general, which runs the risk of what Cozolino (2010) refers to as the “medicalization of healing,” and rings of Edith Kramer’s legacy, “ever art” (Anand & Gerity, 2015). The lack of heart is becoming more concerning in a system where holistic treatment is compromised by time constraints and administrative and insurance-related duties that anesthetize the patient experience and are counterintuitive to why many practitioners enter the field in the first place. I often speak with my medically minded colleagues about the nonspecific therapeutic effect, which I understand in this context to be the relational component within a physician-patient dyad that has potential to affect not only the outcome of treatment, but also the ease with which doctor and patient experience a procedure or intervention. It seems perhaps some doctors perceive that they do not have the time to create such a nonspecific therapeutic effect, but it can be done through simple interpersonal awareness of self and other. It is possible that physicians might feel less anxious, more confident, and perhaps even less burned out if they knew that they were developing better outcomes through simple statements and nonverbal gestures that reflect empathy and kindness. Art therapists can help healthcare professionals understand their own experiences and those of others by providing empathy training to medical

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students, an example of how arts-based teaching and learning contributes to medical student education and research. Art therapists have responded to this subject in the past (Beers Miller, 2010; Potash, Chen, Lam, & Chau, 2014), a response which helps to address an otherwise untapped area of research and program development. Having an objective perspective of one’s own art-making and reflection in an educational forum makes it easier to see and understand one’s own behaviors and those of others. Such a perspective could be a useful teaching and training tool, in addition to providing a necessary stress relief and decompression for working physicians and healthcare practitioners that tend to be “on call” 24–7 and 365 in our current healthcare climate. In addition to this text as a resource for teaching the competency areas of neuroscience and trauma in the expanded educational guidelines set forth by the American Art Therapy Association, it also serves as a useful educational and supervision tool that can be used in many creative ways. For example, giving students a template of the ETC and the accompanying theories that outline visual information processing in this text is an interesting, practical, and informative way to apply clinical case information within a neuroscience framework as an interactive exercise. Exploring the role of the MNS and other neurobiological processes leads to important dialog for how to further conceptualize the components of the therapeutic relationship, the influence of materials in the relationship, and the potential benefits of therapist co-creation as the therapist makes art alongside patients in session. Neuroscience provides support for the inclusion of arts-based learning in the classroom, an additional dimension to this interpersonal understanding. Using an art-based pedagogical approach, Gerber et al. (2012) studied how the art is reminiscent of a life narrative that emerges and is reconstructed and co-created within the intersubjective space. The arts contribute to an understanding of how our early attachment experiences influence our understanding of relationships throughout life. This research provides a multitude of opportunities to apply neurobiological theories in our profession to understand how artwork represents the multiple levels of consciousness, memory, and perceptions, as well as, how these various components are processed and experienced by our students, clients, and ourselves. Consider a symphony orchestra performance; the Self can be thought of as the conductor and the musicians coming together in an effort to extract the best music from the best talents; whereas the ego is the orchestra’s manager who makes the humble but necessary decisions about bookings and tickets, hotels and transportation and meals. The manager is obviously not the music, and it would be catastrophic to confuse the manager’s role with that of the conductor, but without the manager’s services, the orchestra doesn’t play. Irene Gad, Jungian Analyst, in describing the concept of Self Humans become a culmination of their memories, but as the authors describe in this book, we do not need to be at the mercy of our life experiences. We have

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unlimited capacities to understand, express, evolve, and heal, based in the very nature of how we are built. It is my goal that the reading audience contemplates this work with a flexible authenticity, one that does not become too attached to certain ways of thinking, therefore allowing for an enlightened consideration that art therapy and neuroscience contribute to best practices for holistic and quality care. I invite you to contemplate that the conductor is the art therapist, the musicians are our patients, and neuroscience is the manager. Within this metaphor, we together create inspiring and universal reverberations of hope and transformation.

References Anand, S. A, & Gerity, L., (2015, July 10). Friday plenary: The Kramer legacy—A curious and inclusive artist’s world view. Conference Bridging cultural terrains: Expanding the lens of art therapy. Minneapolis, MN. Baydala, L., & Wikman, E. (2001). The efficacy of neurofeedback in the management of children with attention deficit/hyperactivity disorder. Paediatric Child Health, 6 (7), 451–455. Beers Miller, R. (2010). An art therapy in-service program model for medical students and residents. Journal of Allied Health, 39(2) 49–54. Belkofer, C. M. (2012). The impact of visual art-making on the brain. Unpublished doctoral dissertation. Lesley University. Cambridge, MA. Belkofer, C. M., & Konopka, L. M. (2008). Conducting art therapy research using qualitiative EEG measures. Art Therapy: Journal of the American Art Therapy Association, 25(2), 56–63. doi: 10.1080/07421656.2008.10129412 Belkofer, C. M., Van Hecke, A. V., & Konopka, L. M. (2014). Effects of drawing on alpha activity: A quantitative EEG study with implications for art therapy. Art Therapy: Journal of the American Art Therapy Association, 31(2), 61–68. Bremner, J. D. (2007). Neuroimaging in post-traumatic stress disorder and other stressrelated disorders. Neuroimaging Clinics of North America, 17(4), 523–38. doi: 10.1016/ j.nic.2007.07.003 Chapman, L. (2014). Neurobiologically informed trauma therapy with children and adolescents: Understanding the mechanisms of change. New York, NY: W.W. Norton. Chapman, L., Morabito, D., Ladakakos, C., Schreier, H., & Knudson, M. (2001). The effectiveness of art therapy interventions in reducing post-traumatic stress disorder (PTSD) symptoms in pediatric trauma patients. Art Therapy: Journal of the American Art Therapy Association, 18(2), 100–104. Cohen, B. & Cox, C. (1995). Telling without talking: Art as a window into the world of multiple personality. New York: WW Norton & Co. Collie, K., Backos, A., Malchiodi, C., & Spiegel, D. (2006). Art therapy for combat-related PTSD: Recommendations for research and practice. Art Therapy: Journal of the American Art Therapy Association, 23(4), 157–164. Cozolino, L. (2010). The Neuroscience of Psychotherapy. New York, NY: WW Norton. Deaver, S. P. (2011). What constitutes art therapy research? Art Therapy: Journal of the American Art Therapy Association, 19(1), 23–27. doi:10.1080/07421656.2002.10129721 Doidge, N. (2007). The brain that changes itself: Stories of personal triumph from the frontiers of brain science. New York, NY: Penguin Group.

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Fuchs, T., Birbaumer, N., Lutzenberger, W., Gruzelier, J. H., & Kaiser, J. (2003). Neurofeedback treatment for attention-deficit/hyperactivity disorder in children: A comparison with methylphenidate. Applied Psychophysiology and Biofeedback, 28(1), 1–12. Gad, I. (n.d.). Quotation. Retrieved from: www.jung.org/jungs%20model%20of%20 the%20psyche_gad.html Gerber, N. (1996). The brief art therapy screening evaluation (BATSE). Unpublished manual, Ph.D. program in Creative Arts Therapies, Drexel University, Philadelphia, PA. Gerber, N., Templeton, E., Chilton, G., Cohen Liebman, M., Manders, E., & Shim, M. (2012). Art-based research as a pedagogical approach to studying intersubjectvity in the creative arts therapies. Journal of Applied Arts and Health, 3(1), 39–48, doi: 10.1386/jaah.3.1.39_1 Harrington, G. S., Farias, D., & Davis, C. H. (2009). The neural basis for simulated drawing and the semantic implications. Cortex, 45(3). 386–393. doi: 10.1016/j.cortex.2007. 10.015 Harrington, G. S., Farias, D., Davis, C. H., & Buonocore, M. H. (2007). Comparison of the neural basis for imagined writing and drawing. Human Brain Mapping, 28(5), 450–459. Hass-Cohen, N. (2008). CREATE art therapy relational neuroscience principles (ATR-N). In N. Hass-Cohen & R. Carr (Eds.), Art therapy and clinical neuroscience (pp. 283–309). New York: Jessica Kingsley. Hass-Cohen, N., & Clyde Findlay, J. (2009). Pain, attachment, and meaning making: Report on an Art Therapy Relational Neuroscience assessment protocol (a case study). Arts in Psychotherapy, 36(4), 175–184. Hass-Cohen, N. & Clyde Findlay, J. (2015). Art therapy & the neuroscience of relationships, creativity, and resiliency. The Interpersonal Neurobiology Series. New York: W.W. Norton. Hull, A. M. (2002). Neuroimaging findings in post-traumatic stress disorder: Systematic review. The British Journal of Psychiatry, 181(2), 102–110. doi: 10.1192/bjp.181.2.102 Jung, C. G. (1963). Memories, dreams and reflections. New York: Random House. Kaplan, F. (2000). Art, science, and art therapy: Repainting the picture. London: Jessica Kingsley. King, J. (2015). Art therapy: A brain based profession, in D. Gussak and M. Rosal (Eds.), The Wiley Blackwell handbook of art therapy (pp. 77–89). Oxford, England: John Wiley. Kruk, K. A., Aravich, P. F., Deaver, S. P., & deBeus, R. (2014). Comparison of brain activity during drawing and clay sculpting: A preliminary qEEG study. Art Therapy: Journal of the American Art Therapy Association, 31(2), 52–60. doi:10.1080/07421656.2014. 903826 Lubar, J. F., Swartwood, M. O., Swartwood, J. N., & O’Donnell, P. H. (1995). Evaluation of the effectiveness of EEG neurofeedback training for ADHD in a clinical setting as measured by changes in T.O.V.A. scores, behavioural ratings, and WISCR performance. Biofeedback and Self-Regulation, 20(1), 83–99. doi: 10.1007/BF01712768 Lusebrink, V. B. (1990). Imagery and visual expression in therapy. Emotions, personality, and psychotherapy. New York: Plenum Press. Makuuchi, M., Kaminaga, T., & Sugishita, M. (2003). Both parietal lobes are involved in drawing: A functional MRI study and implications for constructional apraxia. Cognitive Brain Research, 16(3), 338–347. doi:10.1016/S0926-6410(02)00302-6

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Index

ABS (alternating bilateral stimulation) 186–188 ACC (anterior cingulate cortex) 28, 46, 115, 116 action potentials 11–12 adaptive responding, memory 107–109, 108, 116, 120–125, 129 ADHD (attention deficit hyperactivity disorder) 168, 217 Adler, Alfred 158–159 adopted children 139, 142–143, 145–149, 148, 152, 164–165 Adverse Childhood Experiences (ACE) study 68 Affective Level see Perceptual/Affective affect regulation 70, 78, 100, 121–122, 129, 144, 182 affect synchrony 144 Afghanistan war veterans 6–8 age, developmental vs chronological 146, 147, 152 agenesis 14 airplane crashes 125, 126 allostatic balance 107, 112, 114, 120–122 alpha-wave activity 14–15, 26, 201, 215, 216 alternating bilateral stimulation (ABS) 186–188 altruism 117, 126 American Art Therapy Association xiii, 2, 160, 218, 220 American Psychological Association 141 AMITS (art-mediated-interpersonaltouch-and-space) 119 amygdala (AMY) 24, 46, 48, 62, 63, 106, 109; emotional deregulation 42; memory 104, 105, 114, 120, 122, 125–126; neuroimaging 182 ancillary therapies 69

animals: as projection of self 57, 85, 92, 148, 150, 151, 153; relationships with 82 ANP (“apparently normal personality”) 72 anterior cingulate cortex (ACC) 28, 46, 115, 116 anxiety: brain processes 42, 117, 147, 157, 179; case studies 24–27, 25, 29–32, 57, 92, 168; comorbidity xii, 74, 157, 175; PTSD 71; treatment 142, 147, 179 “apparently normal personality” (ANP) 72 Arnheim, R. 164, 169 arousal state 24, 69, 73, 74, 95, 114, 118, 121, 125, 127, 145, 146, 157, 159, 169, 173, 174, 175, 178, 181, 213, 217; see also nervous system art-as-therapy 2 art-mediated-interpersonal-touch-andspace (AMITS) 119 art psychotherapy 2, 81, 128, 160 art therapy: central tenets 6; definition 2 art therapy relational approach (ATR-N): autobiographical memories 105, 123–125, 127; principles 101, 105, 107–109, 108, 128, 129; sensory-motor art 178–179 art therapy trauma protocol (ATTP) 181 asymmetry, brain 22–23, 70 ATR-N see art therapy relational neuroscience approach attachment: children 5, 139–141, 144–152, 213, 220; brain processes 70, 72, 142, 159, 175, 213; case study 83, 139–141, 144–145, 149, 151–153; complexity of 107, 144–145, 175; fostered children 149, 151; treatment concerns 118, 123, 124, 127, 142, 182, 212 attention deficit 168, 217

Index ATTP (art therapy trauma protocol) 181 attunement: mother-child 144; therapeutic 79, 163–164 autism 5, 13, 27, 110, 217–218 autobiographical memories: ETC 47; brain processes 109, 116; resiliency 101–106, 104, 129; timelines 123–125, 127–128; vs traumatic memories 103 avoidant personality disorder 74 axon 12, 15, 19, 21 babies see infants BAI (Beck Anxiety Inventory) 30 basal ganglia 11, 45, 48, 114, 115, 197, 198, 199 BATSE (Brief Art Therapy Screening Evaluation) 217 BDI (Beck Depression Inventory) 30 BDNF (brain derived growth factor) 13 Beck Anxiety Inventory (BAI) 30 Beck Depression Inventory (BDI) 30 behavioral-cognitive treatments 5, 121, 141, 149, 151, 176, 181 behavioral issues 15, 17, 25, 100, 106, 113, 143, 148, 153, 157, 162–163, 165–166, 168, 173, 195, 201, 217; see also regulation skills behaviors, neuroimaging 13–14, 17–18, 32, 33 Belkofer, C. 201, 213, 214 Berger, Dr. H. 17 big T trauma 184 bilateral processes 6, 174, 179–181; see also somatically-informed bilateral art therapy binaries, brain function 1 biochemical signals 13, 15, 18–19 biological perspectives 1, 4, 5–6; see also brain processes; neurobiology blood flow 18, 19, 158, 200 body, and trauma: neuroscience 158–161, 168–169; somatically-informed bilateral art therapy 174, 177–178, 184–190, 185–189 body image 184, 186–187 body language 110 BOLD-MRI 18 Bollas, C. 159 borderline personality disorder 74 bottom-up approaches 67–68, 182, 213; ETC 49, 53–57, 62, 63 Bowlby, J. 142 brain-based profession, art therapy 219

225

brain derived growth factor (BDNF) 13 brain development 5, 15–16, 33, 42, 141, 157; attachment issues 142–144, 146–147, 159; gender 23–24; right hemisphere 70 brain processes 1, 4–5, 11–13, 213–214; anxiety 157; and body 158–159; cellular communication 13–15; cognitive functioning 173; Eye Movement Desensitization and Reprocessing 179; gender 16, 23–24; imaging methods 16–22; lateralization 22–23; networks 11–12, 13–15, 19, 23, 25, 26, 33; neuroplasticity 6, 11, 13, 159, 214, 219; Parkinson’s disease 197–199, 201–202 brain structure 11–12; development 16; dual brain theory 71–72, 73, 74; imaging methods 17; memory 104; preverbal trauma 70; and relationships 159–160 brain wave activity 20, 201, 206, 214–215, 216, 217 Brief Art Therapy Screening Evaluation (BATSE) 217 Brief Symptom Inventory (BSI) 203–204, 204 broaden-and-build theory 116 Broca’s area 22, 73, 182 BSI (Brief Symptom Inventory) 203–204, 204 burdened, feeling of 80, 184–185, 185, 188–190 Cairns, R. B. 145 case studies 211–212; anxiety 24–27, 25, 30–32, 168; attachment issues 139–141, 144–152, 153; ETC 50–63, 51–55; imaging methods 24–29, 30–32; preverbal trauma 78–86, 86–91, 91–94; PTSD 6–8, 161–164, 169; somaticallyinformed bilateral art therapy 184–191 cellular communication 5, 13–15; function 11–13; learning 12–13 Chapman, L. 147, 149, 181 Chatterjee, A. 5 checking art work 124–125 childbirth 77–78, 79–80, 83–84, 86–91 childhood sexual abuse (CSA) 51, 80, 118, 164–168 children 139–142, 153, 157; attachment issues 5, 139–141, 144–152, 213, 220; brain development 5, 15–16, 33, 42, 141, 157; early childhood 5, 141, 142–147, 151–152, 173; ETC case study

226

Index

50–63; neuroscience research 142–152; prefrontal cortex 42; preverbal trauma 45, 67–69, 77–79, 85, 93–94, 173; PTSD case study 161–164, 169; rejection 148, 151–152, 157 chronic hyper-synchronization 15 chronic stress 32, 119–121, 120, 178 chronological age vs developmental age 146, 147, 152 chronologies, autobiographical memories 123–125, 127–128 clay, as art medium 119, 122, 147–152, 148, 150, 151, 164; ETC 50, 53–57; Parkinson’s disease 202–203, 205, 205–207 clients see therapist-client relationship clinical treatment 1, 11, 211 Clyde Findlay, J. 119–120 cognitive-behavioral treatments 5, 121, 141, 149, 151, 176, 181 cognitive evoked potentials 21–22, 25 cognitive functioning: early childhood 173; ETC case study 57–59, 58; Parkinson’s disease 195, 196, 200; restructuring 32–33, 57–59, 58 Cognitive/Symbolic: case studies 51–52, 57, 61–63; ETC approach 44, 46, 48, 161 collages, as art medium 50, 53, 54, 56, 60, 111 color: brain processes 45, 163, ETC case study 45, 57, 59, 59, 62; externalized dialog 76, visual art 7, 47, 81, 169–170, 206–207 communication, implicit 91, 101, 112, 114, 118, 122, 125, 159, 178 compassion, memory 107, 129 complex trauma symptoms (CTS) 100–101; autobiographical memories 101–105; creative embodiment 110; reconsolidation processing 105–107; relapse prevention 121, 125–128; therapist-client relationship 118, 119 computed tomography (CT) 17; SPECT 19 conscious states 14, 20, 47, 49, 57, 62, 72–73, 75, 76, 77, 145, 146, 173, 176–177 contextualization, memories 105–107 cortical activity 15, 19, 22, 23, 26, 46, 48, 69, 104, 108, 114, 115, 144, 147, 149, 152, 174, 216 Couch, Dr. M. 219 CREATE model 107–109, 108, 112, 128

creative embodiment, memory 107, 108, 110–113, 129 Creative (CR) level 44, 47, 57, 63 creativity xii, 4, 43, 47, 107, 113, 125, 201; ETC 43; and memory 101, 103–105; positive responses 6, 117, 212 CSA (childhood sexual abuse) 51, 80, 118, 164–168 C/Sy see Cognitive/Symbolic CT (computed tomography) 17; SPECT 19 CTS see complex trauma symptoms curiosity 101, 117, 119, 185 DA (dopamine) 19, 23, 114, 115; Parkinson’s disease 195, 197, 199, 200 Damasio, A. R. 45, 159 dance therapy 113, 142–143, 160, 164 dark colors 7–8 data: genetic mapping 32–33; imaging methods 16–22, 26; neuroplasticity 11; PTSD 7; quantitative EEG 19–21, 24–28, 26, 28, 201, 206, 214–215, 216–218; for research 212 DBS (deep brain stimulation) 200 decision-making 13–14 deep brain stimulation (DBS) 200 default mode network (DMN) 104, 115 definitions: art therapy 2; evidence-based practice 141; neuroscience 5 degenerative diseases xi, 15, 195, 216; see also Parkinson’s disease dementia xii, 216 dendrites 11–12, 22 depolarizing membrane potentials 12 depression xii, 74, 113, 158, 196, 200, 217, 219 brain processes 13, 18, 113, 157; case studies 7, 24–27, 25, 30–32, 52–62, 189–190, 205–207 Derogatis, L. R. 203–204 DES (Dissociative Experiences Scale) 82, 94 developmental age 146, 147, 152 diagnosis: foundation trauma 67, 74–75, 91–92, 94, 175; imaging methods 29–30; Parkinson’s disease 195, 197; PTSD 71; safe environments 110 Dietrich, A. 47, 48 diffusion tensor imaging (DTI) 19 dissociation 67, 71, 72, 73, 76, 83, 94, 117, 125, 173, 175, 178 Dissociative Experiences Scale (DES) 82, 94 Dissociative Regression Scale 82, 83, 95

Index distant communication, brain 14 DMN (default mode network) 104, 115 dopamine (DA) 19, 23, 114, 115; Parkinson’s disease 195, 197, 199 dopamine agonists 199 dopamine replacement therapy (DRT) 199, 200 dorsal vagal complex (DVC) 74, 110, 111, 112 Drama of the Gifted Child (Miller) 77 dreams 3–4, 57, 61 DRS (Dissociative Regression Scale) 82, 83, 95 DRT (dopamine replacement therapy) 199, 200 DTI (diffusion tensor imaging) 19 dual brain theory 71–72, 73, 74 DVC (dorsal vagal complex) 74, 110, 111, 112 dysregulation 6, 25, 27, 73, 93, 157, 173–174, 178, 197 early childhood 5, 141, 142–147, 151–152, 173 eating disorders 24–25, 184–185, 218 EBP (evidence-based practice) 141, 218, 219 ED (externalized dialog) 75–76, 84–91, 93 EEG (electroencephalogram) 14, 17, 19, 20–22, 26, 27, 201, 216; see also qEEG effective excitatory membrane potential (EPSP) 12 ego ideal 8 electrical activity mapping 21 electrical signals, brain 12, 13, 17 electrical source localization 20 electroencephalogram (EEG) 14, 17, 19, 21, 216; see also qEEG electrophysiological networks 11 embodied simulation theory 119 EMDR (Eye Movement Desensitization and Reprocessing) 174, 179, 180, 181, 182, 183, 185, 191 emotion: ETC 46, 50–63; nonverbal 149, 165; Parkinson’s disease 197; preverbal 78–79; safe environments 114–117; see also regulation skills emotional personality 72 empathy: ATR-N 107, 108; early childhood 146; medical students 219–220; memory 125–128, 129; mirror neurons 164 empowerment model 77–78 entrainment 163–164

227

environments: brain development 15, 16; memory resiliency 110–117 EP (emotional personality) 72 epilepsy xii, 15 EPSP (effective excitatory membrane potential) 12 ETC see Expressive Therapies Continuum evidence-based practice (EBP) 141, 216, 218, 219 Evoked Potentials 21–22, 25 evolution, humans 1, 70, 73 excitation 12, 53, 105, 109, 122–123 excitatory membrane potential (EPSP) synapses 12 experience, life 220–221 expressive communicating, memory 107, 108, 113–114 expressive therapies: ATR-N 129; children 146, 152–153; memory 93, 176; neuroscience 42–43, 142; Parkinson’s disease 202–203 Expressive Therapies Continuum (ETC) 4, 43–47, 44, 63; case studies 50–63, 51–55; functional systems 47–48; media choices 50, 53–56, 161; qEEG 216; use of 48–50, 220 externalized dialog (ED) 75–76, 84–91, 93 Eye Movement Desensitization and Reprocessing (EMDR) 174, 179, 180, 181, 182, 183, 185, 191 faces: attachment issues 141, 147, 149, 150–151, 152; brain processes 23 Fairbairn, W. R. D. 145 false results, mTBI 21 fatness 184 fiber-based narrative art therapy intervention (F-NAT) 218–219 fight/flight instincts 72, 73–74, 75, 122, 177–178; see also immobilizing response; instinctual trauma response (ITR) flow, ETC 50, 56, 61 fluid media 50, 60, 164 fMRIs (functional magnetic resonance imaging) 215 F-NAT (fiber-based narrative art therapy intervention) 218–219 Ford, J. 173 fostered children 51, 139, 142–143, 145, 147, 148, 148–149, 151–153, 164 foundation trauma 67, 74–75, 91–92, 94, 175 Fredrickson, B. L. 116

228

Index

freedom, feeling of 82, 189, 189–190 freeze reactions 72, 110, 111, 112, 123, 169, 177 Freud, Anna 2 Freud, Sigmund 3, 76, 158 frontal operculum 22 functional imaging techniques 18 functional magnetic resonance imaging (fMRIs) 215 Fuster, J. M. 44, 48 future, sense of 104, 123, 125, 127 Gad, I. 220 games in therapy 142, 146, 147, 165 Gantt, L. 71, 179; see also Intensive Trauma Therapy Inc. gender, brain processes 16, 23–24 Gerber, N. 220 Gestalt therapy process 75–76 gesture drawings 122 glial cells 15 GN (graphic narrative) 75, 83–84, 91, 179, 181 Goforth 26 graphic narrative (GN) 75, 83–84, 91, 179, 181 gray matter 11, 15, 16, 17, 21, 22 half-lives 19 handwriting 76 hard science 2 Harvey, S. 142 Hass-Cohen, N. 119–120, 163, 178–179, 213 head injuries 6–7, 14–15, 20–21, 27–29 healing, medicalization of 219 healthcare professionals 219–220 helplessness 24, 72, 169, 175, 177, 184, 185, 185, 190 hemispheres, brain: bilateral processes 180; case studies 31, 31; ETC 50; gender 24; memory 174; neuroscience 22–23, 201; preverbal trauma 69–70, 76–77, 93, 94; reward system 114–117; somatically-informed bilateral art therapy 176, 182; see also left brain; right brain Herman, J. 81, 83, 109, 175 hierarchy, brain 13–15 hippocampal memory 105, 114, 126; network 18, 26, 31, 42, 46, 63, 104, 120, 126; volume 16, 42 hippocampus 46, 104–105, 120, 126 historical perspectives 2, 67–68

holism theory 9, 43, 44, 70, 158–159, 200, 219, 221 homeostasis 6, 70, 116 hormones: brain development 23, 24; memory 106; trauma 120, 157, 158 Huang, M. 5 Hugo, V. 2 Huss, E. 53 hyperactivity 168, 217 hyperpolarizing membrane potentials 12 hyper-synchronization 15 hypervigilence 146 ice cream cone case study 161–164 identity: art therapy 201–202, 213; case study 81; trauma 7, 213, 219 idiosyncracy, therapy 118, 153 IES (Impact of Events Scale) 82, 95 illness: brain derived growth factor 13; degenerative diseases 15, 195, 216; see also Parkinson’s disease imagined entities 76 imaging methods 33, 214–215; brain processes 16–22; case studies 24–29, 30–32; genetic mapping 32–33; personcentered approach 29–32 immobilizing response 110, 111, 112, 123, 169, 177; see also fight/flight instincts; instinctual trauma response (ITR) Impact of Events Scale (IES) 82, 95 implicit communication 91, 101, 112, 114, 118, 122, 125, 159, 178 impulse control 168; see also regulation skills incest 80, 82 infants: attachment 144; childbirth 77–78, 79–80, 83–84, 86–91; see also early childhood inhibition, preverbal trauma 69, 72, 76–77 inhibitory membrane potential (IPSP) synapses 12 instinctual brain 70 instinctual trauma response (ITR) 72–74, 75 institutionalized children 139, 148–149 Intensive Trauma Therapy Inc.: case studies 78–86, 91–94; preverbal trauma 68–69, 74–76, 94–95; sensory-motor art 179 interdisciplinary research 5, 211–212, 216–217, 219–221 interpersonal neurobiology 70, 108, 159, 175 interpersonal relations see relationships

Index interpersonal space 112 IPSP (inhibitory membrane potential) 12 Iraq war veterans 6–8 ITR (Instinctual Trauma Response) 72–74, 75 ITT approach see Intensive Trauma Therapy Inc. Jernberg, A. 142 Johnson, D. R. 43, 141, 160 Jung, C. 3 “just notice” 183, 184 Karlsson, H. 42–43 Kinesthetic/Sensory: case studies 51–52, 56, 62–63, 167; ETC approach 44, 45, 48, 161; Parkinson’s disease 202–207 Kolodny, P. 181 Konopka, L. M. 201, 214, 216 Kramer, E. 219 Kruk, K. A. 201, 216 K/S see Kinesthetic/Sensory labor (childbirth) 77–78, 79–80, 83–84, 86–91 Lahad, M. 181 Lahad, S. 109 language: areas 22, 73, 182; barrier 7; development 144; see also verbal processing lateralization 22–23 Lear, J. 3 learning brain 173 left brain: art making 26, 47, 78, 174, 180–181, 190, 201, 206, 213–215; development 72–73, 93, 175; function 114, 127, 146, 176; impairment 25–26, 196; interpersonal relations 79, 94; verbal processing 22–23, 43, 70, 77, 146, 174, 176, 179, 183, 190 life experience 220–221 ligands 19, 26 light colors 7 Likert scales 203–204 limbic regulation 27, 70, 82, 148 limbic system: brain structure 70; fight/flight instincts 73–74; relationships with animals 82; reward system 114–117, 115 long term stress 32, 119–121, 120, 178 LORETA 20, 25, 26 Lusebrink, V. B. 4–5, 44, 161 lysosomal system 199

229

McHenry, B. 42–43 McHenry, J. 42–43 MacLean, P. 70 McNamee, C. 179, 180–181 “magical operations” 2 magnetic resonance imaging (MRI): brain development 16; case studies 27–29, 71; fMRIs 215; imaging methods 17–20, 21, 26 magnetoencephalography (MEG) 21–22 Malchiodi, C. 212 mastery, artistic expression 50, 56–57, 59, 61, 63, 101, 121–123, 125, 129, 179 maturation see brain development MBAT (mindfulness-based art therapy groups) 6–8 media choices: ETC 50, 53–56, 161; safe environments 111–112; sex abuse case study 164–168; visual art 163, 169 medicalization of healing 219 medication 3–4, 219; attachment issues 152; neuroimaging 18–19, 20, 21, 22; Parkinson’s disease 199–200 MEG (magnetoencephalography) 21–22 memory 100–101, 128; adaptive responding 121–125; art therapy relational neuroscience approach (ATR-N) 107–109; and attachment 145; autobiographical memories 101–105, 103; cellular learning 12; environments 110–117; ETC 47; Eye Movement Desensitization and Reprocessing 179, 180; neuroscience research 142; Parkinson’s disease 199; preverbal trauma 67–68, 69; PTSD 173–174, 178; reconsolidation processing 105–107; relapse prevention 125–128; relationships 117–121; somatically-informed bilateral art therapy 174, 176–177; trauma focused cognitive-behavioral therapy 141–142 mental shrapnel 69 mild traumatic brain index (mTBI) 20–21 Miller, Alice 77–78, 85, 94 mind 159–160; see also brain processes mindfulness 70, 101, 111, 174, 176, 182–183, 185, 190 mindfulness-based art therapy groups (MBAT) 6–8 mindfulness self-compassion (MSC) 126–127 Mind, Theory of (ToM) 101–102, 104, 109

230

Index

mirror neurons (MN) 113, 118–119, 127, 128, 164, 213, 220 Mirror Neuron System (MNS) 118, 128, 213 modalities, senses 12 mothers: as attachment figures 144–145; childbirth 77–78, 79–80, 83–84, 86–91 motion (studio environment) 112–113 motivation (reward system) 108, 109, 114–117, 115, 127, 128 motor expressions 45; see also Kinesthetic/Sensory motor symptoms, degenerative diseases 195–196, 196 MRI see magnetic resonance imaging MRI spectroscopy (MRS) 18–19 MSC (mindfulness self-compassion) 126–127 mTBI (mild traumatic brain index) 20–21 multisensory focus 176, 201 music 22, 113, 115, 119, 146, 160, 164, 215, 220–221 myelinated tracts 14, 19, 33 myelin sheath 68, 76–77 narratives: ETC 55, 55–56; externalized dialog 75–76, 84–91, 93; graphic narrative 75, 83–84, 91, 179, 181; memory 106–107; nonverbal 160; preverbal 69, 75–76; somaticallyinformed bilateral art therapy 178–179; trauma focused cognitive-behavioral therapy 141–142 negative responses 76, 84, 113–118, 122 neocortex 15, 70 neomammalian brain 70, 73; see also triune brain nervous system 5, 6, 13, 72, 73–74, 77, 110, 117, 120, 175, 178, 181, 183, 197; see also arousal state networks, brain 11–12, 13–15, 19, 23, 25, 26, 33; see also brain processes neural evolution 13 neuroaesthetics 4–5 neurobiology 5; art therapy relational neuroscience approach 101; attachment 144; the body 158; interpersonal 70, 108, 159, 175; nonverbal approaches 67; see also brain processes neuroception 177 neurodegenerative disorders 195, 199 neurodegenerative diseases see degenerative diseases neurofeedback 32, 174, 217

neurogenesis 6, 126 neuroimaging 1, 4, 33; amygdala 182; art making 214–215; brain processes 16–22; case studies 24–29, 30–32; genetic mapping 32–33; medication 18–19, 20, 21, 22; person-centered approach 29–32; PTSD 71, 174 neurons 1, 4, 6; brain development 15; brain processes 33; brain structure 11–12; mirror neurons 113, 118–119, 127, 128; Parkinson’s disease 197 neuropathways 144; see also brain processes neurophysiology xi, xiii, 4, 11, 21, 22, 25, 157, 158 neuroplasticity 6, 11, 13, 18, 24, 159, 214, 216, 219 neuroscience 4–5, 9; and art therapy 160, 212–213; children 142–152; expressive therapies 42–43, 142; sensory materials 201–202; vs cognitive behavioral treatments 141 neurosequential model of therapeutics (NMT) 109, 146–147, 148, 149 neurotransmitters 4, 120; brain development 16; brain structure 11, 13, 15, 23, 114; Parkinson’s disease 197, 206 nightmares 57, 58, 61–62 NMT (neurosequential model of therapeutics) 109, 146–147, 148, 149 nonspecific therapeutic effect xi, 219 nonverbal communication 6, 22, 67, 75, 76–77, 78, 84, 111, 146, 153, 159, 169, 174, 177, 179, 203, 213, 219 nonverbal emotions 26, 70, 149, 165 nonverbal memories 42–43, 52, 63, 69, 91, 93, 142, 178; see also preverbal trauma nonverbal narratives 160–161, 164–165 Nourishment Hypothesis 218 novel information 107, 125–126 nuclear: imaging 26, 27 medicine techniques 19 objects, relating to 161–164, 169 OEF/OIF veterans 6–8 OFC (orbital-frontal cortex) 46–47, 115, 116 OIF veterans 6–8 open mindedness 3 orbital-frontal cortex (OFC) 46–47, 115, 116 ordinary magic 2 organ maturation 15–16

Index P/A see Perceptual/Affective pain 27, 42, 68, 78, 116, 118, 122, 124, 127, 145, 152, 158, 162, 168, 175, 186, 188, 211 paleomammalian (limbic system) 70, 73–74; see also triune brain parents: adopted children 142, 149, 168; attachment 68, 145; case studies 80, 83, 149; empowerment model 78; see also mothers parietal lobe: ETC 44–49, 63; neuroimaging 214–215; sensory pathways 14, 73, 104, 216 Parkinson’s disease xii, 195–197, 196, 207; changes to brain 15, 197–199, 201–202; treatment xi, 199–200, 202–206 paroxysmal activity 25, 25, 31 participatory action research 211 pathways 144 PD see Parkinson’s disease Pearson, M. 161 peer support 32 Perceptual/Affective: case studies 56, 62–63; ETC approach 44, 45–46, 48, 161 Perry, B. 109, 144, 146–147, 148, 149, 159, 213 person centered therapy 29, 33 personality disorders 74, 118; case studies 25, 27 PET (positron emission tomography): 19; case studies 26–27, 28; Parkinson’s disease 197, 198 pets see animals PFC (prefrontal cortex): 104, 108, 115; amygdala hippocampal network 42, 63; bilateral processes 180; childhood 42; ETC 46–48 photographing art work 124–125 physical immobilization response 110, 111, 112, 123, 169, 177 physical violence, attachment case study 143, 144, 148 physiology xii, 4, 82, 202, 211 Pictures of a Childhood (Miller) 77 play therapy 56, 122, 142–143, 147, 148, 153, 177, 212 poisonous pedagogy 77–78 polarities, brain function 1 polyvagal system 73, 109, 110, 111, 114 Porges, S. 73, 110, 119, 177 positive responses: art therapy relational neuroscience approach 101, 105, 107;

231

bilateral processes 179, 181, 183, 190; children 142–143, 168; EEG 216, 217–218; Intensive Trauma Therapy Inc 85; Parkinson’s disease 202, 206; PTSD 7; reward system 114–117, 115, 127, 128; safe environments 110–119, 122–123 positron emission tomography (PET) 19; case studies 26–27, 28; Parkinson’s disease 197, 198 post-traumatic growth (PTG) 43, 50, 56, 63, 100, 105, 119–122, 125, 126 post-traumatic stress disorder see PTSD powerlessness 165, 175, 183 power struggles 165 prefrontal cortex (PFC): 104, 108, 115; amygdala hippocampal network 42, 63; bilateral processes 180; childhood 42; ETC 46–48 pregnancy case study 189 pre-post assessments 203, 204 preverbal trauma 5, 67; brain structure 70; case studies 78–86, 86–91, 91–94; children 146–147; dual brain theory 71–72, 74; empowerment model 77–81; historical perspectives 67–68; inhibition of 69, 72, 76–77; Instinctual Trauma Response 72–74; Intensive Trauma Therapy Inc 68–69, 74–76, 94–95; PTSD 71; role of right brain 71–72, 144, 146, 174, 176, 190 proteasomal system 199 psychiatry xi, 3, 5, 17–18 psychoanalysis 4, 78, 176, 213 psychobiology 5 psychological symptoms, degenerative diseases xi–xiii, 196–197 psychology 2, 219 psychopathology 44, 45 PTG (post-traumatic growth) 43, 50, 56, 63, 100, 105, 119–122, 125, 126 PTSD (post-traumatic stress disorder): autobiographical memories 102; brain processes 16, 17, 43; case studies 6–8, 161–164, 169; memory 173–174, 178; nonverbal emotions 169; preverbal trauma 70–71; relational resonating 117–118 publicity, imaging methods 18 puppets, as projection of self 76, 85, 92 qEEG (quantitative electroencephalography) 214–215, 216, 217–218

232

Index

qEEG (quantitative electroencephalogram) 19–20, 21, 24, 25, 201, 206; case studies 26, 26–27, 28 quadrune mind 73 qualitative data 212 quantitative EEG see qEEG radioactivity, ligands 19 Rankin, A. B. 179 reconsolidation processing 100, 105–107, 109, 119, 122–126, 128, 129; see also memory regulation skills: and body 157, 161, 169; children 143, 144, 146, 148, 151, 168; limbic 82; memory 100, 117, 121–122, 129; neuroscience 25–27, 31, 31–32, 42, 46, 70; nonverbal 6, 176; PTSD 173–174 rejection 62, 69, 79, 146, 148, 151–152, 157 relapse, memory resiliency 125–128, 129 relational resonating, memory 107, 108, 117–121, 129 relationships 3, 8; autobiographical timelines 123; and brain structure 159–160; children 5, 142, 146, 147–148, 149, 152–153; memory resiliency 117–121; neurobiology 175; therapistclient 8, 110–121, 119, 163–164, 213; see also art therapy relational neuroscience approach (ATR-N) relaxation strategies 112, 121, 122, 124, 151, 180, 202, 216 remembrance 81, 101, 109, 121–125; see also memory REM sleep 180 reptilian (instinctual brain) 70, 73, 75 resiliency, memory processing 100, 105–107 resistive media 50, 53–56, 164 reward system 108, 109, 114–117, 115, 127, 128 right brain: art making 47, 50, 77, 78, 201, 215–216; bilateral processes 22, 43, 70, 180; development 42, 70, 76; function 23, 48, 70; impairment 27, 31; integration 43, 69, 74, 91; preverbal memory 71–72, 144, 146, 174, 176, 190; Schore, Allan 70, 72, 73, 74, 78; sensory-motor art 179 risk factors, social 118 Rothschild, B. 178 “Royal Road” 3 Rubin, J. 211

Sacks, O. 3 safe environments 110–117, 177 Sagan, C. 213 Sarid, O. 53 Scaer, R. 68, 75, 178 Schore, A. 213; attachment issues 144; neuroscience research 142; right brain 70, 72, 73, 74, 78 Schulkin, J. 121 Schwartz, R. 76 science 2–3 SCL-45 (Symptom Check List 45) 82, 95 sculpture, attachment case study 148, 149, 150–151, 152, 153 secure environments 110–117, 177 secure remembrance model (SR-5) 107–109, 129 self-compassion 126–127 self-portraits 124, 139–141, 140 self-regulation see regulation skills self-state 79, 81, 85, 93 sense of self: autobiographical memories 101–105; mirror neurons 119; positive responses 117; self-state 79, 81, 85, 93 Sensory level see Kinesthetic/Sensory sensory materials: ETC 50; meaning of 170; neuroscience 201–202; visual art 161–164, 169–170 sensory modalities 12 sensory-motor art 147, 174, 178–179; Parkinson’s disease 202–206, 205, 205–207 sensory pathways 13–14 sex abuse, children 51, 80, 118, 164–168 Shapiro, F. 179 short distance communication, brain 14 short term stress 27, 119–121, 120 side effects of medication 200 Siegel, D. 213; brain hemispheres 70, 94; relationships 159, 163, 175; unresolved trauma 177 Sikorski, A. 42–43 single photon computed tomography (SPECT) 19 sleep 3–4, 14, 24, 57, 61, 158, 178, 180, 196 sleep specialists 3–4 small t trauma 184, 190 smearing, art work 81 social risk factors 118 social self 102, 128; see also relationships soft science 2 Solso, R. L. 215 soma 12

Index somatically-informed bilateral art therapy 174–175, 179–183, 190–191; body 177–178; case studies 184–191; Eye Movement Desensitization and Reprocessing (EMDR) 179; memory 173, 174, 176–177; narratives 178–179; stress 175–176; trauma treatment 176, 177–178 somatosensory system 23, 44, 70 spatial summation 12 SPECT (single photon computed tomography) 19 “speechless terror” 175 split-brain patients 23 SR-5 model 107–109, 129 statistics see data stealing 168 stories see narratives stress: brain development 16; excitation 123; memory processing 106; peers 32; short and long term 119–121, 120; somatically-informed bilateral art therapy 175–176 structural dissociation 72 structure see brain structure studio environment 9, 110–113, 165–167 suicide 24, 27–29, 30, 60, 62, 158 supportive mirroring 113, 127 survival brain 110, 173; see also fight/flight instincts Symbolic level see Cognitive/Symbolic symptomatic therapies, Parkinson’s disease 199 Symptom Check List 45 (SCL-45) 82, 95 symptom management 3, 219; eating disorders case study 184, 190; foundation trauma 74; historical perspectives 67–69; neuroimaging 18, 19; Parkinson’s disease 195–197, 199–200, 202–203, 205–207; personcentered approach 29–30; PTSD 7, 158, 173, 175, 178; see also complex trauma symptoms (CTS) synaptic plasticity 13; see also neuroplasticity synchronization, brain networks 14, 144, 215 tactile aspects, artwork 110, 111, 114, 119, 125, 195, 202, 203, 205, 206, 207 Talwar, S. 181 TAS (Toronto Alexithymia Scale) 82, 94, 95

233

Taucher, L. C. 179 TBI (traumatic brain injury) 6–8, 14–15, 20–21 teaching 6, 47, 56, 82, 84, 220 temporal lobe 25, 31, 45, 73, 214 TF-CBT (trauma focused cognitivebehavioral therapy) 122, 141–142 Thatcher, R. 20–21 Theory of Mind (ToM) 101–102, 104, 109 therapeutic attunement 79, 163–164 therapeutic practice, interdisciplinary research 2–3, 211–212, 216–217, 219–221 therapist-client relationship 110–121; children 142–143, 146, 149, 153; evidence-based practice 219, 220; importance of 8, 213; safe environments: therapeutic attunement 163–164 Theraplay 142, 143 timelines, autobiographical memories 123–125, 127–128 Tinnin, L. W. 71, 77, 179; see also Intensive Trauma Therapy Inc. Tobin, B. 181 ToM (Theory of Mind) 101–102, 104, 109 top-down approaches: ETC 46, 49, 57–62, 63; preverbal trauma 67–68; trauma treatment 182 Toronto Alexithymia Scale (TAS) 82, 94, 95 transformative integrating, memory 107, 108, 128, 129 Trauma and Recovery (Herman) 81 Trauma Informed Therapy and Trauma Informed Expressive Arts Therapy 212 trauma focused cognitive-behavioral therapy (TF-CBT) 122, 141–142 trauma profiles 82–83, 94–95 Trauma Recovery Scale (TRS) 95 traumatic brain injury (TBI) 6–8, 14–15, 20–21 traumatology 1; memory 100, 101, 107, 109, 126 Tripp, T. 181 triune brain 70, 73 TRS (Trauma Recovery Scale) 95 t trauma 184, 190 unconscious states 3–4, 13, 139, 140, 145, 158, 174, 176, 177, 190

234

Index

universality 8, 50, 72, 75, 128, 221 unmyelinated tracts 14 unresolved trauma 67, 80, 175, 177, 181, 190; see also preverbal trauma “unthought known” 159 vagal complex 73–74; dorsal 110, 111, 112 vagal tone response 110 validation: art therapy profession 33, 217; in therapy 80, 118, 168 van der Kolk, B. 76, 145, 159, 169, 175, 176, 177, 213 ventral vagal complex (VVC) 73, 110, 111, 112 ventromedial prefrontal cortex (VMPFC) 47, 48, 63 verbal processing 6; Brief Symptom Inventory 204–205; case study 7; expressive therapies 42–43; inhibiting preverbal trauma 69, 72, 76–77; left brain 146, 174, 176, 179, 183, 190; quadrune mind 73; trauma focused cognitive-behavioral therapy 141–142 veterans 6–8, 117, 121

violence, attachment case study 143, 144, 148 visual art 161–164, 169–170 visual expression 201; ETC 44, 45–47, 48–49 VMPFC (ventromedial prefrontal cortex) 47, 48, 63 volcanoes case study 161–164, 169 volume, brain 16, 17, 19, 42 VVC (ventral vagal complex) 73, 110, 111, 112 war veterans 6–8, 117, 121 weight gain 184, 189 white matter 11, 16, 17, 21, 22 Wilson, H. 161 wordless event, trauma 6; see also preverbal trauma x-rays 17 Yalom, I. 8 yoga 146, 162, 174; strategies 122 Zeki, Semir 4