Brief Cognitive Behavioral Art Therapy For Anxiety Disorders

146 Pages·2015·25.82 MB·English

by  Frances Johanna Morris

Florida State University Libraries
Electronic Theses, Treatises and Dissertations The Graduate School
2013
Brief Cognitive Behavioral Art Therapy for
Anxiety Disorders
Frances Morris
Follow this and additional works at the FSU Digital Library. For more information, please contact [email protected]
THE FLORIDA STATE UNIVERSITY
COLLEGE OF VISUAL ARTS, THEATRE, AND DANCE

BRIEF COGNITIVE BEHAVIORAL ART THERAPY FOR ANXIETY DISORDERS

By
FRANCES MORRIS

A Thesis submitted to the
Department of Art Education
in partial fulfillment of the
requirements for the degree of
Master of Science

Degree Awarded:
Summer Semester, 2013
Frances Morris defended this thesis on June 20, 2013.
The members of the supervisory committee were:

Marcia Rosal
Professor Directing Thesis

David Gussak
Committee Member

Tom Anderson
Committee Member

The Graduate School has verified and approved the above-named committee members, and
certifies that the thesis has been approved in accordance with university requirements.

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TABLE OF CONTENTS
List of Tables .................................................................................................................................. iv
List of Figures .................................................................................................................................. v
Abstract .......................................................................................................................................... vii
INTRODUCTION ........................................................................................................................... 1
LITERATURE REVIEW .............................................................................................................. 10
METHODS AND PROCEDURES ............................................................................................... 34
RESULTS ...................................................................................................................................... 47
DISCUSSION ................................................................................................................................ 97
APPENDICES ............................................................................................................................. 117
A. COGNITIVE BEHAVIORAL ART THERAPY FOR PANIC DISORDER WITH
AGORAPHOBIA MANUAL .............................................................................................. 117
B. COGNITIVE BEHAVIORAL THERPAY FOR GENERALIZED ANXIETY DISORDER
MANUAL ............................................................................................................................ 123
C. INFORMED CONSENT FORM ......................................................................................... 129
D. IRB APPROVAL LETTER ................................................................................................. 131
REFERENCES ............................................................................................................................ 133
BIOGRAPHICAL SKETCH ....................................................................................................... 137

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LIST OF TABLES
Table 1- Research Design in Case 1 and Case 2 ........................................................................... 35
Table 2- Brief Cognitive Behavioral Art Therapy Course of Treatment for PDA, GAD ............. 42
Table 3- Severity of Panic Attack Features (Scale 0-4) ............................................................... 49
Table 4- Proportion of Days with Agoraphobic Avoidance .......................................................... 53

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LIST OF FIGURES
Figure 1. Case 1 number of panic attacks per week ...................................................................... 48
Figure 2. Case 1 ratings of panic expectancy ................................................................................ 50
Figure 3. Case 1 ratings of expected aversiveness ........................................................................ 51
Figure 4. Case 1 ratings of maximum fear of panic ...................................................................... 52
Figure 5. Case 1 ratings of inconvenience due to agoraphobic avoidance .................................... 53
Figure 6. Case 1 ratings of agoraphobic anxiety ........................................................................... 54
Figure 7. Case 1 ratings of general anxiety ................................................................................... 55
Figure 8. Case 1 ratings of general feelings of goodness .............................................................. 56
Figure 9. Case 2 ratings of general anxiety ................................................................................... 57
Figure 10. Case 2 ratings of general feelings of goodness ............................................................ 58
Figure 11. Case 1, session 1 panic brainstorm .............................................................................. 60
Figure 12. Case 1, session 1 panic cycle ....................................................................................... 61
Figure 13. Case 1, session 2 watercolor breathing technique ........................................................ 62
Figure 14. Case 1, session 2 safe place painting ........................................................................... 63
Figure 15. Case 1, session 3 “unlikely” cognition drawing .......................................................... 64
Figure 16. Case 1, session 4 scribbled drawing ............................................................................. 65
Figure 17. Case 1, session 4 mandala ............................................................................................ 66
Figure 18. Case 1, session 4 shoeprint painting ............................................................................ 67
Figure 19. Case 1, session 5 least-feared desensitization image ................................................... 69
Figure 20. Case 2, session 1 anxiety brainstorm ........................................................................... 72
Figure 21. Case 2, session 1 anxiety cycle .................................................................................... 73
Figure 22. Mandala 1 ..................................................................................................................... 75
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Figure 23. Mandala 2 ..................................................................................................................... 76
Figure 24. Case 2, session 2 support system drawing ................................................................... 78
Figure 25. Case 2, session 2 support systems chart ....................................................................... 78
Figure 26. Case 2, session 3 “unlikely” cognition drawing .......................................................... 80
Figure 27. Mandala 3 ..................................................................................................................... 81
Figure 28. Case 2, session 3 restructured cognition painting ........................................................ 82
Figure 29. Case 2, session 4 watercolor breathing technique ........................................................ 83
Figure 30. Mandala 4 ..................................................................................................................... 84
Figure 31. Mandala 5 ..................................................................................................................... 85
Figure 32. Case 2, session 5 least-feared desensitization image ................................................... 86
Figure 33. Mandala 5 ..................................................................................................................... 88
Figure 34. Case 2, session 5 moderately-feared desensitization image ......................................... 89
Figure 35. Case 2, session 6 least-feared mastery image .............................................................. 90
Figure 36. Case 2, session 6 most-feared desensitization image ................................................... 92
Figure 37. Case 2, session 7 bridge drawing ................................................................................. 94
Figure 38. Cross-comparison of case 1 and case 2 general anxiety ............................................ 101
Figure 39. Cross-comparison of case 1 and case 2 general feelings of goodness ....................... 102

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ABSTRACT
Using a single subject research design, two university students, one with Panic Disorder with
Agoraphobia (PDA) and one with Generalized Anxiety Disorder (GAD), received seven
individual, one-hour sessions incorporating art therapy components into a model of brief
cognitive behavioral therapy for anxiety and panic. Sessions in the GAD case were conducted
through Internet video chats. Foci of therapy included: psychoeducation, identification and
development of support systems, breathing retraining, cognitive restructuring, interoceptive
exposure, in vivo exposure, and relapse prevention. Outcomes on symptoms of both disorders
were measured using daily self-report ratings completed by both participants. Panic frequency
and some features of fear of fear (panic expectancy and expected aversiveness) and agoraphobia
(amount of avoidance) were significantly reduced in Case 1 with PDA. Reductions in other
measures of fear of fear (maximum fear of panic) and agoraphobia (agoraphobic anxiety) were
marginally significant in Case 1 as was reduction in general anxiety in Case 2 with GAD. There
was no significant change in general anxiety in Case 1 or general feelings of goodness in either
case.
Keywords: cognitive behavioral art therapy, panic disorder, generalized anxiety disorder
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CHAPTER ONE
INTRODUCTION
Anxiety disorders, including Panic Disorder with Agoraphobia (PDA) and Generalized
Anxiety Disorder (GAD), are relatively common and often have an onset in early adulthood.
Therefore, the period of change and upheaval experienced by most college students can interact
with biological and psychological traits to result in the development in these disorders. PDA is a
psychological disorder involving catastrophic interpretations of physiological cues and the
phobic avoidance of situations perceived as inescapable (Craske & Barlowe, 2000). GAD is
characterized by excessive and persistent worry over an extended period of time (APA, 2000).
Cognitive Behavioral Therapy (CBT) is the preferred intervention for PDA and GAD;
however, traditional CBT often requires 14 or even 21 weeks of sessions and may be difficult for
clients to afford or access if they do not live near a metropolitan area (Marchand, Todorov,
Borgeat, & Pelland, 2007). Furthermore, many of the activities involved in CBT, including
cognitive restructuring and/or the development of anxiety and panic-provoking stimuli
hierarchies, may be difficult for certain clients with lower verbal communication skills. CBT
may also require more visual components for imaginal desensitization to avoided imagery and
situations. Therefore, a brief CBT program including Internet video sessions and art therapy
components could be a viable alternative to traditional CBT for college students with PDA and
GAD.
This research report will discuss the problem investigated, providing a purpose,
justification, and definition of terms for the study. Relevant theoretical literature and related
studies will be reviewed. The hypotheses, research design, sample, instruments, and procedures
will be detailed, followed by a discussion of internal and external validity with respect to the
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study and methods of data analysis. The report will also include a discussion of quantitative and
qualitative results as well as limitations and implications of the study.
Problem Investigated
The following single-subject case studies focused on the problem of providing an
effective treatment for PDA and GAD. CBT has been found effective in treating these relatively
prevalent disorders, and the condensation of sessions and addition of art therapy components to
enhance CBT treatment goals may increase convenience and comprehensibility to a larger client
base.
Purpose of the Study
The purpose of this study is to determine whether a brief intervention incorporating art
therapy and/or Internet video sessions into traditional cognitive behavioral processes and an
accompanying manual (see Appendices A, B) for clients can significantly reduce the symptoms
of PDA (i.e. panic attacks, anxiety concerning future panic attacks, and agoraphobic avoidance)
and GAD (i.e. general anxiety). This brief seven-session intervention is a condensation of a
traditional cognitive behavioral intervention developed by Craske and Barlowe (2000) that
included 14 sessions addressing anxiety and panic and seven sessions addressing agoraphobia.
Although Marchand et al. (2007) effectively utilized a condensed seven-session form of Craske
and Barlowe’s (2000) model, this study represents the first attempt to incorporate art therapy and
Internet video sessions into its various cognitive behavioral interventions. The manual included
original as well as modified portions of Craske and Barlowe’s (2000) manual. As discussed
below in the justification, the art therapy components and Internet video sessions are intended to
enhance the cognitive behavioral therapeutic components as well as make the intervention more
accessible.
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