Constructing a Personal Visual Vocabulary

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Electronic Theses, Treatises and Dissertations The Graduate School

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Constructing a Personal Visual Vocabulary:An Art Therapy Intervention Study forAdolescents from Families with AlcoholUse DisordersAlexandria Wyeth Zettler

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FLORIDA STATE UNIVERSITY

COLLEGE OF VISUAL ARTS, THEATRE, & DANCE

CONSTRUCTING A PERSONAL VISUAL VOCABULARY:

AN ART THERAPY INTERVENTION STUDY FOR ADOLESCENTS FROM FAMILIES

WITH ALCOHOL USE DISORDERS

By

ALEXANDRIA WYETH ZETTLER

A Dissertation submitted to the

Department of Art Education

in partial fulfillment of the

requirements for the degree of

Doctor of Philosophy

Degree Awarded:

Spring Semester, 2014

ii

Alexandria Wyeth Zettler defended this dissertation on March 19, 2014.

The members of the supervisory committee were:

Marcia L. Rosal

Professor Directing Dissertation

Lisa Waxman

University Representative

David Gussak

Committee Member

Tom Anderson

Committee Member

The Graduate School has verified and approved the above-named committee members, and

certifies that the dissertation has been approved in accordance with university requirements.

iii

This study is dedicated to my daughters, Tessa Marie and Anna Louise; and my husband,

Christian Leonhardt, whom I simply could not be without.

iv

ACKNOWLEDGMENTS

I want to express my appreciation to the people who have assisted me in the development and

completion of this study:

Marcia Rosal, chairperson of this doctoral committee, whose logic, scholarly

reviews of this study, and expertise of cognitive processes and personal symbols

have been invaluable in guiding me to its completion;

Dave Gussak, committee member, for his passion for philosophy;

Tom Anderson, committee member, for his wealth of knowledge and critical eye;

Lisa Waxman, university representative, for her professionalism and kindness;

Peter Zettler, my father, who taught me to communicate through the language of

art;

Elizabeth Zettler, my mother, who modeled tenacity and excellence in teaching;

Katie, Nicole, Anthony, Brook, and CJ, my former high-school art students,

whose talents are boundless; and all the children and school personnel who made

this study a reality, especially Paige Thomas, for her extraordinary diligence and

support.

v

TABLE OF CONTENTS

LIST OF TABLES ........................................................................................................................ vii

LIST OF FIQURES ..................................................................................................................... viii

ABSTRACT ................................................................................................................................... xi

CHAPTER ONE: CONSTRUCTING A PERSONAL VISUAL VOCABULARY .......................1

Philosophical Underpinnings of Therapeutic Methods ...........................................................2

Hegelian Dialectics ..................................................................................................................3

Chaos and Adverse Childhood Experiences ............................................................................5

Research Problem ....................................................................................................................6

A Brief Overview of the Study ..............................................................................................11

Summary ................................................................................................................................12

CHAPTER TWO: REVIEW OF THE LITERATURE .................................................................14

Children of Alcoholics ..........................................................................................................14

Theories of Alcohol-Related Disorders .................................................................................16

Family Systems Theory: Roles and Rules .............................................................................17

Interrelated Issues of Alcohol, Aggression, Violence, and Abuse ........................................18

Primary Prevention Models: Significant Components ..........................................................20

The Motivation for Change ...................................................................................................22

Cognitive Behavioral Therapy and Adolescents ...................................................................24

Art Therapy and Visual Language ........................................................................................25

Context and Visual Language ...............................................................................................26

Visual Dynamics and Personal Constructs ............................................................................28

Summary ................................................................................................................................31

CHAPTER THREE: METHODS ..................................................................................................32

Research Design ....................................................................................................................32

Sample ...................................................................................................................................33

Setting ....................................................................................................................................34

Procedures .............................................................................................................................34

Assessment Tools and Instruments .......................................................................................38

Data Collection and Evaluation Procedures ..........................................................................42

Summary ................................................................................................................................44

CHAPTER FOUR: RESULTS ......................................................................................................46

Description of the Sample .....................................................................................................47

Quantitative Results ...............................................................................................................48

Summary of Quantitative Results ..........................................................................................53

Qualitative Results .................................................................................................................56

Summary of Qualitative Results ............................................................................................66

CHAPTER FIVE: DISCUSSION AND CONCLUSION .............................................................67

Discussion ..............................................................................................................................67

Limitations .............................................................................................................................73

Clinical Implications and Suggestions for Further Research ................................................75

Conclusion .............................................................................................................................76

APPENDICES...........................................................................................................................................80

A: List Of Acronyms .............................................................................................................80

vi

B: Intake Form .......................................................................................................................81

C: Correlating Data for Tennessee Self Concept Scale, Second Edition (TSCS:2) and the

Piers-Harris Children's Self-Concept Scales, Second Edition (PH:2) ...............................82

D: Collected Demographics and Scores for All Participants ................................................86

E: Depression Scales From the FEATS .................................................................................88

F: Scoring Sheets for Qualified Sample's and Matched Sample's Artwork Using the

Depression Scales from the FEATS ..................................................................................91

G: Model and Explanation of the Expressive Therapies Continuum ....................................94

H: Analytical Art Criticism Model ........................................................................................95

I: End Of Study Objective/Criteria Assessment Questionnaire ............................................98

J: SASS Output of Paired T-Tests Scores for Qualified Sample...........................................99

K: TSCS:2/PH:2 Output, Self Statements, and Artwork .....................................................114

L: Florida State University Internal Review Board Approval and Consent Forms.............135

M: Copyright Permission Letters ........................................................................................141

REFERENCES ............................................................................................................................145

BIOGRAPHICAL SKETCH .......................................................................................................154

vii

LIST OF TABLES

Table 1. Randomized Pretest-Midtest-Posttest Experimental Study Design with One Control

Group. ........................................................................................................................................... 33

Table 2. Assessment Schedule with Total Collected Data/Scores for Three Group Participants,

Over All Three Observation Periods ............................................................................................ 35

Table 3. Art Therapy Study Directives for the Two Experimental Interventions, X1 And X

2 ...... 37

Table 4. Self-reported Data on Qualifying Status and Demographics. ....................................... 47

Table 5. TOT Scores, Means Percentage of Change after Each Intervention for the Qualified

Participants and the Control Group ............................................................................................. 50

Table 6: TOT Scores, Means, Standard Deviation, and Rate of Increase for all Participants ... 55

Table 7. Qualified Sample and Matched Sample’s Supplementary Scores Mean Increase ......... 60

Table 8: Mean Scores for Qualified Sample and Matched Sample's End of Study

Objective/Criteria Assessment Questionnaire .............................................................................. 65

Table 9. List of Frequently Used Acronyms ................................................................................. 80

Table 10. Correlation of the TSCS:2 Scores with the PH:2 from the TSCS:2 Manual ............... 82

Table 11. Correlation Table between the PH:2 And TSCS:2 from the PH:2 Manual ................. 83

Table 12. Corresponding Subtests and Correlations Used for TSCS:2 and PH:2 at O1 ............. 84

Table 13. Concatenate Table from PH:2 and TSCS:2 for TOT Scores at O1 .............................. 85

Table 14. Collected data from all participants ............................................................................ 86

Table 15. Scoring Sheets for the Qualified and Matched Samples' Artwork Using the Depression

Scales from the FEATS ................................................................................................................. 91

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LIST OF FIGURES

Figure 1. T-test statistics output for TOT of qualified sample from O1 to post-X

1. .................... 49

Figure 2. T-test statistics output for TOT of qualified sample from O1 to post-X

2. .................... 49

Figure 3. Distribution of difference for qualified sample from O1 to post-X

1. ............................ 49

Figure 4. Distribution of difference of qualified sample from O1 to post-X

2 .............................. 49

Figure 5. Paired profiles for qualified sample from O1 to post-X

1. ............................................. 49

Figure 6. Paired profiles of qualified sample from O1 to post-X

2. ............................................... 49

Figure 7. T-test results for the control group. .............................................................................. 51

Figure 8. Distribution of difference for the control group. .......................................................... 51

Figure 9. Line of projection for the control group. ...................................................................... 51

Figure 10. T-test statistics output for tot of experimental groups from O1 to post-X

1. ................ 54

Figure 11. T-test statistics output for tot of experimental groups from O1 to post-X

2. ................ 54

Figure 12. Distribution of difference for experimental groups from O1 to post-X

1..................... 54

Figure 13. Distribution of difference for experimental groups from O1 to post-X

2..................... 54


1.............................................. 54


2.............................................. 54

Figure 16. Comparison of group TOT score means at observations O1, O

2, and O

3. .................. 55

Figure 17. FEATS depression scale ratings at O2 and O

3. ........................................................... 57

Figure 18. Cluster of simple means for FEATS major depression score scales. ......................... 57

Figure 19. Comparison of sample means for a specific outlier scale score on the directive

entitled, The Element of Line. ...................................................................................................... 58

Figure 20. Artwork from the qualified sample and the matched sample showing little color and

level of completion. ...................................................................................................................... 59

Figure 21. Qualified sample’s percentage of change in TSCS:2 supplementary mean scores related to Beck’s theory of internal communication system. ........................................................ 60

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Figure 22. Sample of artwork completed by nonqualified participants from the experimental

groups. ........................................................................................................................................... 63

Figure 23. Qualified samples' self-report on the intervention rating scale. ................................. 65

Figure 24. Initial intake form used to determine qualification for the study and for calculating

demographics. ............................................................................................................................... 81

Figure 25. Depression Scales, a portion of the Formal Expressive Arts Therapies Scales by

Linda Gantt (1998). ....................................................................................................................... 88

Figure 26. Symbolic content and schematic representation of the Expressive Therapies

Continuum (ETC) by Vija Lusebrink (1990)................................................................................ 94

Figure 27. Analytic Art Criticism Method (formally known as Anderson's CritCard Method)

from Anderson and Milbrandt (2005). .......................................................................................... 95

Figure 28: Example of the end of study objective/criteria assessment questionnaire. ................ 98

Figure 29. Statistical output of paired t-test on INC score means for qualified sample. ............. 99

Figure 30. Statistical output of paired t-test on SC score means for qualified sample. ............. 100

Figure 31. Statistical output of paired t-test on FG score means for qualified sample. ............. 101

Figure 32. Statistical output of paired t-test on RD score means for qualified sample. ............ 102

Figure 33. Statistical output of paired t-test on TOT score means for qualified sample. .......... 103

Figure 34. Statistical output of paired t-test on CON score means for qualified sample. .......... 104

Figure 35. Statistical output of paired t-test on PHY score means for qualified sample. .......... 105

Figure 36. Statistical output of paired t-test on MOR score means for qualified sample. ......... 106

Figure 37. Statistical output of paired t-test on PER score means for qualified sample. ........... 107

Figure 38. Statistical output of paired t-test on FAM score means for qualified sample. ......... 108

Figure 39. Statistical output of paired t-test on SOC score means for qualified sample. .......... 109

Figure 40. Statistical output of paired t-test on ACA score means for qualified sample. .......... 110

Figure 41. Statistical output of paired t-test on IDN score means for qualified sample. ........... 111

Figure 42. Statistical output of paired t-test on SAT score means for qualified sample. .......... 112

x

Figure 43. Statistical output of paired t-test on BHV score means for qualified sample. .......... 113

Figure 44. Case O1 - Blue's individual SASS output, artwork, and self-statements from aesthetic

criticism....................................................................................................................................... 114

Figure 45. Case 03 - Nicht Werden's individual SASS output, artwork, and self-statements from

aesthetic criticism........................................................................................................................ 116

Figure 46. Case 09 - Ghost's individual SASS output, artwork, and self-statements from


Figure 47. Case 12 - Brody's individual SASS output, artwork, and self-statements from


Figure 48. Case 16 - Destructo's individual SASS output, artwork, and self-statements from


Figure 49. Case 04 - Vortex's individual SASS output, artwork, and self-statements from


Figure 50. Case 02 - Shirayuki's individual SASS output, artwork, and self-statements from


xi

ABSTRACT

There is a lack of research on intervention protocols for adolescent children of alcoholics who

are high-achieving and demonstrate a low probability of substance use disorders. Historically,

these children have high academic success and their familial issues often remain secret; thus,

school counselors or mental health professionals may overlook any psychosocial or emotional

issues. The primary problem this study addresses is how to identify and serve this specific

population as a mental health clinician.

The purpose of this study is to increase this population‘s positive self-concept—a

measurable and observable trait related to resiliency—using one or both of the following

experimental art therapy interventions: a) an art education-based intervention entitled,

Constructing a Personal Visual Vocabulary and b) Cognitive Behavioral Art Therapy based

directives, which include working toward a personal visual narrative, or trauma narrative. The

philosophical approach for this study is based on Hegelian dialectics.

This study used a randomized pretest–midtest–posttest experimental research design with

a control group. The double blind method was used to prevent research outcomes from being

'influenced' by observer bias. The participants’ qualifying criteria were determined following the

closing of the study.

Levels of self-concept were measured by statistical analysis of the Tennessee Self

Concept Scale, Second Edition (TSCS:2) and correlated with the Piers-Harris Children's Self-

Concept Scale, Second Edition (PH:2) to determine the total self-concept over three observation

periods. To provide additional information on the participants' clinical state, their clinical notes,

self-statements, and artwork were reviewed using the depression scales, a portion of the Formal

Elements Art Therapy Scale (FEATS), Beck's theory of internal communication system, and the

Expressive Therapies Continuum (ETC).

A paired-samples t-test using total scores (TOT) from the TSCS:2 was performed for the

qualified sample, all of the experimental participants, and the control group. The participants’

TOT scores, measuring the levels of self-concept, before and after each of the two interventions

were compared. The results indicated a significant difference in the TOT mean scores for all of

the experimental participants after both interventions, at Observation Three, t(18) = -4.71, p =

0.0002. The computed total self-concept scores from the qualified sample were too small to infer

xii

a significant effect value at observation three; t(4) = -1.52, p = 0.2034; thus, the percentage

changes for the mean total self-concept scores were calculated for each sample.

The qualified sample demonstrated a TOT mean score increase of 26.9% in positive self-

concept at Observation Two and maintained a TOT mean score increase of 16.5% at Observation

Three. Based on these results, the null hypothesis was rejected; it was inferred that sixteen

weeks of art therapy sessions increased the positive self-concept for high-achieving adolescent

children of alcoholics who demonstrated a low probability of substance-use disorders. Further

implications suggest that constructing a personal visual vocabulary increased positive self-

concept at a higher rate for the qualified sample than cognitive-behavioral therapy with a focus

on creating a personal visual narrative.

Keywords: art therapy, Cognitive Behavioral Art Therapy, visual language, visual

vocabulary, adolescent, children of alcoholics, alcohol use disorder, self-concept, resiliency,

Formal Elements Arts Therapy Scale (FEATS), Expressive Arts Therapy Continuum (ETC),

cognitive theory of internal communication, Anderson’s CritCard method, Hegelian dialectics

1

CHAPTER ONE

CONSTRUCTING A PERSONAL VISUAL VOCABULARY

Creating art is inherently a cognitive process. It is an active way to analyze, synthesize,

and create solutions for complex problems. Thus, one of the philosophical precepts for the

mental health field of art therapy is based on the belief that creating art is a healing and life-

enhancing experience. Art therapy provides tangible and active opportunities to examine,

problem solve, and reflect on these intricate processes.

This art therapy experimental research study specifically utilized Cognitive Behavior Art

Therapy (CBATx)1 techniques to assist children of alcoholics (CoA) with increasing their

positive self-concept through improved understanding and use of visual language. The focus

population was a sample of adolescent CoA who were high-achieving and demonstrated a low

probability of substance-abuse disorders (SUDs). The mental health community has historically

underserved this specific population.

CBATx techniques often facilitate the construction of alternative cognitions and

different ways for the clients to view their life and build a more holistic sense of self, or to

combine the physical, emotional, mental, and spiritual aspects of their personalities. The theory

is that an increased positive self-concept for this specific population corresponds to the concept

of resiliency, or the ability to overcome adverse childhood experiences (ACE). The hope is that,

if this population enhances its understanding and use of visual language, this ability would

facilitate the externalization of thoughts and feelings that are usually difficult for adolescents to

verbalize in therapy.

This process included constructing a personal visual vocabulary. A personal visual

vocabulary (PVV) is related to visual literacy (or, as it is colloquially known, visuacy), which is

the ability to interpret, negotiate, and make meaning from information presented as images.

Visual literacy is based on the idea that pictures can be read and that meaning can be

communicated through reading these pictures. For this study, a PVV is defined as a system of

symbols or icons to which the participant attaches personal meaning and uses consistently over

1 A list of acronyms frequently used in tare listed in Appendix A.

2

time in a variety of media and artwork. In her discussion on visual literacy, art therapist Judith

Rubin (2010) wrote:

We have abundant evidence—from such normal phenomena as dreams and such

abnormal ones as hallucinations—that much of what is encoded in the mind is in

the form of images. In fact, there is no question that a great deal of human

thought, at all levels of consciousness, is what psychologist Rudolf Arnheim

(1969) called “Visual Thinking.” (p. 86)

American photographer Minor Martin White (1963) wrote, “If we had no words, perhaps

we could understand one another better” (p. 18). White used formal art elements and design

principles to trigger specific emotional responses. He borrowed American photographer Alfred

Stieglitz’s theory of “equivalents” to describe this particular phenomenon. White (1963) wrote:

“If the individual viewer realizes that for him what he sees in a picture corresponds to something

within himself—that is, the photograph mirrors something in himself—then his experience is

some degree of Equivalence” (p. 18).

Perhaps White was a visual symbolizer, or a person whose primary cognitive process was

visual language. He used the play of light on mundane objects, such as walls, windows, and

doors, as the physical forms of concepts or signifiers. In the case of visual language, the formal

elements of art—such as line, shape, color, and value —may be compared to the vowels and

consonants of written language. Perhaps the rules of composition or the principles of design

could be considered the grammatical rules. Meaning is constructed when these parts are put

together or an idea becomes tangible reality. White‘s intention in his photographs was to use

these formal elements of art to facilitate the viewers’ understanding; he purposely used the

special quality of light and image sequencing to create personal narratives. When we, as the

viewer, "read" his narrative, we are experiencing the phenomenon of equivalence; for a moment,

we understand White‘s language.

Philosophical Underpinnings of Therapeutic Methods

This study was based on a fundamental principle of art therapy: art serves as a primary

language for communication. One of the ways in which many cognitive behavioral therapists

help clients with post-traumatic stress disorder is by using a directive entitled the trauma

narrative (Jongsma, Peterson, & McInnis, 2006). People who are exposed to traumatic events

have a profound need to make sense of them. Talking about a traumatic experience helps people

http://www.ptsdtraumatreatment.org/the-trauma-narrative/

http://www.ptsdtraumatreatment.org/the-trauma-narrative/

3

to organize their memories and feelings into a more manageable and understandable

psychological “package.” The paramount part of this process involves setting the traumatic

events securely in the past and seeing oneself as a survivor (Gantt & Tinnin, 2007).

Creating a visual narrative—a Cognitive Behavioral Art Therapy (CBATx)–based

intervention—meets this goal. Furthermore, the intervention of constructing a personal visual

vocabulary (PVV) was designed to alleviate issues involving alexithymia and verbally exposing

secrets from a closed-family system. This study provides data that emphasizes the validity of

learning and adapting the formal art elements of lines, shape, and color to aid in the treatment of

adolescent children of alcoholics (CoA).

The idea of constructing a PVV is based on Rhyne‘s (1979) work with mind-state

drawings, Jungian archetypal and symbol theory (Jung, 1986), and visual literacy (Avgerinou,

2005; Dake, 2007; Dondis, 1994). The structure for constructing the PVV utilizes elements of

art, specifically line, shape, color, value, and form. The second intervention used in this study is

based on Hegelian dialectics (Gaiger, 2002), Bandura (1986), Vygotsky (1930/1980), and Beck

(1955/1997)’s cognitive learning theories, and Rosal’s (2001) CBATx work with children and

teens. The final project for this intervention is based on Kelley (1955/1963)’s ideas about

personal constructs and narrative art therapy.

Hegelian Dialectics

In describing a threefold process for achieving telos—or the state of perfection—German

idealist Hegel used the verb aufheben or the noun Aufhebung for concepts that are difficult to

translate. For example, a concept first needs to be defined. Second, the concept requires

mediation or examination regarding what it is not, so that, third, one can determine what it truly

is and move beyond the original concept’s limitations (Papineau, 2004). However, the term

sublation is often used to describe how a concept may be both preserved and changed through a

dialectical interaction with another concept, Aufhebung. Often, this dialectical process is

described as thesis, antithesis, and synthesis, or when the contradiction of the thesis and the

tension between the two has been resolved. However, Hegel uses the terms abstract, negative,

and concrete. For example, in art-making, we might have an idea or a vision of something. When

we try to create that vision in the natural world, we discover all of the physical problems.

Perhaps our frustration results in a new representation of the problem, and perhaps the new art

4

object is even better than our original vision—or not. Still, we move on to a new vision, and the

cycle continues through time.

This threefold process is referred to as Hegelian dialectics or the logic of contradiction. In

other words, (a) everything gradually changes over time; (b) in a spiraling method as opposing

forces or contradictions rise above one another, which (c) results in significant holistic changes

(Cooper, 1995; Honderich, 2005). Hegel’s idea was that history is never static, always

teleological, and moving forward through the dialectal process. Theoretically, this implies that

all ideas and concepts—even the world itself—will eventually reach a final, ultimate state of

being. He termed the final state the Geist, which translates from German both as the spirit and as

the mind. Geist in Hegelian theory represents the absolute idea or truth (Hofstadter & Kuhns,

1976). Honderich (2005) wrote:

Because the German term covers both these meanings, Hegel is able to use it in a way that

suggests an overarching collective mind that is an active force throughout history, and of which

all individual minds—that is, all human beings, considered in their mental aspect—are a part. (p.

368)

Hegel’s approach to aesthetics developed out of his mature philosophical ideas and is

understood in terms of a meaningful succession of styles or expressions of the worldviews of

cultures or historical periods (Cooper, 1995; Gaiger, 2002). In his Lectures on Aesthetics (1820)

published posthumously,

[Hegel] emphasized the meaning and the content of works of art and takes those

works to be superior that have as their content the most concrete and fully

articulated ideas, but also express meaningfully the culmination of the historical

aspects of the culture in which it exists. (Cooper, 1995, p. 182)

When considering the purpose of making art in a therapeutic setting, at least three aspects

of Hegelian aesthetics theory applies to CBATx via theories of dialectical cognitive

constructivism: a) the ability of art to externalize internal processes for the purposes of

reflection, b) the dialectical process of initiating gradual change through the examination and

reframing of cognitions, and c) the emphasis on creating meaning through metacognition. In

order to create meaning, individuals form associations using subjective organizational structures

based on previous knowledge acquired via experiences in the external world, cognitive

abstraction, and the outcomes of mental contradictions.

5

For the purposes of therapy, it is also beneficial to view humans as being teleological or

having an innate drive to improve, although we may not agree on what constitutes

“improvement." Rather than subscribing to Hegel’s concept of attaining the Absolute Ideal

(Gaiger, 2002), it seems important to consider sociocultural and personal contexts, as the “ideal“

point of view implies a metanarrative or type of universal imperative for what self-realization

may look like. Therefore, as art therapists, it is important to help individuals discover and

emphasize what they find worthy within themselves. Explicitly, it seems imperative to suspend

value judgments on the aspect of aesthetics that deals with what is beautiful; instead, we ought to

provide materials, opportunities, and encouragement for individuals to participate in their own

dialectical process through metacognition.

According to Geiger (2002),

For Hegel, art takes its place alongside religion and philosophy as a form of self-

understanding through which human beings arrive at knowledge about themselves

and the world they inhabit.

Hegel suggests that one of the ways by which such knowledge [of self and

the world] is acquired is through a process of “externalization.” In working upon

and changing external things, we come to recognize ourselves in the changes we

have brought about. Works of art can thus be seen as the result of a highly

developed ability to articulate and make explicit the life of the mind. (p. 134)

By creating artwork (the thesis), individuals have an opportunity to reflect on the

psychological expression evidenced in their work and the experience of creating the work (the

antithesis), and therefore reframe or further the ideas found therein (synthesis). The hope is that

this approach will enable self-efficacy and self-regulation within the client‘s sociocultural and

personal context.

Chaos and Adverse Childhood Experiences

Family life for children whose primary caretaker(s) have alcohol-related disorders is

often characterized by chaos and unpredictability (Johnson, 2002; Nodar, 2012; Ross & Hill,

2001). As the family system breaks down, adults often cite the adolescent’s behavior as the root

cause of their substance issues (Kaufman & Yoshioka, 2005). As a result, children from these

maladaptive family systems often feel they have to present a false self to the public, to assure

their teachers, friends, employers, and even extended family members that all is “fine at home“

6

(Kaplan, Lui, & Kaplan, 2001; Straussner, 2011) . The consequence of keeping secrets within a

“closed” family system regarding alcohol-use disorders and other adverse childhood experiences

often causes issues, such as poor self-concept, depression, and eating disorders (Straussner,

2011).

Although coming from a family with alcohol use disorders is not always the primary

problem, rather, according to Anda (2006)'s report on the Adverse Childhood Experiences

(ACE) Study, issues may stem from concurrences of neglect or abuse. One of the possible

outcomes for people who have suffered severe ACEs is the development of a condition coined

by Sifneos in 1973 as alexithymia, or the inability to attach words to emotionally laden events. In

other words, some CoA decide not to tell the family secret and some CoA just cannot.

In general, there is a lack of research on intervention protocols for mental health

professionals serving adolescent children of alcoholics (CoA) who demonstrate a low probability

of having substance use disorders (SUDs), much less CoA who are high-achieving as well. Most

CoA who are treated have a wide range of health problems or presenting problems, such as

aggression, low school performance, or evidence of SUDs. However, because of this specific

population’s academic success, the psychosocial or emotional issues this specific population may

develop are often undetected by mental health professionals until later in their adult lives, when

perhaps their own family systems break down, (Eskin, Retaken, & Demir, 2008; Pilat & Jones,

1984/85). In other words, this particular population is often unobserved and therefore

underserved.

Research Problem

Statement of the Problem

The primary problem addressed in this study is how mental health clinicians can identify

and serve adolescent children of alcoholics who are high-achieving and demonstrate a low

probability of substance use disorders.

Purpose of the Study

The purpose of this art therapy study was to increase the positive self-concept of this

specific population using one or both experimental interventions. The specific interventions were

Cognitive Behavioral Art Therapy techniques and/or the construction of a personal visual

vocabulary.

7

Research Questions

The primary research question was whether the positive self-concept of all the

experimental participants and/or the qualified sample will increase after participating in

Cognitive Behavioral Art Therapy (CBATx) and/or constructing a personal visual vocabulary

(PVV), as measured by the Tennessee Self Concept Scale, Second Edition (TSCS:2) and the total

self-concept (TOT) scores from Piers-Harris Children‘s Self-Concept Scale, Second Edition

(PH:2).

Hypotheses

The implications for this study are reflected in the following hypotheses: First,

participation in one or both of the art therapy interventions will significantly increase the level of

positive self-concept, as measured by the correlated TOT scores for all of the experimental

participants or the qualified sample. This directional hypothesis describes a positive causal

relationship between participation in one or both of the interventions (independent variables) and

increased positive level of self-concept (dependent variable) for this population.

Null Hypothesis

The null hypothesis (H0: p-value > 0.05) is that there will be no statistically significant

increase in the level of positive self-concept, as measured by the TOT scores, for all of the

experimental participants or the qualified sample after participation in one or both art therapy

interventions.

Justification

According to Gantt and Tinnin (2007; 2009), one of the principal objectives for treating

trauma and abuse is to narrate the event or “tell the story“ in order to externalize the trauma and

set the events securely in the past.” Once the client sees himself or herself as a survivor, the

concepts of self-reliance, self-efficacy, and so on are reinforced. However, many clients are

reluctant to tell family secrets because of the concept of the “closed-family system” (Straussner,

2011), or they are unable to verbalize the abusive events due to issues involving alexithymia

(Lusebrink, 1990, Gantt & Tinnin, 2007, 2009; Sifneos, 1973). For these reasons, in addition to

specific CBATx directives, the experimental groups created a PVV for the visual expression of

secrets in an educational setting before working on a personal visual narrative.

According to psychologist Erik Erikson (1994)’s theory of the eight stages of

development, most adolescents are in the fifth stage of socialization, or learning identity versus

8

identity diffusion and the development of fidelity. At this stage, healthy development is

dependent on acquiring a sense of self-certainty, as opposed to self-consciousness and self-doubt.

In other words, the primary job of adolescence is individuation, or the process of developing an

individual identity. Accordingly, adolescence seems to be the primary stage in psychosocial

development during which an interruption of maladaptive familial patterns could occur (Gruber,

Celan, Golik-Gruber, Agius, & Murphy, 2007; Robertson, David, & Rao, 2003).

Typically, the specific population that this study focuses on is identified as well-adjusted

academically; therefore, a deliberate academic approach to cognitive–behavioral therapy (CBT)

may impart the feeling of a familiar or safe environment (Eskin, Ertekin, & Demir, 2008; Riley,

1999, Fenster, 2011). CBT methods enhance problem-solving skills and facilitate self-efficacy.

Often in CBT, the therapist is seen as a collaborator, rather than the expert. Consequently, CBT

techniques empower adolescent CoA to develop strategies and resolve feelings or behaviors

caused by the chaos and unpredictability of their maladaptive family systems (Riley, 1999a; de

Shazer, Dolan, Korman, Trepper, McCollum, & Berg, 2007). Specifically, Rosal (2001) wrote:

The portrayal of tough personal and social situations through drawings is a

technique used by several art therapists to increase problem-solving (Packard,

1977; Rosal, 1985, 1992, 1993, 1996). Having children depict complex life

moments can be followed by generating alternative solutions in pictures. This

technique can increase behavioral choice. (p. 215)

Most of the literature available on breaking the cycle of familial alcohol use disorders

agrees with the following statement from the Substance Abuse and Mental Health Services

Administration (SAMHSA, 2004):

The life skills CoA [need] can be gained through educational support groups and

healthy relationships with others, especially adults who show that they care about

children. By providing these children with experiences in which they have

opportunities to succeed, CoA can learn to respect themselves and cope with their

situations. (p. 15)

Although family therapy is often the primary intervention model for familial alcohol-related

disorders (Riley, 1999; 1999a) , a separate treatment program for children of alcoholics (CoA)

with an early positive intervention in a familiar environment with trusted adults who are not

family is recommended (Fenster, 2011; Kaufman & Yoshioka, 2005; Leichtling, Gabriel, Lewis,

9

& Vander Ley, 2006; Robertson, David, & Rao, 2003). Yalom (2005) advocated that a “therapy

group reincarnates the primary family” (p. 87). Additionally, peer therapy groups may quickly

provide the social support system necessary to develop group cohesion, catharsis, universality,

hope, altruism, guidance, interpersonal learning, and so on (Yalom, 2005). An advocate of

Yalom‘s principles when working with youth, Malchiodi (2008) wrote that “group work reduces

isolation, promotes corrective emotional experiences, and enhances interpersonal skills” (p. 252).

Walker and Lee (1998) suggested that the primary goals when working with CoA should be to

emphasize their individual strengths and develop their relational resilience outside their family of

origin, before working with the family as a whole. The hope is that the participants will work

together to summarize, question, contradict, and teleologically move towards a more holistic

sense of self.

Definition of Terms

Adolescence. Adolescence is indicated by chronological age (i.e., being 13–17 years

old).

Alcohol Use Disorder (AUD).This disorder is defined by a cluster of behavioral and

physical symptoms, which can include withdrawal, tolerance, and cravings. AUDs are specified

on a continuum from moderate to severe that includes various levels of remission. At present,

individuals with an alcoholic use disorder may continue to consume alcohol despite the

knowledge that continued consumption can pose significant physical, psychological, social, or

interpersonal problems within a 12-month period (American Psychiatric Association, 2013).

Alcoholism. The fifth edition of the Diagnostic and Statistical Manual of Mental

Disorders (2013) collapsed the medical distinction between problem drinking and alcoholism.

According to previous terminology, alcoholism was a chronic disease with genetic, psychosocial,

and environmental factors that influence its development and manifestations. The disease is often

progressive and fatal. It is characterized by continuous or periodically impaired control over

drinking, preoccupation with alcohol, use of alcohol despite adverse consequences, and

distortions in thinking, most notably denial (NCADD, 2013).

Alexithymia. Coined by Sifneos in 1973, the terms describes a dimensional personality

trait wherein the person is unable to experience or communicate feelings consciously or an

inability to recognize or describe their emotions.

10

Children of Alcoholics (CoA). Children of alcoholics are biological or non-biological

children and/or adolescents with at least one caregiver who qualifies as having an alcohol-related

disorder, as reported during the participant‘s initial intake interview.

Cognitive Behavioral Art Therapy (CBATx). Cognitive Behavioral Art Therapy is a

psychotherapeutic approach that incorporates the assessment of one’s higher cognitive processes

with the creative process of art making to 1) externalize internal processes, 2) facilitate self-

control, 3) increase problem-solving, and 4) improve one’s ability to cope with stress (Rosal,

2001).

Expression. Expression is defined as the act of expressing. In this study, expression is

the manifestation or publication of ideas in a tangible manner (i.e., by the human senses of sight,

sound, touch, taste, and/or smell).

High-achieving. High-achieving for this study was determined as educationally

mainstreamed students with a weighted GPA of 3.0 or above. This fits the initial eligibility

requirements for the State of Florida’s 2013 Bright Futures Florida Medallion Scholarship

award.

Substance Use Disorder (SUD). The substance use disorder combines the DSM-IV

categories of substance abuse and substance dependence into a single disorder that is measured

on a continuum from mild to severe. Each specific substance is addressed as a separate use

disorder, but nearly all substances are diagnosed based on the same overarching criteria (APA,

2013). The criterion of “demonstrating a low probability of SUDs” in this study has been

measured by the Substance Abuse Subtle Screening Inventory: Adolescent (Miller, 1985/1999).

Personal Constructs. Personal constructs are bipolar, or diametric, self-statements that

represent our most basic values and sense of self. The term is based on Kelly (1963/1999)’s idea

that people maintain their identities and existence by making assumptions about themselves

based on their experiences in the world and therefore behave in ways that support these

assumptions. According to Kelly, personal constructs are critical for the evolution and

organization of our larger construct system (e.g., “I am a good or bad person because…“).

Personal Visual Vocabulary (PVV). A personal visual vocabulary is a term that was

coined for this study and is defined as a system of symbols or icons that the participant attaches

personal meaning to and uses consistently over time in a variety of media and artwork. A PVV is

related to visual literacy (or, as it is colloquially known, visuacy), which can be described as the

11

ability to interpret, negotiate, and make meaning from information presented as an image

(Avgerinou, 2007; Braden, 1996; Brill, Kim, & Branch, 2007; Csillag, 2009; Dake, 2007;

Dondis, 1973; Moore & Dwyer, 1994). The concept of visual literacy is based on the idea that

pictures can be read and that meaning can be communicated through reading these pictures.

Qualified Sample. For this study, the qualified sample is a convenience sample of

adolescent CoA who were high-achieving and demonstrated low probability of SUDs.

Resiliency. Resiliency is the ability to cope, adapt, or recover from illness, depression,

adversity, trauma, and the like (Karatas and Cakar, 2011).

Secret. A secret is something that is not open or public and is kept private or not

revealed. A secret in this study is defined as a painful thought or idea that the participant reported

as not having previously expressed.

Self- concept. According to Kelly (1963/1999), self-concept is a person’s perspective of

himself or herself. This psychological construct includes the way a person sees, understands, and

defines him or herself in terms of beliefs and emotions. The degree of positive self-concept was

measured by using the TSCS:2 (Fitts & Warren, 2003) and the PH:2 (Piers & Harris, 2009).

A Brief Overview of the Study

This art therapy study investigates the efficacy of an intervention, or combination of

interventions, designed to increase the positive self-concept for high-achieving adolescent

children of alcoholics (CoA) who demonstrated a low probability of substance abuse disorders

(SUD). Since several standardized assessment tools for positive self-concept are available and

positive self-concept is one trait that supports one‘s ability to be resilient, positive self-concept

was chosen as the observable and measurable trait for this population. The levels of self-concept

were measured by statistical analyses of the Tennessee Self Concept Scale, Second Edition

(TSCS:2), correlated with the Piers-Harris Children‘s Self-Concept Scale, Second Edition’s

(PH:2) Total Self-Concept (TOT) score, over three observation periods. The TSCS:2 subtest

scores, self-reports, clinical notes, and client artwork provided additional supporting information.

The study used a randomized pretest-midtest-posttest experimental research design with a

control group. Data were analyzed from the qualifying sample to test and observe for significant

improvements in positive self-concept, as indicated by TSCS:2 and PH:2 TOT scores. To

elucidate the findings further, the art therapy discipline’s foundational theory, the Expressive

Therapies Continuum (ETC; Lusebrink, 1990); the depression scales; a portion of the Formal

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Elements Art Therapy Scales (FEATS; Gantt and Tabone, 1998); and Anderson’s CritCard

method (Anderson and Milbrant, 2005) were used to evaluate the clinical notes, self-statements,

and the participants' artwork.

The convenience sample consisted of nine qualified adolescents out of 23 voluntary

participants from three small public schools in North Central Florida. All participants were

randomly assigned to one of two experimental groups or one control group. After completing the

study, the participants were qualified as having met the study criteria using information gleaned

from the original intake questionnaires/instruments. The qualifying participants had the

following attributes: they were 1) adolescent; 2) children of alcoholics or children from families

with alcohol use disorders; and 3) high-achieving; and 4) demonstrated a low probability of

substance-abuse disorders.

Participants were offered either a) eight 90-minute weekly sessions of art education–

based directives to construct a (PVV, followed by eight 90-minute weekly sessions based on

CBATx directives, while working towards a visual narrative or b) the opportunity to participate

in a control group. The study uses a randomized, three-interval test (O1, O

2, and/or O

3) design

with one control group and includes two interventions (X1 and X

2). The control group took a pre-

test (O1) and a post-test (O

2) after an approximate 18-week interval. The art education–based

intervention focused on the construction of a PVV using the art elements of line, shape, color,

value, and form. The CBATx interventions focused on feeling states, visual problem solving,

storytelling, and visual narrative development. In keeping with the tenets of art therapy, all of the

art directives were designed to move the participant around the ETC by providing opportunities

to work with a variety of materials.

Summary

Research indicates that a significant percentage of American children are growing up in

families that exhibit alcohol-use disorders. Some studies assert that parental alcohol abuse and

alcoholism cause ongoing maladaptive familial patterns of behavior that last for generations.

Furthermore, using functional magnetic resonance imaging (fMRI) technology, strong

correlations have been made between alcohol consumption and genetic factors and violent or

aggressive behavior, reduced impulse control, and an increased tendency for risk taking.

Additional studies have inferred through controlled multivariable research that the co-

occurrence of parental alcoholism and abuse are more likely to determine the long-term effects

13

on children born into these family systems than the use of alcohol per se. In other words,

children growing up in an alcoholic family system have an increased likelihood of having one or

more adverse childhood experiences, such as witnessing family violence, experiencing a

combination of physical, sexual, or emotional abuse, and being subjected to neglect and overall

poor parenting styles. Consequently, CoA are highly likely to develop alcohol use disorders and

continue maladaptive family patterns of internalized and externalized behavior, such as

aggression or depression. Evidence-based theories suggest that early intervention with trusted

adults and peers in a familiar environment is the most beneficial method of intervention for CoA.

The purpose of this study is to increase the positive self-concept of adolescent CoA who

were high-achieving and demonstrated a low probability of SUDs using one or both

experimental interventions—CBATx and/or the construction of a PVV. Specifically, the first

intervention utilized an educational approach to art therapy, and the second intervention focused

on established CBATx directives, including creating a visual narrative.

The philosophical approach for this study was based on Hegelian dialectics. The precept

was that an improved self-concept helps an individual overcome adverse childhood experiences

and disrupts the maladaptive familial pattern of issues surrounding alcohol-related disorders. The

hypothesis is that participation in one or both of the art therapy interventions will significantly

increase the CoA’s level of positive self-concept, as measured by the correlated TOT scores for

all of the experimental participants or the qualified sample. This directional hypothesis describes

a positive causal relationship between participation in one or both of the interventions

(independent variables) and increased positive level of self-concept (dependent variable).

Because several standardized assessment tools for positive self-concept (PH:2 and the TSCS:2)

are available and positive self-concept is one trait that supports one‘s ability to be resilient,

positive self-concept was chosen as the observable and measurable trait for this population.

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CHAPTER TWO

REVIEW OF THE LITERATURE

There is a lack of research on intervention protocols for adolescent children of alcoholics

(CoA) who are high-achieving and demonstrate a low probability of having substance use

disorders (SUDs). As discussed briefly, this population is difficult to identify due to their

academic achievement and the secrecy inherent in a maladaptive or dysfunctional family system.

For that reason, this literature review begins with a discussion on the specific term, the

meaning associated with, and the implications of being a CoA or being from a family system

with alcohol-use disorders, specifically the health and social impacts of growing up around

alcohol-use issues. Following is a discussion of the significant components for a successful

intervention and prevention programs and an overview of various cognitive theories. Finally,

there is a discussion of the efficacy of using art therapy and visual language to treat maladaptive

personal constructs for this population.

Children of Alcoholics

Studies reported by various national and government data-collecting groups indicate that

at least 17.6 million people, or one in every twelve adults, have an alcohol use disorder (AUD),

which can be further classified as either alcohol dependence or alcohol abuse2—both fall under

the larger category of SUDs. More than 28 million Americans are children from a family system

that is impacted by alcohol-related issues; nearly 11 million are under the age of 18 (Centers for

Disease Control, 2013; National Council on Alcoholism and Drug Dependence, 2013, National

Institute on Alcohol Abuse and Alcoholism, 2013).

Numerous empirical studies assert that parental alcohol-related disorders cause

multigenerational maladaptive patterns. CoA, or children from families with AUDs, are four to

six times more likely than their peers to develop a wide range of health problems, including

alcohol-related issues. (Anda, 2006; Gruber, Celan, Golik-Gruber, Agius, & Murphy, 2007;

Johnson, Cohen, Kasen, & Brook, 2008; Lejuez, Magidson, Mitchell, Sinha, Stevens, & De Wit,

2010). The presenting problems for CoA who seek treatment often include a variety of mental,

2 Using the DSM-V (American Psychological Association, 2013) terminology, “alcoholic” may be written as a

person with alcohol-related disorders or an alcohol-use disorder (AUD). Therefore, this study will use children of

alcoholics (CoA) and children from families with AUDs interchangeably.

15

physical, and emotional issues, such as difficulty talking about painful events, overachievement,

low self-esteem, external locus of control, anxiety, depression, and eating disorders (Anda, 2006;

Anda et al., 2002; Burnette et al., 2008; Dube et al., 2001; Elgán & Leifman, 2013; Kaufman &

Yoshioka, 2005; Straussner, 2011; Walker & Lee, 1998).

Additionally, CoA often have concurrent adverse childhood experiences (ACE), such as

witnessing family violence, experiencing a combination of physical, sexual, or emotional abuse,

and neglect, which may seriously affect their positive self-concept (Gantt & Tinnin, 2007).

Because of the poor parenting that is associated with ACEs, these children are highly likely to

continue maladaptive familial patterns of internalized and externalized behavior, such as

aggression and depression (Anda, 2006; Anda et al., 2002; Hall & Webster, 2007; Burnette,

Ilgen, Frayne, Lucas, Mayo, & Weitlaug, 2008; Dube, Anda, Felitti, Crogt, Edwards, & Giles,

2001; Johnson, 2002; Nicholas & Rasmussen, 2006; Mignone, Klostermann, & Chen, 2009). If

the family environment included significant trauma for the child, he or she may have developed a

condition called alexithymia. The operational definition of alexithymia is having a deficiency in

understanding, processing, or describing emotions (Lusebrink, 1990; Gantt & Tinnin, 2007;

2009; Sifneos, 1973).

Recently, researchers have focused on factors that contribute to resiliency, which is a

quality or process that seems to help interrupt the maladaptive family patterns associated with

ACEs or growing up in chaotic family environments (Kim & Lee, 2011; Mylant, Ide, Cuevas,

Meehan; 2002; Karatas & Caker, 2011). The internal characteristics associated with resilience

include positive self-concept, self-efficacy, perseverance, internal locus of control, and problem

solving, coping, and adaptation skills (Center for Substance Abuse Treatment, 2004; Hall &

Webster, 2007; Karatas & Cakar, 2011; Kim & Lee, 2011; Rekart, Mineka, Zinbarg, & Griffith,

2007; Mylant et al., 2002; Richards & Nelson, 2012; Walker & Lee, 1998).

The definition of children of alcoholics/children of substance abusers (CoA/CoSA) is

“any child whose parent (or parental caregiver) uses alcohol or other drugs in such a way that it

causes problems in the child’s life” (CoA/CoSA, 2013, para. 1). Does this label “children of

alcoholics” imply pathology? In their article Uncovering Strengths of Children of Alcoholic

Parents, Walker and Lee (1998) wrote, “CoA (Children of Alcoholics) are described as if CoA

were a diagnosis” (p. 521). The label CoA puts the focus on the child rather than the parent, as if

the child has the problem. Although the literature continues to use the label “CoA,” being a CoA

16

is not pathological. In the introduction of their book Children of Substance Abusing Parents:

Dynamics and Treatment, Straussner (2011) wrote:

Children of alcoholics and other drug-abusing parents, who will be referred to as

“children of substance-abusing parents,“ or CoSAPs, run the risk of a multitude of

short- and long-term problems and are likely to become the next generation of

individuals who are alcohol and/or drug dependent, thus perpetuating this cycle

into the future (Hissing et al., 2008). However, since CoSAPs exhibit not only

problematic behaviors but also strengths or resilience, careful individual

assessment of each family and each child is required. Help needs to be age- and

culturally appropriate and systemic and must take into account the needs of the

individual child and his or her family members. (p. 2)

In the literature on CoA, familial alcohol abuse, and the etiology of alcoholism, the

following questions were the most frequent: Why do CoA/CoSA often suffer from low self-

concept, anxiety, depression, aggression, locus-of-control issues, and substance-use disorders?

What specific factors lead to the high proclivity for continuing the cycle of behaviors modeled

by their maladaptive family systems? Is there a correlation between paternal substance-use

disorders, particularly of alcohol, and violence, abuse, and poverty?

Theories of Alcohol-Related Disorders

According to NIAAA (2003), “alcohol-use disorders are medical conditions that doctors

can diagnose when a patient’s drinking causes distress or harm…Like many other diseases,

alcoholism is typically considered chronic, meaning that it lasts a person‘s lifetime“ (para. 5).

If we accept, for the purposes of this study, that 1) alcoholism is a disease or that alcohol-use

disorder may cause a chronic disease if a person becomes addicted and 2) that the effects of

alcohol are subject to each individual‘s physiology, it behooves us to explore the etiologic

theories of addiction. Typically, these theories fall into the three main categories of a) biological,

b) psychological, and/or c) sociocultural issues. The combinations of these theories correspond to

the bio-psychosocial theory of use, abuse, and addiction (Keys, Hatzenbuehler, Grant, & Hasin,

2012).

Biological Theory

The biological theory for the use and abuse of alcohol and other drugs is based on years

of research in the area of alcohol-related issues. Biological or bio-psychosocial and genetic

17

theories suggest that some people are chemically predisposed to alcohol abuse; however, “no

specific genetic marker that predisposes a person towards alcoholism has ever been isolated”

(McNeece & DiNitto, 2005, p. 30). Nevertheless, there is sufficient evidence to suggest a

familial proclivity or genetic vulnerability for substance abuse. Specifically, recent studies that

include functional magnetic resonance imaging (fMRI) suggest a connection between alcohol-

use disorders and the tendency for impulsivity and/or risk-taking behaviors (Brody, Beach,

Philibert, Chen, & Murry, 2009; Lejuez et al., 2010; Newton, O‘Leary-Barrett, & Conrad, 2013;

Wai-Yuing, Zubieta, Weiland, Samudra, Zucker, & Heitzeg, 2012).

Psychological Theory

Psychological theories describe the cravings for alcohol as being based on cognitions and

emotions. For example, according to Keys et al. (2012), one explanation for alcohol use is as a

learned behavior, reinforced by the desire to reduce anxiety and stress, or that certain personality

traits are predictors for alcohol-related disorders. Specifically, the authors discuss how the

psychological and psychiatric effects of stress affect alcohol consumption and AUDs, such as

post-traumatic stress disorder caused by combat experiences and childhood maltreatment, as well

underdeveloped skills for coping with interpersonal issues, such as divorce and job loss.

Sociocultural Theory

Finally, sociocultural theories suggest that environmental factors are the primary cause

of alcoholism. According to the United Nations International Drug Control Programme

(UNDCP; 1995), poverty, unemployment, and marginalization are the some of the primary

contributing social factors for alcoholism and other SUDs. Other contributing factors may be

familial or cultural behavior modeling, a combination of risks taken during the process of

establishing one‘s individual and social identity, or the development of coping strategies (Ellis,

Zucker, & Fitzgerald, 1997; Hussong, Flora, Curran, Chassin, & Zucker, 2008; Hussong et al.,

2007).

Family Systems Theory: Roles and Rules

According to McNeece and DiNitto (2005), a maladaptive family is like a delicately

balanced mobile where the relationships among the members are interrelated and reciprocal. If

alcohol-use disorders are involved, alcohol is the central regulating theme. The mobile is a

“closed system" dependent upon itself. The entire system is organized by rules (strings) and roles

(the weights). In family systems theory (Gilbert, 2006), each member adjusts his or her behavior

18

(position) and plays a carefully developed role in order to maintain homeostasis (balance). In

other words, an alcoholic family has a circular rather than linear causality; the problem behavior

is a symptom of the larger context (McNeece & DiNitto, 2005).

Often, the focus of the alcoholic family may be on accommodating the alcoholic to keep

peace; thus, family members inadvertently inhibit the growth of the family or morphogenesis and

enable the alcoholic to escalate his or her dysfunctional behavior, rendering the entire system

dysfunctional (Hoshino, 2008; McNeece & DiNitto, 2005). Because of these behaviors, the

members become secretive and learn the rules: 1) “Don’t talk,” causing the members to possibly

live an elaborate lie; 2) “Don’t feel” causing the members to hide or discount their feelings

because expressing them only causes more trouble and upsets the homeostasis; and 3) “Don’t

trust,” causing the members to withdraw and become dependent on only themselves. Finally, all

of the members of the maladaptive system may develop a deep sense of shame, as each continues

to “fail” to meet the standards set forth by the system, i.e., perfectionism, blame, denial, and

control (McNeece & DiNitto, 2005; Straussner, 2011). Typical interpersonal familial

relationships do not occur, as positive authentic interactions that encourage this development are

severely inhibited. Any members of this family may display codependent tendencies and/or

perpetuate the cycle, which is dependent on their resiliency to the dysfunction (Fenster, 2011;

McNeece & DiNitto, 2005; Mylant et al., 2002; Nodar, 2012; Price & Emshoff, 1997).

Interrelated Issues of Alcohol, Aggression, Violence, and Abuse

As discussed in Chapter One, the result of growing up in a family with alcohol-use

disorder present often continues the maladaptive family patterns of internalized and externalized

behaviors, such as depression and aggression (Hussong et al., 2008; Hussong et al., 2007).

Nicholas and Rasmussen (2006) indicated, “childhood abusive and supportive experiences, inter-

parental violence, and parental alcohol use are a prediction of young adult depressive symptoms

and aggression” (p. 44). However, the authors go on to suggest that the connections among

alcoholism and violence and aggression are misleading. Specifically, when variables (i.e.,

alcoholism, abuse and aggression, parenting style, the sex of the parent, and the sex of the child)

are isolated, the findings indicated that, first, children of alcoholics are not necessarily adversely

affected and, second, of the three operationalized forms of abuse (i.e., emotional, physical, and

sexual), emotional abuse is the most frequent predictor for furthering maladaptive issues. In their

extensive literature review, the authors found a high incidence of child abuse in families with

19

AUD, but stated that “adult CoA have been compared to adult children from families judged to

be dysfunctional for reasons other than alcohol abuse and to adults from non-alcoholic,

functional families, [and that] adult CoA…did not differ from adult children of dysfunctional,

non-alcoholic families” (p. 44). After completing the study, the overall results demonstrated that

alcoholism, per se, did not predict depression. However, the combination of an abusive father, a

low-supportive mother, and witnessing family violence increased depression in women, whereas

low-supportive parenting from either parent increased depression in men. It seems important to

note, “There were few pathological outcomes due to growing up in an alcoholic family, per se”

(p. 44). Thus, the possibility that being a victim of child abuse, rather than growing up with

alcoholic parents, could account for the continued cycle of maladaptive patterns observed in CoA

(Burnette et al., 2008; Johnson, 2002; Nicholas & Rasmussen, 2006).

Nevertheless, in a report made to the National Adult Children of Alcoholics' board of

directors on his long-term study, co-investigator Anda (2006) reported that, out of the 17,337

predominately well-educated, middle-class participants, of which 54% were female and 46%

were male, with a mean age of 56 years, 27% reported growing up in dysfunctional homes with

SUDs. Of those children growing up around family members with AUDs, 81% reported at least

one other “adverse childhood experience” (ACE), specifically (a) emotional, sexual, or physical

abuse; (b) emotional and/or physical neglect; (c) household mental illness and/or parental

separation and divorce; and/or (d) crimes such as battery of the child’s mother. In the entire

study population, a mean of 87% of participants reported experiencing two or more ACEs. In

conclusion, Anda (2006) wrote:

One of the strongest relationships seen was between the ACE score and alcohol

use disorders and abuse. Given recent research indicating the negative impact of

alcohol use on the neurodevelopment of adolescents, the relationship of ACEs to

early initiation of alcohol use is particularly worrisome. The negative health and

social consequences of alcohol-related disorders constitute a major public health

problem—and ACEs have a particularly strong association with alcohol abuse. In

addition, it is notable that the perpetuation of the cycle of alcohol abuse appears to

be tightly interwoven with the number of ACEs, including marriage to an

alcoholic. (p. 9)

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Although researchers have yet to find a genetic marker for alcoholism, neurobiological

imaging continues to provide significant information on addictions and the mesolimbic pathway,

or our neurobiological reward and impulse-control systems. In a meta-analysis conducted by Ito,

Miller, and Pollock in 1996, a strong correlation was made between alcohol consumption and

violent or aggressive behavior. In support of this, a plethora of recent studies have emerged

correlating the effects of family history, sex/gender, alcohol use, and impulse control using

functional magnetic resonance imaging (fMRI). Specifically, Lejuez et al.‘s (2010) recent review

of behavioral and biological research on AUDs and the brain found that alcohol use affects the

functioning of the central nervous system in very specific ways. Their findings included

increased impulsive behaviors, decreased awareness of social and environmental clues, and

decreased attention span. Claus, Kiehl, and Hutchison (2011) and Claus and Hutchison (2012)

used fMRI to investigate the neural basis of increased impulsivity among individuals with

alcohol-use disorders. According to their findings, people with AUDs demonstrated functional

irregularities in the brain regions involved in cognitive and emotional control. This resulted in

delayed responses, reduced ability for critical thinking, increased impulsivity, and increased risk-

taking behaviors.

Primary Prevention Models: Significant Components

Public information and educational primary prevention programs for adolescents have

traditionally been described as ineffectual, didactic shock-and-scare tactics (Beets et al., 2009;

McNeece & DiNitto, 2005; NIAAA, 2013). Currently, the most successful programs include

significant components that consider the biopsychosocial culture of the population through an

interactive, multi-component, and holistic approach. It seems that the significant components for

primary prevention programs are dependent on 1) the population and 2) the purpose. The best

prevention program that has integrated significant components may be ineffectual if it does not

address the etiology and include an attempt to stabilize the population.

Therefore, Price and Emshoff (1997) suggested that the significant components of a

primary prevention program for children from families with alcohol-use issues should include a

research-based model with stress-reduction techniques, educational components on a variety of

substances and their consequences, and coping and social-competence skills. Additionally, the

program should provide a social-support system, including peer-to-peer networking, a safe

environment, and a mode to express feelings, as well as healthy alternative activities. The

21

proposed setting should be within the school system to avoid humiliation, and the format should

be short term and small group. For example, three programs that employ all of the above

significant components are the Stress Management and Alcohol Awareness Program, Students

Together and Resourceful (STAR), and the Strengthening Families Program.

Other integrated research-based prevention models include (a) cognitive behavioral skills

training, which works to change dysfunctional thinking that affects behavior; (b) biopsychosocial

models that focus on education, values clarification, and skill-building techniques; (c) reducing-

harm models that teach normative beliefs, perceptions of harm, and refusal and decision-making

skills, as well as moderation and avoidance of developing alcohol-related issues; and (d) family-

based prevention models (Beets et al., 2009; Brody et al., 2009; NIAAA, 2007; Price & Emshoff,

1997; and Stephens et al., 2009). According to Morehouse (2011), “while all adolescent CoSAPs

can benefit from activities that increase awareness about the impact of parental substance abuse,

the adolescent’s individual need for services should be the primary determination of what

interventions are provided” (p. 215).

Thus, considering the current zeitgeist of short-term and high-efficacy treatment plans

and family therapies, peer-group treatment is the most commonly utilized form of therapy for

this population (Price & Emshoff, 1997). In fact, Fenster (2011) cited a study by Leichtling,

Gabriel, Lewis, and Vander Ley (2006) wherein 221 adolescents participated in treatment for

substance-related disorders. Fenster wrote, “At the 6-month data collection point, involvement in

family counseling was linked with increases in substance use among adolescents from

substance-involved families, an effect that was not observed among teens living with non-

substance-abusing parents” (p. 138). Based on Leichtling et al.'s study, Fenster (2011) stated,

“for parents and teens in earlier stages of recovery, individual and group treatment for

adolescents may be more effective than family treatment” (p. 138). In other words, small-group

therapy in a school setting imparts a feeling of a familiar or safe environment (Riley, 1999; Eskin

et al., 2008). Specifically, peer-group interventions can normalize the adolescent CoA’s

cognitions and emotions regarding the behaviors of their substance-abusing caregivers, as well as

provide pro-social modeling, problem solving, and empowerment, increase self-efficacy, reduce

social anxiety, and foster a feeling of acceptance (Fenster, 2011; Morehouse, 2011; Riley, 1999).

22

The Motivation for Change

Psychology is the science of behavior and mental processes. In this field, the four major

research perspectives are biological, cognitive, behavioral, and sociocultural (Griggs, 2006). The

biological perspective’s focus is on how physiological mechanisms affect human processes; the

cognitive perspective focuses on how memory, perception, problem solving, and so on affect

behavior; behavioral perspectives use external stimuli to condition observable behavior; and

sociocultural perspectives focus on the interactions between human processes and their cultural

context. These perspectives can be divided into two basic causal factors: internal and external.

The biological and cognitive perspectives emphasize internal factors, while the behavior and

sociocultural perspectives emphasize external factors (Griggs, 2006).

Because the traits and mechanisms that make up an individual’s personality tend to be

enduring (Larsen & Buss, 2009), the goal of therapy is usually to change maladaptive behaviors

to more adaptive behaviors (Nolen-Hoeksema, 2010). The following is an overview of cognitive

therapy from the perspective of discerning the best-possible (and most-practical) therapeutic

method to elicit behavioral change in adolescent clients.

Cognitive Theory

Cognitive theory includes many cumulative ideas but asserts that humans are thinking

creatures; therefore, examining cognitive processes, or metacognition, is central to understanding

human learning and maladaptive functioning. Cognitive theories include social-learning theories,

social–cognitive theories, and cognitive behavioral theories.

Social learning theory. While studying adolescent aggression and extinguishing

phobias, Canadian psychologist Alberta Bandura began to construct a transitional theory, or

bridge, between the conditioning theories posited by psychologists such as Pavlov, Skinner, and

Watson and cognitive learning theories. He originally referred to his idea as the social learning

theory (SLT; 1977) but later renamed the theory to the triadic reciprocal model of causality

(1986), stating that triangulation exists in interactions between people, the environment, and

observed behaviors (Griggs, 2006; Schunk, 2008). Bandura (1986) wrote that “most human

behavior is learned observationally through modeling: from observing others, one forms an idea

of how new behaviors are performed, and on later occasions this coded information serves as a

guide for action” (p. 22). In other words, primary learning is based on modeled behaviors,

environmental reinforcers for the practicing of that behavior, and the learner's emotional reaction

23

to the reinforcers. He noted that merely observing a behavior does not necessary result in a

behavior change; the learner must be motivated to repeat the modeled behavior (1986; 1997).The

motivation could be in the form of an emotional reinforce—“It feels good” or an environmental

reinforce—“Mom says, ‘good job” and so on.

To elucidate this idea further, Bandura (1986; 1997) suggested that the motivation for

learning is enabled through the interrelated concepts of self-efficacy and self-regulation,

operationalized as the belief in one’s abilities and the integrated process of personal motivation,

goal setting, and assessment. In other words, the type of response we receive from our

environment influences how we feel about others and ourselves and therefore may dictate our

behavior in any given situation. However, he noted that the action or behavior must be within the

learner‘s ability to achieve. An example could be that modeling the process of creating a contour

line drawing for a three-year-old might be an exercise in futility, whereas modeling how to use a

crayon to draw circular shapes is within a typical three-year-old’s fine motor skills and cognitive

ability.

Social cognitive theory. Although writing in the early 1900s, Russian psychologist Lev

Vygotsky proposed a similar theory entitled social cognitive theory (SCT), based on his work

with children and language acquisition. He posited that learning occurs in a complex interaction

between schematic memory, biological development or readiness, and concrete reinforcement of

the action (Van der Veer & Valsiner, 1994). In other words, “every aspect of [the learners’]

developing attitudes, values, motivations, aspirations, and, most important, their perceptions of

their own self-worth are influenced by their experiences within these varying and often

conflicting contexts of the community” (Thornburg, Hoffman, & Remieka, 1991, p. 200).

Vygotsky (1978) presented this idea of working within reach of an individual‘s ability level as

the zone of proximal development, which can be defined as “the difference between the

difficulty level of a problem a child can cope with independently and the level that can be

accomplished with help” (Bruning, Schraw, & Ronning, 2010, p. 218).

In addition to introducing an interrelated intrinsic–extrinsic model for experience-based

learning, both Vygotsky and Bandura suggested that humans are able to affect their environment

with both negative and positive consequences (Bandura, 1986, 1997; Vygotsky, 1978). They

asserted that humans internalize learning through the formation of cognitive maps based on

subjective ideas. They further maintained that the process of learning is enabled through self-

24

efficacy, belief in one’s abilities, and self-regulation, the integrated process of personal

motivation, goal setting, and assessment (Griggs, 2006; Schunk, 2008). Therefore, certain

assumptions must be made in applying both SLT and SCT theories: the learner must have the

capacity to (1) pay attention, (2) retain information, (3) reproduce the desired behavior, and (4)

be motivated to imitate the behavior. Once these criteria are met, some of the most powerful

tools a “teacher” can use are the ability to integrate and model desired behaviors in a social

environment and to provide positive feedback (Schunk, 2008).

Cognitive–behaviorism. As with SCT, proponents of cognitive behaviorism believe that

learners are actively engaged in a cyclical process of interpreting, reflecting, and imitating

modeled behaviors in their social and physical environments. The higher-order thinking process

associated with this activity has been termed metacognition, or the process of consciously

controlling cognitive activity (Brown, 1987; Flavell, 1985). In other words, cognitive–

behaviorism further conceptualizes the work of Bandura and Vygotsky but includes a model for

changing dysfunctional behaviors based on the learner’s ability to actively metacognate and, in

effect, be his or her own agent for change. American psychologist Aaron Beck (1955/1977)

posited that these internal changes are reflected via observable external behaviors, such as

positive self-statements and the use of coping skills.

Cognitive Behavioral Therapy and Adolescents

After examining his own anxiety-producing and self-critical thoughts, Beck suggested

that one‘s negative thoughts and feelings about oneself cause a downward-spiraling effect, which

he named the cognitive triad theory for depression (1955) but later renamed Beck‘s theory of

internal communication system (1997). Specifically, in determining a person‘s sense of self, he

suggested noting the 1) frequency of negative self-statements, i.e., statements that undermine a

person‘s self-efficacy; 2) arbitrary inference, i.e., erroneous cause-and-effect statements; and 3)

biased processing, i.e., interpreting situations subjectively (1997). In other words, the knowledge

of our own thoughts and the factors that influence thinking significantly increase learning

efficacy, motivation, problem solving, transfer, and concept attainment (Beck, 1955/97; Beck,

2011).

The cognitive behavioral model for therapy, or cognitive behavioral therapy (CBT),

suggests that, in order to initiate significant change in maladaptive behavior patterns, personal

beliefs and convictions must be examined to modify and create new mental constructs (Beck,

25

1955/97; Beck, 2011; Rosal, 2001). Using metacognition, the learner can (1) further his or her

quest for knowledge through self-efficacy, (2) find motivation for his or her own learning, and

(3) use reflection to assess and set goals or self-regulate (Brown, 1987; Beck, 1955/1997; Beck,

2011).

The CBT model includes developing healthy thinking patterns and solving current

problems, while behavioral techniques focus on developing healthy behavior. Specifically, CBT

facilitates identifying and challenging distorted thinking as well as reflecting on the risks and

benefits of choices (Beck, 2011). Thus, we can summarize the cognitive therapy model as an

interactive process of overcoming issues and working towards self-efficacy through the

examination of our thoughts, feelings, and behaviors in a social context. By working

collaboratively with the therapist and/or group members, individual clients have opportunities to

identify problematic emotional responses, behaviors, and arbitrary or erroneous inferences.

Metacognition, or the process of thinking about thinking, facilitates the modification of

behaviors in an emotionally safe environment and, subsequently, the generalization of these

newly learned and tested behaviors in their broader sociocultural context. In general, cognitive

theories encourage exploration, discovery, and the need for the learner to experience the world

directly (Schunk, 2008).

According to Fenster (2011), cognitive therapies have demonstrated efficacy in helping

adolescents presenting depression, anxiety, and disruptive behavior patterns as a result of

choosing constructive roles, positive role models, and developing affirmative relationships with

peers to raise their positive self-concept (Fenster, 2011). CBT may encourage adolescents to

examine how their cognitions influence maladaptive behaviors. As a benefit, CBT includes

important aspects of conditioning theory and social learning theory. Using problem-solving

techniques often results in an increased internal locus of control by utilizing the learner’s ability

to make choices and thereby motivating change.

Art Therapy and Visual Language

In Approaches to Art Therapy with Children, American art therapist Marcia Rosal (1996)

details the general principles of cognitive therapy and personal construct psychology, the role of

the art therapist, and evidence of efficacy in treatment, in terms of Cognitive Behavioral Art

Therapy, or CBATx. The author stated, “Recently, psychotherapists in the field are discovering

that mental processes, particularly mental images, are powerful tools for changing problem

26

behaviors—especially of self-control” (p. 48). Specifically, “mental imagery as a cognitive

process can be tapped and altered…concrete images can alter mental images, and mental images

can alter concrete images” (p. 70). In other words, the child or adolescent’s imagery is a direct

reflection of mental processes and therefore can be utilized as the means for change in

maladaptive behaviors and cognitions.

According to Rosal (2001), when we engage in artmaking, we use a full range of

cognitive processes, such as attention, memory, perception, decision-making, reasoning,

language, emotion, learning, problem solving, and so on. Therefore, CBATx combines the

internal control-building aspects of cognitive therapy with artmaking using techniques such as

(a) discovering, promoting, enhancing, and reconfiguring mental images; (b) comparing and

contrasting drawings; (c) choosing and portraying problem-specific situations and events; and (d)

creating pictorial metaphors of feelings and mind states. In discussing the efficacy of art in

therapy, Rosal (2001) wrote:

Art therapy is particularly suited to CBT, because art is an inherently cognitive

process. When creating a piece of art, the artist must be involved in uncovering

mental images and messages, recalling memories, making decisions, and

generating solutions. Whether drawing or sculpting, creating art involves instant

feedback systems and the ongoing reinforcement of satisfying behaviors. Each

brush stroke that appears on the paper can suggest or promote further action

(feedback) as well as delight (reinforce) the artist. Creating art means that there is

a concrete record of inner processes. (p. 217)

Additionally, the use of CBATx in a small-group setting may increase the efficacy of treating the

adolescent population, as art provides immediate opportunities for empathy, problem solving,

and goal setting with peers. If the goal of therapy is to change maladaptive cognitions and

behaviors to more-adaptive cognitions and behaviors, the cognitive learning theory model

facilitates this transformation, as evidenced by the artwork.

Context and Visual Language

It is important to note that, based on the idea that humans can be taught to see, the field of

visual literacy and visual language has grown exponentially diverse, from the field of art and

design to the construction of computer languages, thus further complicating an operational

definition (Avgerinou, 2007; Brill, Kim, & Branch, 2007). All one has to do is conduct a Google

27

search for “image as language” to find a plethora of explanations of how to learn to use visual

vocabulary to “tell your story” in images. Though there does not seem to be a universal visual

language, generally, a visual language is defined as a system of communication using visual

elements in a spatial context rather than in linear form (Dake, 2007; Marriott & Meyer, 1998).

One of the specific fields interested in developing a visual language is art and design.

Csillag (2009) wrote:

I have noticed that students, typical teenagers and young adults, would always

like to ‘break the rules’ of design and art, which I always supported. Yes,

supported for the sake of creativity, and I would tell them, “As long as you know

what you are doing and are aware of the nature of the eye!” (p. 127)

Despite Csillag’s (2009) extensive research and proposed operational model of visual perception,

the fact is that current understanding of the relationship among incoming sensory data, neural

activations, and the construction of meaning based on prior experiences remains elusive at best

(Dake, 2007). Perhaps part of the problem in devising a grammatical structure for visual

elements is that the meanings of these elements are usually culture-specific. Regarding the

cultural aspect of image making and constructing meaning, Anderson and Milbrandt (2005)

wrote:

Seeing is based on biology and framed by culture. We all have similar sensory

equipment, but at an early age the way in which we use our senses to construct

become increasingly social in nature. We have an innate desire to communicate;

our communication begins with imitation of other’s communications, but as we

learn to use the system, we become increasingly individuated. (p. 50)

The contextual aspect of the art elements was exemplified when a group of this

researcher’s adult clients described their feelings associated with a specific color, such as purple.

One participant in the group filled a circular shape with wild purple lines and explained:

Purple, for me, represents pain and confusion. Purple is how I felt about the

people in my life when I was growing up. I found that I could not trust any person

to be . . . to be good to me. Purple is a hard color. (Anonymous, 2010)

In the same group, another client swirled purple paint into her circle, explaining, “

28

Purple is pure happiness for me. It makes me feel like a princess. Everything around me

is purple, my rugs, my blankets, my curtains, my clothes, my jewelry. If I could, I would

dye my hair purple. Purple makes me happy.”

It seems obvious that, for both clients, though they were about the same age and race and had the

same socio-cultural background, the color signified completely different concepts. The color was

a clue about their personal constructs.

If we view visual language as evidence of personal construct, as in Cognitive Behavior

Art Therapy, we are no longer concerned with an operational definition of visual literacy or

visual language. Rubin (2010) wrote:

Those who emphasize the therapy [rather than the art] are less likely to be

concerned with quality and more likely to focus on the communities’ value of the

artistic product. They too are interested in the image but primarily for what it says

rather than how well it speaks. Rhyne (1995), who studies line drawings of

feelings-states based on Kelly’s “personal construct” theory, described such

creations as “visual language.” (p. 73)

Rhyne’s specific use of Arnheim’s (1969) concept of visual thinking and Kelly’s

(1963/1999) idea of personal constructs was the basis for her work in her doctoral dissertation,

“Drawings as Personal Constructs: A Study in Visual Dynamics” (1979).

Visual Dynamics and Personal Constructs

Rhyne (1979) stated that the primary concern for her work on visual dynamics and

personal constructs was to “explore empirically potential applications of theoretical tenets

toward better understanding of personally constructed cognitive content in drawings” (p. 6).

Rhyne listed three specific problem areas that she intended to address: (a) the problem of visual

literacy, (b) the problem of visual dynamics, and (c) the problem of visual form as content. In

terms of visual literacy, she wrote “visual languages, no matter how expressive, are difficult to

codify” and that “the various fields of humanities and the social sciences commonly relate

cultural variables to visual expression” (p. 10). However, she extended the premise that “the

effectiveness of visual communication is subject to principles of composition whose parameters

can be intelligently and systematically explored” (p. 10). In terms of visual dynamics, Rhyne

focused on the abstract qualities of the artwork rather than the representation of symbolic

content. Specifically, Rhyne used what Dondis called the “structural properties and elements in

29

drawings,” or “how form [as, the element of art] relationships convey meaning in their structural

dimensions of composition organization” (p. 12).

Finally, in terms of the problem of visual form as content, Rhyne wrote, “This study is

concerned with the testing of Gestalt psychology’s tenets that configurational characteristics in

visual form show traces of similar characteristics of those who created the drawings” (p. 13).

Specifically, referring to Arnheim’s idea of “artistic activity as a form of reasoning” (p. 23),

Rhyne “examines questions of how organizations of form in visual images are used to express

personal constructs of life experiences” (p. 13). She relied on cognitive psychologist Kelly’s

(1963/1999) work, and the subsequent use of repertory grids to devise a mathematical way of

exploring how a person’s assumptions, or how he makes sense of the world, affect his idea of

reality based on experience. Thus, in addition to limiting the study to the abstract structures and

elements of artistic expression, she emphasized that one of the objectives of the study was,

To obtain, organize, and present data consisting entirely of information gathered

from the subjects’ perceptions of their own drawings. Of prime importance in this

research is the insistence that questions of intended meaning in drawings are best

answered by their own creators. To maintain this objective, to classify

introspective reports in both visual and verbal media, this study has treated both

drawings and their perceived properties as personal constructs. (p. 17)

Rhyne’s (1979) study involved 50 participants either working or attending university in

the western United States and required each participant to (a) create 15 black line drawings on

white paper in response to 15 emotionally laden “concept words” and then (b) code his or her

mind-states on the Repertory Grids. By collecting the participants’ insights about their artwork,

problems associated with an operational definition of visual literacy and cultural bias or dictated

constructs were avoided. The results indicated that commonalities and interrelationships in

expressive structure exist within clusters of some mind states, but that “personal constructs of

mind-states have shown idiosyncrasies that can be comprehended only within the context of that

individual’s ideation system” (p. 250).

Rhyne’s work on visual dynamics and personal constructs supports the Cognitive

Behavior Art Therapy assumption that art activities are reflections of one’s cognitions or

personal constructs. The term “personal constructs“ was based on Kelly’s idea that people make

assumptions about themselves based on their experiences in the world and, therefore, behave in

30

ways that support these assumptions. Kelly went into detail about the varying types of constructs

found in the general population, but toward the end of the book, he laid out specific conditions

considered favorable and unfavorable for the formation of new constructs. Kelly (1963/1999)

wrote:

We pointed out that new constructs could be formed with less danger of

paralyzing effects if they are first approached in contexts that do not involve the

client’s self or members of his immediate family. . . . A person might first develop

a new hypothetical cast of characters and only later find that they were like the

people with whom he is living every day. (p. 161)

Rhyne’s (1979) study supports previously mentioned imperatives that therapists first

suspend aesthetic judgment and then seek meaning based not on preconceived ideas or

unconscious precepts but rather on the client’s personal perceptions. Additionally, the personal

construct approach is related to the cognitive therapy approach in that the knowledge of one’s

own thoughts and the factors that influence thinking significantly increase learning efficacy,

motivation, problem solving, transfer, and concept attainment. Once the learner understands

personal thought processes, strategies such as questioning, summarizing, elaborating, and

organizing may be learned. Additionally, the application of heuristics, or rules of thumb, for

further learning and problem solving may be used. In other words, using metacognition, the

learner can further the quest for knowledge through self-efficacy, find motivation for learning,

and use reflection to assess and set goals or self-regulate. The cognitive theory method, together

with art, promotes efficacy through immediate problem-solution techniques and the

externalization of internal processes or personal constructs.

As indicated previously, the primary intervention objectives for this study included the

construction of a PVV) and the application of the personal visual vocabulary to the CBATX

process and the creation of the visual narrative. The emphasis on the personal or individual

aspects of creating a visual vocabulary helped avoid problems associated with outlining an

operational definition of visual literacy and cultural bias or dictated constructs regarding the

underlying grammar associated with visual languages. The use of a PVV to produce visual

narratives inherently addresses each participant’s individual physical, emotional, mental, and

spiritual aspects through the interplay of internal cognitions and external socio-cultural contexts

or personal constructs

31

Summary

In general, there is a lack of research on intervention protocols for adolescent children of

alcoholics (CoA) who are high-achieving and demonstrate a low probability of substance abuse

disorders (SUDs). As a result, the literature review focused on the treatment protocols for

adolescents from maladaptive family systems who have suffered adverse childhood experiences,

including issues with familial alcohol use.

In treating adolescent CoA, it is important to avoid considering the label as pathology in

itself. Additionally, significant numbers of CoA find the support systems, necessary strengths,

and resiliency to cope with and interrupt maladaptive familial patterns. Thus, sensitivity to the

individuals’ attitudes regarding their family systems must be taken into account. However, the

literature reviewed suggested a high concordance rate between growing up in a family with

alcohol use disorder and traits of violence and abuse. These studies offer a possible explanation

for the circular causation of poor self-concept, anxiety, depression, aggression, locus of control

issues, and substance abuse disorders in CoA.

Of the plethora of intervention strategies recommended, family therapy is often

suggested for adolescents. However, for adolescent CoA whose family members are still actively

using, group therapy seems to provide a more appropriate therapeutic venue due to peer-to-peer

support, empathy, and empowerment, and may reduce risk of shame regarding the telling of the

family secret(s).

Specific to this study, Cognitive Behavior Art Therapy (CBATx) combined the internal

control-building aspects of cognitive therapy with art-making, using techniques such as:

discovering, promoting, enhancing, and reconfiguring mental images; comparing and contrasting

drawings; choosing and portraying problem-specific situations and events; and creating pictorial

metaphors of feelings and mind-states. Especially important to this study was the expression of

personal constructs, problem-solving, and exploring feeling states. Additionally, this study relied

on the client’s ability to develop a personal visual language and to interpret, negotiate, and make

meaning from visual information in order to apply that learning to a personal visual narrative, or

a visual trauma story.

32

CHAPTER THREE

METHODS

The Cognitive Behavioral Art Therapy (CBATx) model and double-blind method with a

focus of personalizing standard art education elements through the development of a personal

visual vocabulary (PVV) was designed to minimize the anxiety and stress resulting from being

identified as a child from a family with alcohol use disorders. The purpose of this study was to

increase this population’s positive self-concept, a measurable and observable trait related to

resiliency, using one or both experimental art therapy interventions. The specific interventions

were (a) an art education-based intervention, constructing a PVV and (b) CBATx based

intervention, which included working toward an image based personal narrative, or Trauma

Narrative. The philosophical approach for this study was based on Hegelian dialectics.

Following is specific information on the research design and methodology, including the

how the sample population was obtained, the setting for the study, and the procedures. The

validity and reliability for the assessment tools and instruments are given, followed by a

discussion of possible internal threats to validity. Finally, detailed information is stated regarding

data collection and evaluation procedures. The results for this study are given in Chapter Four.

Research Design

The study used a randomized pretest-midtest-posttest experimental research design with a

control group (see Table 1). Voluntary participants were randomly assigned to either one of two

experimental groups or a control group. This research study was intended to examine an inferred

causal relationship between positive self-concept (dependent variable) and participation in one or

both interventions, CBATx and/or constructing a PVV (independent variables). This design

implicitly controlled for the testing threat and maturation threat to internal validity as the Piers-

Harris Children’s Self-Concept Scale, Second Edition (PH:2) and the Tennessee Self Concept

Scale, Second Edition (TSCS:2) total self-concept (TOT) scores and relevant subscales scores

were highly correlated (Fitts & Warren, 2003; Piers & Harris, 2009). The control group did not

receive any interventions during the period of the study. To hold the variables of adolescent

children of alcoholics who were high-achieving and demonstrated a low probability of substance

use disorders constant, all participants completed an intake questionnaire and the Substance

Abuse Subtle Screening Inventory, Adolescent (SASSI-A2).

33

Table 1. Randomized pretest-midtest-posttest experimental study design with one control group.

Groups Intake SASSI-

A2

PH:2

(O1)

TSCS:2

(O1)

PVV

(X1)

TSCS:2

(O2)

CBATx

(X2)

TSCS:2

(O3)

Experimental Group

(Y1)

R O O

O

- X

- X O

Experimental Group

(Y2)

R O O

O

O

X

O

X O

Control Group (Y3) R O

O

O

O

C

- C O

Note. The following is a list of abbreviations used in this table:

Ex = experimental group (Y1 & Y

2)

C = control group (Y3)

R = randomly assigned

TSCS:2 = Tennessee Self Concept, Second Edition

PH:2 = Piers Harris Children's Self-concept Scale, Second Edition

PVV = Personal Visual Vocabulary

CBATx = Cognitive Behavioral Art Therapy

SASSI-A2 = Substance Abuse Subtle Screening Inventory, Adolescent

Sample

This art therapy study was approved and conducted in accordance with the Florida State

University Internal Review Board and Human Subjects Committee in 2012 and was revised and

renewed in February 2013 and February 2014. Involvement in this study was voluntary;

participants volunteered after seeing distributed flyers, posters, or hearing about the study by

word of mouth. The wording on the flier stated that the purpose of the study was to measure

levels of self-concept after using art materials in a small-group setting. Informed consent was

obtained from all of the participants and parents/guardians as required by the aforementioned

board and committee. During the initial intake interview, the parents/guardians of the adolescents

were informed of the purpose of the study, but the participants were not, in order to avoid the

Hawthorne Effect, according to which participants alter their behavior as a result of being part of

a study. Additionally, the parents/guardians and the participants were informed that the study

was “double- blind” in that neither the participants nor I would know who qualified as the

sample, as I did not access intake data until the study was complete.

After attrition, data was collected for 23 voluntary participants from three small public

schools in north Florida. Six participants from the experimental groups qualified as the sample

for the first intervention (n=6), five participants qualified as the sample for the second

34

intervention (n=5), and three participants qualified in control group (n=3). Participants’

qualifying criterion was determined following the closing of study.

Setting

All sessions were held in an after-school art therapy program. Confidentiality was held

constant as the designated classroom was isolated from other after-school programs but used

consistently for art-related purposes and/or tutoring services. Additionally, the door was locked

from the exterior, but not from the interior. Artwork was photographed and then stored in

individually made portfolios labeled with the client’s participation number and self-generated

pseudonym. Confidential documents were held in a secure locked cabinet and clinical notes were

composed on a computer independent of the school’s networking system. All school personnel

were informed regarding the necessary ethical responsibilities of the therapist and the rules of

confidentiality. As with all after-school programs offered, snacks were provided by parents, the

therapist, the school, and/or the participants themselves.

Procedures

After completing the initial intake questionnaire, all volunteer participants completed the

SASSI-A2 and PH:2, chose pseudonyms, and were randomly assigned to one of two

experimental groups or one control group. Once the volunteers were randomly assigned to either

the control or an experimental group, the observations were conducted over three meetings that

were not included in the weekly session count (see Table 2). These observations proceeded as

follows:

Prior to beginning the first intervention, random participants from the experimental

groups (R-Y1 and R-Y

2) and all participants from the control group (Y

3) completed the

TSCS:2 (O1).

After participating in the first intervention (X1), but before the second intervention,

random participants from the experimental groups (R-Y1 and R-Y

2) completed a second

administration of the TSCS:2 (O2).

All experimental subjects participated in a review based on the Analytical Art Criticism

Model (Anderson & Milbrandt, 2005).

After participation in the second intervention (X2), all participants from both the

experimental groups and control group (Y1, Y

2, and Y

3) completed a third administration

35

of the TSCS:2 (O3) and participated in an individual review based on the ETC and the art

therapy study’s therapeutic objectives and criterion.

The results from these instruments were not examined or scored until the completion of the

study. The data were summarized and reported using descriptive statistics. Clinical documents

and client artwork was examined and discussed using standardized art therapy assessment

protocols and qualitative analysis. The total testing and interview hours did not exceed two

contact hours for any individual.

Table 2. Assessment schedule with total collected data/scores for three group participants, over

all three observation period.

Group Intake SASSI PH:2 TSCS:2 PVV TSCS:2 CBATx TSCS:2

O1 O

1 O

1 O

1 X

1 O

2 X

2 O

3

Y1

Non-qualified

n=6 n=6 n=6 n=5 n=6 n=0 n=3 n=3

Y1

Qualified

n=4 n=4 n=4 n=4 n=4 n=4 n=4 n=4

Y1

Total Tuesday

n =10 n =10 n =10 n=9 n =10 n=4 n =7 n =7

Y2

Non-qualified

n =7 n =7 n =7 n=0 n =7 n=0 n =7 n =7

Y2

Qualified

n=2 n=2 n=2 n=0 n=2 n=0 n=2 n=2

Total Thursday n=9 n=9 n=9 n=0 n=9 n=0 n=9 n=9

Y3

Non-qualified

n=1 n=1 n=1 n=1 n=0 n=0 n=0 n=1

Y3

Qualified

n=3 n=3 n=3 n=3 n=0 n=0 n=0 n=3

Total Control n=4 n=4 n=4 n=4 n=0 n=0 n=0 n=4

Grand Total n=23 n=23 n=23 n=13 n=19 n=4 n=16 n=20

The presenting problem, goals, and long-term objectives for the experimental group

interventions were stated as:

Presenting problem: need for increased positive self-concept,

Group Goals: increase positive self -concept through familiarity with art materials, visual

symbol development, and autobiographical story telling; and

Long-Term Objective: development of a PVV for therapeutic storytelling.

36

The weekly directives for the experimental groups’ eight 90-minute art-education-based

sessions were as follows (see Table 3): Session 1 included establishment of group rules and

confidentiality and media exploration based on a power animal symbol from a set of Native

American Medicine cards. Session 2 focused on Rhyne’s (1979) work on mind-state drawing

directive and used I-Ching cards to create a line drawing. Sessions 3 and 4 involved discussions

on icons and symbols, the development of personal symbols associated with a “Love/Hate” or

“Adore/Loath” list in the form of a “T-chart,” followed by the creation of a construction paper

radial collage based on Matisse style shapes. Sessions 5 and 6 focused on exploring color

psychology to identifying an “inside” color and an “outside” color and using those colors to

create a value scale and central painting. Session 7 focused on identifying an archetypal or

personal symbol and creating that symbol three dimensionally using clay. Session 8 focused on

helping each individual identify his or her PVV using the Anderson CritCard method as a guide.

Random participants were given the TSCS:2 between the interventions.

The directives for the Cognitive Behavior Art Therapy groups’ eight 90-minute sessions

were as follows (see Table 3): Sessions 1, 2, and 3 included a review of confidentiality and group

rules, individual symbol exploration, art storytelling using past-present-future stories, and

instruction on Japanese accordion-fold book binding techniques. Session 4 focused on relaxation

techniques and anxiety issues using body-breath painting. Participants made single word

associations for each drawing and completed a “free” painting. Session 5 focused on cognitive

reframing through problem-solution collages and the choice of telling a fact or fiction problem

and solution. Session 6 involved identifying and documenting the four feeling states and the

choice of telling a fact or fiction feeling state story. Sessions 7 and 8 focused on completing the

personal visual narrative books and final critique using the End of Study Objective/Criteria

Assessment Questionnaire (see Appendix I). During the closing session (the final observation for

the end of the study), the group met to complete the TSCS:2 and create artist trading cards to

share. The total contact hours for the individuals involved amounted to 24 hours of group

participation and a maximum of two assessment hours for each client.

A snack was made available to the participants before the sessions started and every

session began with a review of confidentiality, group rules, and an opportunity to discuss any

unfinished business from the previous week. Every session ended with a discussion based on

what went well or what was unexpected using a “round-robin” method.

37

Table 3. Art Therapy Study Directives for the Two Experimental Interventions, X1 and X

2

Sessions Y1

(Tuesday) & Y2 (Thursday) Y

3

O1 Winter 2012

Intake, SASSI-A2, PH:2, TSCS:2,

Winter 2012

Intake, SASSI-A2, PH:2, TSCS:2,

X1 PVV

1 Establish Rules, Confidentiality, & Procedures

Media Exploration (Native American Animal Cards)

2 Elements of Art: Line

Painted Line Drawings (Rhyne & I-Ching Cards)

3 Elements of Art: Shape Adore/Loath List

(Jungian Personal Symbols)

4 Elements of Art: Shape

Radial Collage (Matisse)

5 Elements of Art: Color & Value

Inside/Outside Colors (Color Psych)

6 Elements of Art: Color & Value

Inside/Outside Mandala (Color Psych)

7 Elements of Art: Form

Three-dimensional Clay Symbols (Jungian Archetypes)

8 Critical Analysis

Anderson CritCard

(Jungian Archetypes and Personal Symbols)

O2 TSCS:2:

X2 CBATX &

Visual Narrative

1 Establish Rules, Confidentiality, & Procedures

Media & Symbol Exploration

(Art Cards & Japanese Tarot Cards)

2-3 Symbols & Past Present Future Stories

Book binding techniques

(Art Cards & Japanese Accordion Book)

4 Watercolor Body Breath Exercises

Image-Word Association

5 Problem-Solution Collage/

Fact or Fiction Reframe story

6 Feeling States/

Fact or Fiction Personal Narrative

7 Narrative Art

Japanese Accordion Book

8 Narrative Art & Individual Critiques

Japanese Accordion Book & Questionnaire

O3

Closing and TSCS:2

Artist Trading Cards

TSCS:2

38

Assessment Tools and Instruments

As previously discussed as the primary problem, identifying CoA who are high-achieving

and demonstrate a low probability of SUD is difficult, at best. Although this population often

conceals a variety of psychological, emotional, and physical issues caused by their parents’

SUDs, most of the participants were willing to disclose academic history and familial alcohol

issues on the intake questionnaire. Although the SASSI-A2 cannot guarantee that a sample is

substance-use free, it is one of the few clinically based screening instruments currently available

for this population. Other types of drug tests, specifically, technical examinations of urine, blood,

semen, sweat, and oral fluid samples, were deemed inappropriate for this study.

To avoid the possible effect of test-retest validity issues, the PH:2 was used to measure

the self-concept of all participants and correlated with the TSCS:2. According to the TSCS:2

manual, the correlation of the TSCS:2 subtest scores, including the TOT scores, have a

correlation value of .66 and above (Fitts & Warren, 2003; See Appendix C). It should be noted

that the questions on the PH:2 are overt, and participants may recognize the nature of the study

and answer accordingly. The primary dependent variable data was measured using the TSCS:2.

The intention of administering a pretest, midtest, and posttest assessments using the TSCS:2

were to elicit comparative data on the efficacy of the specific experimental tool, the construction

of a PVV and/or CBATx, in improving positive self-concept. To provide additional information

on the participants’ clinical state, the participants’ artwork was reviewed using the Depression

Scales, a portion of the FEATS, and the TSCS:2 summary scales that corresponded to Beck’s

theory of internal communication system and the Substance Abuse Subtle Screening

Inventory, Adolescent (SASSI-A2)

The SASSI-A2 is a brief screening tool designed to identify individuals’ probability of

having a substance-related disorder (Miller, 1999). The SASSI-A2 has proven effective even

with individuals who are unable or unwilling to acknowledge relevant behaviors; its decision

rules yield an overall accuracy of 94% (NIAAA, 2013). Since 1990, an adolescent version of the

SASSI has been available. The second version of the Substance Abuse Subtle Screening

Inventory, Adolescent, the SASSI-A2, has a 94% overall accuracy of identifying an adolescent

with a substance-dependence disorder, including both substance abuse and substance

dependence. The SASSI-A2 is designed to screen individuals who are 12 to 18 years old. The

39

accuracy of the SASSI-A2 is not affected by the respondent’s gender, age, ethnicity, education,

employment status, living situation, prior legal history, or general level of functioning.

Piers-Harris Children’s Self-Concept Scale, Second Edition (PH:2)

The second edition of the PH:2 provides a total score and six subscale scores in addition

to two validity scores based on the adolescent’s own perceptions of him- or herself (Piers, Harris,

& Herzberg, 2002). The scale assesses self-concept of individuals, ages seven to 18, and is

written at a second-grade reading level. The test requires approximately 10 to 15 minutes, and

the participant responds “yes” or “no” to a list of descriptive statements. Information retrieved on

the PH:2 was as follows:

Reliability. The PH:2 is comprised of nationally representative norms based on a sample

of nearly 1,400 students, ages 7 to 18, recruited from school districts throughout the United

States. The reported internal consistency scores were .91 for the total score and .69 for the two-

week test-retest score.

Validity. Interscale correlation analysis provides evidence that domain scales on the

PH:2 demonstrate moderate to high correlations with each other. The domain scales also

correlate strongly with the overall total score (Community University Partnership for the Study

of Children, Youth, and Families, 2011).

The Tennessee Self Concept Scale, Second Edition (TSCS:2)

The Tennessee Self Concept Scale, Second Edition is a self-report instrument that has

been normed on an age-stratified sample of more than 3,000 individuals from seven to 90 years

of age (Fitts & Warren, 2003). The TSCS:2 can be administered individually or in a group

setting in about 15 minutes and has been proven one of the most reliable self-concept tests

available; it is in concordance with the Minnesota Multiphasic Personality Inventory-2

(MMPI:2). Information retrieved on TSCS:2 was as follows:

Reliability. The reliability estimates for all TSCS:2 scales are retest coefficients based on

a sample of 60 college students over a two-week period and in general range from .60 to .90.

Validity. The manual presents correlations between the TSCS:2 scales and those of the

MMPI:2, the Edwards Personal Preference Schedule, and several other well-known measures. A

great many of these correlations are significant—so many, in fact, that where the MMPI is

concerned, it appears that the two inventories nearly overlap. Researchers have reviewed a

40

number of factor-analytic studies and concluded that none supports Fitts’ specific hypothesis of

15 dimensions of self-concept (Center for Psychological Studies, Nova, 2008).

Formal Elements Art Therapy Scale (FEATS)

The Formal Elements Art Therapy Scale is an art therapy assessment that was normed for

adults (Gantt & Tabone, 1998). The purpose of the FEATS, used in conjunction with the Person

Picking an Apple from a Tree (PPAT) assessment (standardized by Gantt, 1990/2000), is to

provide a method for understanding how adults draw, rather than what they draw, in order to

analyze possible graphics correlated to DSM-IV criteria for specific disorders. The FEATS is

comprised of 14 scales; these scales are labeled as, #1 prominence of color, #2 color fit, #3

implied energy, #4 space, #5 integration, #6 logic, #7 realism, #8 problem solving, #9

developmental level, #10 details, #11 line quality, #12 person, #13 rotation, and #14

perseveration. This study examined the participants’ artwork using the depression scales, which

include scales one, two, three, four, ten, eleven, and twelve.

Reliability. The authors used 37 raters across the different groups of raters to rate 30

drawing from their pilot sample. Interrater reliability was reported to be .90 or higher for eight of

the 14 scales. Of the remaining scales, the rotation and perseveration scales did achieve interrater

reliability, neither of which was used in this study. Reliability for use in this study may be in

question, as the FEATS has not been normed for children or adolescents.

Validity. Of the remaining twelve scales, the authors reported that 10 scales significantly

correlated to the DSM-IV diagnostic groups of major depression, bipolar disorder/mania,

schizophrenia, and delirium, dementia, amnesia, or other cognitive disorders. This study only

used scales associated with the diagnoses of major depression and validity may be question, as

the FEATS has not been normed for children or adolescents.

Internal Threats to Validity

Subjects’ characteristics may have been affected by the degree of parent(s)’ substance use

disorder issues, socioeconomic background, previous counseling, support circle (family, friends,

and community), and previous level of art education. This study was designed to address the

following internal threats to validity:

History. The treatment and control groups were tested at similar times and in similar

settings.

41

Maturation. Maturation issues were addressed by pre- and post-testing a control group

(without intervention) over a 24-session period.

Thus, the control group mean was compared to the experimental groups to ensure the increase in

self-concept did not naturally occur over time in the sample population.

Testing. The pretest may have alerted the participant to the self-concept issue. One

treatment group did not take the TSCS:2 as a pretest, and random treatment participants were

given the midtest. All participants took the PH:2 as a pretest and the TSCS:2 as a posttest, which

were highly correlated.

Instrumentation. Instrumentation may have threatened the internal validity if the

researcher/therapist’s characteristics were too varied. However, the same therapist(s) and

directives were used throughout the study. The TSCS:2 was used in all three observations, and

the PH:2 scores were then used to replace missing TSCS:2 pretest scores to validate the effect of

the independent variable. Additionally, the FEATS is normed for adults, although the use of the

depression scales with these participants was deemed appropriate and may contribute to further

studies to establish validity and reliability for use with children and adolescents.

Regression. The mean differences include the extreme scores for both the control and

treatment groups.

Selection. All volunteer participants were randomly assigned one of two treatment

groups or the control group.

Mortality. Because of the size of the study, mortality could have been an issue; however,

the researcher was prepared to form an additional set of groups and repeat the study if necessary.

As the treatment group’s dropout rate was higher than the control group’s rate, this remained an

issue; and because the sample size was so small, all inferences must be viewed with caution.

External Threats to Validity

Interaction of testing, selection, and “X.” Extraneous variables that may have affected

the hypothesis include (1) the degree of parent(s) alcohol-related disorder(s) and subsequent

behavior, (2) socioeconomic background, and (3) extent of emotional support (family, friends,

and community).

Reactive arrangements. The volunteers for both the treatment and control groups were

from small public schools and may not be representative of the sample population at large.

42

Data Collection and Evaluation Procedures

The data collected were both quantitative and qualitative in nature and included self-

reported information from the intake interview, SASSI-A2, PH:2, TSCS:2, and coding of

patterns observed in participants’ artwork and self-reports as recorded in the researcher’s clinical

notes. The SASSI-A2, PH:2, and TSCS:2 are norm referenced to older children and adolescents.

The FEATS is normed for adults, but was used appropriately in this study.

The intake and screening data were recorded electronically for each individual, which

facilitated comparison, grouping, and regrouping of data for statistical analysis (see Appendix

D). The quantitative outcome data of the TSCS:2 and the PH:2 were also recorded electronically

for each individual and used for comparative data analysis using IBM’s Statistical Analysis in

Social Science, previously known as by the acronym SPSS.

In order to establish a baseline for self-concept before participating in the study and avoid

the testing error for internal validity, all of the original participants took the PH:2. Randomly

selected experimental subjects, as well as all of the control group subjects, took the TSCS:2

before beginning the study. According to Fitts and Warren (2003), the correlation coefficient

between the two self-concept instruments ranged from 0.51 to 0.80, with the Total Self-concept

(TOT) scores correlation coefficient as 0.66. The TSCS:2 manual’s reported correlation

coefficient (r = 0.66) agrees with the PH:2 manual (Piers, Harris, & Herzberg, 2009), therefore

the correlation coefficient of 0.66 was used in the analysis of this study’s data (see Appendix C).

Specifically, using the correlation table between the PH:2 and TSCS:2, 15 separate paired

t-tests were performed on the subtest scores, including the TOT scores and the supplemental

scores for the domains of O1 to X

1 and O

1 to X,

for all the participants (see Appendix J). The

tests were performed again for the qualified sample group. The paired t-tests were used to

compare how the experimental and control groups performed before and after an intervention, as

well as over the course of both interventions. For the subtests, which had a significant change in

p-values (p < .05) or at least one p-value that was greater than (p > .05) and the set significance

value of 0.05 (sig = 0.05), it was necessary to look into the distribution of difference and the

pattern of change in the mean scores to identify the effects of X1 (PVV) and X

2 (CBATx).

The TSCS:2/PH:2 supplementary scores from the participants’ individual butterfly charts

were evaluated, as they appeared to correspond to Beck’s (1997) theories around internal

43

communication. Specifically, this refers to negative self-statements, arbitrary reference, and

biased processing. According to Fitts and Warren (2003):

The Supplementary scores are groups of TSCS:2 items from each Self-Concept

subscale that have historically been classified as expressing one of three primary

messages: (a) this is who I am, this is how I identify myself or Identity (IDN); (b)

this is how satisfied I am with myself, or Satisfaction (SAT); and (c) this is what I

do, this is how I behave, or Behavior (BHV). These are scores that have been

delineated on a theoretical basis only, and they are assumed to represent an

internal frame of reference within which the individual describes himself or

herself. (p. 25)

In order to elucidate these findings further, the qualitative criterion for each activity was

rated by using measurable objectives. Moreover, the qualified sample’s artwork was analyzed in

comparison to matched experimental subjects’ artwork. The measurable objectives were: The

participant utilized art materials to 1) identify, categorize, and create feeling states, 2) reduce

anxiety, associated with feeling states, 3) generate solutions to problems, 4) construct a PVV to

identify, categorize, and generate symbolic content in artwork, 5) apply the PVV to address the

participant’s familial issues in a visual narrative format, as evidenced by participant artwork,

clinical notes, or self-report, and 6) explore levels of the ETC by using a variety of media.

Further evaluation of the artwork was conducted by using Gantt and Tabone’s (1998)

Depression Scales, a portion of the FEATS (see Appendix F) and Lusebrink’s (1990) theory of

the ETC (see Appendix G). Specifically, Lusebrink’s ideas on formal elements, associated with

“masked depressive reactions,” alexithymia, and Jungian theory on symbol development were

recorded. A guided critical analysis and group discussion were completed using an adaptation of

Anderson and Milbrandt’s (2005) Analytical Art Criticism Model (see H). Finally, the

experimental participants were given the opportunity for a closing review, during which we

reviewed the therapeutic objectives and the study criteria, using an End of Study

Objective/Criteria Assessment questionnaire (see Appendix H). The subjects used a Likert scale

to rate themselves as No (1) = not meeting the objective/criterion; Sometimes (2) = meeting the

objective/criterion; or Yes (3) = met the objective/criterion.

44

Summary

This Art therapy study used a randomized pretest-midtest-posttest experimental research

design with a control group. The purpose of this study was designed to increase the positive self-

concept for high-achieving adolescent children of alcoholics, who demonstrated a low

probability of substance abuse disorders, using Cognitive Behavior Art Therapy (CBATx),

and/or the development of a personal visual vocabulary (PVV). The implication for this study

was reflected in the following hypothesis: Participation in one or both of the art therapy

intervention will significantly increase the level of positive self-concept, as measured by the

correlated total self-concept (TOT) scores for all of the experimental participants or the qualified

sample. The levels of self-concept were measured by statistical analysis of the Tennessee Self-

Concept Scale, Second Edition (TSCS:2), correlated with the Pier Harris Children’s Self Concept

Scale, Second Edition (PH:2) TOT scores during three observation periods.

The convenience sample consisted of nine qualified adolescents out of 23 voluntary

participants from three small public schools in north central Florida. All participants were

randomly assigned to one of two experimental groups or one control group. After completing the

study, the participants were qualified as having met the study criteria, using information from the

original intake questionnaires/instruments. The qualifying participants had the following

attributes: a) adolescent, b) children of alcoholics or children from families with alcohol-use

disorders (CoA), c) high-achieving, and d) demonstrating a low probability of substance abuse

disorders (SUDs).

Participants were offered eight 90-minute weekly sessions of art education-based

directives in constructing a PVV, followed by participating in eight 90-minute weekly sessions,

based on CBATx directives, while working towards a visual narrative, or the opportunity to

participate in a control group. The study used a randomized, three-interval test (O1, O

2, and/or

O3) design with one control group and included two interventions (X

1 and X

2). The control group

took a pre-test (O1) and a posttest (O

2) with an approximate 18-week interval. The art

education-based intervention focused on the construction of a PVV, using the art elements of

line, shape, color, value, and form. The CBATx interventions focused on feeling states, visual

problem-solving, storytelling, and visual narrative development. In keeping with the tenets of art

therapy, all art directives were designed to move the participant around the Expressive Therapies

Continuum (ETC) by providing opportunities to work with a variety of materials.

45

The quantitative outcome measurement instruments for this study were the TSCS:2 and

the PH:2, which were administered pre-interventions for one control group and one experimental

group; administered to a few experimental participants between interventions; and administered

to all the participants at the end of the study. There were post-interventions for all three groups.

Quantitative data were collected, coded, and organized electronically, so they could be

compared, grouped, and regrouped, according to intake information (see Figures 27 to 41). The

qualitative measurements included participants’ artwork, self-statements, and evaluation of pre-

established objectives (see Figures 42 to 48).

46

CHAPTER FOUR

RESULTS

The primary problem addressed in this study was, how to identify and serve adolescent

children of alcoholics (CoA) who were high-achieving and demonstrated a low probability of

substance-use disorders as a mental health clinician. The purpose was to increase this

population’s positive self-concept, a measurable and observable trait related to resiliency, using

one or both experimental art therapy interventions. The specific interventions were a) an art

education-based intervention, “constructing a personal visual vocabulary (PVV),” and b)

Cognitive Behavioral Art Therapy (CBATx) based directives, which included working toward an

image based personal narratives, or the trauma narrative.

As mentioned in Chapter Three, the design and methodology of this study used

techniques to reduce anxiety and stress associated with being identified as a child from a family

with substance abuse issues, or children of alcoholics (CoA). CBATx and art education based

directives were given in a peer-to-peer supportive educational environment in order to create a

sense of belonging, acceptance, and normalization. Furthermore, the focus on personalization of

symbolic content was designed to strengthen the population of interest's self-concept through

individuation while facilitating positive reframing and the non-verbal expression of difficult

thoughts and feelings and family secrets.

Following is a description of the experimental and control group's demographics, as well

as the presentation of both quantitative and qualitative results after attrition. The qualified

sample's artwork, self-statement, and Tennessee Self Concept Scale, second edition (TSCS:2)

supplementary scores were compared to that of the matched sample's corresponding data to

further triangulate the quantitative findings. The qualified sample was consisted of the

experimental groups' high-achieving adolescent CoA who demonstrated a low probability of

SUDs and the matched sample consisted of the experimental groups' non CoA adolescents

demonstrating a low probability of SUDs. These participants were matched in terms of age, sex,

and achievement level. The discussion, implications, and limitations for this study are given in

Chapter Five.

47

Description of the Sample

Qualifying demographic attributes were self-identified using a questionnaire, approved

by the Florida State University Internal Review Board and Human Subjects Committee (see

Appendix B). Participant demographics were self-reported (see Table 4 and Table 14). The mean

ages for the participants were as follows: 13 years in the experimental group, 14 years in the

qualified sample group, and 14.5 years in the control group. The experimental group’s age range

was from 10.2 to 15.2 years, with a mode of 14. The qualified sample group’s age range was

from 13 to 15.2 years with a mode of 14. The control group’s age range was from 13 to 16.9

years with a mode of 13. In the experimental group, 58% reported being children of alcoholics,

whereas 75% of the control group and 100% of the qualified sample indicated familial alcohol-

related issues. Success in school was assessed using the grade point average (GPA) needed to

earn a State of Florida’s Bright Future Scholarship and was self-reported based on current grade

point average. The mean GPA for the experimental group was 3.6, the qualified sample’s mean

GPA was 3.6, and the control group’s mean GPA was 3.8.

Table 4. Self-reported Data on Qualifying Status and Demographics.

All Experimental

Participants (n = 19)

Qualified Sample (n

= 6)

Control Group

(n=4)

Familial Alcohol Use

Disorder

CoA

Not

CoA

56%

44%

100% 75%

25%

Age Range

Mode

Mean

10.19-15.19

14

M: 13.01, SD 1.65

13-15.19

14

M: 14.22, SD .86

13-16.91

13

M: 14.6, SD 1.69

Grade Point Average

(GPA)

M=3.6; SD=0.47 M: 3.6, SD: 0.38 M: 3.78, SD: 0.26

Sex Female

Male

55%

45%

17%

83%

100%

Race/Ethnicity Other

Asian

Black

White

11%

0%

26%

63%

0%

0%

33%

67%

0%

0%

0%

100%

Note. The following is a list of abbreviations used in this table:

CoA = Children of Alcoholics

n = number of participants

M = mean

SD = standard deviation

48

For the purpose of this study, the terms ‘sex’ and ‘race’ were defined in the following

way: Sex was listed as male or female, and race was listed as white, black, Asian, or other.

Persons who identified as Hispanic, Native American, or any other race or ethnicity had the

option of choosing “black, white, Asian, and/or other” with a space for further delineation, as

desired by the participant. Although some of the participants discussed various options with me

at the intake, only one participant chose “other” but did not elaborate. Out of the experimental

participants, 47% reported their sex as female, 13% of the qualified participants reported their

sex as female, and 100% of the control group reported their sex as female. With the four

racial/ethnic groups listed—White, Black, Asian, and other—the participants were self-identified

as follows: the experimental group was 63% White, 26% Black, 0% Asian, and 11% other. The

sample was 67% White and 33% Black. The control group was 100% White.

Quantitative Results

Results for Qualified Sample

The qualified sample consisted of six participants (n=6) for the first intervention and five

participants (n= 5) for the second intervention. However, not all of the participants in the

qualified sample used the Tennessee Self Concept Scale, Second Edition (TSCS:2) during all

three observation periods. Therefore, the statistical results suggest that we proceed with caution

when calculating the effect size.

Nonetheless, initial results from the paired t-test indicated that there was no statistically

significant difference in the correlated TSCS:2 and the Piers-Harris Children’s Self-Concept

Scale, Second Edition (PH: 2) total self-concept score (TOT) score means for the qualified

sample, following the participation in one or both interventions (see Figures 1 and 2).

Specifically, using the correlation table between the PH:2 and TSCS:2, the TOT score means, for

the domains of O1 to O

2 and O

1 to O

3 for the qualified sample, indicate there was no significant

change in p-values after the first intervention (t = -2.16, p = 0.1630), or after both interventions(t

= -1.52, p = 0.2034). In other words, the p-values were greater than the set significance value of

0.05 (sig = 0.05); this indicates an acceptance of the null hypothesis for the qualified sample.

Moreover, it was necessary to examine the distribution of difference and the pattern of change in

the score means to identify the effects of X1

(PVV) and X2 (CBATx) on the qualified sample.

49

Figure 1. T-test statistics output for TOT of

qualified sample from O1 to post-X

1.

Figure 2. T-test statistics output for TOT of


2.

Figure 3. Distribution of difference for


1.

Figure 4. Distribution of difference of


2

Figure 5. Paired profiles for qualified sample

from O1 to post-X

1.

Figure 6. Paired profiles of qualified sample

from O1 to post-X

2.

50

Table 5. TOT Scores, Means Percentage of Change after Each Intervention for the Qualified

Participants and the Control Group

The distribution of difference for the qualified sample (see Figures 3 and 4) shows a normal

distribution of means after the first intervention (O2) but clearly demonstrates an outlier in the

final observation after both interventions (O3). Possible reasons for this skew will be commented

on in the discussion section of this text.

The results of the paired profiles for the qualified sample (see Figures 5 and 6) indicate

that the trend of scores increased significantly from observation one (O1) to observation two

(O2). The trend of scores continued to increase slightly over the course of the whole study, as

indicated at observation three (O3). Furthermore, in calculating the percentage of increase, the six

qualified subjects from the experimental groups (Y1 +Y

2), who were measured after the first

intervention (X1), demonstrated significant improvements in positive self-concept (O

2; +24%).

Additionally, the five qualified subjects (Y1 + Y

2), who participated in both interventions (X

1 +

X2), demonstrated a higher improvement in positive self-concept (O

3; +16.5%), in comparison to

the three qualified subjects (Y3) from the control group (O

3; +6.7%). As both groups’ TOT score

means increased over time, we may calculate the maturation error by simply subtracting the

percentage of TOT score means’ increase for the control group from the percentage of TOT

Ex Ex Ex Ex Ex Ex C C C Ex C

ID

Number

01 03 21 16 09 12 17 18 20

Group Y1 Y

1 Y

1 Y

1 Y

2 Y

2 Y

3 Y

3 Y3 Y

1 +Y

2 Y

3

n=6 n=3

TSCS:2/PH:2 TOT O1 36 56 52 54 41 41 52 59 68 M=46.7

SD=8.3

M = 59.66

SD = 6.58

PVV X1 1 1 1 1 1 1 0 0 0

TSCS:2

TOT

O2 57 59 62 54 - - M=58

SD=8.5

Percentage of

change

+24%

CBATx X2 1 1 0 1 1 1 0 0 0 n=5 n=3

TSCS:2

TOT

O3 35 56 - 59 50 72 61 62 68 M=54.4

SD=13.5

M = 63.67

SD = 3.10

Percentage of

change

+16.5% +6.7%

Total Percentage of Change for Qualified Sample +9.8%

51

score means’ increase for the experimental groups. Therefore, the statistic demonstrates a 9.8%

increase for the experimental group, after the group participated in both interventions (O3; see

Table 5).

Figure 7. T-test results for the control group.

Figure 8. Distribution of difference for the

control group.

Figure 9. Line of projection for the control

group.

Results for Control Group Sample

The control group consisted of four participants; three of the subjects qualified as high-

achieving, adolescent CoA, who demonstrated a low probability of SUDs. As with the qualified

sample, the corresponding results for the control group for the paired t-test indicate a p-value that

was greater than 0.05, (O3; t = -1.51, p = 0.2278; see Figure 7). Therefore, the probability of

52

significance is inconclusive. However, the distribution of difference plot indicates a normal

distribution (see Figure 8). In addition, the paired profile plot indicates a minimal positive

increase in self-concept (see Figure 9), which is also indicated with the difference in increase for

the control group's percentages of means (+ 6.7%; see Table 5). This information is useful for the

purpose of the control group; we may subtract the control group’s percentage of increase for the

score means from that of the qualified sample and that of the experimental group in order to

calculate the percentage of increase accurately.

Results for All of the Experimental Participants

The total number of participants from the experimental groups, both qualified and not

qualified, for the first intervention was 19. The total for the second intervention was 16. As with

previous results, not all of participants took the Tennessee Self Concept Scale, Second Edition

during all three observation periods Therefore, the statistical results suggest that we proceed with

caution when calculating the effect size.

Nonetheless, the initial results from the paired t-test indicated that there was a statistically

significant difference in the correlated TOT scores for all experimental participants, after the

participation in both interventions at observation three (O3), but not after the first intervention

(see Figures 10 and 11). Specifically, for the domains of O1 to X

1, the statistics were O

2, t = -

3.44. p = 0.0698, and for the domain of O1 to X

2, the statistics were O

3, t = -4.71, p = 0.0002).

In other words, after both interventions, the p-value was less than the set significance value of

0.05 (sig = 0.05), which indicates a rejection of the null hypothesis.

As with the qualified sample, to further elucidate the effects of X1 (PVV) and/or X

2

(CBATx), an examination of the output data provided important information. Specifically, this

refers to the distribution of difference (see Figures 12 and 13) and the plots of paired profiles

indicated (see Figures 14 and 15). The distribution of difference shows a normal distribution of

means after each intervention. Furthermore, the trend lines from the paired profile plots

demonstrate a significantly increase, after the PVV intervention, which continues over the course

of both interventions.

For the calculation of the percentage of increase, the participants from the experimental

groups, who participated in both interventions (X1 + X

2), demonstrated a higher improvement in

positive self-concept (O3; +14.4%), in comparison to the participants from the control group (Y

3;

O3; +6.3%). Because the TOT score means for both groups increased overtime, we can calculate

53

the maturation error by subtracting the percentage of TOT increase for the control group from

the percentage of TOT increase for the experimental groups. This statistic demonstrates an 8.1%

increase in TOT score means for the participants from experimental group at observation three

(O3). The TOT score means for each observation and the percentage of change for all the

participants are presented below in Table 6.

Summary of Quantitative Results

A paired t-test was used to calculate total self-concept (TOT) scores for the qualified

sample, all the experimental participants, and the control group. Levels of self-concept before

and after each of the two interventions were compared. The results indicated statistical

significance for all the experimental participants after both interventions using the set

significance value of p<0.05 (Y1+Y

2; O

3; t(18) = -4.71, p = 0.0002), or from Observation One

(O1; M = -10.5, SD = 7.6), to Observation Three (O

3; M = -14.4, SD = 13.3), based on the

correlated TSCS:2/PH:2 TOT scores. The number of computed TOT scores from the qualified

sample were too small to infer a significant effect value at Observation Two after the first

intervention (O2 ; t(2) = -2.16, p = 0.1630), or at observation three after the second intervention

(O3;

t(4) = -1.52, p = 0.2034); therefore, the percentages of change for the TOT score means

were calculated.

The qualified sample demonstrated a 24% increase in positive self-concept at

Observation Two (O2) and maintained a total increase of 16.5% at Observation Three (O

3). All

of the experimental participants demonstrated a 14.4% increase in positive self-concept over the

course of the study (O3). Moreover, the control group demonstrated a 6.7% increase of positive

self-concept (O3). In other words, according to the linear trend lines, the difference in mean TOT

score means indicated a positive increase for the qualified sample after the first intervention, and

the positive increase continued until the end of the study (O3).

According to the trend lines and

percentage of increase across both interventions and all three data collection points of the

TSCS:2/PH:2 TOT score means, the qualified sample, as well as all the participants in the

experimental groups, the qualified and nonqualified sample, (Y1 and Y

2), increased their

positive self-concepts by at least 8% (see Table 6).

Based on these results, we may infer that 16 weeks of art therapy sessions increased the

positive self-concept for high-achieving adolescent CoA, who demonstrated a low probability of

SUDs. Additionally, we may reject the null hypothesis, as the effect value was less than the set

54

significance value (p < .05) for all the participants, after they participated in both interventions.

Additionally, the results indicated that constructing a PVV increased positive self-concept at a

higher rate than both constructing a PVV and participating in CBATx with a focus on creating

visual narrative (see Table 6 and Figure 16).

Figure 10. T-test statistics output for tot of

experimental groups from O1 to post-X

1.

Figure 11. T-test statistics output for tot of


2.



1.



2.


from O1 to post-X

1.


from O1 to post-X

2.

55

Table 6: TOT Scores, Means, Standard Deviation, and Rate of Increase for all Participants

Figure 16. Comparison of group TOT score means at observations O

1, O

2, and O

3.

46.7 44.6

59.7 58 59.3 54.4

59.1 63.7

0

10

20

30

40

50

60

70

Qualified Sample Qualifed and

Nonqualified

Participants

Control Group

TO

T G

rou

p M

ea

ns

Groups

Comparison of Group TSCS:2/PH:2 TOT Score

Means

Pre-Interveions - O1

After PVV - O2

After PVV and CBATx - O3

Y1

+ Y2 Y

3

n=23 n=4

TSCS:2/PH:2 TOT O1 M = 44.6; SD = 10.05 M = 60.0; SD = 6.6

Intervention X1

n=4

TSCS:2 TOT O2 M = 59.25; SD = 2.06

Percentage of Change +14.65%

Intervention X2

n=19 n=4

TSCS:2 TOT O3 M = 59; SD = 10.9 M = 63.8; SD = 3.10

Percentage of Change +14.4% +6.3%

Y1

+ Y2 - Y

3 = ^8.1%

56

Qualitative Results

Sample and Matched Experimental Participants

The sample’s artwork was evaluated for symbolic content and graphic indicators. Then,

the artwork was compared to a sample of nonqualified experimental subjects’ artwork, the

matched sample (see Appendix K). Clinical notes were scanned for negative self-statements that

were made during the aesthetic criticism process or the final individual evaluation. Although I

noted several disruptive behaviors and a few negative self-statements, there were not enough

incidents to draw meaningful conclusions over time. Therefore, the individual supplementary

scores of the TSCS:2 that corresponded to Beck’s theory of internal communication system were

evaluated. Additionally the participants’ artwork and self-statements that were made during the

art criticism process provided interesting information that substantiates increased self-efficacy

and positive self-concept.

The FEATS major depression scales. According to Gantt and Tabone (1998), the

purpose of using the FEATS in drawing analysis is to focus on how the participants draw, rather

than what they draw; this is meant to provide objective information on the non-symbolic aspects

and structural characteristics of the art. The FEATS was developed primarily for use with adults

and for use in conjunction with the PPAT assessment. Therefore, the ratings may not be accurate.

The authors listed the following characteristics in the FEATS scales as graphic equivalent of

major depression symptoms; a) depressed mood, which includes scale #1-Color Prominence and

scale #2-Color Fit; b) loss of energy, which includes scale #3-Energy and #4-Space; and c)

diminished interest, which includes scale #7-Realism, scale #10-Details, and scale #12-Person.

The artwork by the qualified sample, who participated in both interventions, was

compared to the artwork by matched (age and sex) members from the experimental group. This

comparison was made by using the scales that Gantt and Tabone associated with the DSM-IV

criteria for Major Depression. The specific scales used were: Color Prominence, Color Fit,

Energy, Space, Realism, Details, and Person (See Appendix E).

The FEATS scales range from zero (no drawing) to five (meaning varied per scale), with

a three being more or less average. The mean for the qualified sample’s artwork, after the first

intervention, (O1 to O

2) was 3.1, as compared to the mean for the matched participants, which

was 3.4. The mean for the qualified sample’s artwork, after the second intervention (O1 to O

3),

was 3.4, as compared to the mean for the matched participants, which was 3.6 (see Figure 17).

57

Figure 17. FEATS depression scale ratings at O

2 and O

3.

Figure 18. Cluster of simple means for FEATS major depression score scales.

3.1

3.4 3.4

3.6

2.8

2.9

3

3.1

3.2

3.3

3.4

3.5

3.6

3.7

PVV CBATx

FE

AT

S s

cale

Ra

tin

g

Interventions

Comparison of Sample

Means for FEATS Major Depression Scale

Qualified Sample

Matched Sample

Linear (Qualified Sample)

Linear (Matched Sample)

0

1

2

3

4

5

6 1

2.5 2.5 2 3.5 2.5

3.25 3.75

3 4

3.6 3.6 3.6 3.6 2.7 3.6 2.8

2.4 4.2

4.2 3.3

3.8 3.4

3.5 1 1 2.8 4 3.4 3.6 4.6 2.5

2.5 2.5

3.25 4.75

2 3.75

3.75 3

3.5 2.75

3 4.25

5 3

4.5 3.75

3.5 2.5

4.5 3 5 5 5

Distribution of Sample Means for

FEATS Major Depression Scale

Scores

58

Figure 19. Comparison of sample means for a specific outlier scale score on the directive

entitled, The Element of Line.

On a scale from one to five, even a half-point increase seems significant. As indicated

previously, the linear trend lines demonstrate that the average graphic equivalents for depression

decreased during the course of both interventions. Furthermore, the scale score means for both

groups at both observations was equal to or above the average score means (<=3.0), as indicated

by the clustering of FEATS scale score means in Figure 18.

In the examination of specific paired outlying scores for specific directives, it was noted

that both the qualified and matched samples demonstrated similar means, as seen in Figure 19.

This indicates that there was a similar response from both the qualified sample and the matched

sample in creating the artwork for that specific directive. For example, both of the drawings in

Figure 20 demonstrated low-color prominence and low energy (unfinished work). As all outlying

scores demonstrated patterns that were similar to those shown in Appendix E it may be inferred

that graphic indicators for depression decreased significantly. It may be also inferred that none of

the participants demonstrated the graphic equivalents of major depression symptoms over the

course of the study.

1.8

2.3 2.5

3

2 2

0

0.5

1

1.5

2

2.5

3

3.5

Depressed Mood Loss of Energy Diminished Interest

Qualified Sample

Matched Sample

59

Qualified Participant's Artwork- Nicht Werden

Matched Participant's Artwork - Vortex

Figure 20. Artwork from the qualified sample and the matched sample showing little color and

level of completion.

Beck’s theory of internal communication system and the TSCS:2. Beck’s (1977)

theory of internal communication system, or his cognitive triad theory for depression, suggests

noting a person’s anxiety-producing and self-critical self-statements in order to determine that

person’s sense of self. Specifically, the concepts behind negative self-statements, arbitrary

reference, and biased processing were matched to three TSCS:2 supplementary scores, identity

(IDN), satisfaction (SAT), and behavior (BHV). Increases in these scores indicate a decrease in

negative self-statements. A score between 40 and 70 falls within the typical or average range.

The results indicated that the qualified sample demonstrated an increase of 37% for the

TSCS:2 supplementary mean score from Observation One to Observation Two (O1 to O

2), as

compared to the matched sample's increase of 59%. The qualified sample demonstrated a 24%

increase of The TSCS:2 supplementary mean scores from Observation One to Observation

Three (O1 to O

3). By comparison, the mean increase for the matched sample from O

1 to O

3 was

27%. Finally, the increase from O1 to O

3 for control group was 27% (see Table 7). As previously

60

noted, the rate of increase for both samples was higher after participating in the first intervention

than after participating in both interventions (see Figure 21).

Table 7. Qualified Sample and Matched Sample’s Supplementary Scores Mean Increase

Figure 21. Qualified sample’s percentage of change in TSCS:2 supplementary mean scores related to Beck’s theory of internal communication system.

41

56 51

41

65

52

0

10

20

30

40

50

60

70

O1 O2 O3

T

SC

S:2

Su

mm

ary

Sco

res

Percentage of Change

Qualified Sa ple’s TSCS:2 Scores related to Beck’s I ter al Co u itatio Syste

Qualified Sample

Matched Sample

Linear (Qualified Sample)

Linear (Matched Sample)

01 16 12 03 09 21 Mean 02 04 Mean

Blu

e

De

structo

Bro

dy

Nich

t

We

rde

n

Gh

ost

Ary

an

Sh

iray

uk

i

Vo

rtex

O1

IDN 35 43 37 49 33 47 244/6 40.6 45 33 78/2 39

SAT 29 58 29 58 29 50 253/6 42.1 57 23 80/2 40

BHV 34 35 34 56 39 48 246/6 41.0 46 35 81/2 41

Total Mean 124/3=41 120/3=41

O2

IDN 43 55 61 61/3 53.0 65 65/1 69

SAT 54 61 58 58/3 57.6 69 69/1 69

BHV 53 53 63 63/3 56.9 58 58/1 58

Total

Mean

168/3=56 196/3=65

% of increase +37% +59%

O3

IDN 28 43 61 52 43 227/5 45.4 43 52 95/2 46

SAT 40 66 72 56 46 280/5 56.0 63 61 124/2 62

BHV 31 63 70 52 47 263/5 52.6 48 48 96/2 48

Total Mean 154/3=51 156/3=52

% of increase +24% +27%

61

In examining the individual scores from the qualified sample’s butterfly charts

(see Figure 20), both Blue and Brody presented scores outside of the typical range. In general,

Blue’s low scores, in combination with its low TOT score, indicated a “self-view that is

particularly venerable to situational factors and to the reactions and opinions of others” (Fitts &

Warren, 2003, p. 25). Although Brody’s low scores at Observation One indicated some of the

same issues, regarding negative self-statements, Brody’s above-average cluster, in combination

with an above-average TOT score, indicated inflexibility and a resistance to change. In other

words, Brody may be experiencing biased internal cognitions, based on arbitrary referencing.

Moving around the Expressive Therapies Continuum (ETC). According to Lusebrink

(1990), “The intrinsic qualities of the media influence differentially the levels of information

process involved” (p. 243). The artwork of the qualified samples and matched participants was

analyzed and compared for themes of aggressive, violent, or self-damaging images; Lusebrink

(1990) suggested that these themes are associated with masked depressive reactions. Artwork

was also examined for a) an avoidance of emotional or symbolic content, b) a need for control

over imagery, and c) stereotypical images. Lusebrink (1990) associated all of these factors with

issues related to alexithymia. The goal of an art therapist is to help the client move easily from

“sensory/kinesthetic” interactions with the media to an “affective/perceptual” response during

the cognitive/symbolic processes. When this is achieved, the client is considered to be on the

creative level of the ETC. Achieving the creative level of the ETC suggests the client had begun

the teleological process, needed for self-efficacy and problem-solving

Using Anderson and Milbrandt’s (2005) Analytical Art Criticism Model as a guide, the

groups participated in an aesthetic criticism of their own work (see Appendix H and Appendix

K). In reviewing the qualified sample’s work, as well as the matched participants’ work, the

themes of aggression and violence, solitude, loneliness, and the unknown were noticed. When

examining Nicht Werden’s inside-outside color psychology/ color value painting and line

drawings (see Appendix K, Figure 43), the group asked questions such as, “Are you going into

the unknown? Would you like to have a companion?” Nicht Werden's and a member of the

matched sample, Shirayuki, both expressed anxiety over transitioning to high school; however,

Shirayuki work did not express such heavy thematic content around loneliness and isolation (see

Appendix K, Figure 49). She stated that "exploring the materials" was her focus rather than

62

trying to build a cohesive PVV. Both Nicht Werden and Shirayuki had stated early in the

sessions that they were not familiar with most art processes.

In speaking about his collection of work (see Appendix K, Figure 45), Destructo said,

“These figures have power over evil, mystical figures that have mastered the unknown, are all

seeing, over time and place." Similar in thematic content, a member of the matched sample,

Vortex commented on his line drawing and form pieces, “It looks like sorrow is coming. My

eyes are drawn to the swords." Vortex mentioned that his work seemed “bi-polar” and that

everything has opposites. He continued to state, “There is evil and destruction in the world but

also happiness. These are the opposites” (see see appendix K, Figure 48).

Finally, Blue, who worked on her inside-outside color psychology and color value

painting (see Appendix K, Figure 42) during most of the first intervention, stated the following

about her finished piece, “These are my ancestors. I want to stand out from my ancestors. I want

to leave; I want to be the light. But it looks like I am getting sucked into a tunnel. I am in the

center or a tornado. There is chaos and nothing."

Artwork from the qualified sample featured animals, such as the bat, bird, wolf, dog, and

meerkats; single figures; mountainous, barren, and open landscapes; elements of fire and water;

objects such as food, swords, castles; geometric shapes; and colors of blue, black, and red.

Although the artwork did not feature images of self-harm, the aesthetic criticism process

revealed themes of aggression and violence, as well as loneliness and helplessness. According to

Jungian theory, these free associations are indicators of buried thoughts and feelings about one’s

everyday world. Jung (1968) and Lusebrink (1990) suggested these theme of violence and

aggression, loneness and helplessness, suggest a masked depressive reaction. Although not

classified in the DSM-5 (American Psychology Association, 2013), the idea behind masked

depressive disorder is that these types of overt behaviors disguise the underlying affective

disorder, or depression. Lusebrink described a masked depressive reaction as one type of

response for people who experience trauma.

On the other hand, most of the nonqualified participants’ artwork featured warm colors,

flowers, sports, and other images. During critiques, the participants indicated themes of hope,

nature, and happiness (see Figure 21). A member in the group even stated, “The fire-breathing

dragon looks like it is protecting something good [the ball], rather than planning something

63

destructive. Another participant said about her work, “Everything is very pretty, colorful and

pink. Everything looks exciting.”

My Adore Shape Mandala

My Adore Shape Mandala

Inside Outside Color Psychology

Inside Outside Color Psychology:

Form Sculpture: The Queen of Rods

Form Sculpture: Star

Figure 22. Sample of artwork completed by nonqualified participants from the experimental

groups.

64

In the examination of the artwork, in terms of the ETC, only one of the qualified participants,

Brody, used resistive materials and depictions of real-world objects throughout the study, despite

being offered a variety of materials (see Appendix K, Figure 45). According to Lusebrink

(1990), “Constriction in the expression and experience of emotion as a psychological

manifestation has been defined by the term alexithymia” (p. 225). In other words, Brody

continued to use constrictive or resistive materials and draw representative or perceptual

drawings, rather than explore symbolic content. Although symbolic content may be “read” into

the artwork, Lusebrink (1990) wrote:

“Memories for alexithymic individuals consist predominately of recollection

imagery, whereby the images are simple reproductions of the objects and

situations without any emotional or personal elaborations. The recall imagery has

a stereotypical quality. The objective quality of the recall imagery increases in

traumatic situations (M'Uzan, 1974) ... This inability to form emotional imagery is

also manifested in the lack of dreaming or inability to remember dreams (Apfel &

Sifneos, 1979). Rigidity and stony expression (Krystal, 1979) also are

characteristic of alexithymia. These characteristics indicate a control of the

sensory-motor component as a means to control emotions... ” (p. 226).

As an illustration of these points, Brody’s final personal narrative book was a depiction

of his family’s trips across the country, using postcard-type colored pencil drawings.

Although Brody’s drawings suggest issues related to trauma-based alexithymia, when the

sculptural piece that he created after the first intervention is examined and compared to a

piece that he created after the second intervention, there is movement from a “constricted

form” to a more abstract and organic form. It may be assumed that Brody was

progressing through the ETC (see appendix K, Figure 45).

Evidence of issues related to alexithymia-masked depressive reactions were indicated by

the individuals’ artwork, based on the ETC and Jungian theory. Specific examples are: a)

Brody’s avoidance of the symbolic level, his need for control over the imagery, and the use of

stereotypical images; b) Destructo’s use of violent and aggressive images; and c) Nicht Werden

and Ghost’s minimal use of space and lone figures. Overall, the qualified sample had the highest

rate of incomplete artwork. In comparison to the matched sample’s finished visual narratives, the

qualified sample’s visual narrative, and artwork in general, was characterized by less color, more

65

empty space, constriction, disorganization, and less completeness and meaningfulness (see

Appendix K).

When participating in the final individual critiques, four out of five qualified participants

stated that they had met the therapeutic objectives and criteria for each project most of the time.

Additionally, three of the five felt that they had experimented with various types of media,

movement around the ETC; this implies increased information-processing, problem-solving, and

self-regulation (see Figure 23 and Table 8).

Figure 23. Qualified samples' self-report on the intervention rating scale.

Case Number 01 16 09 12 03 02 04

Pseudonym Blue Destructo Ghost Brody Nicht

Werden

Shirayuki

Vortex

PVV goals 6/3=2 3/3=1 3/3=1 5/3=1.7 6/3=2 9/3=3 6/3=2

CBATx goals 5/2=2.5 2/2=1 4/2=2 4/2=2 6/2=3 4/2=2 5/2=2.5

ETC 1/1=1 3/1=3 2/2=2 2/2=1 2/1=2 3/1=3 3/1=3

Total 2 1.5 2 2 2.3 2.7 2.3

Note. Self-assessment given to participants at the end of the study during individual processing. The

participants used a Likert Scale to rate their performance in meeting the groups' objectives. The scale

range was from one to three, with the following associations:

1 = no, 2 = sometimes, 3 = yes.

2

1 1

1.7 2

2.5

1

2 2

3

1

3

2

1

2 2

1.5

2 2 2.3

0

0.5

1

1.5

2

2.5

3

3.5

Blue Destructo Ghost Brody Nicht Werden

Lik

ert

Sca

le S

core

Me

an

s

Qualifed Participants

Summary of Self Report on Achieving

Goals and Objectives

PVV CBATx ETC Mean

Table 8: Mean Scores for Qualified Sample and Matched Sample's End of Study

Objective/Criteria Assessment Questionnaire

66

Summary of Qualitative Results

The analysis of the qualified sample and the matched sample’s artwork, using the

graphic indicators that were associated with the FEATS depression scales, indicated that none of

these participants suffered from major depression. Moreover, the mean scores for the scales

increased as well during the course of both interventions. When the comparison of individual

scores between the qualified sample and the matched participants indicated an issue, such as a

zero score for color prominence, it was found that the actual directive for the artwork was the

cause.

The TSCS:2 supplementary scores, which correspond to Beck’s theory of the internal

communication system, indicated an increase of means after the first intervention of at least 27%

for both the qualified and matched samples. In reviewing the clinical notes for possible reasons

of Blue and Brody’s outlying TSCS:2 TOT scores, it was found that Blue’s low score of self-

concept and Brody’s high scores, indicated different responses to high levels of personal trauma;

this is associated with the alcohol-related issues of the individuals’ parents.

After reviewing the artwork and self-statements made during the critical analysis

procedures, I agreed with the participants’ assessments of their final objective. I believed that all

the participants effectively developed functional self-symbols through power animals, lines,

shapes, colors, value, and form development. Extraordinary examples of self-symbols were the

participants’ power animals, painted line drawings, inside-outside color paintings, and clay

symbolic forms. Evidence that issues, related to alexithymia or masked depressive reaction, were

improved, as indicated by the individuals’ artwork. Specifically, a) participants were able use

words to describe images and tell stories to the group about their images and b) most of the

participants experimented with different materials and expressed themselves symbolically,

perceptually, and kinesthetically. In general, the qualitative data effectively elucidates and

supports the quantitative data in accepting the hypothesis of this art therapy study. In other

words, participation in CBATx and/or developing a PVV did significantly increase the level of

positive self-concept, among the qualified sample.

67

CHAPTER FIVE

DISCUSSION AND CONCLUSION

The primary purpose of this art therapy study was to increase the positive self-concept of

high-achieving children of alcoholics (CoA) who demonstrated a low probability of substance

abuse (SUD), which was the focus population, using one or both experimental interventions. The

specific interventions were Cognitive Behavior Art Therapy (CBATx) techniques and/or the

construction of a personal visual vocabulary (PVV). The results indicated higher efficacy for all

the experimental participants, including the focus population, after participating in the first

intervention, i.e., constructing a PVV. Additionally, results from the paired t-test using the

Tennessee Self Concept Scale, Second Edition (TSCS:2) correlated with the Piers Harris

Children's Self-concept Scales, Second Edition (PH:2). The total self-concept (TOT) scores

indicated the probability of both interventions having a statistically significant effect on the

positive self-concept on all of the experimental participants. These results from both the

quantitative and qualitative assessment tools and instruments are discussed in reference to the

literature as well as the efficacy of the methodology and research design. Additionally, the

limitations, clinical implications of this study, and suggestions for further research are given.

Discussion

Significant numbers of adolescents have experienced familial alcohol-related issues

(Centers for Disease Control, 2013; National Council on Alcoholism and Drug Dependence,

2013, National Institute on Alcohol Abuse and Alcoholism, 2013). In fact, more than 55% of the

experimental participants in this study were willing to disclose familial alcohol use disorders or

statuses as CoA. As was previously noted in this study’s introduction and literature review, this

population has a tendency to internalize rather than externalize their thoughts and feelings. In

other words, they "fly under the radar," making it difficult for school counselors and other mental

health clinicians to identify and meet this specific population's needs (Kaplan, Lui, & Kaplan,

2001; Straussner, 2011). Some of the behaviors identified within this study's focus population, or

qualified sample, were consistent with the broader literature findings. Specifically, the qualified

sample demonstrated a below-average self-concept, anxiety, evidence of masked depressive

disorder, and difficulty talking about painful events (Anda, 2006; Anda et al., 2002; Burnette et

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al., 2008; Dube et al., 2001; Elgán & Leifman, 2013; Johnson, Cohen, Kaser, & Brook, 2008;

Lusebrink, 1990; Straussner, 2011; Walker & Lee, 1998).

The study design emulated research-based models on successful primary prevention

programs for children from families with alcohol-use issues as suggested by Eskin et al. (2008),

Fenster (2011), Price and Emshoff (1997), and Riley (1999). The after-school small group setting

provided a safe environment and social-support system that included peer-to-peer networking, a

mode to express feelings, and healthy alternative activities, specifically art making. The peer-

group interventions normalized cognitions and emotions regarding the behaviors of their

substance-abusing caregiver (Fenster, 2011; Price & Emshoff, 1997, Riley, 1999)

In keeping with Rosal's (2001) principles of CBATx, the methodology included using art

processes to facilitate development of problem solving and stress-reduction techniques, coping

and social-competence skills, expression of personal constructs, and the exploration of feeling

states. Additionally, the participants significantly increased their understanding of visual literacy,

dynamics, and visual form as content (Arnheim, 1969/2004; Dondis, 1994; Rhyne, 1979). The

group members practiced putting individual words to images, discussed how the elements of art

worked together to create meaning, and used the Analytical Art Criticism Model (Anderson &

Milbrant, 2005) to personalize symbolic content and discuss personal constructs as they built

their PVV.

This study's primary focus on the development of personal symbols supported a critical

‟job of adolescence,” e.g., the development of a strong Self or undergoing the process of

individuation (Jung, 1968; Erikson, 1950/1993). The secondary focus on the art process, rather

than the final product, gave group members the freedom of expression and opportunity to view

every mark as valuable and meaningful. Individual styles emerged through the reciprocal

exchange of ideas, art making, and peer-to-peer discussion. Additionally, the visual narrative and

storytelling directives supported Gantt and Tinnin's (2007) optimal process for working through

trauma, adverse childhood experiences, and issues of alexithymia.

Assessment Tools and Instrumentation

According to the results of the paired t-tests and review of the artwork, clinical notes, and

self-statements, the results indicated that participation in small-group art therapy interventions

over a course of 16 sessions significantly increased the mean total self-concept (TOT) scores for

all the experimental participants in the study. Multiple methods were used to infer an acceptance

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of the hypothesis, which was stated as, participation in one or both of the art therapy

interventions will significantly increase the level of positive self-concept, as measured by the

correlated TSCS:2 and PH:2 TOT scores for all of the experimental participants or qualified

sample. The results also indicate an increase in positive self-concept for the focus population of

this study, CoA, who were high-achieving and demonstrated a low probability of SUDs. This

directional hypothesis described a positive causal relationship between the participation in one or

both of the interventions (independent variables) and increased positive levels of self-concept

(dependent variable) for this population. These methods included examining the TOT scores and

score means using paired t-test, linear trendlines, and the percent of change. Additional

information was examined to support the hypothesis, and this included evaluating TSCS:2

subtests, participant artwork, self-statements, and clinical notes. A discussion of the results for

the specific assessment interments and tools, the limitations, the implications, and suggestions

for further research follows.

Paired t-tests. Although the qualified sample was too small to infer a significant effect

value (p > .05) based on the TSCS:2/PH:2 TOT scores for the qualified sample, further analysis

of the subtest did demonstrate a significant positive change (p < .05) for some of the subtests.

The specific subtests were self-criticism (SC), conflict (Con), and academic/work self-concept

(ACA). Fitts and Warren (2003) indicated that an improvement in the SC scores suggest the

subject had a more realistic self-concept and decrease in defensiveness. An improved Con score

signifies s/he had a more balanced self-concept and self-acceptance. An improved ACA score

indicates s/he sees him or herself as more confident and has increased feelings of competency in

learning and work situations. The improved ACA score also indicates s/he was more willing to

approach new tasks. Nevertheless, given the small sample size, any findings from the paired t-

tests must be inferred with caution. Additionally, it seems important to note that of the

experimental group, 56% reported being CoA, whereas 75% of the control group and 100% of

the qualified sample indicated familial alcohol issues. In other words, subjects who did not meet

every criterion of the qualified sample self-reported familial alcohol issues. These participants

could not be included in the qualified sample because they did not meet all the criteria, e.g., they

were too young or their grade point average was below the set value of 3.0 or above.

Linear trends and the percent of change. The qualified sample demonstrated a

significant increase in positive self-concept after focusing on the construction of a PVV when

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looking at the linear trend lines and calculating the percent of change. The sample also

demonstrated a limited degree of improved positive self-concept after the visual narrative portion

of CBATx. Possible explanations for these trends are discussed further in the Personal Visual

Vocabulary and the Adolescent portion of this discussion.

Formal Elements Art Therapy Scales (FEATS). As previously mentioned, the FEATS

is normed for adults, and although the depression scales were appropriate, valid for this study,

and helpful in triangulating of data, the inferences may not be valid for artwork produced by

adolescents. Specifically, the FEATS foci are on structural elements of art, which provide an

easy framework for comparing artwork across populations (Gantt, 2009). The raters in this study

included a practicing fine artist as well as the principal investigator, a certified art educator and

art therapist. The secondary purpose for applying the FEATS depression scales within this study

was to encourage more art therapists and mental health workers to systematically correlate art

therapy assessments alongside standardized assessment tools. In doing this, we strengthen the

field of art therapy and improve the validity and reliability of these assessments.

Beck’s theory of internal communication system and the TSCS:2 supplementary

scores. Several members’ unpleasant behaviors (e.g.), graphic descriptions of violent video

games and hoarding of art materials and food) significantly diminished over the course of the

study. Additionally, both experimental groups independently established, operationalized, and

enforced a version of the rule “be nice.” The groups agreed that this rule applied to self-

statements and talking about each other’s artwork. For example, Nicht Werden expressed

frustration that everyone thought he was a girl because of his long hair. Immediately another

group member said, “It doesn’t matter what people think, you have beautiful hair!” This verbal

pattern of exchange was so frequent so it was not possible to make a meaningful tally of negative

self-talk when scoring Beck’s theory of internal communication system. Therefore, it was

necessary to find the corresponding subtests means from the TSCS:2. The mean scores for each

individual qualified participant confirmed the previous findings by indicating an increase in

positive self-statements, which contributed to the overall TOT scores.

Foundational Philosophical Theories and Therapeutic Approach

The philosophical underpinnings of this study are rooted in Hegelian dialectics, or the

idea that change occurs when the tension caused by a contradiction has been resolved. As

evidenced by an examination of the art, both symbolically and formally, self-statements about

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creating the work, and the improved TSCS:2 scores, it may be inferred that the art criticism

process helped the participants discover and emphasize what they found worthy within

themselves and their artwork. The process of making art for these adolescents allowed them to:

a) externalize and reflect on internal processes, b) initiate gradual change toward more adaptive

or self-satisfactory mental processes, and c) create meaning through metacognition. In other

words, the participants demonstrated the beginning of an ongoing dialectical process, including

an interaction with cognitions, behavior, and environment (Bandura, 1976; Gaiger, 2002;

Vygotsky, 1930/1980).

These experiences will enable self-efficacy and self-regulation within the participant’s

sociocultural and personal context by suspending value judgments on the aspect of aesthetics that

deals with what is beautiful and instead providing materials, opportunity, and encouragement. In

other words, using the idea of Hegelian dialectics, the participants will continue to partake in a

tri-fold process where their self-concept will gradually change over time, creating a spiraling

effect as opposing forces or contradictions rise above one another (Gaiger, 2002). The

supposition is that this teleological effect will result in significant holistic change.

Small Group Cognitive Behavioral Art Therapy and the Trauma Narrative

The participants enthusiastically participated in the body-breath exercise painting,

problem-solution collage, and feeling state drawings directives (Rosal, 2001). The specific

CBATx intervention that proved most difficult for the qualified sample was perhaps the visual

narrative directive or the trauma narrative (Gantt and Tinnin, 2007). The final project involved

the application of their PVV to create visual narratives about their lives. Only two of the five

qualified participants completed this project. Destructo did not complete any part of his narrative

book. Brody created postcard-like drawings of his move from one side of the county to the other.

He did not include any people. Nicht Werden made a series of drawings of the earth from space

entitled The First Three Minutes after Death. Each drawing was the same. It seems these three

participants were reluctant to “expose” family secrets in such a short period (eight or so sessions)

and operated primarily in the cognitive and perceptive domains of the Expressive Therapies

Continuum (ETC; Lusebrink, 1990). One possible explanation for their reluctance might be that

these participants did not have the reflective distance or physical or temporal space to reflect yet

needed to tell their stories.

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Nevertheless, small group therapy provided an appropriate therapeutic venue, as

participants enjoyed peer-to-peer support and empathy and indicated individual feelings of

empowerment (Fenster, 2011, Price & Emshoff, 1997; Riley, 1999; 1999a). Over time,

participants demonstrated significantly reduced problem behaviors, such as negative cross

talking and negative self-comments, while in the group (Beck, 1955/97; Beck, 2011). According

to the clinical notes, it was determined that both experimental groups successfully monitored and

adjusted to the therapeutic factors (Yalom, 2005), or the mechanisms that effect change in group

therapy. Socialization, catharsis, interpersonal learning, altruism, and universality were

specifically noted. This was evidenced by the significant decrease in a few difficult behaviors

and negative comments. Evidence of peer-to-peer support was remarkable, especially when

difficult issues and participant history were discussed. Therefore, it seems CBATx externalized

internal processes in a tangible and lasting way for this population.

Personal Visual Vocabulary and the Adolescent

After completing the dynamic visual vocabulary directive (Rhyne, 1979) and attempting

to sort the “marks” into “alike” categories to represent emotionally laden words, the

experimental group participants reported similar conclusions to Rhyne. Specifically, participants

agreed that some of their marks had some similarities, but a universal line language could not be

made without a “dictator” or decider. This conclusion was foundational to the study, as the group

understood the goal to make a PVV. In other words, they agreed that symbolic language is

personal.

Although the participants spent a significant amount of time researching and interpreting

universal symbols using various resources, during Anderson and Milbrandt's (2005) aesthetic

criticism process, the group as a whole helped each member discover individual patterns and

themes that emerged in their artwork. This process was essential to the intervention. The

participants created art about themselves in an authentic way that helped them interpret and

negotiate their familial issues in the real world by becoming visually literate and constructing a

PVV. Foundational to the intervention based on art education directives in this study were ideas

regarding considering personal context when working with adolescents in the school setting:

I believed in the value of drawing upon personal history, of looking within

oneself as a point of reference. In other words, we should create art about what we

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know, about who we essentially are. We should address our own social, cultural,

political, and emotional points of view

That is what I expected of my students. I expected them to demonstrate

technical skills, such as an understanding of the elements of art and the principles

of design. Importantly, I expected them to use these skills to develop personal

visual vocabularies and to use them for unadulterated self-expression, critical

analysis, and problem solving. I expected every contour line drawing, every

Matisse-style shape collage, every mandala, illustration, portrait, landscape, or

photograph to communicate each individual student’s point-of-view. My final

evaluative question always was, “Did you communicate the idea you intended to?

Why or why not? And if not, did something better evolve?”

Through this process—the creation, publication, and critical analysis of

personal work—my hope was for my students to deconstruct their histories and to

reconstruct new meanings in their lives. My hope was for them to develop a

strong sense of self and to earn a place in the global community, based on their

own extrinsic and intrinsic analyses of their lives. This is authentic problem

solving, ... beyond stereotype, beyond merely extrinsic definitions based on race

or gender or economic status, reflecting the deeper and more genuine qualities of

their shared human lives. (Zettler, 2010, p. 147)

As indicated in the literature review, adolescents are in the fifth stage of development,

identified as learning identity (Erikson, 1950/1993). At this stage, a person is focused on him or

herself in relation to social situations. In other words, the primary objective is to develop a sense

of self and personal identity separate from their families, perhaps even from their friends. The

process of construction of a PVV supported this objective, specifically because the intervention

focused on increasing the sense of self through personal symbols or symbolic representations of

“who I am as an individual.”

Limitations

Results, Study Design, and Sample Size

The primary limitation of this study was the sample size. In the original proposal for this

study, the plan was to exclusively select qualified subjects to participate in the study. However,

as stated in the review of the literature, adolescents who meet all the criteria are underserved

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because they are difficult to identify. Additionally, in trying to recruit participants through

organizations such as Alcoholics Anonymous, Al-Anon/Alateen, and the National Association

for Children of Alcoholics, the indication was that family members recovering from alcohol-use

issues are generally focused on adult issues and rarely involved the children in therapy. Thus,

rather than using only qualified matched participants, any volunteer could participate in the study

with his/her guardian’s permission, and the “blind study” criterion was introduced.

Nevertheless, collecting voluntary participants continued to be a challenge, so study the

design had to be changed at its midpoint. Rather than using the randomized Solomon four-group

design with a control group, the study became a randomized pretest, midtest, and posttest

experimental research design with a control group. Although this test design was appropriate and

valid, the reduced sample size significantly diminished the study’s statistical power and the

magnitude of the effect (e.g., the outlying scores skewed the normative range).

Setting, Population, and Lurking Variables

The therapist/researcher was unaware of which experimental participants would be part

of the qualified sample. Additionally, the participants represented a unique selection of the

adolescent population as they were enrolled in either a rural public school or small public charter

schools. This specific population had strong parental advocates as public charter schools are part

of a CHOICE program. During the consent interview, all of the participants’ guardians expressed

a desire for their children to participate in the study due previous social/emotional issues. It was

interesting to note that most of the participants indicated an interest in being in art therapy,

primarily because they "felt they needed to get better at art." However, most of the participant's

intake TOT scores from the PH:2 and TSCS:2 indicated scores of below-average to average, or

average self-concept. Because the study was “double-blind,” it was assumed that there were

numerous external validity issues. Extraneous variables that may have affected the outcome

were: a) the degree of familial alcohol-related disorder(s) and subsequent behavior, b)

socioeconomic background, and c) extent of emotional support (family, friends, and

community).

In terms of self-reported demographics, the study participants did not reflect the 2010

U.S. Census Report. The qualified sample was 67% White and 33% Black. The report indicated

63.7% non-Hispanic White, 12.2% non-Hispanic Black, 4.7% non-Hispanic Asian, 16.4 %

Hispanic or Latino, and 3% other.

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Outliers, Absenteeism, and Problem Behaviors

Of particular interest in distribution of difference plots were the outliers, or the extreme

individual scores of two qualified participants from the experimental groups. These scores

caused two issues in terms statistical analysis: 1) a decreased positive trendline over the course

of the two interventions, and 2) a two-hump skewed distribution of mean for the TOT scores at

observation three (O3). However, a review of each client’s backstory indicated extreme external

threats to validity. For example, around the midpoint of the study, Blue’s biological sister, who

was her guardian, decided to turn her over to the custody of the state. Her absenteeism increased

and her affect alternated between somewhat flat to elevated. During the final session, she

demonstrated an elevated affect and ran out of the room before the group members could say

goodbye. Her final TSCS:2 subtest scores were as follows: the inconsistent responding (INC)

and Con scores were extremely high, and the faking good (FG) score was extremely low. Fitts

and Warren (2003) suggested this combination suggests ambivalence and a disturbed self-

concept.

Another issue was absenteeism, as many of the members were involved in other

extracurricular activities, specifically a musical theatre performance and chess club competitions.

There was a school-wide flu epidemic in the spring, toward the end of the study. The clients

upheld their agreement to come as often as possible. An interesting aside was that four of the

qualified sample had the highest attendance and participation rate.

Clinical Implications and Suggestions for Further Research

From these results, it was found that that 16 group sessions of CBATx and/or developing

a PVV does increase positive self-concept for the qualified sample and participation in both

interventions, and significantly increased positive self-concept for all the experimental

participants. Possible reasons for these results were developing a PVV that a) supports the

primary “job” of adolescence, to individuate, and b) supports adolescents’ foci on identity and

fidelity versus identity diffusion. Additionally, it may be easier to process difficult material

visually rather than having to “tell the secrets,” as art is a way to externalize internal processes.

The construction of a PVV followed by CBATx with a focus on feeling states, problem

solving, and creating a visual narrative was an appropriate and valid approach for increasing an

individual’s positive self-concept. As indicated previously, in treating adolescent CoA, it is

important to avoid considering the label of CoA as pathology in itself. Additionally, sensitivity to

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the individual’s attitudes regarding the family system must be taken into account and care must

be taken not to rush the client into revealing the “family secret” before the participant is ready,

even using a PVV. Finally, it is important to spend extra time closing treatment with fragile

clients. Consider recommending another group or art therapist and follow-up as needed.

The possibilities for further research studies are considerable, however, in the interest of

this research, suggestions for further studies include:

Increased correlation studies using art therapy assessments and standardized mental

health instruments by art therapists and other mental health professionals alike.

Increased studies documenting the correlation between resiliency and positive self-

concept for adolescents from families with substance-use disorders.

Further exploration on how constructing a PVV affects the positive outcomes for

adolescents in small group CBATx.

Conclusion

Not only does constructing a personal visual vocabulary (PVV) support adolescents' need

to individuate but CBATx also helps externalize internal processes, providing opportunities for

concept mapping and reframing. Art naturally facilitates the use of created objects such as

houses, cars, and power animals to take on the role of self and facilitates the participants’

understanding of the interrelated nature of cognitive processes, behavior, and their assumptions

about the world as reflected in an improved positive self-concept.

The design of this art therapy study, a double-blind and randomized pretest-midtest-

posttest experimental research design with a control group, supported evidence based research

models that the participants were unaware of the qualifying criteria for the study and the

principal investigator was unaware of which participants would be part of the qualified sample.

The participants were randomly assigned to one of two experimental groups or one control

group. After attrition, data was collected for 23 voluntary participants from three small public

schools in north Florida. Six participants from the experimental groups qualified as the sample

for the first intervention (n=6), five participants qualified as the sample for the second

intervention (n=5), and three participants qualified in the control group (n=3). After completing

the study, the participants were qualified as having met the study criteria using information

gleaned from the original intake questionnaires. The qualifying sample had the following

attributes: a) adolescent, b) children of alcoholics or from families with alcohol-use disorders, c)

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high-achieving, according the criterion set forth by the state of Florida’s Bright Future’s

Scholarship, and d) demonstrated a low probability of substance-use disorders as evidenced by

the SASSI-A2.

Participants were offered eight 90-minute weekly sessions based on art education

directives, followed by eight 90-minute weekly sessions of CBATx based directives. Three

separate sessions were held for completion of the intake materials and assessment tools. The

observations were made via the TSCS:2 at three intervals before and after the two interventions.

The control group took a pretest and a posttest with an approximate 18-week interval to

eliminate the maturation error to internal validity. The educational approach focused on the

development of a PVV using the art elements of line, shape, color, value, and form. The

therapeutic approach was CBATx with an emphasis on feeling states, visual problem solving,

and visual narrative development.

Both quantitative and qualitative data were analyzed to test and observe for significant

improvement in TOT scores as evidenced by the TSCS:2 and the PH:2. The qualitative data

included rated participants’ artwork using the depression scales, a portion of the FEATS, and the

ETC. Visual themes, symbolic imagery, and self-statements were critically analyzed using

Anderson and Milbrandt’s (2005) analytical art criticism model, Beck’s theory of internal

communication, and the Tennessee Self Concept Scale: Second Edition summary scales.

Fifteen separate paired t-tests were performed on each subtest in the domains of to

Observation Two and Observation One to Observation Three using a correlation of the TSCS:2

and the PH::2 TOT scores for the qualified sample, all experimental participants, and control

group. Levels of self-concept before and after each of the two interventions were compared. The

results indicated a significant effect size on the TOT scores for all the experimental participants

after both interventions, t(18) =-4.71, p=0.0002), or from observation one (M=-10.5, SD=7.6) to

observation three (M=-14.4, SD=13.3). The percentages of change for the total self-concept

score means were calculated because the number of computed total self-concept scores from the

qualified sample was too small to infer a significant effect value at Observation Two after the

first intervention, t(2)=-2.16, p=0.1630, or at Observation Three after the second intervention,

t(4)=-1.52, p=0.2034.

The qualified sample demonstrated a 24% increase in positive self-concept at

Observation Two and maintained a total increase of 16.5% at Observation Three. All of the

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experimental participants demonstrated a 14.4% increase in positive self-concept over the course

of the study, and the control group demonstrated a 6.7% increase of positive self-concept. In

other words, according to the linear trendlines, the difference in mean total self-concept score

indicated a positive increase for the qualified sample after the first intervention, and continued to

increase at the end of the study. According to the trendlines and percentage of increase across

both interventions and all three data collection points of the TSCS:2 and the PH:2 TOT score

means, in the qualified sample and as well as all the experiment’s qualified and nonqualified

samples increased their positive self-concepts by at least 8.1%.

Based on these results, 16 weeks of art therapy sessions increased the positive self-

concept for high-achieving adolescent CoA who demonstrated a low probability of SUDs.

Therefore, we may reject the null hypothesis, as the effect value was less that the set significance

value (p<0.05) for all the experimental participants at the end of the study. Additionally, the

results indicated that constructing a PVV increased positive self-concept at a higher rate than

CBATx with a focus on creating a personal visual narrative.

It could be inferred that the average participant maintained higher levels of positive self-

concept over the course of the two interventions then the qualified sample by comparing the

difference of the TSCS:2 and the PH:2 TOT scores means between the qualified sample and all

the participants. This conclusion was reached regardless of age, sex, health, race, or parental

marital status. Even so, for the qualified sample and all experimental participants, further

analysis indicated a decrease in the FEATS associated with depression, an increase in the

creative level on the ETC, reduced negative self-statements, arbitrary associations, and biased

judgment according to the TSCS:2 supplementary scores.

The purpose of this study was to increase the positive self-concept of adolescent CoA

who were high-achieving and demonstrated a low probability of SUDs using one or both

experimental interventions: CBATx and/or the development of a PVV. A review of the literature

indicated that the level of a person’s positive self-concepts is interrelated to one’s resiliency and

the ability to interrupt teleological maladaptive family patterns, including alcohol-use disorders.

Therefore, this study used the observable and measurable personality characteristic described as

positive self-concept. As per the theory of Hegelian dialectics and methods behind group therapy

and the CBATx process, the making and critical analysis of the art was to provide immediate

opportunities for socialization, catharsis, universality, and so on in order to modify behaviors,

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provide environmental reinforcement, and encourage more adaptive cognitions. As a result,

small group CBATx allowed the experimental population to focus on themselves in the “here

and now,” normalizing their experiences, thoughts, and feelings in a safe environment as

evidenced by the artwork, self-statements, and positive linear trends, which was seen through the

assessment instrument and tools. The philosophical underpinnings for the study were based on

Hegelian dialectics, or the idea that the threefold process referred to as the logic of contradiction.

In other words, everything gradually changes over time in a spiraling method as opposing forces

or contradictions rise above one another and result in significant holistic change.

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APPENDIX A

LIST OF ACRONYMS

Table 9. List of Frequently Used Acronyms ACE Adverse childhood experiences

AUD Alcohol use disorder

C or Con Control group

CBATx) Cognitive Behavioral Art Therapy

CBT Cognitive-behavioral Therapy

CLT Cognitive Learning Theory

CoA Children of Alcoholics

CoSA Children of Substance Abusers

ETC Expressive Therapies Continuum

Ex Experimental groups

FEATS Formal Elements Art Therapy Scales

fMRI Functional Magnetic Resonance Imaging

M Mean or average

n Value for data input

O Observation

PH:2 Pier Harris Children's Self Concept Scale

p-value Probability of significant effect size

SAM or QS Qualified Sample

SD Standard Deviation

sig Significance of Effect

SLT Social Learning Theory

SUD Substance abuse disorder

TOT Total Self-Concept

t-score Raw data score

TSCS:2 Tennessee Self-Concept Scale, Second Edition

X intervention

Y group

81

APPENDIX B

INTAKE FORM

Figure 24. Initial intake form used to determine qualification for the study and for calculating

demographics.

82

APPENDIX C

CORRELATING DATA FOR TENNESSEE SELF CONCEPT SCALE, SECOND

EDITION (TSCS:2) AND THE PIERS-HARRIS CHILDREN'S SELF-CONCEPT

SCALES, SECOND EDITION (PH:2)

Table 10. Correlation of the TSCS:2 Scores with the PH:2 from the TSCS:2 Manual

83

Table 11. Correlation Table between the PH:2 And TSCS:2 from the PH:2 Manual

84

Table 12. Corresponding Subtests and Correlations Used for TSCS:2 and PH:2 at O1

TSCS:2 Subtests PH: 2 Subtests

INC = inconsistent response INC = inconsistent response

SC = self criticism

FG = faking good TOT = >66 = faking good

RD = response distribution RES = Response bias

TOT = total self concept score TOT = total self concept

CON = conflict

PHY = physical self concept PHY = physical appearance and attributes

MOR = moral self concept

PER = personal self concept HAP = happiness and satisfaction

FAM = family self concept

SOC = social self concept POP = popularity

ACA = academic/work self concept INT = intellectual and school status

IDN = identity FRE = freedom from anxiety

SAT = satisfaction HAP = happiness and satisfaction

BHV = Behavior BEH = behavioral adjustment

Note. According to Fitts and Warren (2003), the correlation coefficient between the two self-

concept instruments ranged from 0.51 to 0.80, with the Total Self-concept (TOT) scores correlation

coefficie t as 0.66. The TSCS:2 a ual’s reported correlatio coefficie t (r = 0.66) agrees with the

PH:2 manual (Piers, Harris, & Herzberg, 2009), therefore the correlation coefficient of 0.66 was

used i the a alysis of this study’s data.

85

Table 13. Concatenate Table from PH:2 and TSCS:2 for TOT Scores at O1

86

APPENDIX D

COLLECTED DEMOGRAPHICS AND SCORES FOR ALL PARTICIPANTS

Table 14. Collected data from all participants

87

Table 14 - continued

88

APPENDIX E

DEPRESSION SCALES FROM THE FEATS

Figure 25. Depression Scales, a portion of the Formal Expressive Arts Therapies Scales by

Linda Gantt (1998).

89

Figure 25 - continued

90


91

APPENDIX F

SCORING SHEETS FOR QUALIFIED SAMPLE'S AND MATCHED SAMPLE'S

ARTWORK USING THE DEPRESSION SCALES FROM THE FEATS

Table 15. Scoring Sheets for the Qualified and Matched Samples' Artwork Using the Depression

Scales from the FEATS

Case Number 01 16 09 12 16 Mean

Score

x Mean

Score

y

Pseudonym

Blu

e

De

structo

Gh

ost

Bro

dy

Nich

t

Sh

irayu

ki

Vo

rtex

PVV

ANIMAL - 3D 3D 3D 3D

#1 Color

Prominence

- - - 2 0 2/2 1 1 - 1/1 1

#2 Color Fit - - - 5 0 5/2 2.5 5 - 5/1 5

#3 Energy - - - 2 3 5/2 2.5 2 - 2/1 2

#4 Space - - - 1 1 2/2 2 2 - 2/1 2

#7 Realism - - - 4 3 7/2 3.5 2 - 2/1 2

#10 Details - - - 2 3 5/2 2.5 2 - 2/1 2

#12 Person - - - - -

Tally - - - 16/6 10/6 2.2 14/6 - 2.3

LINE

#1 Color

Prominence

- 3 5 5 0 13/4 3.25 2 5 7/2 3.5

#2 Color Fit - 5 5 5 0 15/4 3.75 1 5 6/2 3

#3 Energy - 4 3 3 2 12/4 3 2 3 5/2 5.5

#4 Space - 5 5 5 1 16/4 4 1 4 5/2 2.5

#7 Realism - 4 5 5 0 14/4 3.6 1 5 6/2 3

#10 Details - 4 5 5 0 14/4 3.6 1 5 6/2 3

#12 Person - - - - - - -

Tally 25/6 28/6 28/6 3/6 8/6 27/6

4.16 4.66 4.6 .5 3.5 1.3 4.5 9.3/2 2.9

SHAPE

#1 Color

Prominence

5 5 3 5 0 18/5 3.6 4 4 8/2 4

#2 Color Fit 3 5 5 5 0 18/5 3.6 4 3 7/2 3.5

92


Case Number 01 16 09 12 16 Mean x Mean y

#3 Energy 3 4 2.5 4 0 13.5/5 2.7 3 3 6/2 3

#4 Space 5 5 3 5 0 18/5 3.6 5 4 9/2 4.5

#7 Realism 2 5 3 4 0 14/5 2.8 4 4 8/2 4

#10 Details 2 5 2 3 0 12/5 2.4 3 3 6/2 3

#12 Person - - - - - -

Tally 13 35 19.5 28 0 3.1 15 14 32.1/12 3.7

COLOR

#1 Color

Prominence

5 4 4 3 5 21/5 4.2 5 5 10/2 5

#2 Color Fit 5 5 4 2 5 21/5 4.2 5 5 10/2 5

#3 Energy 5 4 3 1.5 3 16.5/5 3.3 3 4 7/2 3.5

#4 Space 5 3 4 2 5 19/5 3.8 5 5 10/2 5

#7 Realism 3 3 3 3 5 17/5 3.4 3 5 8/2 4

#10 Details 5 3 2.5 2 5 17.5/5 3.5 4 5 9/2 4.5

#12 Person - - - - - - -

Tally 28 22 20.5 13.5 28 3.7 25 29 4.5

FREE

DRAWING

#1 Color

Prominence

- 0 0 5 0 5/5 1 0 0 0/2 0

#2 Color Fit - 0 0 5 0 5/5 1 0 0 0/2 0

#3 Energy - 3 3 4 4 14/5 2.8 1 3 4/2 2

#4 Space - 5 5 5 5 20/5 4 1 3 4/2 2

#7 Realism - 4 4 4 5 17/5 3.4 1 3 4/2 2

#10 Details - 3 5 5 5 18/5 3.6 1 4 5/2 2.5

#12 Person - 5 4 - 5 14/3 4.6 - 5 5/2 2.5

Tally - 20 21 28 24 3.4 4 18 1.7

BODY BREATH

#1 Color

Prominence

5 2 2 1 - 10/4 2.5 5 -- 5/1 5

#2 Color Fit 5 2 2 1 10/4 2.5 5 - 5/1 5

#3 Energy 3 4 2 4 13/4 3.25 3 - 5/1 5

#4 Space 5 5 4 5 19/4 4.75 5 - 5/1 5

#7 Realism 3 2 0 3 8/4 2 5 - 5/1 5

93


Case Number 01 16 09 12 16 Mean x Mean

#10 Details 2 3 0 4 9/4 2.25 3 - 3/1 3

#12 Person - - - - - -

Tally 3 19 9 16 - 2.9 3 4.3

FEELING

STATES

#1 Color

Prominence

5 5 0 2 3 15/4 3.75 5 5 5/2 5.5

#2 Color Fit 3 5 0 3 4 15/4 3.75 5 5 5/2 2.5

#3 Energy 4 4 0 2 2 12/4 3 5 3 8/2 4

#4 Space 5 5 0 2 2 14/4 3.5 5 5 10/2 5

#7 Realism 3 4 00 2 2 11/4 2.75 3 3 6/2 3

#10 Details 3 3 0 2 4 12/4 3 5 4 9/2 4.5

#12 Person - - 0 - -

Tally 23 26 13 17 3.3 28 25 4.4

VISUAL

NARRATIVE

#1 Color

Prominence

5 - 5 5 2 12/4 4.25 5 5 10/2 5

#2 Color Fit 5 5 5 5 15/4 5 5 5 10/2 5

#3 Energy 3 2 4 3 9/4 3 4 4 8/2 4

#4 Space 5 5 5 3 13/4 4.5 4 5 9/2 4.5

#7 Realism 3 5 5 2 12/4 3.75 4 5 9/2 4.5

#10 Details 0 5 5 4 14/4 3.5 5 5 10/2 5

#12 Person - - 5 5 - 10/4 2.5 - -

Tally 21 - 32 34 19 4.1 27 29 4.7

ARTIST CARDS

#1 Color

Prominence

5 3 5 5 - 18/4 4.5 5 2 7/2 3.5

#2 Color Fit 5 3 5 5 18/4 4.5 5 4 9/2 4.5

#3 Energy 3 2 3 4 12/4 3 3 2 5/2 2.5

#4 Space 5 5 5 5 20/4 5 5 3 8/2 4

#7 Realism 5 5 5 5 20/4 5 4 2 6/2 3

#10 Details 5 5 5 5 20/4 5 4 3 7/2 3.5

#12 Person - - - -

Tally 28 23 28 29 4.5 26 16 3.5

94

APPENDIX G

MODEL AND EXPLANATION OF THE EXPRESSIVE THERAPIES CONTINUUM

Figure 26. Symbolic content and schematic representation of the Expressive Therapies

Continuum (ETC) by Vija Lusebrink (1990).

95

APPENDIX H

ANALYTICAL ART CRITICISM MODEL

Figure 27. Analytic Art Criticism Method (formally known as Anderson's CritCard Method)

from Anderson and Milbrandt (2005).

96


97

Figure 27 continued

98

APPENDIX I

END OF STUDY OBJECTIVE/CRITERIA ASSESSMENT QUESTIONNAIRE

Complete the following rating form with each client using the following scale:

1= No, 2 = Sometimes, 3 = Yes, or N/A

Did the participant...

CBATx: Identify, categorize, and create feeling states? ___

CBATX: Reduced anxiety associated with feeling states. ___

CBATX: Generated solutions to problems? ___

Score ______/ 3__

PVV: Identify, categorize, and generate symbolic content in artwork? ___

PVV: Applied the PVV to address his or her familial issues in a visual narrative

format as evidenced by participant artwork, clinical notes, and self-report? ___

Score _____/ 2 _

ETC: Explored levels of the ETC and various types of media? ___

Score ____/_1_

Figure 28: Example of the end of study objective/criteria assessment questionnaire.

99

APPENDIX J

SASS OUTPUT OF PAIRED T-TESTS SCORES FOR QUALIFIED SAMPLE

Figure 29. Statistical output of paired t-test on INC score means for qualified sample.

100

7

Figure 30. Statistical output of paired t-test on SC score means for qualified sample.

101

Figure 31. Statistical output of paired t-test on FG score means for qualified sample.

102

Figure 32. Statistical output of paired t-test on RD score means for qualified sample.

103

Figure 33. Statistical output of paired t-test on TOT score means for qualified sample.

104

Figure 34. Statistical output of paired t-test on CON score means for qualified sample.

105

Figure 35. Statistical output of paired t-test on PHY score means for qualified sample.

106

Figure 36. Statistical output of paired t-test on MOR score means for qualified sample.

107

Figure 37. Statistical output of paired t-test on PER score means for qualified sample.

108

Figure 38. Statistical output of paired t-test on FAM score means for qualified sample.

109

Figure 39. Statistical output of paired t-test on SOC score means for qualified sample.

110

Figure 40. Statistical output of paired t-test on ACA score means for qualified sample.

111

Figure 41. Statistical output of paired t-test on IDN score means for qualified sample.

112

Figure 42. Statistical output of paired t-test on SAT score means for qualified sample.

113

Figure 43. Statistical output of paired t-test on BHV score means for qualified sample.

114

APPENDIX K

TSCS:2/PH:2 OUTPUT, SELF STATEMENTS, AND ARTWORK

Qualified Sample

Case 01 - Blue

Data Output

Love/Hate List and Love Mandala

Value and Color Psychology Painting

Figure 44. Case O1 - Blue's individual SASS output, artwork, and self-statements from aesthetic

criticism.

115

Body Breath Exercised

Feeling States

Personal Narrative

BLUE: Aesthetic Criticism

General Reaction: Circles, happiness, feeling of going into a tunnel. Looks like a chess game.

Description: formal relationships seem to be contrasting between sad and happiness. Dark colors

inside surrounded by love and cheerfulness. The mood feels like confusion and sadness. Colors are

intense and there is black in the center. The colors seem in a way, over the top.

Context: Feelings about home and school.

Interpretation: When you look closely, there is either sadness or even evilness. The hopeful genesis

of light looks like a tunnel instead. I am covered by darkness. I am blue. I am surrounded by the joy

and my ancestors. Blue is my inside color; blue is the essence of color. The sky is blue, water is blue.

Blue is life. Turquoise is the lightest of this color and this is the color I surround myself with. It is my

outside. It is the light. I want to stand out from my ancestors. I want to leave. I want to be the light.

But it looks like I am getting sucked into a tunnel. I am in the center of a tornado. There is chaos and

nothing Judgment: I am in the center. I am getting sucked into the center, unwillingly.

Themes: Circles, black, blue, intensity. The Panther is my animal.


116

Case 03 - Nicht Werden

Output data

Material exploration

Line drawings

T-chart for Adore/Loath list


Figure 45. Case 03 - Nicht Werden's individual SASS output, artwork, and self-statements from

aesthetic criticism.

117

Form Free

Drawing

Feeling States

Problem Solution Collage


118

Personal Narrative Book


119

NICHT WERDEN: Aesthetic Criticism

General Reaction: Circles, science, outer space.

Description: there are many circles, black, and celestial shapes. The darkness has a relationship with

the celestial shapes. There is contrast between known and unknown. The mood is quiet. There is

quiet in space. If colors were yellow, like the sky. It would feel happier with the green oceans.

Context: Thinking about quiet, life, graduating.

Interpretation: How I am on the outside is pretty much how I am on the inside. It is like, "Are you

going into the unknown? Would you like to have a companion?" I am not sure what my art is telling

me.

Judgment: "I am teal inside and out. My dog looks like an elephant, I am not good at painting, and I

mean I do not have much experience with painting. I like to draw with pencils."

Themes/symbols: unknown, space, earth shape


120

Case 09 - Ghost

Data Output

Material Exploration

Line Drawing

Adore/Loath List and Radial Adore Collage

Figure 46. Case 09 - Ghost's individual SASS output, artwork, and self-statements from


121

Value and Color Psycholtoy Painting

Form Sculpture

Free Drawing

Body-Breath Exercised


122

Feeling States




GHOST: Aesthetic Criticism

General Reaction: There are many blue and powerful details. The dragon looks like a Pokémon

character.

Description: Each picture has a solitary figure and there is not anything in the center of the

mandala. The mood is sad and lonely. There is a lot of white space and only really a few colors,

orange, blue, white, black, and red. Except the fox, he looks natural.

Context: Everything was done at school, but I was not thinking about anything. I just did things

that I like.

Interpretation: Everything except the figure drawing seems unfinished there is a journey into

the unknown. I could not really get excited about the "adore" mandala and I did not want to

think about the things I loathe. Except licorice.

Judgment: I like coming to the group and doing things. I do not know what I want to make next. I

think about food a lot.

Themes/symbols: single figures, fox, journey, food, blue, black, orange/red, loneliness


123

Case 12 - Brody

Data Outpu

Material Exploration and Power Animal

Line Drawing

Adore/Loath List and Adore Collage

Figure 47. Case 12 - Brody's individual SASS output, artwork, and self-statements from

aesthetic criticism

124


Form Sculpture

Free Drawing

Feeling States

Body Breath Exercises and Free Painting


125


Free Form Sculpture


BRODY: Aesthetic Criticism

General Reaction: There is a sense of loneliness even with all the shapes and colors. The mandala makes me think

of a big black hole sucking up everything.

Description: Every color is used, but they are soft and light. Except the black and gray spheres floating in

white space. The eye is drawn to the red /yellow circle behind the scarecrow and the big black blob in the

middle of the mandala. I think we feel alone and nervous, surrounded by smoke.

Context: the context is just about what I wanted to draw now. The mandala is about the things that I love

about gaming, bacon, coke, and candy.

Interpretation: My colors are copper and purple, even though I was going to do silver and copper. I think

the house and the guardhouse are self-symbols. The guard tower is sitting and gathering moss, it is not on

fire because you can live and be on fire. If I came upon the abandoned house, I would walk away. The

windows and it is shabby. The scarecrow is protecting the wheat and doing a great job because the birds

are going away. I am the black shape in the middle of the mandala, and I am happy because I am going to

right into the coke bottles. The fox is on the hunt and I do not know about the tree picture.

Judgment: I have learned I really do not care for painting. I am more comfortable with colored pencils.

The clay was good.

Themes/symbols: loneliness, dilapidation, power/guard, orange, yellow (Fall Colors) and black.


126

Case 16 - Destructo

Data output

Media Exploration and Power Animal

Line Drawing

Love/Hate list and Love Collage

Figure 48. Case 16 - Destructo's individual SASS output, artwork, and self-statements from


127

Value and Color Psychology

Form Sculpture

Free Drawing

Body-breath Exercises and Free painting

Feeling States



128

DESTRUCTO: Aesthetic Criticism

General Reaction: Scary and Evil. Everything is like sorcery, with fire, dragons, and enchantment.

Description: the images are thin, red, and wispy. The black and red colors are intense and stand out

from all the white spaces. The bat is white too. His inside is amber. The mood is intense and we are

meant to feel in awe.

Context: In my head. The things I like to read about.

Interpretation: I am purple and red. The colors of passion and royalty. I am rare and intense. Like the

bat, I have ancient wisdom carried within my soul. I am alone in my quest with the help of

knowledge, the eagle." In the center, I am the all-knowing eye, like the eye of Sauron. These figures

have power over evil. Mystical figures that have mastered the unknown, are all seeing, over time

and place.

Judgment: The intention was communicated, but I'm frustrated because I see the pictures better in

my head.

Themes: Mythology, ancient wisdom, swords, red, black, and purple.


129

Matched Sample

Case 04- Vortex

Data Output

Line drawing

Love/loath List and Love collage

Figure 49. Case 04 - Vortex's individual SASS output, artwork, and self-statements from


130

Value and Color Psychology

Form Sculpture

Free Drawing

Feeling States


131


VORTEX: Aesthetic Criticism

General Reaction: It looks like sorrow is coming. My eyes are drawn to all the swords.

Description: The yellow sphere is popping of the page in the field of blue. I am yellow on the

inside and blue on the outside. I like dark blue. There is an overall mood of being bi-polar,

because blue is the opposite of yellow on the color wheel. There is a mood of injustice and

oppression.

Context: My imagination

Interpretation: There is evil and destruction in the world, but also light and happiness. These are

opposites.

Judgment: Never feel like I have enough time to finish. Hard to "play" with materials. The shape

collage was not worth doing, but the rest was important to me.

Themes: swords, solitary figures, lynx, and balance


132

Case 02 - Shirayuki

Data Output

Power animal and material Exploration

Line Drawing

Adore/Loath List and Love collage

Figure 50. Case 02 - Shirayuki's individual SASS output, artwork, and self-statements from

aesthetic criticism

133

Value Painting and Color Psychology

Form Sculpture

Free Drawing

Feeling States

Body Breath Exercises

Problem Solution collage


134


SHIRAYUKI: Aesthetic criticism

General Reaction: Asian feel. The figures are all on their own in each picture.

Description: I see a tiger, and a starving wolf. The shapes are simple and are like a shrine.

Then there is a "Ka-Bam" repeated shape. Orange is repeated in all the art cards I chose to

work with, the sunset, the tiger, my inside and outside color. Both are inside and outside

colors. I like to read and I like nature.

Context: Graduating from the 8th grade in a small school and going into a big high school.

Interpretation: I like the blue/orange because of the balance. I feel like I am at a beginning,

going up into the unknown but I need shelter. I am uncertain but also know that I am

trustworthy with secrets and meditative. That is the shrine. The blue is meditative.

Judgment: I like to get things puurrrfect. I didn't finish the work but I learned about the

materials.

Themes: Balance between two opposites. Aggressive vs. Meditation. Tiger and Water.


135

APPENDIX L

FLORIDA STATE UNIVERSITY INTERNAL REVIEW BOARD APPROVAL AND

CONSENT FORMS

136

137

138

139

140

141

APPENDIX M

COPYRIGHT PERMISSION LETTERS

142

APPENDIX M continued

143

144

145

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BIOGRAPHICAL SKETCH

Alexandria Zettler's passion is working with adolescents and transitioning adults

in rural communities, both educationally and therapeutically. Zettler earned a Doctor of

Philosophy: Art Education (2014) and Master in Science: Art Therapy (2010) from

Florida State University, Master in Teaching: Elementary Education (1996) from City

University, and a Bachelor of Art: Studio Art (1983) from Oberlin College. She has

taught in a range of positions from PreK to 12th grade, including exceptional, elementary,

technology, and visual arts education. Additionally, Alexandria has traveled, lived, and/or

worked throughout North and South America, from Brazil to the coastal waters of

Alaska. Zettler and her husband are committed to further developing their limited liability

corporation, Studio1, and providing eructation and therapeutic services to their local

community.

Education

2014 Florida State University Tallahassee, FL

Doctorate of Philosophy: Art Education with a specialty in Art Therapy

Dissertation: Constructing a Personal Visual Vocabulary: An Art Therapy

Intervention Project for Adolescents from Families with Substance Abuse

Disorders

2010 Florida State University Tallahassee, FL

Master in Science: Art Education/Art Therapy

Master Project: Experiencing Control of the Self: A Mandala Action Research

Project with Children

1996 City University Renton, WA

Master in Teaching: Elementary Education

Thesis: On-task Behavior for the Student with an External Locus of Control

1983 Oberlin College Oberlin, OH

Bachelor of Arts: Studio Art in Photography & Drawing

Individual Senior Art Exhibit: “Phantasmagoria”

Presentations

March, 2014 Cedar Key Library-Friends of the Library Cedar Key, FL

Presenter: Constructing a Visual Vocabulary: An Art Therapy Intervention Study for

Adolescents from Families with Alcohol Use Disorders

January, 2012 Art & Social Justice Symposium Tallahassee, FL

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Presenter: Action Research Project: Control of the Self

July, 2011 American Art Therapy Assoc. Conference Washington, DC

Workshop Co- Presenter: Containing the Anger Monster

January 2011 Art & Social Justice Symposium Tallahassee, FL

Poster-board Presenter: Laylah Ali, Symbols of Power and Repression

August, 2010 Play Therapist Association Jacksonville, FL

Co-presenter: The Therapeutic Use of Art in Treating Anxiety

August, 2010 Florida State University Tallahassee, FL

Presenter: Master in Science Research Project: Experiencing Control of the Self: Action

Research Project with Children

Publications

Zettler, A. (2010). Considering personal context for authentic problem solving. In

Anderson, T., Gussak, D., Hallmark, K., & Paul, A. (Eds.). Art education for

social justice (pp. 140-147). Reston, VA: NAEA.

Coordinated middle school student group for illustration of:

Bagert, B. (2006). Hormone jungle: Coming of age in middle school, Gainesville, FL:

Maupin House Quiet Space

Documents

Constructing a Personal Visual Vocabulary