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2007

Evaluating the Use of Art Therapy with Couples in Counseling: A Qualitative and Quantitative Approach Dina L. (Dina Leah) Ricco

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THE FLORIDA STATE UNIVERSITY COLLEGE OF VISUAL ARTS, THEATRE AND DANCE

EVALUATING THE USE OF ART THERAPY WITH COUPLES IN COUNSELING; A QUALITATIVE AND QUANTITATIVE APPROACH

By Dina L. Ricco

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, 2007

Copyright 2007 Dina L. Ricco All Rights Reserved

The members of the Committee approve the dissertation of Dina Ricco defended on March 30, 2007.

__________________________ Marcia Rosal Professor Directing Dissertation

___________________________ Mary Hicks Outside Committee Member

___________________________ David Gussak Committee Member

___________________________ Penelope Orr Committee Member

Approved: ____________________________________________ Marcia Rosal, Chair, Art Education Department

_____________________________________________ Sally McRorie, Dean, College of Visual Arts, Theatre and Dance

The Office of Graduate Studies has verified and approved the above named committee members.

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To Johnny and Jada who are the joys of my life.

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ACKNOWLEDGMENTS There are many people that have encouraged, supported, listened, gave precious time, imparted great knowledge and shared experiences as I have embarked on this journey. I thank my committee members for the time, patience and encouragement that they have steadily provided. From each I received unique benefits. My committee chair Dr. Marcia Rosal gave the perfect combination of gentle yet challenging guidance and a role model for stellar accomplishment. Dr. David Gussak’s enthusiasm for art therapy research was contagious. His humor and positive energy was most enjoyable as well. I appreciated Dr. Penny Orr’s reflective feedback. Dr. Mary Hicks inspired me with her skills when working with married couples. I would also like to express my appreciation to Mathen Koshy for his assistance with statistical analysis and to Family Foundations of Jacksonville, Florida for providing the research site and accommodated my needs to complete this study. I am also deeply grateful to the participants of this study who have graciously consented to share their art and their perceptions. Their identities have remained obscured in this text but I will always remember them fondly. On a more personal note there are many friends that have believed in me and supported me through the challenges that I experienced along the way. I would like to also acknowledge my family-of-origin, my mother for her constant ear and encouragement, my father for teaching me that perseverance is the main ingredient in the recipe of achieving a goal, my sister Linda whose humorous comments became mantras of wisdom and for my sister Christina for reflecting her belief in me and provided a mirror of hope. Finally, I could not have done this without the ever present support, encouragement, strength and stability from my husband Johnny. I must also acknowledge my daughter Jada. Spending time with her was my most joyous respite.

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TABLE OF CONTENTS List of Tables List of Figures Abstract

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1.

INTRODUCTION

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2.

REVIEW OF THE LITERATURE

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3.

METHODOLOGY

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4

RESEARCH FINDINGS

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5

SUMMARY AND DISCUSSION

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APPENDIX

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REFERENCES

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BIOGRAHICAL SKETCH

154

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LIST OF TABLES 4.1 Marion’s Identified Pivotal Moments 4.2 John’s Identified Pivotal Moments 4.3 Susan’s Identified Pivotal Moments 4.4 Todd’s Identified pivotal Moments 4.5 Janice’s Identified Pivotal Moments 4.6 Terry’s Identified Pivotal Moments 4.7 Wilcoxon Signed Ranks Test 4.8 Spearman’s rho Calculation 1 4.9 Spearman’s rho Calculation 2 4.10 Spearman’s rho Calculation 3 4.11 Cross Case Analysis of Pivotal Moments and DAS Scores

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73 73 95 96 114 115 116 117 117 118 121

LIST OF FIGURES 4.1 Marion and John’s Genogram 4.2 Marion’s Lifeline from session two 4.3 John’s Lifeline from session two 4.4 Marion Have/Need Collage – the Have side 4.5 Marion Have/Need Collage- the Need side 4.6 Marion and John’s Joint Picture from session six 4.7 Marion’s Torn Paper Collage from session seven 4.8 John’s Torn Paper Collage from session seven 4.9 Susan Lifeline drawing from birth to 5th grade 4.10 Susan’s Lifeline drawing from 5th grade to high school graduation 4.11 Susan Lifeline drawing college years 4.12 Susan’s Lifeline drawing from college years to present 4.13 Todd’s Lifeline drawing from birth to present 4.14 Todd and Susan’s Joint Picture 4.15 Susan’s Dream within the Conflict Collage – Conflict side 4.16 Susan’s Dream within the Conflict – Dream side 4.17 Todd’s Dream within the conflict Collage-Conflict on left/Dream on right 4.18 Front side of Susan’s Torn Paper Solvable Problem Collage 4.19 Back side of Susan’s Torn Paper Solvable Problem Collage 4.20 Todd’s Torn Paper Solvable Problem Collage 4.21 Susan’s Bridge Drawing 4.22 Todd’s Bridge Drawing 4.23 Janice’s Lifeline 4.24 Terry’s Lifeline – birth to junior year of high school 4.25 Terry’s Lifeline – senior year through college 4.26 Terry’s Lifeline 1999-2004 4.27 Terry’s Lifeline 2004-2005 4.28 Terry’s Lifeline 2005-Present 4.29 Janice and Terry’s Joint Picture 4.30 Janice’s Dream within the Conflict image – conflict focused 4.31 Janice’s Dream with the Conflict image – dream focused 4.32 Terry’s Dream wit the conflict image – dream focus 4.33 Terry’s Dream within the Conflict – conflict focus 4.34 Janice’s Marital Landscape 4.35 Terry’s Marital Landscape

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57 58 60 62 63 65 69 70 78 79 79 80 81 83 84 85 85 89 89 90 92 93 99 99 100 100 101 101 103 104 105 106 106 110 111

ABSTRACT Few research studies have been conducted specifically focused on change process in marital art therapy. A need for more quantitative research in art therapy has been established. This research study focused on the results of a quasi-experiential study evaluating the use of art therapy with couples in counseling. Both qualitative and quantitative measures were employed to support the use of art therapy techniques with couples to increase relationship satisfaction and identify specific pivotal moments that bring about change process. Art therapy techniques were combined with Gottman’s (1999) Sound Marital House approach to create a treatment plan for marital art therapy. Three couples participated in eight marital art therapy sessions. Pre and post test of The Dyadic Adjustment Scale (DAS) (Spanier,1976), analysis of transcripts of therapy sessions, post session questionnaires developed by the researcher and used after each counseling session and analysis of art work made during sessions were used as outcome measurement tools. The results of this study revealed that the couples who received marital art therapy services significantly increased marital satisfaction as measured by the DAS. Pivotal moments identified by the couples were described on the post-session questionnaires. The number of pivotal moments identified by the couples, individually and collectively, was assessed for correlation to the amount of increase on the DAS. A correlation was found however, it was not considered to be statistically significant. Analysis of transcripts and art work strengthened the understanding of trends, patterns and themes. How and what needed to be in place for a couple to become aware of negative patterns and make a positive change emerged with commonalities across all three cases as well as distinct environments for each couple and each individual.

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CHAPTER ONE INTRODUCTION Dramatic changes have occurred in the past hundred years in our culture that have a profound effect on the nature of marriage and committed relationships (Miles & Miles, 2000). Physical demands of life have been diminished by technology affording the time to focus more on the quality of long-term relationships. However, this opportunity has proven to be a complex challenge that requires several paradigm shifts regarding the nature of intimate relationships. Coupled with more advanced practices in childbirth and the treatment of infectious disease, life expectancy has doubled in the last hundred years. As a result marriages must sustain a longer life and require a new model or evolution (Miles & Miles, 2000). Marriage is no longer an economic necessity. This changes expectations about romantic love and rituals regarding choosing a marriage partner. Couples are less connected to extended family. Less involvement with extended family creates pressure for the couple to be all things to one another and their children. Adjustment to these changes as well as the evolution of the more equal roles of marriage partners have lead to approximately 55 percent of today’s marriages ending in divorce with second marriages at an even higher rate (Miles & Miles, 2000). Salient features in relationships that eventually end in divorce include the lack of skills to resolve conflict and communicate effectively. Couples in conflict turn to self-help books, popular lecture speakers, talk and radio show hosts as well as to therapy in order to resolve their conflicts and improve their communication. Frequently these interventions fail and more successful therapy techniques that transform communication styles and resolve underlying issues are needed (Larson, 2000). Art therapy is a technique that has not been fully explored in the pursuit of successful interventions for couples. The use of art therapy techniques provides an additional means of communication and expression. The images that couples create and react to are spontaneous and genuine. They are less guarded by defense mechanisms than traditional verbal expressions. Similar to symbolic dream images, art created and processed in therapy can be a fast track to the unconscious (Wadeson, 1980).

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Although couple art therapy is widely practiced, few clinicians have recorded their work in print (Riley, 2003). Art expressions can greatly improve the likelihood of a positive outcome for couple therapy. A myriad of issues arise in a relationship which reflect beliefs from the past, roles that society has imposed, and the differing viewpoints of men and women. “These issues can be made visible through the use of art and, when made visible, transform abstract words into material that can be altered” (Riley, 2003, p.397). The illumination of the true issues in a safe and creative environment is tantamount to growth and positive long-term change in marital satisfaction. Researchers strive to find creative solutions to address the issue of the rise in dissolutions of marriages. As a result of the increased divorce rate, there has been an increase in the amount of research in the past 10 years examining aspects of marriage and parenting that effect child adjustment. To assess the cognitive, emotional and sociological effects on children, longitudinal studies have been conducted providing more sophisticated design and statistical analysis resulting in a more complex understanding of the source of children’s adjustment problems (Kelly, 2000). Children that have experienced divorce or high marital conflict have been reported to be more aggressive, impulsive and engage in more antisocial behavior. The manner in which parents resolve their conflict has been determined to affect the impact of high conflict on children’s adjustment. Chronic unresolved conflict is associated with greater emotional insecurity in children. (Kelly, 2000, p. 965) Young adults who come from families with high marital conflict or divorce, when compared with those who have not experienced a divorce or high marital conflict have more pregnancies outside of marriage, earlier marriage (a risk factor for later divorce) poorer marital relationships, increased propensity to divorce and poorer socioeconomic attainment (Kelly, 2000). Fathers in high conflict marriages tend to withdraw from the family more. Angry mothers in high conflict marriages may exclude fathers from the parenting role. Couples in high conflict relationships exhibit more depression. Parents and children that experience highly conflictual relationships suffer consequences that generally result in more impaired family functioning (Kelly, 2000).

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These consequences for children and families are multifarious. The interventions to these consequences are also varied and complex. Therapists that engage in counseling with couples encounter unique challenges such as the understanding of the couple in biological, psychological, and interpersonal terms. This complexity normally requires lengthy, complicated and cautious assessment procedures. Art therapy techniques ease the process of uncovering potentially important intrapsychic characteristics of each individual within a couple. This uncovering may be a valid means of quickly and successfully removing obstacles from the course of dyadic therapy (Barth & Kinder, 1985). Interventions through an art activities provide innovative approaches and helps the couple to become aware of redundant patterns in unsuccessful problem solving they may have (Riley & Malchiodi, 1994). The style or manner in which conflict is resolved is most predictive of negative consequences for children who observe that conflict. The manner of resolving conflict is a learned behavior and most typically established by observing family-of-origin patterns. Couples in distress focus on negative perceptions regarding one another’s dialogue and behaviors. These negative perceptions and responses manifest from observing negative patterns in the family-of-origin. Couples in conflict are stuck in the inherent paradox; while they need to express and process the conflict, they lack the skills to do so. The appropriate environment needs to be created so that the couple can gain the insight in order to transcend this gridlock. Johnson, Wilkinson and McNeil (1995) recommend that therapists help adults attain emotional middle ground by separating and individuating from their families without emotionally cutting-off and encourage setting firm boundaries with parents to avoid lack of differentiation. Providing therapeutic opportunities for insight into family-of-origin patterns is also encouraged. Prominent marriage and family therapy author and clinician, David Schnarch, discussed using a couples’ sexual style as an elicitation window to the relationship and its inherent paradox. In his book, Constructing the Sexual Crucible: An Integration of Sexual and Marital Therapy, Schnarch (1991) describes the Quantum Model of integrating sex and marital therapy. He compared the sexual crucible to a metallurgy crucible, claiming that constructing the sexual crucible is like adding different mixtures at a certain level in a container that is designed to hold them. The therapist’s role is to

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create the therapeutic environment or container by bringing in the mix of the clients issues, object relations, levels of differentiation, sexual style and level of intimacy functioning. The therapist then refers to personal integrity as a segue to the elicitation window (Schnarch, 1991). Once the crucible is constructed, the therapist can use it as a holding environment. The therapist can provide observation and interpretation yet remain neutral. Consequently, giving clients the choice to pursue the direction that they wish and offering help while clarifying what has worked for the couple and what has not (Schnarch, 1991). Similarly, art therapy can provide an elicitation window through the images created by the couple, through the materials they chose to create them and the process in which they are created. Art expressions made in therapy should be used as a releasing agent for the expression of feelings (Barth & Kinder, 1985). Art is a valuable form of communication because it provides a device for clients who are unable or unwilling to speak about their issues. Similar to a dream being viewed as unreal by the dreamer, the art production is less guarded and is produced with less inhibition or guilt arousal than spoken words might be. Dyadic art therapy techniques allow the clients personally to recognize and release their feelings and attitudes. Often one single session of art therapy will make a number couple’s issues apparent for the first time, despite much previous therapeutic work (Barth & Kinder, 1985). Purpose of the Study The purpose of the study was to provide research to support the use of art therapy techniques with couples in marriage counseling. This researcher aimed to provide data that would strengthen the validity of using art therapy as a treatment modality for couples in therapy. This combined qualitative/quantitative study attempted to identify specific pivotal moments in dyadic art therapy by illuminating distinct therapeutic environments that create opportunities for positive change to occur. In the field of marriage and family therapy there is an identified need in for more change process research, requiring qualitative methods to reveal successful techniques for couples seeking therapy. In the field of art therapy there is an identified need for more quantitative data that explore the

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effectiveness of art therapy (Rosal, 1989). By combining qualitative and quantitative measures, this study responded to the need identified in both fields. Additionally, this study responded to the article by Gottman and Notorius (2002) which identified marriage and family research needs for the 21st century. These needs include: more observation in a naturalistic setting, the need to revisit personality, the need for continued focus on the sequences or patterns of interaction, and the need to recognize the importance of positive affect. The art therapy techniques developed for this study illuminated each of these needs with the additional advantage of spatial expression. The goals for this study were to: (1) evaluate the use of art therapy as a treatment modality with couples in therapy; (2) identify pivotal moments in dyadic art therapy and the processes of change that are associated with those pivotal moments; (3) describe these processes of change in depth; (4) generate categories of analysis applicable to pivotal moments; (5) generate themes and patterns of change associated with pivotal moments through analysis of multiple sources of data; and (6) discern if there is a relationship between the number of pivotal moments accounted for and the level of increase of marital adjustment/satisfaction on the Dyadic Adjustment Scale (DAS). Instruments used included a pre and post test of the Dyadic Adjustment Scale (DAS), a post session questionnaire and a demographics assessment screening (both developed by this researcher). The DAS was used to measure couple satisfaction; participants completed the post session questionnaire after each session to discern pivotal moments in therapy. The researcher filled out the demographics/ assessment screening during the initial interview. This was used primarily to rule out any personality disorders, addictions, depression or other serious mental health challenges that would interfere with a valid assessment of marital adjustment/satisfaction. Each couple attended eight sessions of therapy. The therapy sessions were audio recorded and transcribed. These transcriptions were used by the researched to identify emerging themes and patterns and make modifications to interventions as needed. They were also used to assist in clarifying when and in which session pivotal moments occurred. Methodology is more thoroughly discussed in chapter three. This study contributed to the fields of art therapy and marriage and family therapy with the exploration of a new combined treatment model of art therapy and marriage therapy.

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Justification The use of art therapy with couples addresses the need for highly effective therapeutic techniques to promote healthy interactions. There is a critical need not only to help couples mitigate the increase in the divorce rate but to decrease the equally harmful effects of high marital conflict on children. The literature indicated that the effects of divorce on children are most certainly multifarious and reach the realms of cognitive, emotional and sociological functioning. Cognitive effects were evident in the decrease in academic achievement reported in several studies. Emotional effects were evident in the behavior problems of children and adolescents as well as the lack of adequate skills required to maintain a long-term intimate relationship. This appeared to be most salient as it illuminated the multigenerational transmission process of divorce. Sociological effects were evident in the poor role models resulting in lack of appropriate problem-solving skills, which effected not only success in romantic relationships but social and professional relationships as well. It is paramount to recognize the theme from the literature indicating that the amount of conflict is not necessarily what effected children but the manner in which parents resolved their conflict. Therapeutic intervention can address these issues through prevention and intervention techniques. In an effort to establish credibility for marital therapy, researchers have focused on outcome studies. Groups receiving couple therapy experienced better outcomes when compared with no treatment groups. More specifically, results indicated that couple therapy increased marital satisfaction, reduced conflict and prevented divorce (Hafen & Crane, 2003). Treatment approaches such as behavioral, cognitive, emotionally focused and insight-oriented have been empirically supported to reduce couple conflict and distress. Levy et al. (1997) also supported systemic therapeutic prevention/interventions which explore family-of-origin dynamics. Family-of-origin perceptions of conflict have a profound effect on an individual’s ability to respond with positive behavior and not respond with a negative behavior given an antecedent negative behavior. Although the individual experience of both men and women is related to their reports of functioning in their family-of-origin, functioning in the women’s family-of-origin appeared to be of

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greater importance regarding successful couple conflict resolution. There are essentially two intertwined tasks for a couple building a marriage relationship: to define their family–of-origin heritage and to define their new relationship’s identity. These issues are most successfully addressed in couple therapy. Once negative family-of-origin influences of communication patterns have been identified more successful ways of interacting must be learned. Gottman, Coan, Carrere and Swanson (1998) hypothesized a gender pattern based on the female demand/male withdraw pattern. They recommended that wives begin discussions with a softness and gentleness in the start-up. Learning to de-escalate and physiologically soothe when conflict rises is also paramount as well as shifting the balance of power in favor of the husband’s increased acceptance of influence from his wife. When treating couples that who have conflict in their relationship, Beckerman and Sarracco (2002) recommended using key concepts from attachment theory. Emotionally Focused Couple Therapy (EFCT) uses attachment theory to conceptualize relationship conflict. EFCT demonstrates significant clinical effectiveness by focusing on reestablishing positive primary attachment with the goal of regaining empathic alliance between partners. Cognitive therapists assist couples in recognizing conflictual patterns and addressing these patterns by avoiding, terminating, and dealing with the aftermath of the conflict (Epstein, Baucom & Rankin, 1993). By employing problem-solving skills a couple can circumvent usual sources of conflict. In addition to designing ways to minimize destructive conflict, couples can stop inevitable conflict in the process by choosing to respond to a negative statement with a neutral or positive one. This can be done by meta-communicating (commenting on the conflictual interaction) or by temporarily ending an interaction that is likely to be destructive until a later time when each can approach more rationally. Empirical research findings indicate that regardless of the theoretical approach or system of therapy, common outcomes prevail. Observing this phenomenon, Prochaska (1999) suggested that the field of psychotherapy needs to shift away from investigating the effectiveness of theoretical approaches to investigating specifically how people change. In his analysis of people in treatment as well as people who are not in treatment,

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he identified processes that are among the most powerful approaches to producing change. Prochaska stated that change involves progress through a series of stages; at different stages people apply particular processes to progress to the next stage. The six stages included: precontemplation, contemplation, preparation, action, maintenance, and termination. Theoretical processes can be successful when matched with the appropriate stage of change. With patients in the earlier stages of change, therapists can enhance progress through more experiential processes that produce healthier cognitions, emotions, evaluations, decisions and commitments. In later stages, we seek to build on such solid preparation and motivation by emphasizing more behavioral processes that can help condition healthier habits, reinforce these habits, and provide physical and social environments supportive of healthier lifestyles.(Prochaska, 1999, p 244) Using the transtheoretical model, therapist can bring knowledge of systems and change process together to assist couples in conflict that are stuck in gridlock and contemplating divorce to define the inherent paradox, examine their family-of-origin dynamics that contribute to the paradox, and map a journey to a healthier, more satisfying marriage. Art therapy has the ability to be assimilated into a broad range of theoretical approaches (Riley, 1993). Artwork leads sensitive therapists to an awareness of the message embedded in the product. Visual images need few words and speak an international language. Art therapy is the bridge between the reality of the client and the ability of the art therapist to appreciate that reality. Although there are many successful art therapy techniques used to facilitate learning and behavior change with couples in conflict there seems to be few research studies that specifically explored art therapy with couples. By combining qualitative and quantitative measures this study responded to the need for empirical evidence in the field of art therapy reported by Reynolds et al (2000). Research Design and Questions This research study was a quasi-experimental design, combining qualitative and quantitative measures. The setting was at Family Foundations, a Marriage and Family Counseling Center in Jacksonville, Florida. There were three couples that participated in

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the study. The participants completed a pre test and post test of the Dyadic Adjustment Scale (DAS) in order to address marital satisfaction. Analysis of session transcriptions, post-session questionnaires and art work created in sessions were employed to address pivotal moments. The participants met for approximately eight therapy sessions. Convenience sampling was used to select participants. A more thorough delineation of the methodology is available in Chapter Three. This study addressed the following research questions: 1) Will the use of art therapy techniques with couples in counseling improve the quality of their relationship? 2) What significant or meaningful events in art therapy do the participants consider to be pivotal? 3) How do participants account for the pivotal moments they experience in therapy? 4) Is there a relationship between the number of pivotal moments identified and the level of increase on the Dyadic Adjustment Scale (DAS)? Limitations Change process research has been identified as crucial to the growth marital therapy; this requires qualitative investigation. There have been few qualitative studies that examine change processes in couples therapy from the point of view of the clients (Helmele & Sprenkle, 2000). Process research has attempted to clarify the relationship between process and outcome by elucidating the specific outcomes that occur within sessions. This type of investigation provides an important role in understanding how, when, and what changes occur in dyadic therapy. However, several gaps in process research remain. There have been numerous calls to supplement what has been learned in outcome and process research with qualitative studies of change. A need for more quantitative research in art therapy has been established (Rosal, 1989). Specifically, there is a need for a combined qualitative and quantitative investigation into the use of art therapy with couples. This study attempted to address the fore mentioned needs with systemically oriented art therapy as a theoretical base. Two basic tasks of systemically oriented art therapist are to help people in relationships get in touch with their special culture, experience, and

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needs through directed and spontaneous art expressions and to organize inner chaos into coherent form, thereby facilitating inner healing. (Arrington, 1991, pp 209-10) Financial resources were limited dictating a small study. This influenced the choice of convenience sampling instead of random sampling causing this study to be quasi-experimental instead of experimental which limited the internal validity of the study. Definition of Terms Art Therapy Incorporates the knowledge of art experience, psychology, human behavior, and visual symbols, with normal and abnormal cognitive graphic, and personality development. Art therapists develop this extensive background through graduate level programs which require an intensive focus in three areas; studio art, psychology, and art therapy. Art therapists are part of treatment teams, as well as consultants, administrators, and supervisors. Art therapy itself can be used diagnostically and therapeutically (Rubin, 1983). Change Process Research Change process research refers to the specification of models of change in specific insession contexts. A focus on the process of the change to allow theoreticians and practitioners to explain how a particular set of interventions creates change in a particular therapeutic context (Johnson & Greenberg, 1988). High Marital Conflict Marital conflict is considered high when the presence of conflict and verbal disagreement reaches a threshold at which risk to child adjustment and loss of parental stability occurs. This threshold is unique to each family and relies on the intensity and frequency of parental conflict, the style of conflict, its manner of resolution and whether buffers, which can ameliorate the negative effects, are present (Kelly, 2000) Multigenerational Transmission Process of Divorce A process in which children of divorced families appear to have a higher propensity to divorce due to risk for problems in their own intimate relationships. The lack of healthy

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differentiation in the adult relationships with their parents continues in their relationship with their significant others. (Johnson, et al, 1995) Pivotal Moments A specific type of change process focused on specific sessions, interventions, discussions, and/or activities rather then a general aspect of change in therapy (Helmeke & Sprenkle, 2000). Paradigm Shift In scientific research a shift in the paradigm alters the fundamental concepts underlying research and inspires new standards of evidence that are radically incommensurate with the old one. Paradigm shift as it relates to marital therapy occurs when the participant takes on a new world view after examination and processing of family-of-origin experiences and the negative patterns in their current life that have resulted from these experiences. Once aware, the participant can make a conscious choice to cognitively reframe and choose a more effective interaction style (Beckerman & Sarraco, 2002; Kuhn, 1964.) These and other terms will be discussed more fully and will be defined within the context of the literature review and methodology. Summary Divorce and high conflict marriages have been identified as critical issues and provide justification for research involving successful techniques in marriage therapy to address these issues. A need for a new model of marriage therapy that recognizes the evolution of the roles and expectations of marriage partners has been established. Specifically, the need for more successful techniques that create and opportunity for pivotal moments in therapy to occur is paramount. Salient issues experienced by distressed couples and the use of art therapy as an effective treatment modality to address these issues was explored. The use of art therapy as an elicitation window to the inherent paradox of the couple was discussed. When used in this way art therapy can illuminate family-of-origin issues and negative patterns providing insight to transcend gridlock and encourage differentiation. The purpose and goals of the study, the research design and the research questions as well as the limitations of the study were also discussed. A brief commentary regarding

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the instruments and methods of data collection was provided. A list of terms used throughout this study and their definitions were included. The next chapter discusses the literature that is relevant to this study.

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CHAPTER TWO REVIEW OF THE LITERATURE Art therapy practice involves application of knowledge about human emotional, social, and behavioral development. The roots of art therapy are ancient and universal (Rubin, 1999). They extend to prehistory with the images of cave-paintings and carvings of fertility figures (Junge & Asawa, 1994). Egyptians painted protective symbols as part of their burial rituals, Tibetan Buddhist created mandalas in sand and therapeutic rituals of the Navaho included sand-paintings. African sculptures and ritual masks were also created for healing purposes. The professional use of art therapy can be traced to the early 1900s (Reynolds, Nabors, & Quinlan, 2000). In the 1940’s Margaret Naumburg published the first professional literature regarding art therapy. In the early 1960’s the American Art Therapy Association (AATA) was founded (Junge & Asawa, 1994). Shortly following the foundation of AATA, the first professional journal in the field, the Bulletin of Art Therapy was published by Elinor Ulman (Rubin, 1999). Although, there has been close to a century of widespread clinical use, it is difficult to identify empirical evidence regarding the effectiveness of art therapy as a treatment modality for marital counseling. Published literature on art therapy focuses on the theoretical concepts and results of case studies. The professional journals in the field Art Therapy and The Arts in Psychotherapy have focused on the importance of incorporating research into the practice of art therapy. Additionally, the type of art therapy research needed in the field has been identified. With the goal of substantiating the power of art therapy, Rosal (1989) recommended that researchers in art therapy move away from narrative case studies and toward the use of more clinical research methodologies which include single case design, combining qualitative and quantitative approaches. Due to the lack of empirical data specifically focused on the use of art therapy with couples, this literature review contains several studies that are tangentially related. The literature search included psychological abstracts from PsycINFO and PsycFirst databases. The following keywords were used: marital conflict, marital disruption, couple therapy, art therapy, conjoint marital therapy, family therapy, art psychotherapy, marital psychotherapy, marriage counseling, group counseling, interpersonal relations,

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interpersonal communication, conflict management, conflict resolution, communication, mediation, and interpersonal conflict. Due to lack of representation of art therapy research in data bases, this researcher also searched manually through the table of contents of the professional journals; Art Therapy, The Arts in Psychotherapy, Contemporary Family Therapy, Journal of Marital and Family Therapy, Journal of Marriage and the Family, Journal of Sex and Marital Therapy, Family Process, and Family Relations from 1990- current issues. Secondary sources met the following criteria: 1) Reviews of literature that specified and validated the need for research on effective techniques with couples, 2) Theoretical concepts that supported the use of art therapy with couples, 3) Successful art therapy techniques with couples illuminated through case studies. Primary sources met the following criteria: 1) Approaches to Marriage and Family Therapy, 2) Outcome Research in Marriage and Family Therapy, 3) Outcome Research in Art Therapy. The review of the literature will begin with the secondary sources, proceed with primary sources and conclude with implications for this study. Secondary Sources In this section the review of the literature will focus on the need for research on effective techniques with couples, theoretical concepts that support the use of art therapy with couples and successful art therapy techniques with couples illuminated through case studies. Need for Research on Effective Therapeutic Interventions with Couples Chapter one highlighted the need for highly effective therapeutic techniques to promote healthy interactions among couples. Emphasis was placed on addressing the problem of the increasing divorce rate and the cognitive, emotional and sociological effects of divorce and high marital conflict on children. In this section the literature lends strong support for this identified need. In a study by Kelly (2000), children in both married and divorced families who have experienced divorce or high marital conflict have been reported to be more aggressive and impulsive and to engage in more antisocial behavior. Several large longitudinal studies found that as many as half of the problem behaviors and academic challenges of children in marriages whose parents later divorced were observed 4 to 12

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years prior to separation. The characteristics identified in children of divorced or high conflict marriages include: conduct disorders, antisocial behaviors, difficulty with peers and authority figures, depression, academic and achievement problems. Efforts to understand what aspects of marital conflict create adjustment problems in children have led to the recognition of both direct and indirect effects on child development. “Direct negative effects of high conflict include children’s modeling of parental behaviors, failure to learn appropriate social interactions, and physiological effects” (Kelly, 2000, p 965). As a result of observing their parents responses to frustration and rage, children develop an inappropriate repertoire of angry, impulsive, and violent behaviors into their own behavior. Examples of resolving conflict are generally absent and children do not learn social skills and control of aggression necessary for successful peer relationships. High marital conflict indirectly affects child adjustment by undermining the quality of parenting; including discipline, parent-child aggression and affective responses. Mothers in high conflict marriages are less warm and empathic, more rejecting and exhibit more harsh discipline toward their children. Fathers in high conflict marriages withdraw more from the parenting and tend to be more negative with their children (Kelly, 2000). Research indicated that the frequency, the intensity and the style of conflict are most important predictors of child adjustment. The manner in which parents resolve their conflict has been determined to be most meaningful in assessing the impact of high conflict on children’s adjustment. Overtly hostile conflict styles, physical, and verbal affect such as slapping, screaming, contempt, and derision were more strongly associated with externalizing and internalizing behaviors in children than either covert conflict styles or frequency of conflict and behaviors. Covert conflict styles such as passiveaggressive behaviors, triangulation of the child, resentment and unspoken tensions were linked to more internalizing symptoms in children. Internalized symptoms include depression, anxiety and withdrawal. Severe marital conflict that focuses on the child results in children expressing more self-blame, shame, and fear of being drawn into the conflict. Additionally, Kelly (2000) found that chronic unresolved conflict is associated with greater emotional insecurity in children and high-frequency conflict is linked to

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more negative effects on children as compared with moderate or low-frequency conflict in marriage. Although parental warmth diminished the effects of high marital conflict for girls, it did not serve the same buffering for boys (Kelly, 2000). Positive sibling relationship had the strongest buffering affect in high conflict marriages. Sibling support was associated with more positive adjustment in late adolescence, particularly in self-esteem and social relationships compared with those with low sibling support or only children. In a comparison study of divorcing versus intact families, Mathis and Yingling (1990) revealed that family functioning of divorcing couples differs from family functioning of intact couples. Divorcing families are characterized by extremely low levels of cohesion: meaning that they experience little closeness, lack loyalty, have high independence and engage in more I than we thinking. Familial cohesion provides a sense of belonging necessary in child development to foster a secure sense of self. Exposure to marital conflict and parental aggression can be stressful for youth and can negatively impact their health and well-being. In addition, hostile expression which frequently accompanies divorce, can impact parenting practices (Krishnakumar & Buehler, 2000). Interparental conflict seems to affect three key parenting behaviors: parental involvement, parental disciplinary practices and parental consistency. In a metaanalytic review, Krishnakumar and Buehler (2000) found a significant negative relationship between marital conflict and parenting practices supporting the spillover hypothesis. The ‘spillover hypothesis’ suggests that the emotions, affect, and mood generated in the marital realm transfers to the parent–child relationship. In a healthy marital relationship positive mood affect generated by the relationship allows parents to engage in optimal parenting practices such as engaging, consistent, and inductive. However, the affect and mood created by hostile marital interactions are usually anger and frustration which are associated with dysfunctional parent-child interactions. (Krishakumar & Buehler, 2000, p.26) After a divorce children frequently experience a substantial decline in their standard of living in the custodial home leading to greater economic instability and reduced access to resources such as better schools and neighborhoods (Oppawky, 2000). Additionally,

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children who have experienced divorce rely more on their peer groups resulting in more use of alcohol, cigarettes and marijuana. Divorced parents are also more likely to use more drugs and alcohol than do never-divorced parents. From research conducted with German children in families of high marital conflict, heading for divorce, Oppawky (2000) found parental discord in any intensity or communication form provoked the most negative effects on children. Parental discord caused increased and prolonged periods of crying, experience of sadness in varied degrees, as well as feelings of shame. Decrease in academic achievement is attributed to witnessing severe parental strife in most children. Fear was a common feeling experienced by children of all ages. They were fearful of the unknown and of losing contact with the non-custodial parent. The intensity of the parental strife fueled the children’s reactions increasing fear, aggression, hate, and hostilities toward the parents as well as shame due to the parents’ behavior. As the home became a battlefield – an insecure place –the children responded by developing tension, frustrations, and aggressions themselves. As the children’s trust, optimism, feeling loved and lovable, and sense of self-respect faded, intense anger and hate toward one or both parents because of their behavior rose. As these parents became grossly inadequate role-models, the children denounced and repudiated them. These reactions caused the children to feel insecure, isolated, helpless, hopeless, and subjected them to severe loyalty conflicts. (Oppawsky, 2000, p.146) The worsening conditions in the home eventually resulted in a decline in the children’s academic achievement. Reportedly, many of the children wished to separate from the family as soon as possible. These wishes were interpreted to be a search for more adequate role models. From the view of the children, a reduction in trauma from the divorce could be achieved if the parents would reduce parental strife. Parent child-relationships are formed early in children’s lives and are vital to their development, adjustment, well-being, and educational attainment throughout the life course (Orbuch, Thornton & Cancio, 2000). When parent relationships are positive, this emotion carries over and positively affects the quality, behaviors, and interactions within

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parent-child bonds. Alternatively, the compensatory framework hypothesized a negative effect of parental marital quality on parent–child relations. Studies focused on the adverse effects of low marital quality and divorce by parents and have found these effects to be immediate, especially regarding father-child ties. Orbuch et al. (2000) investigated the long-term effects of parental marital quality and disruption on children’s relationships with their parents. The relational quality between 18-31 year old children and both their mothers and fathers was chosen for study because this is a time when children are transitioning into adulthood and forming their own marital/intimate relationships. A limited number of studies have previously asked the question of whether the effects of parental divorce on parents’ relationships with children are constant across a lifetime. Of these studies, research indicated that parental divorce has a negative effect on relationships between parents and adult children, particularly for father-daughter relationships. Several explanations have been proposed for why parental divorce has negative consequences for children’s well-being. These theories were reviewed by Orbuch (2000). One perspective discusses the loss of economic and financial resources. Economic instability or long-term poverty following a divorce may be detrimental for children’s educational, occupational, and emotional well being. Another framework examined the weakening of attachment to community institutions such as religion. The reduction in the number of parental figures who can supervise and direct children in issues such as school involvement and extracurricular activities is presented as a link. Another explanation focused on the affective tone of the family system indicating that children learn their relational patterns by watching or experiencing the relationships presented and displayed by their parents and may repeat these patterns in other relational patterns as adults. Using these theoretical constructs, Orbuch (2000) explored the interrelatedness of mother-father relations on parent-child relationships as children progress to adulthood. Findings indicated that the effects of parental marital quality and divorce on the parentchild relations were found to differ depending on gender of the parent and child. For mother-child relations, parental quality has short-term significant consequences

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regardless of child gender. Long-term consequences of decline in father-daughter relationships are most salient. Johnson et al. (1995) also focused on the impact of parental divorce on young adult development. Drawing from the literature, five hypotheses were explored: (1) timing of the divorce would be a significant predictor for poor adjustment, (2) as women increased in age they would have more difficulty post divorce relative to men, (3) parent remarriage would predict better adjustment for men than for women while single parent status would predict better adjustment for women relative to men, (4) continued interparental conflict would predict poor post-divorce adjustment as well as would predict poor adjustment in respondents from intact families. The study provided support for the hypothesis that parental divorce interferes with the attainment of developmental tasks of young adulthood: specifically less intimate satisfactory relationships with parents, more difficulty with differentiation and attaining emotional middle ground without cut off, and risk for problems in intimate relationships. These findings provided support for the multigenerational transmission process of divorce (Johnson et al., 1995). Findings also indicated that women adjust well immediately after a parental divorce, develop problems during late adolescence and then steadily decrease in adulthood. Conversely, men have considerable problems immediately following a parental divorce, improve in young adulthood and then increase in middle adulthood. “Family conflict regardless of parental marital status not only hinders development of a satisfactory parent-child relationships and individuation processes it also increases the likelihood that adult children will be triangulated into their parents’ marriage and feel intimidated by their parents.”(Johnson et al., 1995, p 257). Amato and Booth (1996) found that the quality of the parents’ marriage has both direct and indirect long-term consequences for parent-child affection. Reaching adulthood does not ameliorate strained relations between children of divorced families and their parents. These findings concur with the theoretical views on family-of-origin influences. Individuals who experienced poor family functioning in their family-of-origin also perceived their partners’ behavior as more negative (Levy, Wamboldt & Fiese, 1997).

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Researchers of marital satisfaction have consistently demonstrated that how married couples resolve conflict is more important for their relationship satisfaction than either the presence or amount of conflict in their marital relationship. These studies indicate that distressed marital couples demonstrate an over-reliance on negative communication behaviors in that they are: 1) more likely to send negative messages when discussing problems with their spouse; 2) more likely to perceive their partners behaviors as negative and 3) more likely to respond with a negative communication after perceiving their partners behavior as negative. These negative communication behaviors are perhaps the best surface marker for marital dysfunction because they can reliably predict marital distress. (Levy, et al, 1997, pp 297-298) The review of the literature pertaining to the negative effects of divorce and high marital conflict strongly validates the need for research on effective marital therapy techniques. The therapist must be an educator and a guide in the journey of exploration, insight and change. It is paramount to closely examine what has been successful in helping couples and what has failed. In an article which reviewed advances in the field of marriage and family therapy in the 20th century and addressed the marital research agenda for the 21st century, Gottman and Notarius (2002) delineated five seminal research needs. These identified needs include; more observation in a naturalistic setting, continued focus on sequences or patterns of interaction, recognition of the importance of positive affect in relationships, revisiting the study of personality and its effect on the couple relationship, and the need to study the management of stress spill-over into the marriage. Art therapy techniques can be used to address these research needs. Theoretical Concepts that Support the Use of Art Therapy with Couples Although couple art therapy is widely practiced, few have recorded their work in print (Riley, 2003). Art expressions can greatly improve the likelihood of a positive outcome for couple therapy. A myriad of issues arise in a relationship which reflect beliefs from the past, roles that society has imposed, and the differing viewpoints of men and women. “These issues can be made visible through the use of art and, when made visible, transform abstract words into material that can be altered” (Riley, 2003, p.397).

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A dominant need that prevails with all couples entering counseling is that each partner wishes that the other partner see the world through his or her lens (Riley, 2003). Each member of the dyad is convinced that all would be well and subsequent negative behaviors would alleviate if the other could only see their perspective of the problem. To ‘see’ is the key. To see is not possible with words alone; therefore, it becomes logical to introduce the visual form of therapy because it responds to the declared need of the client. Art therapy makes ‘seeing’ a reality as it adds descriptions of problems (Riley, 2003, p. 388). As proposed by Gardner (1999), people have a wide range of capacities. Intelligence is defined as “… a bio-psychological potential to process information that can be activated in a cultural setting to solve problems or create products that are of value in a culture”(Gardner, 1999, p. 33). Art therapy is an action-oriented mode of problem solving which uses spatial, linguistic, intrapersonal and interpersonal intelligences. These identify underlying conflict issues and uncover family-of-origin dynamics that couples commonly bring to counseling. Art therapy techniques provide an opportunity to engage in spatial as well as linguistic intelligence when communicating thoughts and feelings. Traditional verbal therapy is limited to linguistic expression. Insights in art therapy happen naturally in the very process of actively creating an art expression. Through the process of art therapy intrapersonal and interpersonal intelligence are developed as insights occur and are incorporated into the life space of each individual in the partnership. This correlates Gottman and Notarious’ (2002) identified marriage and family research need of more observation in a naturalistic setting. Specific theoretical concepts to support art therapy as an effective treatment modality with couples will be discussed in the next section. Hanna Kwiatkowka was one of the first researchers/ clinicians in family art therapy. She attributed the origin of family art therapy as a natural development of analytically oriented art therapy (Kwiatkowska, 1967). Family art therapy is considered useful as a psychotherapeutic technique because of its ability to engage the family in an expressive activity simultaneously (not possible with verbal therapy). The informal, indirect nature of communication through images lessens the superego defenses and controls.

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The symbolic images express unconscious feelings and gradually help to uncover and clarify ambivalent, and confused attitudes within the family, feelings which are often too intense to express in words. Thus, in some instances, the therapeutic process can be accelerated by the family art therapy program. (Kwiatkowska, 1967 pp37-38) Strategic interventions, which include the use of art therapy, are useful and may achieve successful outcomes for couples. Riley and Malchiodi (1994) stated strongly the need to see couples together. The goal is to encourage an increased level of differentiation for each partner. Conjoint therapy encourages this goal and acknowledges each member’s growth as well as the growth of the relationship. This approach does not encourage or avoid the maintenance or dissolution of the marriage. The possibility of dissolution is always present when change occurs. The process of differentiation from the family-of-origin is one of the basic tasks that must be successfully completed in order to achieve adulthood and to establish a functional, intimate relationship. Each individual is attracted to others who have achieved similar degrees of individuation from their families-of-origin. It is also important to have an understanding of the touching, holding and bonding of the familyof-origin. The therapist must be aware that even the modest sharing of how each partner recalls his or her childhood moments of intimacy or yearning for affection can be very revealing in couples work (Riley & Machiodi, 1994). The very nature of the triadic structure of couples art therapy gives mobility and flexibility to joining and destabilization processes available to the therapist. (Riley & Malchiodi, 1994, p119) This perspective in therapy refers to the theory of social constructionism. Social constructionism looks at the invented worlds we all uniquely construct, the power of words to shape our thinking, and the necessity to be gender sensitive in defining problems. Within this framework other theories may comfortably co-exist and assist a marriage therapist with treatment. The art product becomes the window to the client’s world and the resource that informs the therapist about the couple’s meaning in their stories. Art therapy gives the couple an action–oriented mode of problem solving.

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The action is based in the creative process, both in the execution of art expressions and in the invitation to be innovative in solving problems. The art process encourages the clients to move from the frame of a rigid, unsolvable problem to one that is more manageable and resolvable. (Riley & Malchiodi, 1994, p122) Although the primary focus of dyadic therapy is the couple relationship, the therapist must still be well acquainted with personality development theory (Weeks,1989). The dynamics which contribute to the formation of each individual lead to the development of identity and a personality style which directly affects the way an individual relates to other people. It becomes necessary in couples therapy to give both people an opportunity to express their feelings and thoughts, their sense perceptions, and intuitions, in their own characteristic ways (Singer, 1972). When both can present their views with clarity and respect to a certain issue, and it becomes clear that the views are radically different, the introduction of the theory of types from Jungian psychology may be extremely helpful. When people are of opposite types, they are foreordained to see the world differently. There are two ways to deal with the problem of typology (Singer, 1972). One is to allow it to become an insurmountable barrier and to become resigned to the feeling that one type can never understand the other. The second way is to recognize that each type provides the other with insights into the world which that person would never have without that particular partner. Rather than standing up for one’s own point of view and tearing down or depreciating the other’s, it makes more sense to try to understand and learn from the other. This approach may enable the couple to be led to see that if each one can recognize the validity of the views of the other they could accept the other’s views as necessary to round out a more whole approach to a set of circumstances. This correlates to Gottman and Notarious’ (2002) identified marriage and family research need to revisit personality. As the art product reveals additional meanings and invites a fresh look at longstanding beliefs, the couple can look at their situation through the image, create a new meaning for old patterns and invent a future that meets their desires. The therapists can be more effective since the information in the art expression allows her to see the

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couple’s world and appreciate their viewpoint. With this insight the therapists can utilize many theories and modes of intervention, as well as introduce a variety of art directives that reflect the couple’s story with the goal of giving new meaning to long-standing myths of the family (Riley and Malchiodi,1994). With a social constructionism approach, Riley and Malchiodi (1994) contend that a well-designed synthesis of narration and art expression often results in an accelerated and successful conclusion of the therapeutic contract. Using art therapy in this construct allows for it to become an exploration where the goal is to find a new outcome for an old nonproductive story. This new outcome aims for co-constructing a more creative meaning to events in one’s life. The therapists will expect the clients to express their own interpretations (Riley & Malchiodi, 1994). The therapist is curiously involved in the process. Although the therapist may be responsive, they engage in nonjudgmental dialogue. The principle that guides this approach to therapy is the therapist’s positive belief that clients have previously overlooked their innate powers to solve problems. Consequently, the clinician’s role is to create, together with the clients, a new perspective on their difficulties. This approach is referred to as narrative and is given the term “reauthoring the dominant story.” The focus is on finding alternate descriptions of events. These descriptions offer multiple opportunities to interpret happenings and invite more satisfactory endings to ongoing situations that have been seen by the couple as irreconcilable. When entering into a client relationship, an art therapist asks, “How do you see the situation?” This inquiry implies action and contributes to the recognition that this will be an interview constructed by both parties involved (Riley & Malchiodi,1994). By questioning in this way the art therapy contributes to the interview as the concrete expression bringing action and recognition to the therapy session. As the client continues to tell how they see the situation and the therapist encourages the re-storying of the experiences, the active involvement necessitates the reorganization of their experience. Looking at the problem as external to their person the couple is able to take the blame away from each other. The problem can then be reframed as “the problem” and organizing the couple to join as a team to combat the problem is the key to depathologizing the assessment and therapeutic relationship.

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As the couple explores externalized visual expressions in their art making it gives the therapist and the clients a common ground on which to establish a mutual exploratory view of each circumstance as it is revealed. In reflecting on the situation during sessions, the therapist can offer a variety of alternative meanings that have been revealed but overlooked in the narrative (Riley& Malchiodi, 1994). This process emphasizes that there are multiple meanings to any event in one’s life. Cognitive field interactionists focus their meaning of learning upon the aspects of situations where an individual’s psychological environment intersects with life space. This approach seems particularly conducive to couples therapy because it is the life space of each partner in the relationship and the relationship as a whole that needs to be understood in order for learning or resolving conflict to occur (Bigge & Shermis, 1999). This theory of learning describes how a person gains understanding of oneself and one’s universe in a situation so construed that both the person and the person’s psychological environment compose a totality of mutually interdependent, coexisting factors. (Bigge & Shermis, 1999, p.175) The main thrust of using art therapy in the model is to provide an opportunity for insights to occur. Insights, defined in the cognitive-field interactionists approach, are basic sense of or feelings for relationships. They are meanings or discernments in relation to a certain pattern. A person may apply these discernments to several similar situations or processes. A person will acquire an insight through actually symbolically doing something and seeing what happens. Insights provide a grasp of the situation that often goes deeper than words (Bigge & Shermis,1999). These insights may be gained by the process of art therapy or expressed through the process of art therapy. The next section will describe specific art therapy techniques well suited for use with couples. Successful Art Therapy Techniques used with Couples Art therapy techniques are valuable in uncovering potentially important intrapsychic characteristics of each individual within a couple undergoing therapy. The primary purpose of using art therapy techniques in couples therapy is to highlight the interactional processes underlying the relationship between the partners. Art therapy techniques have been used as a primary modality of treatment as well as and adjunct to other counseling programs (Barth & Kinder, 1985). The Family Portrait exercise directs

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each partner to produce a portrait of their family independently. The portraits are then compared during the session and commented upon. This exercise indicates feelings of isolation, for example, when and individual leaves out their spouse or themselves. Sources of conflict about who is actually included in the family arise. This technique usually involves drawing, however, collages can be used instead in many instances. Such collages may include lettering and drawn modifications as well as an assortment of pictures cut out from magazines and newspapers. Using collage may alleviate concerns about artistic abilities for clients and may also help blocked creativity if clients experience difficulty getting started. Art expressions made in therapy should be used as a releasing agent for the expression of feelings (Barth & Kinder, 1985). Art is a valuable form of communication because it provides a device for clients who are unable or unwilling to speak about their issues. Similar to a dream being viewed as unreal by the dreamer, the art production is less guarded and is produced with less inhibition or guilt arousal than spoken words might be. Dyadic art therapy techniques allow the clients personally to recognize and release their feelings and attitudes. For example, clients may find it difficult at first to talk about their sexual behavior, but after representing and describing that behavior in graphic form, they may tend to be less anxious and more able to discuss the subject matter of their drawings in a frank and spontaneous manner. Often one single session of art therapy will make a number of aspects of a couple’s relationship apparent for the first time, despite much previous therapeutic work (Barth & Kinder, 1985). Barth and Kinder (1985) recognized that when counseling involves sexual matters, the therapist’s task may become even more complex. The sex therapist must come to an understanding of the couple in biological, psychological, and interpersonal terms. The clinician must also develop an understanding of the nature and meanings of the couple’s specific sexual behaviors. The complexity of this task normally requires long-term, complicated and cautious assessment procedures. Art therapy assessment may assist in quickening the process and successfully resolving assessment issues by removing the obstacles typically encountered when using traditional verbal therapy alone. The art therapy assessment has the additional benefit of a tangible art product that remains as a tangible record to refer to and can be important because it is imperious to

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memory distortions. The art therapist not only has the client’s finished products and associations to reflect on for assessment but also the observation of the process by which the art production was made. The order and manner in which different elements are produced may offer information on hidden feelings, areas of conflict, and the relative importance of different elements. In a recent article reporting results from an informal pilot research study, Frame (2006) discussed using an art therapy technique which uses the MARI (Mandala Assessment and Research Institute) Card test and madala drawings. This assessment tool included archetypal designs and color choices, as well as the drawing of a white and black mandalas for assessing the compatibility of two people in a committed relationship. The mandalas were processed using a division of quandrants and understanding of the Great Round of the mandala and its symbolism. Twenty-two couples were given the assessment and interpreted according to seven comparison categories associated with compatibility. The seven categories were related to the couples’ choices on the card test. Two mandala drawings added insights and further information which complemented the interpretation of the test. Case studies were used to communicate the process and findings. Reportedly, the assessment was particularly helpful at the beginning of therapy because it provided nonverbal information that may not have been available in more traditional intake interviews. Additionally, it was identified as useful for use at the end of therapy as a measure of change in the relationship. Therapists working with couples need to be able to access many of the nonverbal communications which can affect dyadic relations (Weeks, 1989). There are three major drawing directives that are helpful in dyadic evaluations (Wadeson, 1980). One is the “joint picture”. For this art activity, the couple is instructed to draw a picture together. They are not to use any verbal communication during this activity. The second directive would be to ask the couple to construct individual abstract drawings to represent their relationship. The third is to draw a self-portrait to be exchanged with their spouse. This portrait should be a full figure and be realistic in nature. When this is completed each would exchange their drawing with their spouse with the permission to amend the

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drawing. These drawings may reveal aspects of the relationship such as power struggles and the degree of intimacy. There are five advantages for using art in couples counseling sessions (Wadeson, 1980): (1) the immediacy of doing a task together, (2) the genuineness of unexpected material revealed in pictures (which may challenge old assumptions or beliefs that the couple holds onto firmly), (3) the spatial expression of pictures (which can symbolically reveal the couple’s life space), (4) the permanence encountered whereby the drawing provides a concrete object to study, react to, use for clarification, review and (5) the shared pleasure that picture making can provide for a couple who no longer find themselves having fun together. Immediacy as it refers to art therapy is defined as being engaged in the immediate task of making pictures. The couple is able to look at their manner of handling the task, particularly at the way they relate to each other when they are making a picture together. This provides a field of doing together that is not often seen in conventional verbal therapy. Genuineness is encountered because picture making is a less familiar mode of expression than talking. This correlates Gottman and Notarious’ (2002) identified marriage and family research need of more observation in a naturalistic setting. Over rehearsed assumptions may be undercut by this changed approach to communication (Wadeson, 1973). Unexpected and unplanned material may burst forth in the images to challenge old assumptions. Verbal expression is sequential and not necessarily the clearest way to describe complex relationships. Spatial expression provides the ability to illuminate many facets at the same time with more clarity. Having a tangible record, the picture, provides permanence. When something as complex and evanescent as the understanding of a marital relationship is being explored, studying and reacting to a concrete object that represents many facets of the relationship may be paramount to achieving treatment goals. The pictures form an interesting review over time. They are imperious to the distortions of memory; provide both the couple and the therapist with a permanent record of change. By reviewing this record, trends in development are more easily discerned. This correlates to Gottman and Notarius’ (2002) identified marital research need for continued focus on sequences or patterns of interaction. Specifically multi-modal measures which include various tools of sequence

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analysis, the observational study of marital interaction expanded to the analysis of patterned communication is recommended. The shared pleasure mentioned earlier that a couple may experience is seminal because in many troubled marriages, there is little shared enjoyment. Even vacations can become unpleasant. The art therapy can be experienced as play or a game and has the light heartedness of fun. This correlates to Gottman and Notarius’ (2002) identified marital research need to recognize the importance of positive affect. They suggest that a paradigm shift take place regarding the focus on conflict discussions and negative interactions change to emphasis on the positive shared pleasure and friendship of the relationship Most frequently associated with systems theory, the genogram serves as the primary assessment procedure in the Bowen family model. Within this theoretical framework, the genogram is primarily used to help formulate hypotheses and to design interventions into the family system (Mauzey & Erman, 1995). The genogram has many clinical benefits including: organizing data in a graphical way, engaging the family in sessions, and teaching systemic ideas; clarifying family patterns and characteristics developing intellectual understanding of issues, and reducing events to a common calendar framework. Typical information on the genogram includes the names, ages, and geographical locations of all family members as well as important dates such as births, deaths, illnesses, hospitalizations, marriages, divorces, and relocations. More creative uses of the genogram can extend its use beyond assessment. By adding color and symbolic representation of family members, more in-depth themes may emerge. Systemically oriented art therapists employ the genogram to integrate art therapy with family therapy (Arrington, 1991). Early in the treatment process, family art therapists join with their clients to construct a three generational genogram. The genogram is also used to map the family hierarchy and family structure using pointed questions and observations of verbal art expression. Two basic tasks of systemically oriented art therapist are to help people in relationships get in touch with their special culture, experience, and

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needs through directed and spontaneous art expressions and to organize inner chaos into coherent form, thereby facilitating inner healing. (Arrington, 1991, pp 209-10) Symbolic graphic representations and metaphors are analogies through which the therapist and client can communicate in powerful, direct, but non-threatening ways. When a therapist uses a client’s metaphor, the therapist shapes an intervention that is unique and fits the situation presented by the client (Riley & Malchiodi, 2003). In an article focusing on existential art therapy, Lantz and Alford (1995) described several techniques designed for use with couples and families. There were four art directives described which were specific to couples: The Draw a Couple in the Rain Technique, The Draw Your Marital Relationship as a Car Technique, The Two Pine Trees in a Forest Technique, and The House of The Future Technique. The Draw A Couple in the Rain Technique is used to facilitate dialogue, discussion, and communication between the couple (Lantz & Alford, 1995). This reflection technique may be extremely powerful uncovering relationship problems and the meanings and meaning potentials the couple has associated with these problems. The Draw Your Marital Relationship as a Car Technique is similar to the Draw a Couple in the Rain Technique as it is used as a metaphor for the relationship yet it lacks the environmental element. Specific questions directed to the metaphor about the car parts (e.g. headlights, breaks, steering wheel) can help bring out areas of strengths and weakness in their relationship. The two Pine Trees in a Forest Technique provides the couple with a good opportunity to draw a picture that will facilitate reflection and discussion about communication, structural issues, cohesion-independence issues, and the size of the two relationship members (Lantz & Alford, 1995). This technique may be followed up with the Draw The House of The Future Technique. This task is valuable for couples as they enter different stages of their relationship. In this drawing directive each member of the couple is asked to draw their house of the future. The house is then used to facilitate reflection and discussion about each member of the couple’s goals, hopes, ideals and dreams. When discussed in session greater mutual understanding is achieved.

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Summary of Secondary Sources Clearly, art therapy is a well-suited treatment modality for the working with couples. The need for specific research in effective techniques with couples has been emphasized. Several theoretical perspectives that support the use of art therapy in the treatment of couples and families have been reviewed. Some techniques and art directives designed for use with couples have been described. Many more art therapy techniques are available for use with couples in treatment. Spontaneous art directives can be created to suit individual cases. In the next section, the primary resources will further validate the need for research on the effectiveness of art therapy with couples. Primary Sources In this section the review of the literature will focus on discussion of approaches to marital therapy, process and outcome studies in marital therapy, outcome research in art therapy and the need for specific outcome based research in couple art therapy. Approaches to Marriage and Family Therapy In an effort to establish credibility for marital therapy, researchers have focused on outcome studies. Groups receiving couple therapy experience better outcomes when compared with no treatment groups. More specifically, results indicate that couple therapy increases marital satisfaction, reduces conflict and prevents divorce (Hafen & Crane, 2003). Treatment approaches such as behavioral, cognitive, emotionally focused and insight oriented have been empirically supported to reduce couple conflict and distress. Theoretical approaches have shown more similarities then differences when compared, however, currently there is a debate among prominent researches regarding the best approaches to couple/marital therapy. Cole and Cole (1999) proposed that the greatest hope for helping couples achieve the satisfying marriages they want lies in prevention programs. Longitudinal research on the effectiveness of skills training to enhance marital quality and reduce probability of divorce indicate that communication skill training through enrichment and marital therapy can be effective and continues to have positive effects long term. This approach has recently come under scrutiny since an article was published by Gottman, Coan, Carrere and Swanson (1998) suggesting that the active listening or validation model be abandoned.

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As you might guess, this article has created a firestorm of controversy and is actively being debated and challenged by marriage and family enrichment leaders who use skill-oriented training programs (Cole & Cole, 1999, p 276). Gottman et al. (1998) explored marital interaction processes that are predictive of divorce or marital stability and processes that further discriminate between happily and unhappily married stable couples. In regard to active listening, findings indicated that it occurred infrequently in couples who were happily married and was not predictive of marital outcomes. No support was found for anger as a destructive emotion in marriage yet evidence was found indicating that contempt, belligerence, and defensiveness were destructive patterns in conflict resolution. Specifically, a negative start up to a discussion attempting conflict resolution by the wife and a refusal of the husband to accept influence from his wife as well as the wife’s reciprocation of low intensity negativity in-kind and the absence of de-escalation of low intensity by the husband were identified as destructive patterns. Gottman et al. ( 1998) recognized that the most influential process theory of what is functional in the context of resolution of conflict in marriage is the active listening model. The active listening model is adapted from the client centered model of therapy which was designed to be used in a client/therapist situation and provides validation when a client is discussing a third party. Gottman stated that it is extremely difficult to be validating when the complaints are about the spouse and pointed out that when a client complains about a therapist it is usually called resistance. Based on the outcomes of Gottman’s research, that although it may make intuitive sense as a model of empathy, active listening may be misguided. It appears to be an expectation of “emotional gymnastics from people who, at the moment in that relationship, are somewhat disabled by conflict” (p.18) Gottman et al. (1998) created what has become a significant controversy among marital researchers in the United States of America (Hafen, 2003). While seeking to evaluate predictors of marital happiness from newly-wed interactions, Gottman et al. concluded that interventions in couple therapy which focused on creating active listening between the couple or that viewed anger as a destructive emotion may not be the most effective method of establishing lasting change for couples. Given the prevalence of

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active listening and anger management as key components of couple intervention, it is not surprising that these conclusions met with resistance and debate. Although many have disputed Gottman et al. (1998) results and referenced longitudinal studies on active listening as rebuttal, they maintain that marital therapy needs to abandon the active listening model in favor of a model of increased softening and gentleness in start-up by the wife, de-escalating, changing of balance of power in favor of the husband’s increased acceptance of influence of his wife and increasing physiological soothing by self and partner. The Gottman model emphasized the building of a Sound Marital House. This begins with a foundation of friendship or creating positive affect in nonconflictual contexts (Gottman, 1999). This marital friendship allows for more Positive Sentiment Override which essentially means that there is enough positive feelings of fondness and admiration between the couple that these feelings override or buffer the effects of negativity that occur during conflicts. Positive sentiment also involves the perceptions the spouses have of each other during repair attempts. Consequently, if the opposite, Negative Sentiment Override, is present there is not enough fondness and admiration to buffer negative effects of conflict and perceptions of repair attempts are seen as manipulations and may not received in the spirit in which they are intended. Regulating conflict is the next step in building the Sound Marital House (Gottman, 1999). Regulating conflict refers to the ability of a couple to succeed at repair attempts. It does not necessarily mean the conflict is resolved but rather that the discussion around the conflict during a repair attempt relies on mutual fondness and admiration and that the couple “knows how to negotiate the terrain of both resolvable and unresolvable problems” (Gottman, 1999, p 108). Creating shared meaning is the third step in building the Sound Marital House. This involves creating a unique culture and compilation of meaning with its own symbols, metaphors, and narratives; it also includes the degree to which a marriage enables both partners to feel their life dreams are supported. The Sound Marital House is the model for making a marriage work, Gottman (1999) also identified what to avoid in a marriage. He discussed a harsh start-up as predictive of problems. A harsh start-up is described as negative and accusatory. When

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a discussion leads off with criticism and/or sarcasm as a form of contempt it has begun with a harsh start-up and is doomed to failure. He also discussed what he identified as the Four Horsemen of the Apocalypse; Criticism, Contempt, Defensiveness, and Stonewalling. A complaint focuses on a specific behavior but a criticism throws in blame and character assassination. Criticism is common in relationships, however when it becomes pervasive it evolves to other more serious problems. Contempt involves continuous criticism. Sarcasm, cynicism, name-calling, eye rolling, sneering, mockery and hostile humor are all forms of contempt, which conveys disgust. Defensiveness occurs when a complaint is expressed and the person receiving the complaint does not take responsibility for the behavior. Instead the person defends themself which is a way of blaming the spouse making the complaint. Defensiveness escalates the conflict that can eventually lead to stonewalling. Stonewalling is when a partner becomes so flooding with the conflict that they tune out or ignore their partners’ criticism, contempt and defensiveness; instead of turning toward the partner the person eventually turns away to avoid a fight. However this leads to problems because the more nonreponsive the partner is the more the others’ mood escalates. As mentioned above, flooding is what causes stonewalling. Flooding occurs when a spouses’ negativity is so overwhelming and so sudden that it leaves the partner “shell-shocked” and defenseless against attach. In an effort to avoid this highly unpleasant feeling of flooding the partner will disengage emotionally from the relationship. Recurring episodes of flooding lead to divorce because they signal severe emotional distress when dealing with the partner and because the physical sensations of feeling flooded, such as increased heart rate and sweating, make it impossible to have a productive, problem solving discussion. The debate regarding approaches to successful marital therapy may be controversial yet it seems to provoke thoughtful, logical and convincing discussions that can only improve the quality of the service that is provided to families and couples. However, at this point it may be confusing to practicing clinicians as many in the field believe that “neither the advocates nor the detractors of active listening techniques have provided a convincing argument”(Hafen & Crane, 2003, p.12). A review of several approaches to marital therapy follows in this section.

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Hendrix (1988) suggested that marital hostility is actually the result of childhood wounds; he discussed teaching couples to develop empathy regarding one another’ family-of-origin wounds. Awareness of family-of-origin and view of the family as a system is well established in the marital and family therapy realm. The conceptual development of the family movement has been influenced by three important systems theories: cybernetics, general systems theory, and natural systems theory (Caskie, 1994). Bowen developed a unique view of the family as a natural system. This view of the family differs from other concepts of systems frequently applied to the family because it is based on the premise of Darwin’s theory of evolution by means of natural selection. The natural systems theory contends that despite our uniqueness, human beings are part of nature and subject to the same evolutionary forces as the rest of the living world. Nature as a system organizes according to reciprocal relationships, mutually interdependent and mutually influencing (Caskie, 1994). Bowen proposed a model of the family based in natural systems thinking and conceived the family as a combination of emotional and relationship systems. The family is recognized as a gestalt, greater than the sum of its parts. Families generate a field of energy that impacts on every member. The energy surrounding a family has stability. Reduction of tension and remaining in homeostasis is the primary goal. Each member of the family has a role and there are powerful pressures on each individual to maintain that role in order to preserve the stability of the family unit. Emotionally Focused Couple Therapy (EFCT) is based on attachment theory and views marital hostility as the result of an underlying insecurity (Johnson & Greenberg, 1988). With this approach the therapist helps the couple reframe hostility in the context of more vulnerable emotions. Expressed anger is reframed in order to recognize the underlying fear the spouse is feeling. Couples soften their communication allowing the confrontation to be less harsh and increasing their empathy toward one another. This approach is empirically supported by their research on how change occurs in marital therapy. The ability of the infant and growing toddler to develop a secure attachment with the primary caregiver, as well as tolerate emotions provoked by separation, are the defining developmental tasks that provide the blueprint for all future object

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relations. According to the seminal attachment theorist, adaptive attachment (attachment marked by security and trust) is the essential building block of adaptive personality development and the capacity for adaptive adult relationships. (Beckerman & Sarracco, 2002, p. 24) Therapists using the EFCT approach focus on the affectional significance of their clients’ attachment to one another rather that on content. The goals of EFCT are to access and reprocess the emotional experiences of the couple and restructure interaction patterns. Using interventions such as dyadic interpretation, dyadic facilitation, role modeling constructive communication, and empathic responses, the couple can be brought to a higher level of awareness. Once the core struggle is identified the work in sessions is shifted to reframing the couples’ struggle with the new level of awareness. Using reflective questioning, pattern-dynamic reflection and developmental reflection the therapist can guide the couple to examine their negative cycles in terms of how they are repeating what they experienced in their primary attachments (Beckerman & Sarraco, 2002). Members of distressed couples tend to have lower perceptual agreement than members of nondistressed couples. Cognitive approaches focus on discerning unrealistic beliefs that contribute to biases in spouses perceptions. Empirical studies which have examined correlations between couples’ attributions for relationship events and their concurrent levels of self-reported marital satisfaction result in findings that indicate distress is higher when relationships problems are attributed to traitlike characteristics of the partner (Epstein, Baucom, & Rankin, 1993). Essentially, if a spouse perceives the other spouse’s personality as the source of the problem rather than a mutually responsible faulty problem-solving style, then conflict will be more frequent and escalating. Uncovering and challenging unrealistic beliefs alone may not be pivotal in therapeutic intervention, however, discussing a spouse’s strongly held standards about marriage and exploring the individuals life experiences that may have shaped the standard could be result in pivotal moments. The therapist goal would be to coach the client in evaluating the advantages and disadvantages of applying the standard to the marriage.

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Reflecting on these theoretical approaches to counseling couples in conflict, all roads seem to lead to the same end. Essentially, regardless of the theoretical paradigm, couples in distress present with a focus on negative perceptions regarding one anothers’ dialogue and behaviors. These negative perceptions and responses manifest from observing negative patterns in the family-of-origin. Couples in conflict are stuck in the inherent paradox and lack the skills to appropriately express and process conflict and gain the insight in order to transcend their gridlock. To address the challenge of confronting these issues, Lebow (1984) suggested the use of an integrative approach. In using an integrative approach, therapists can shape intervention strategies in a manner appropriate to individual cases. This allows for a treatment of a broad client population and permits easy expansion of the repertoire of techniques. Combining knowledge and strength of specific approaches can most effectively address the complex issues of marital distress. Review of Recent Outcome Research in Marriage and Family Therapy The American Association for Marriage and Family therapy (AAMFT) published its first major review of research as a special issue of the Journal of Marital and Family Therapy. In an article titled Marriage and Family Therapy: A Decade Review, Piercy and Sprenkle (1990) summarized trends in theory and research on marriage and family therapy over the past decade. In this review they commented on the maturation in methodology and offered recommendations for future research. In reference to outcome research, the writers discussed the new emergence of investigating not only the outcome of therapeutic intervention but the process as well. Process research focuses on the specific session interactions and identifies the relationships between process and outcome variables. Many interventions that appeared promising at that time are now backed by robust outcome data (Sprenkle, 2003). Marriage and Family Therapy overall has improved dramatically due to the increase in the number and quality of investigations across almost all areas of research. In a study by Johnson and Greenberg (1988) the essence of change process is considered to be the accessing of emotional experiences underlying problematic and rigid interactional positions, and the resynthesizing of such experiences to create new interactions. The focus of the investigation was on client performance when resolving

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escalating negative interactional cycles in Emotionally Focused Marital Therapy (EFT). The effectiveness to this approach has been empirically validated. The study sought to identify the in-therapy processes that lead to successful outcomes. Couples who participated in the study were selected from the subject pool of an EFT efficacy study. All couples were screened for factors such as depression and other disorders, such as alcoholism and primary sexual dysfunction. The couples were randomly assigned to a cognitive behavior treatment, experiential systemic treatment, or a wait list control. All therapy sessions were videotaped and checked by blind raters to ensure that each treatment approach was appropriately implemented. From the 29 couples in this original study who received EFT treatment, 6 were selected for intensive study in order to begin to identify the characteristics of client performance which lead to successful outcome. Selection was based on extreme change scores. Three couples were selected for whom EFT created the least amount of change in their marital satisfaction as measured by the Dyadic Adjustment Scale (DAS) as well as three whose scores on this measure showed the largest amount of positive change after therapy. Therapy consisted of 8 sessions of EFT and was conducted by master’s level experienced marital therapists. Other measures employed by this study were the Experiencing Scale (ES) and the Structural Analysis of Social Behavior (SASB). Once the six high and low change couples were identified the researchers selected the best therapy session for each couple for intensive analysis (Johnson & Greenberg, 1988). The session chosen had been rated by the therapist as the one in which the couple made the most progress and came closest to resolving their issues. The most successful couples had a higher percentage of affiliative and autonomous responses on the SASB in best sessions as compared with the least successful couples. Successful couples in best sessions displayed many more responses that were indicative of a deep level of experiencing and disclosure than the unsuccessful couples. These results have implications which suggest that therapist should focus on facilitating deeper levels of experiencing self-disclosure and exploration of the reprocessing of emotional experience. Conclusions are limited due to the small sample size and the correlational nature of the study.

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A study by Helmeke and Sprenkle (2000) differs from previous studies because it focused on a specific type of change process, pivotal moments. This qualitative investigation sought to illuminate the client’s identification and perception of pivotal moments in couples therapy using methods from grounded theory, a method based on theory development from data that were collected and analyzed systematically and recursively. Data collection methods included in-depth interviews, nonparticipant observation, and document analysis. Data sources included audiotapes, video-tapes, field notes, transcripts of therapy session, transcripts of interviews, client and therapist questionnaires completed after each session, quantitative measures of change in therapy a reflective journal kept by the researcher consisting of theoretical and analytical memos, and documents. Criterion sampling was used to select three couples from those who showed interest when invited to participate in the study. All three couples presented with marital issues to a university based family therapy clinic. In order to participate the couples agreed to fill out a brief questionnaire at the end of each session for no more than 10 sessions and to attend two meetings at the end of therapy. Helmeke and Sprenkle (2000) found that clients did identify specific events or discourses in therapy as pivotal and that these often differed from those identified by their spouses and by the therapist. Pivotal moments tended to occur in the discussion of a topic related to a presenting problem as well as when topics under discussion were addressed in previous and subsequent sessions. The locus of change associated with the pivotal moments tended to be in the client reporting the change, rather than a change in the relationship or in the spouse. Several non-pivotal factors emerged as necessary prerequisites for the pivotal moments. A limitation of this study exists in the use of one therapist and only three cases. Caution must be exercised in generalizing the findings. Another study using the client’s perceptions of therapy and change process as part of their methodology was conducted by Christensen, Russell, Miller and Peterson (1998). In this qualitative, open ended approach, researchers interviewed with 24 couples therapy clients about their experience of the process of change. The participants consisted of 24 married or engaged adults who were receiving therapy for relationship distress or whose case had been terminated no more than two weeks before the interview. All of the participants had been seen in a university-based family therapy clinic. Nine therapists

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(masters level students enrolled in a marriage and family therapy program) participated in the study. Five faculty supervisors provided supervision. Some therapist used video-tape and two way mirrors as part of their supervision. The interviewers were part of the research team (students enrolled in a doctoral program who had graduated from an accredited marriage and family therapy program) and also participated in the data analysis (Christensen et al, 1998). The interviews were semi-structured generally asking the participants to tell the interviewer about what the therapist did to help facilitate change and what was happening at the time they thought the most was being accomplished. The constant comparative method of simultaneous coding and analysis of data was used. Although the interviews began with preliminary questions posed to participants, the interview guide was not rigidly adhered to and participants were encouraged to discuss openly opinions, thoughts and ideas. Findings were consistent with previous research indicating that the facilitation of change occurs through shifts in affect, cognition, and communication. The experience of the participants shows that change can start in any one of these clusters and eventually tends to be felt in the other clusters as well. The data suggest that the systems principle of ‘wholeness’ applies; parts of the interpersonal system are interconnected, so change in one part is likely to effect change in other parts.” (Christensen et al, 1998, p185) In addition to the identification of shifts, five contextual preconditions for change were identified by participants. These preconditions were characterized by the researchers as: safety, fairness, normalization, hope, and pacing. The gradual nature of change was also noted by all participants as essential to the process. In a study Gottman et al. (1998) marital interaction processes that are predictive of divorce or marital stability, processes that further discriminate between happily and unhappily marred stable couples were explored. Seven types of process models were also examined: (1) anger as a dangerous emotion, (2) active listening, (3) negative affect reciprocity, (4) negative start-up by the wife. (5) de-escalation, (6) positive affect models, and (7) physiological soothing of the male. Between 1980 and 1992 a two-stage sampling procedure was used to draw a sample of newlywed couples from the Pudget Sound area in Washington.

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There were 179 newlywed couples who met the criteria of having been married for the first time within 6 months and being childless. Couples were contacted and completed the Marital Adjustment Test. Demographic characteristics regarding their marriage, well-being, and health were also discerned. In the second phase of the study, 130 newly-wed couples who represented an even distribution of marital satisfaction were invited to participate in a marital interaction laboratory session and complete additional questionnaires. Anger as a dangerous emotion, active listening and negative affect reciprocity were not supported by the results of this study (Gottman et al. (1998). However, support was found for models of the husband rejecting the wife’s influence, negative start-up by the wife, a lack of de-escalation of low intensity negative wife affect by the husband, or lack of de-escalation of high intensity husband negative affect by the wife and a lack of physiological soothing of the male, all predicting divorce. Support was also found for positive affect model and for balance models of positive-to-negative affect predicting satisfaction among stable couples. In a study by Driver and Gottman (2004) the researchers postulated that the way a couple responds to mundane everyday comments and fleeting interactions have a cumulative effect on major emotional interactions such as conflict and romance. The goal of the study was to discern if there was support for the view that everyday interactions are correlated with positive affect during conflict. Forty-nine newlywed couples with varying levels of marital satisfaction were observed during a 10 minute dinner time discussion and a 15 minute conflict discussion. These observations took place in a semi-natural environment of an apartment laboratory. For the conflict discussion the couples were asked to argue for 15 minutes to try to resolve an ongoing problem in their marriage. The couples were videotaped and coded for positive negative emotions using Specific Affect Coding System (SPAFF). They were also videotaped from 9:00 am to 9:00 pm for 24 hours in the studio-type apartment laboratory. Every day interactions were also coded in an effort to examine the importance of these reactions in correlation to relationship enhancement. The results of the study indicated preliminary support for the hypothesis that couple’s everyday moments contribute to positive affect during conflict.

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The current data provide preliminary support for the theory that couples build intimacy through hundreds of very ordinary, mundane moments in which they attempt to make emotional connections. Bids and turning toward may be the fundamental units for understanding how couples build their friendship (Driver & Gottman, 2004, P. 312). Review of Recent Outcome Research in Art Therapy Relatively few large, quantitative evaluations of art therapy programs have been published. This writer was able to locate one dissertation study that in part assessed outcomes for the use of art therapy with couples. However, several tangentially related studies which address art therapy effectiveness were found. Summaries of these studies are discussed in this section. In a dissertation study incorporating the use of bilateral art therapy, marriage and family therapy, and neuroscience, McNamee (2004) described an art therapy protocol for use with individuals, married couples and other dyads (supervisor/supervisee). The term bilateral art is defined as an art intervention which seeks responses from both the left and right hemisphere of the brain for the purposes of integrating and balancing polarized beliefs, cognitions or feelings. The researcher hypothesized the use of bilateral; art perturbs maladaptive neural organization similarly to how the family therapist perturbs the patterns of behavior when they “join” with a family. Case studies demonstrate clinical application of the intervention to a range of presenting problems including differentiation from family-of-origin, parenting, loss, trauma and self-esteem. Case studies chronicled the development and use of bilateral art protocol focusing on increasing openness and empathy and describe initial experiences. The protocol of bilateral art therapy for use with married couples is described as a neurologically based art therapy intervention that engages both dominant and nondominant hands in the creation of images in response to polarized beliefs, cognitions, and feelings. One partner was asked to identify an element of the relationship that he/she wants to change or explore. The other partner is asked to witness their partner and record their thoughts and feelings in response to the bilateral art intervention. They are then asked to share and reflect upon their experience as a witness. The one case study with a married couple yielded mixed results. In addition to the case study descriptive statistics

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were used. Pre and post measure of scale ratings based upon client’s scaling of strength of belief in their positive and negative elements by were used to provide evidence of intervention effectiveness. Results overall for the study argue for controlled studies to further evaluate effectiveness of the intervention. Saunders and Saunders (2000) conducted a quantitative outcomes–focused study of an art therapy program in a large multi-program, private, nonprofit human service agency. Evidence of program effectiveness was collected for over a 3 year period. The art therapists and research methodologists set out to identify the therapeutic process and behavioral change outcomes that they were most likely to address in working with youth between the ages of 2 and 16. The hypotheses for this study include a prediction of a statistically significant positive change in the client-therapist relationship, a statistically significant positive change in the severity and frequency of the presenting behavioral problems of the youth from program intake to program exit and that clients will achieve the goals identified for them at program intake by the time they exit. Additionally, the following research questions were included: Are there gender differences in outcomes for clients? Are there age differences in outcomes for clients? Does the number of art therapy sessions influence program outcomes? The evaluation of this art therapy program was developed using a pre test/post test design using instruments developed by the program evaluator with the staff (Saunders & Saunders, 2000). Pre and post test data were collected for 94 clients. Analyses were a review of the therapeutic progress/engagement data, the symptomatic behavior scores, and the goal attainment data revealed that the art therapy program had a significant positive impact on the lives of its client and of client’s families (Saunders & Saunders, 2000). Clients were more clearly engaged with their therapist by the exit of the program as compared to the time of entry, they also showed a significant decrease in the frequency and severity ratings of their behaviors. With respect to goal attainment, 93% of the primary goals were completely or partially met, 95% of secondary goals were completely or partially met and 94 % of a third goal was completely or partially met. Gender bias was discounted in the delivery of art therapy. Results pointed to keeping all youth sufficiently long in therapy to help them become engaged with the therapist in resolving the issues that brought them into therapy.

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Another tangentially related study by Quail and Peavy (1994) sought to gain an understanding of a client’s experience in art therapy and to demonstrate a research approach which examines the phenomena that occur in art therapy. The research question in their study was: What meaning is revealed in a client’s descriptions of her experience in art therapy over time? The participant volunteered for the study. She had recently completed a structured art therapy group for women who had been sexually abused. She was interviewed in the presence of the artworks that she had created in a 16week art therapy group. In the interview phase, the participant assumed the role of the co-researcher in investigating and describing her experience. Analysis of data were completed through transcribed audio-tapes, categorizing what the participant experienced and how the participant experienced art therapy (Quail & Peavy, 1994). Each session of art therapy that the client described was drawn out in diagram form in order to get a sense of the movement and to see each session as a whole. The inherent complexities contained in the art therapy process as well as the extensive amount of data made it challenging to grasp and integrate coherent meaning in the work. The analysis of the data took place over an extended length of time. The essential structures and essences of a client’s experience in art therapy were co-constituted by the researcher and the descriptive experience of the participant. In making the art object in art therapy, the client appeared to go through a transition from being preoccupied with her inner world to becoming engaged in the process of art making (Quail & Peavy, 1994). The findings indicated that this took place through letting go of conscious concerns, and opening to the materials, activities and objects of the art making through an analogal processing. This is explained as a process where one medium of activity is used to express another in real time at any instant the one medium of activity explicitly or uniquely expresses the other. A significant finding in this research study is that the relationship exists for the client not only in the artwork or the completed symbolic form, but also in the actual materials and activities that went into making them. This takes place through an analogal process whereby the materials, activities and images assume a parallel level of existence with the emotional state of the client.

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In this research study, Quail & Peavy’s (1994) findings indicated that a client’s experience in art therapy does have its own nature and essence and although there are similarities between theoretical interpretations of this experience, there are also subtle differences. The limitations of this study exist in the framework of phenomenological research which focuses on the sense of the empirical rather than the facts. In phenomenological research no reality claim is being made. Instead each reader of the research report becomes a critical evaluator of the researcher’s essential intuition. A study by Rosal (1993) examined the use of art therapy to modify the locus of control (LOC) and adaptive classroom behavior of children with behavior disorders. The method used for this research included a pretest-posttest control group intervention study. “It was hypothesized that a cognitive-behavioral art therapy approach would be more powerful in helping children alter LOC perceptions than either a traditional art as therapy group or a control group” (Rosal, 1993, p. 233). The participants consisted of students in grades 4, 5, and 6 whose teachers rated their behavior on the Conners Teacher Rating Scale (TRS). Forty eight students were identified as having moderate to severe behavior problems; the parents of 36 students gave permission for their children to participate. The Children’s Nowicki-Strickland Internal-External Locus of Control (CNS-IE), the TRS and the Personal Construct Drawing Interview (PCDI) were used to evaluate outcomes of this study. The results of the study indicate that both types of art therapy appeared to be effective in altering LOC perceptions. The art making process may rely on LOC in order to be realized, therefore, enhancing internal LOC perceptions. Although Kramer touched upon the concept of children gaining control through the art process, she stopped at the point of saying that art is a process of sublimation. Art may go beyond the act of sublimation. The process of creating art may be responsible for changes in LOC perceptions…drawings are derived from inner experiences. The inner experiences may be perceptual, emotional or cognitive processes that are transformed into visual display. Without even examining the content, a drawing is a tangible record of internally controlled

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behaviors. In art therapy these tangible records are discussed, further reinforcing a child’s inner experience ( Rosal, 1993, p 240). An outcome-based art therapy research project by Chapman, Morabito, Ladakakos, Schreier and Knudson (2001) examined the effectiveness of art therapy interventions in reducing Post Traumatic Stress Disorder. The participants included children 7 to 17 years old who had been admitted to a Level I Trauma Center for traumatic injuries. The method included a randomized cohort design. The measurement used for pre test and post test was The Children’s Post Traumatic Stress Disorder Index (PSTD-I). Treatment consisted of the Chapman Art Therapy Treatment Intervention (CATTI). This is a specific drawing treatment intervention designed for ‘incidentspecific, medical trauma’…to provide an opportunity for the child to sequentially relate and cognitively comprehend the traumatic event, transport to the hospital, emergency care, hospitalization and treatment regimen, and post-hospital care and adjustment” (Chapman et al., 2001, p. 101). Preliminary results indicate evidence that the children receiving the art therapy intervention did show a reduction in acute stress symptoms, however, there does not appear to be a statistically significant difference in the reduction of PSTD symptoms between the experimental and control groups. Moments of change in the art therapy process were explored in a study by Ball (2002). A registered art therapist was observed in her sessions with several emotionally disturbed children in an effort to uncover the complex ways in which art therapist and their clients interact and use the artmaking. Participants were selected from a residential treatment center. The art therapist recommended participants that she felt could manage the presence of an observer without negative effects on their treatment. Five children were selected, each of which had been in art therapy for more than a year and had developed a positive relationship with the art therapist and the art process. A total of 50 sessions in the period of one year were observed. Eleven intensive interviews were conducted with the art therapists. Ball (2002) used a systematic analysis of the sessions and developed a coding system as a way of conceptualizing the data and creating a theoretical framework. Many descriptive codes were used and then organized into more general categories and

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eventually into two major axes: the focus of interaction and the mode of interaction. The case study presented illuminated the systematic analysis of interactions between the art therapist, the child and the art revealed significant changes in the child’s processing of traumatic experiences. The child increased her ability to symbolize her experience in words and images, to regulate her emotions and impulses, and to observe herself. As the child learned how to master the ups and downs in the art process she experienced change in managing the ups and downs of her life. This case showed that the mystery of change centered mainly around the emotional aspect of the therapeutic experience and the mutual influence of therapist and client. Empathic process could be discerned in the art therapist’s and the client’s interaction, particularly in the development of dissonance and in the emergence of images from their exchanges. (Ball, 2003, p.91) This study provides a more intimate look at the interaction in the triangle between art therapist, client and art-making. This intimate perspective from a third party observer provides detailed information of what comes before, what constitutes and what follows pivotal moments in the art therapy process. Another tangentially related study exploring the effectiveness of art therapy compared therapeutic factors in verbal and art group psychotherapy (Shechtman & PerlDekel, 2000). The participants were 27 psychiatric patients in a day-treatment clinic. There were 9 men and 18 women whose ages ranged from 19 to 58. Participants had been diagnosed with schizophrenia, affective disorders, and anxiety disorders. Hospitalization ranged from a few days to 1 year. Verbal groups were held by a social worker and the art therapist; art therapy groups were led by two art therapists. Instruments used were the Q-Sort, the Critical Incidents Measure and the Helpfulness Questionnaire (Shechtman & Perl-Dekel, 2000). These instruments were employed to discern the clients’ perceptions of what events were critical or helpful in group sessions. Each was administered at five points of time which averaged out to about every other session, immediately following the session. The Verbal therapy group was introduced as an interpersonal experience in which clients could learn about their relationships in the group and in the outside world. The art therapy group was designed to promote interactions and self-understanding through self-expression in the visual arts.

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The therapeutic factors in the two group treatment modalities were compared by the frequencies of all factors based on the Q-Sort questionnaire and the Critical Incidents Measure. The results only partly support the view that a core of factors in group psychotherapy is universal to all group modalities. The results regarding the differential perceptions of the therapeutic factors in each modality are inconsistent. Differences were found on one measure but not on the other. The limited sample size requires caution in the interpretation of the results. Clients may not have been able to distinguish the two modalities creating a halo effect and possibly skewing the results of the measures. Summary Change process research has been identified as crucial to the growth marital therapy; this requires quantitative investigation. A need for more quantitative research in art therapy has been established. Specifically, the need for a combined qualitative and quantitative investigation into the use of art therapy with couples has emerged as a theme throughout this review of literature. The secondary sources in this literature review provided a theoretical base as well as support through description of successful art therapy techniques for the research questions of this study. The primary sources provided models for the type of research methodology needed to address the research questions proposed by this writer. The next chapters will discuss the methodology for the study and will include theoretical framework, research questions and design, the setting, procedures, instruments and sources of data collection as well as information regarding the internal validity, and statistics.

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CHAPTER THREE METHODOLOGY The purpose of this study was to explore art therapy as an effective treatment modality for marriage/couple counseling. A need for more successful therapy techniques for couples in conflict was validated through the increase in divorce rate, the negative effects of high marital conflict experienced by children and the negative effects upon couples who have experienced a divorce or the dissolution of a long term partner relationship. Change process research has been identified as crucial to the growth of marital therapy; this requires qualitative investigation, which provides a rich description of the dynamics of each therapy session and is key to discerning when, why and how pivotal moments occur in therapy (Helmeke, 2000). Quantitative measures provided data in which to validate the effectiveness of art therapy as a treatment modality for marriage therapy. A need for more quantitative research in art therapy has been established (Rosal, 1989). Specifically, the need for a combined quantitative and qualitative investigation into the use of art therapy with couples has emerged as a theme throughout the review of literature. The following chapter includes a description of the theoretical framework that was used in this study, the research questions and design, the instruments that were used, and the data collection and analysis procedures that were followed. Theoretical Framework Family systems theory was the model used in therapeutic intervention, specifically the Gottman model for building a ‘Sound Marital House’ (1999). In his book The Marriage Clinic, Gottman discusses the importance of focusing on successful marriages and what works in marriage naturally as a model for distressed couples to emulate. The two necessary ‘staples’ of marriages that work are (1) an overall level of positive affect, and (2) an ability to reduce negative affect during conflict resolution. These two empirical facts give us the basics of marital therapy: To create lasting change in troubled marriages, interventions need

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to enhance the overall level of positive affect in both nonconflict and conflict by accepting one another’s influence (Gottman, 1999, p. 105). Building a Sound Marital House includes a foundation of friendship, positive sentiment override, regulation of conflict, and creating a shared meaning system. Gottman also discussed the signs in marital relationships which predict divorce. These include a harsh startup, the Four Horseman of the Apocalypse, flooding, body language, and failed repair attempts. These concepts are more clearly defined in Chapter Two. Therapeutic intervention strategies were developed to assess the presenting problem or gridlock and to engage the couples in making a paradigm shift. Biopsychological and familial histories were completed to identify family-of-origin issues that are unresolved and impeding on the relationship. Couples were guided in the therapy to enhance their marital friendship, discern solvable problems, to accept the inevitable, to build life dreams and shared meaning and to avoid relapsing. Research Design and Questions This research study was a quasi-experimental design, combining qualitative and quantitative measures. The setting was at Family Foundations, a Marriage and Family Counseling Center in Jacksonville, Florida. There were three couples participating in this study. The participants were administered a pre test and post test of the Dyadic Adjustment Scale (DAS) in order to address marital satisfaction. Analysis of session transcriptions and art work made in sessions as well as post-session questionnaires were employed to address pivotal moments. The participants met for therapy for approximately eight sessions. Convenience sampling was used to select participants. This study addressed the following research questions: 1) Will the use of art therapy techniques with couples in counseling improve the quality of their relationship? 2) What significant or meaningful events in art therapy do the participants consider to be pivotal? 3) How do participants account for the pivotal moments they experience in therapy? 4) Is there a relationship between the number of pivotal moments identified and the level of increase on the Dyadic Adjustment Scale (DAS)?

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Setting This study was conducted at Family Foundations, a marriage and family counseling center in Jacksonville, Florida. The sample consisted of three couples that volunteered for the study. Criteria for selection included couples who were at least eighteen years of age, married or life time partners or considering these commitments and were experiencing conflict and/or communication challenges. In order to participate in the study, the participants filled out brief a questionnaire at the end of each session for no more than eight sessions Procedures The procedures for identifying the population for this study will included inviting couples that called the Family Foundations to participate in a research project. If they indicated interest, the researcher contacted the couples, explained what their participation would involve, and informed them that declining the invitation would not affect the delivery of counseling services to them. The couples that agree to participate then met with the researcher for an initial interview to obtain consent and to explain the project procedures and goals. The DAS was administered to each couple prior to the first therapy session. The DAS was administered again after the last session. Each partner was instructed to fill out a post session questionnaire independently and immediately after each session. Analysis of post session questionnaires, and the post session interview with each couple were employed as identification measures for the client’s perspectives of pivotal moments. Analysis of pre and post data from the DAS were used to measure increase in relationship satisfaction as a result of therapeutic intervention. Instruments/ Methods and Sources of Data Collection The methodology chosen for this study was combined qualitative and quantitative. The primary inquiry paradigm guiding the study was grounded theory. This method is based on theory development from data that are collected and analyzed systematically and recursively (Glaser & Strauss, 1967). Grounded theory attempts to derive theories from an analysis of the patterns, themes, and common categories discovered in observational data. Essentially, grounded theory employs the constant

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comparative method by making use of multi-modal measures of observations (Babbie, 2001). Dyadic Adjustment Scale Couple satisfaction/adjustment was measured using the Dyadic Adjustment Scale (DAS). The DAS is designed to provide an overall measure of dyadic adjustment (Spanier, 1976). This scale has been determined to have sufficiently high reliability, content validity, criterion-related validity and construct validity. Post-session questionnaire A post session questionnaire was developed by this researcher to assist in discerning the pivotal moments in therapy sessions and the environment/interaction present when these moments of change occur. The questionnaire was administered at the close of each session to each of the participants. Refer to Appendix A to view specific questions on the Post-session questionnaire. Interviews with researcher This researcher met with each couple for two interviews. The first was prior to the onset of therapy to discuss the specifics of participation in the study, to obtain written consent, to administer the DAS and to complete an assessment to determine demographics and screen for mental disorders that could skew results. A sample of a demographics/assessment screening developed by this writer is available in Appendix B. The second interview occurred as part of the last session. In this session/interview the researcher discussed responses to the Post-session questionnaires. An open-ended discussion of the therapeutic process was initiated. Participants had a chance to reflect on the process and give feedback to the researcher regarding what they thought was helpful. The researcher was familiar with session content through reading the transcriptions of the sessions. When interviewing the couples, artwork completed in sessions was present for reference, reflection and discussion. The DAS was administered again at the close of this session/interview. Internal Validity Financial resources were limited which dictated a small study. This influenced the choice of convenience sampling instead of random sampling. The size and method of

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sampling caused this study to be quasi-experimental instead of experimental which limited the internal validity. Statistics Quantitative data will be gathered after administering the DAS to the clients. This data were analyzed using nonparametric methods. Art therapy techniques (independent variable) were examined as they correlate to pivotal moments (dependent variable). Qualitative data was analyzed using grounded theory and the constant comparative method; this entails coding and development of a matrix for the post sessionquestionnaire and looking for themes, patterns, and emergent assertions. Artwork completed in sessions was considered an additional method for evaluation and was included in the search for themes, patterns and emergent assertions. Summary This chapter provided an overview of the theoretical framework, research design and questions, the setting, procedures, instruments/ methods and sources for data collection, and internal validity and statistics. The next chapter provides the results of the analysis of the qualitative data, quantitative data and a cross case analysis.

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CHAPTER FOUR RESEARCH FINDINGS This research study utilized qualitative and quantitative elements to look at the use of art therapy techniques in couples counseling. Art therapy techniques were used within the framework of John Gottman’s Sound Marital House Theory (1999). Participant’s perceptions of pivotal moments were specifically examined through postsession questionnaires and described through transcriptions of counseling sessions and artwork created in sessions. The level of marital satisfaction was measured through the pre and post administering of the Dyadic Adjustment Scale (DAS, Spanier, 1976). This chapter will begin with a discussion of the findings from the qualitative analyses of all three cases, proceed with a discussion of quantitative data and how it correlates to qualitative data, and conclude with a cross case analysis. Qualitative analysis will consist of a description of each of the pivotal moments identified by participants and any artwork that relates to the session in which this pivotal moment occurred or enhances the description of this moment. It will also include a discussion of themes, patterns, and trends that emerged from the analysis. Quantitative analysis will consist of comparison of the pre and post scores on the DAS as well as how these scores correlate to the number of pivotal moments identified by participants. Pivotal moments are named for ease of reference and to attempt to capture the essence of each. Names are also associated with a code which references the person who identified the pivotal moment and the session that the identification occurred. For example: AM1 Recognized Patterns refers to Couple A, Marion in session 1 Recognized Patterns. The description of the pivotal moments will be discussed in relation to the session in which they occurred and the artwork associated with that session. Qualitative Analysis of Case A “Marion and John” Demographics As of the commencement of marital therapy, John and Marion had been together for about eight years and had been married for six years. They had a four year old son. Both were college educated. Both were African American. Neither had been to previous marriage counseling, although Marion had exposure to psycho-educational dynamics as she had studied psychology as an undergraduate. John was 30 and Marion was 28. John

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was professionally employed in the sales industry and had previously served in the United States Military. Marion was caring for their son and pursuing her Masters Degree in Business. This was a first marriage for both of them. Pseudonyms were chosen to ensure confidentiality. Presenting Problem John and Marion entered therapy with the goal of improving communication. They reported that they were fighting frequently and that these fights escalated to physical altercations in the past and they wanted to learn ways to get along and communicate so that this would not happen again. Both came from single parent families with limited supervision and had challenging childhood experiences. Both seemed to have become resilient as a result of these experiences and perhaps drawn to each other because of them. Both spouses took the Dyadic Adjustment Scale (DAS, Spanier,1976), a measure for assessing the quality of the marital dyad. John scored 85 on the pre test, Marion scored 66 on the pre test. Spanier classified couples scoring 101 and below as relationally distressed and those scoring above 101 and relationally nondistressed. Thus both spouses were in the distressed category. Post test scores are not available for this couple. Pivotal Moments Identified During session one a family Genogram was created and processed. Marion identified two pivotal moments during this session (See appendix C for a full description of the art directive and how it was linked to the Gottman model). The first pivotal moment was named Recognized Patterns (AM1 Recognized Patterns). Marion described how the process of creating a three generational diagram of her family-of-origin and her husband’s brought insight to her current choices and behaviors in her marriage. On the post-session questionnaire Marion wrote: Looking at both my husband’s and my genealogy was amazing! It was emotional to see the pain, deaths, and patterns in our family lines. I recognized that we are not horrible for our behaviors; rather we have just learned them from modeling and habit. If we learn to practice new ones, we might be alright. The therapist

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pointed out that we did not have healthy marriages to pattern ourselves after and I had not previously paid attention to that. The Genogram created in session one is shown in Figure 4.1. The second pivotal moment was named Free-Neutral (AM1 Free-Neutral). Marion described on the post-session questionnaire how she appreciated being able to communicate openly and freely to her spouse with a neutral person present. John identified three pivotal moments in session one. The first was named Loss (AJ1 Loss). John discussed how that for the first time he realized that had experienced many deaths and losses at a young age. He reflected on this realization stating that having so much loss at a young age may have contributed to his struggles with depression. This was also depicted in John’s Lifeline drawing from session two (see Figure 4.3). The second pivotal moment identified in session one was named Gloom to Numb (AJ1 Gloom to Numb). John discussed seeing all the death he experienced at a young age laid out on the Genogram helped him to gain insight (see Figure 4.1). He realized that not knowing how to process death at the time caused him to suppress his feelings. Suppressing his feelings in turn caused him to become numb to many feelings. This was linked very closely to the first pivotal moment identified. On his post-session questionnaire John wrote: When I had to put X’s for all the deaths in my family…all the deaths that are shown that happened in my life time, happened before the age of 23…most of them before the age of 18. I realized that, as a child I saw a lot of death and my family didn’t deal with death healthy. So I have a lot of gloom from pressing all the emotions that I have about death. I realized that it makes me numb to life in some ways. The third pivotal moment John identified was named Lack of Intimacy (AJ1 Lack of Intimacy). John described that he had a very big family and that they were well known is his community. He discussed how everyone thought that they really had it together because the older members of the family were leaders in the church. He stated looking back they were not very close to each other and did not comfort each other with all the loss they experienced. He recalled that other emotions were not processed in his family-

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of -origin as well and that he did not feel like he could express his emotions to his family members.

Figure 4.1 (Marion and John’s Genogram) Session two began with each partner individually and ended with a few minutes together. Each partner had been asked to create a Lifeline. (See appendix C for a full description of the art directive and how this was linked to the Oral history of the Gottman model) Marion did not identify any pivotal moments from session two. She did not fill out a post-session questionnaire. Due to time restrictions she was asked to fill it out and bring it to the next session. Marion did not remember to fill out the post-session questionnaire and bring it back. In session two John identified two pivotal moments. The first was named Remembering Our Story (AJ2 Remembering Our Story). John discussed how telling about the way they met and came together was very pleasant and brought hope to regaining the positive relationship they had in the beginning. This is evident in the following portion of the session transcript:

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John: I think I do have hope. I have a lot of hope. Even if I had played with the thought of getting a divorce, or something like that, or separating in my mind I would think forward and somehow she would be there. Somehow we would be back together. You know what I mean so… Therapist: You really could not imagine her being out of your life. John: No, no, no. Therapist: That’s a lot of hope. John: Even if we did separate or I would leave out the house and say we were done, I would start planning stuff. I would always include her in the stuff that I was doing. Well I am going to find a house…well I have to get a three bedroom house because me and Marion are going to be together.

Figure 4.2 (Marion’s Lifeline from session two) The second pivotal moment identified was named She Cares (AJ2 She Cares). John described how hearing a positive expression about himself from his spouse made him feel like she really cared. He stated that he had not been feeling like that lately and it was encouraging. On the post-session questionnaire John wrote, “Hearing Marion say how much she cared for me and that when I went away from college that she missed me and how much it meant when I came back. It really showed me how much she cared.” 58

The following section from the session transcript further elucidates the development of this pivotal moment: Marion: Even with my friends, they didn’t even know the situation that I came from until like a year and a half later, and so I realized that they had gone through some of the same things, but we met and you know, it was, well a lot of guys would try to talk to you and everything and now John, he said that when he saw me, he knew that I was the one. In a sense even though I heard him, but because of my past and my trust issues, I was not digesting it. What I did have in him was like friendship. Therapist: So you trusted him. Marion: I trusted him. Therapist: There was something about him that made you feel that he was genuine. Marion: Yes. Because I had met people in the military from all over the place, from different countries, you know, in college and everything, but it was something…like I said I hung out with my girlfriends all the time, but there was a point when he was going to leave school and, we were friends, but I was dating someone else and so he started dating someone else. He would like broadcast it throughout the campus that he cared about me and that he wanted to be with me and everything. It was a point where, you know I had gone through some things, and he said he was about to leave college. He said he would come back in a year, but a lot of people say that in college and they don’t really come back. I have had friends that I haven’t seen and they really were friends and they really cared about me and it was like okay, but when he left, it was just something that I couldn’t imagine like, if he didn’t come back, I couldn’t imagine like never seeing him again. That’s when I like start feeling my feelings toward him and understanding my feelings toward him. Therapist: And you were about to lose him, and you thought, I don’t want to lose him because there is all these things about him that I’m attracted to. Marion: Yes and I saw what I had in him, and then another thing was when he told me that he was leaving, I said oh my God, I’m surrounded by all these

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friends, but we just use to laugh and play, and hang out. But I am surrounded by all these close friends, but when he told me he was going to leave school, it was like now who am I going to have, who am I going to be with?

Figure 4.3 (John’s Lifeline from session two) During session three there was a poem about marriage that was shared. The Lifelines were processed more and sparked a discussion about current communication styles and where the couple becomes gridlocked. This session appeared to be particularly powerful. They both seemed to truly respond to the authentic emotional expression that was present throughout this session. Marion identified three pivotal moments in this session. The first was named Reframe Response (AM3 Reframe Response). Marion discussed how she felt being held accountable for expressing her true feelings and the change this made in the communication between she and her husband. She wrote on her post-session questionnaire, “Looking at my pain for what it is, is not a bad thing. I saw a whole different response from John.” The second pivotal moment was named Authentic

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Expression (AM3 Authentic Expression). For this pivotal moment Marion discussed how intense and positive it was for she and her husband to look at each other and express with emotion how they truly felt. The third pivotal moment was named Crossroads Poem (AM3 Crossroads Poem). This pivotal moment relates to hearing the poem about a marriage at the crossroads and how inspirational this was to setting a positive tone for the session. John identified four pivotal moments in this session. The first was named She Needs Me (AJ3 She Needs Me). At the start of the session Marion was guarded due to an argument that they had during the week. John discussed how good it felt to have his wife drop her guard and express that she needed him. He discussed how hearing this changed his whole perspective and made him more motivated to express his true feelings without being judged or criticized. The second pivotal moment identified was named Authentic Expression (AJ3 Authentic Expression). John wrote in his post-session questionnaire, “When Marion’s tears connected with what she was saying, it got to me. I felt that she does love me.” The third pivotal moment was named Past Blame (AJ3 Past Blame). John wrote: “When we got past the pointing fingers and expressed how we really felt”. The fourth pivotal moment was named Affectionate Expression (AJ3 Affectionate Expression). John discussed how much it helped when his wife hugged him as they moved past their gridlock. He wrote, “She gave me a hug and my walls came tumbling down.” During session four the Have/Need Collage was created. (See appendix C for specific art directive and relation to the Gottman model). Marion identified three pivotal moments. The first was named Replace Negative Expression (AM4 Replace Negative Expression). Prior to the start of the Have/Need Collage the therapist reviewed the importance of the softened start-up when making a complaint or discussing an issue. Marion commented on how this was helpful to replace negative expression. She discussed how she always knew that what she was doing was not working but did not know how to replace it with a positive approach yet still get her point across. She explained how she appreciated having boundaries for communication and learning when to take a break and when to start again. The second pivotal moment identified was named Being Heard/Accepted (AM4 Being Heard/Accepted). This was described in a similar

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way to AM1 Free-Neutral. Marion stated that the discussion progressed without escalation due to both she and her husband being heard and validated for their feelings. The third pivotal moment was named Visual Expression (AM4 Visual Expression). Marion wrote on her post-session questionnaire, “The art collage of wants and needs was extremely helpful. I enjoyed having a creative way to express my feelings.” (see Figures 4.4 and 4.5 Marion’s Have/Need Collage).

Figure 4.4 (Marion’s Have/Need Collage – the ‘Have’ side) John identified three pivotal moments in session four. The first was named Visual Expression (AJ4 Visual Expression). He discussed how it was helpful to put his needs into pictures. John stated that as he looked through the magazines he would see an image and it would help him think of things that he might not have considered. This was also linked to the next pivotal moment identified Being Heard (AJ4 Being Seen and Heard). John discussed how explaining his images felt good because his needs were seen and heard. He wrote on his post-session questionnaire, “I liked sharing what I need through the pictures because I don’t always feel that it’s heard.” The third pivotal moment was

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named Repairing Misconceptions (AJ4 Repairing Misconceptions). John stated that he was relieved to b e able to explain what he meant after his wife discussed feelings she had. The therapist discussed repair attempts and positive responses to repair attempts. John stated that he feels that many times Marion gets the wrong impressions of his action and he needed an opportunity to explain his intentions. Session five was a continuation of processing the Have/Need Collage. Marion identified two pivotal moments during this session. The first was named Explaining Visual Symbols (AM5 Explaining Visual Symbols). Marion discussed how helpful it was to explain each image on her collage and what that image symbolized for her. She discussed how it was helpful to clarify for herself her needs and wants and to communicate them in a positive way to her husband. This pivotal moment was linked to the next. The second pivotal moment was named Positive Regard (AM5 Positive Regard). Marion discussed how listening to John explain his visual symbols revealed that “…he looked at me positively and in high regard.” Marion discussed how the images sent a more intense message of John’s true feelings for her and that there was more positive than she realized. John identified three pivotal moments from session five. The first Pivotal moment was named She Showed Me (AJ2 She Showed Me). John discussed how seeing the images helped him to understand what his wife was concerned about more clearly (see Figure 4.5).

Figure 4.5 (Marion’s Have/Need Collage – the ‘Need’ side) 63

John wrote on his post-session questionnaire, “When Marion showed me the picture of the man with the hand over his mouth, I really got it that she feels I need to talk to her more about things that are bothering me.” The second was named Shut Off (AJ5 Shut Off). John discussed Marion’s explanation of her collage and the meaning of the images symbolizing him shutting off and not talking to her. He wrote on his post session questionnaire, “When Marion showed me that when I shut off it hurts her the most. She said it before but seeing that pictures really drove it home.” The third pivotal moment was named Needs Clarification (AJ5 Needs Clarification). John discussed how helpful it was to see and hear specifically what Marion needed from him. The following section transcript from the session described how in a later session this insight was referred to again. Marion: Yeah, I think it went a lot better this week. I did notice when there was confrontation it seems both of us are bending a little bit coming to the middle and that makes a difference. Like yesterday we got into something where normally he would just stay off and don’t say nothing but yesterday he made a difference when he acknowledged that he saw what he was doing was hurting me; I noticed that it was not on purpose and he recognized that the things that we bring up here and what you tell us then that means the world to me that he was not doing it on purpose. That when he is aware of it he will make the adjustments. That will make huge difference in our interactions. Therapist: That sounds like progress. John: Yeah. I shared with her yesterday about what she told me here that when I close up and not say nothing that is the most painful, hurtful thing to her. And so I remember that now. So yesterday I told her if I feel myself beginning to do that, which you know I do, I remind myself that my wife says I do this, this is what my wife says hurts. So I have to press pass it and just like make myself say something, I don’t care what I just say something until we talk through it. Just to say to my wife has definitely has a plus for the week. She has been working hard. We have had some challenges and different things come up. In session five the Joint Picture was created (See appendix C for the complete art directive and how it is linked to the Gottman Model). The couple was asked to create an

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integrated picture together without speaking to each other. Marion identified two pivotal moments in this session. The first was named Visual Communication (AM6 Visual Communication). Marion discussed how the action of communicating visually was revealing of some of the challenges of communication in her marriage. She was able to make some connection to how she may contribute to her husband shutting off at times. The therapist discussed the difference between making a complaint and criticizing. Marion was starting to understand that less criticism meant more communication from her husband. The second pivotal moment was linked to the first. The second pivotal moment was named Accepting Influence (AM6 Accepting Influence). Marion discussed how looking at the joint picture together and noticing the formal elements and what they symbolized about their communication style was insightful.

Figure 4.6 (Marion and John’s Joint Picture from session 6) John identified three pivotal moments in session six. The first was named Lack of Clarity (AJ6 Lack of Clarity). He described how the process of discussing the way they had communicated during the picture making helped him to realize that he did not

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communicate with enough clarity in order for his wife to be able to understand what he was trying to say. The second pivotal moment was named Visual Communication (AJ6 Visual Communication). John wrote on his post-session questionnaire, “I wanted Marion to color the sun and she was focused on drawing the fence. Once I saw she was focused I just went on doing the sun and did not try to get what I wanted across.” John discussed how this further validated his need to pursue the message he is trying to communicate until it is received. He discussed how he would not have fully identified the issue if it had not been played out in the Joint Drawing. The following section from the transcript of the session illuminated the process of how this pivotal moment occurred. Therapist: I noticed that a couple of times you were trying to get her attention and she didn’t see you and you gave up. John: Really. Therapist: You don’t remember?. John: No I don’t. Marion: I remember a couple of times where I didn’t understand what he was saying. Therapist: You didn’t pursue it. John: Um….(looking at the image) Therapist: For instance in the beginning you were trying to tell her color to the sun for you because you could not reach it. John: Right. I did. Therapist: She was focused on something else. John: Right. Therapist: So instead of pursuing it, you just reached over and did it. John: Right. Therapist: But I noticed that after asking for something one time and she didn’t get your message clearly, you didn’t try and push… John: I didn’t, I remember that now. Yeah, I didn’t. Therapist: So what I’m getting from this so far is that when you communicate you might give up a little and if Marion doesn’t get it right away, instead of saying I’m going to be clearer to make sure she does you just stop. But when you wife

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communicates and you don’t get it the first time she is going to have to try to say it another way until you get it. John: Yeah. I think so. I think you got it. Like we actually we say that a lot. She will say, I’ll say and she will say that is the first time I heard that. And I will say I told you that two years ago. She will say no. Then I will say I’m not like that, I tell you something and I not like you to keep going over and over something. I will say how I feel, and then I will leave it alone. Then she will say no, I’m different I will say how I feel and I will keep saying it until you get it. I will say... Marion: To me it’s like a whisper. So I usually forget it, you know what I mean? The third pivotal moment was named Our Space (AJ6 Our Space). John discussed how noticing that Marion took up most of the space on the page while completing the drawing helped him to realize that he needed to be more present in their space as a couple. He linked this back to the other pivotal moments identified and stated that if he was able to pursue communication with more clarity that he would contribute more to relationship. This pivotal moment relates to one of the five advantages of using art therapy with couples (Wadeson, 1980), the spatial expression of pictures (which can symbolically reveal the couple’s life space). The following transcript placed this insight in context: Therapist: How did you feel about how you shared this space? Do you feel like there was equal amount of what both of you put on the space? John: No. Therapist: You don’t. John: No, I don’t. Therapist: Let’s talk about that. Let’s talk more about this part here (pointing to a specific area). John: I had planned to do more on the left handed side. Marion: In my mind, I’m thinking he’s still doing the sun, how did I end up doing all this and then I thought he covered the whole side. Therapist: So what does that remind you of? John: Like everything. This is how everything is really; I may spend more time on something, for instance cleaning.

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Marion: Yes, that’s it exactly. John: I may spend for time stacking, filing or like maybe 20 minutes. In that 20 minutes of what I’ve done, she has washed the dishes, mopped, made the beds, folded clothes. Marion: I might see him, like with the sun, I’m not trying to make it happen, it just happens. When I think we’re doing it equally together, then I will look up and he’s still on that same project. Therapist: Is that a source of frustration for either one of you? Marion: For me it is. John: For her it is. Marion: I didn’t know we could get this much of this picture. It reminded me of home. You are doing these different things you will start feeling tired. That’s one thing. Then he’s just over here, I need help over here. Therapist: I’m wondering do you ever, because your wife get things done so quickly, do you ever want to do something but she’s already done it. Do you ever feel any frustration because you want to do it differently? Marion: This is very important. John: I think so. I think as far as she does things quickly. It may take me more time. The whole thing of being a man and wanting too and she’s already done it, sometimes it’s frustrating. Marion: (Reflecting and looking at the image)For me to see, there are a lot of excellent things I can get from him. Because he loves nature, the sunshine and the rainbow. I may do things, a lot of things, in a strong way that we talk about whereas I see now that it gets to a point where if I pull back he would shed more light and me not seeing the other side of doing things. John: That’s good. Marion: I’m like he knows that I may do things faster than him, I may do it, doing it strong, if I stand back he may lead this family in a way that it is more positive, more peaceful side of life where I don’t even know if that side exist. I’m seeing now I can get us to a certain place; I’m thinking he could have gotten us there is a more peaceful manner than I got us there.

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John discussed how his wife had been telling him this for a long time but that he did not understand what he could do differently. He discussed that he had identified some things he could change to make the relationship better. In session seven the Torn Paper Solvable Problem Collage was created (See appendix C for a description of the art directive). During the processing of these images, Marion appeared very upset. While her husband described his image she began to state that she did not agree with the way the therapy was going and that she was not sure if she wanted to continue. Much of the rest of the session was taken up discussing her feelings regarding the approach of the therapist and how it did not seem to be a match for her. Post-session questionnaires were not completed for this session. During this session John seemed surprised by his wife’s statements. The session was ended with the couple agreeing that they would think about whether they wanted to return and contact the therapist.

Figure 4.7 (Marion’s Torn Paper Collage from session 7) The therapist called both Marion and John to find out what had been decided. John called the therapist back and stated that they had broken up and would not be returning to therapy. At this time the therapist asked John come in for an exit interview and he agreed. On the day of John’s scheduled exit interview John called and asked if

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Marion could come with him and explained that they had gotten back together and wanted to continue. They arrived at the appointment late and brought their four year old son with them. The therapist discussed rescheduling the appointment because of the time and because the son was present.

Figure 4.8 (John’s Torn Paper Collage from session 7) During the session eight the couple also arrived late. The therapist discussed using the session as a review and some time was spent reviewing what had been accomplished and in what direction the couple would like to progress. During this session John began to express his feelings regarding the therapeutic approach. He stated that maybe he needed individual counseling. Marion stated that the couple had been relying too much on therapy and their friends to keep them together and she felt that they needed to work on things on their own. The couple agreed to come in for an exit interview. The therapist attempted several times to schedule an exit interview yet was not able to arrange for the couple to come in. Marion was contacted by phone. She stated several times that the therapist had really helped them a lot. She stated that they were

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very busy and could not come in, however, agreed that she and her husband would fill out the post DAS if it were mailed to them. The therapist mailed the DAS with a self addressed stamped envelop. The information was not returned to the therapist. After some time the therapist attempted to reach John and Marion by phone and they were no longer at the number they had provided. Summary of Case A John and Marion attended a total of eight therapy sessions. A total of 30 pivotal moments were identified by couple A. John identified 18 and Marion identified 12. At a time when therapy appeared to be progressing they decided not to continue. It is difficult to discern what triggered the retreat. In going over transcripts it seemed that the issues were truly being identified and insights were occurring. It is possible, as with many clients in therapy, that as the true work of therapy was coming into light it became too difficult for them to continue. Although a post DAS score was not available, the information on pivotal moments identified was useful. Patterns, Trends and Themes As the pivotal moments were identified they were assigned to a category. Seven categories emerged through the analysis of post session questionnaires, transcripts and artwork. These categories include recognizing familial patterns, communicating openly and freely with a neutral person, remembering good times, hearing positive feelings from spouse, being authentic with expression, reframing/being accountable for learning new skills, and art expression. Each category has been given a brief name for ease of reference. Recognizing familial patterns was named Family-of-Origin Insight (FOO Insight). This category refers to when the participant identified a pivotal moment that caused them to make a connection to their family-of-origin patterns and how they relate to current behaviors and/or choices. Communicating openly and freely with a neutral person was named Free Neutral. This category refers to when a participant identified a pivotal moment that related to being able to state their feelings to their spouse within the boundaries of the therapy session and being heard/validated by the therapist. Remembering good times was named Remembering Positive. This category refers to when a participant identified a pivotal moment the related to remembering good times in the past with their partner and

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this memory bringing hope. Hearing positive feelings from spouse was named Hearing Positive. This category refers to when a participant identified a pivotal moment that related to hearing their spouse state positive feelings about them or notice positive changes that they have made. Reframing/ being accountable for learning new skills was named Reframing. This category refers to when a participant identified a pivotal moment that relates to reframing their view in a way that they take some accountability for their part of the issue and learn new skills to approach an issue. The category Art Expression refers to when a client identifies a pivotal moment that related to the communicating through art, reflecting on the art and gaining insight and being “seen and heard” through the art without interruption or words getting in the way. Table 4.1 examines Marion’s identified pivotal moments by category and by session number. Marion identified one pivotal moment in FOO Insight, two pivotal moments in Free Neutral, one pivotal moment in Hearing Positive, three pivotal moments in Reframing, one pivotal moment in Authentic Expression and three pivotal moments in Art Expression. Examination of the chart reveals more pivotal moments were identified after the third session once the assessment phase of therapy was completed and the issues began to be processed. Marion’s highest number of pivotal moments were split between the categories of Reframing and Art Expression. Although Art Expression has a category of it’s own, many of the other pivotal moments were linked to the process of making art. Out of the 12 identified pivotal moments, four were perceived by Marion to be directly linked to Art Expression. Table 4.2 examines John’s identified pivotal moments by category and by session number. John identified three pivotal moments in FOO Insight, one pivotal moment in Remembering Positive, two pivotal moments in Hearing Positive, one pivotal moment in Reframing, four pivotal moments in Authentic Expression and seven pivotal moments in Art Expression. Examination of the chart reveals more pivotal moments were identified after the third session once the assessment phase of therapy was completed and the issues began to be processed. John’s highest number of pivotal moments identified were in the category of Art Expression. Several of the pivotal moments that were categorized in Art Expression also were linked to the category of Authentic Expression. This was the category which held John’s second highest number of pivotal moments identified. Out

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of the 17 identified pivotal moments, seven were perceived by John to be directly linked to Art Expression. Table 4.1(S = session) Marion’s Identified Pivotal Moments FOO Insight S1

Recognizing Patterns

Free Neutral FreeNeutral

Remembering Positive

Hearing Positive

Reframing

Authentic Expression

Art Expression

Reframe Response Replace Negative Expression

Authentic Expression

Art Expression

S2 S3 S4

Being Heard/ Accepted

S5

Visual Expression

Positive Regard

S6

Explaining Visual Symbols Visual Communication

Accepting Influence Table 4.2 (S = session) John’s Identified Pivotal Moments FOO Insight

S1

S2 S3

Free Neutral

Remembering Positive

Hearing Positive

Remembering Our Story

She Cares She Needs Me

Reframing

Authentic Expression

Past the Blame

Authentic Expression Affectionate Expression Repairing Misconceptions

Art Expression

Loss Gloom to Numb Lack of Intimacy

S4

S5

S6

Lack of Clarity

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Visual Expression Being Seen and Heard She Showed Me Shut Off Needs Clarification Visual Communication Our Space

Qualitative Analysis of Case B “Susan and Todd” Demographics As of the commencement of marital therapy, Todd and Susan had been together for about four years and had been married for three years. They had two young children, a two year old and a 10 month old. Both were college educated. Both were Caucasian. They had been to one previous session of marital counseling and stated that they did not continue because they didn’t connect with the therapist. Susan had been to previous therapy due to childhood trauma issues. Todd was 40 and Susan was 30. Todd was professionally employed in the sales industry and had previously been employed as a police officer and had also run offender groups with mental health professionals. Susan was employed as a Licensed Clinical Social Worker. This was the second marriage for Todd and the first marriage for Susan. Pseudonyms were chosen to ensure confidentiality. Presenting Problem Todd and Susan entered therapy with the goal of improving communication and reducing arguments. They reported that they were fighting frequently, that they were short and critical with each other and were no longer communicating feelings. Todd grew up without his father present and although he discussed some troubling times he seemed to feel he had a pleasant childhood. Susan grew up with both parents present. Although she experienced a childhood trauma it did not result from her nuclear family; when the issue was disclosed it was addressed appropriately and with nurturance and love. Susan stated that she had a happy family that was very close. Both spouses took the Dyadic Adjustment Scale (DAS, Spanier,1976) , a measure for assessing the quality of the marital dyad. Todd scored 73 on the pre test and 96 on the post test. Susan scored 103 on the pre test and 102 on the post test. Spanier classified couples scoring 101 and below as relationally distressed and those scoring above 101 and relationally nondistressed. Thus Todd was in the distressed category; Susan was in the nondistressed category at the beginning of therapy. Todd was still in the distressed category at the end of therapy, however his score increased 23 points and moved close to the nondistressed category.

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Pivotal Moments Identified During the first session the reason for entering therapy was discussed. The therapist addressed the couple’s history, the way they met, how and when they decided to marry, how and when they decided to have children and other information as part of the Gottman Model’s Oral History (1999). The Genogram was eliminated from the treatment plan due to similar information being available with the Lifeline (see appendix C for descriptions and processing for each art directive). Doing both the Genogram and the Lifeline left the couple in the assessment stage of therapy longer. Due to the distressed score of the husband on the DAS, the therapist felt it was best to begin addressing the issues by the third session. Susan identified four pivotal moments from session one. The first was named Identify Problems (BS1 Identify Problems). She discussed how it was helpful to discuss in detail specific areas in communication that are problematic for she and her husband. The second pivotal moment was named Hope (BS1 Hope). Susan discussed how important it was to get a sense of hope from the therapist that the problems they had could be addressed and worked through. The third pivotal moment identified was named Aware of Communication (BS1 Aware of Communication). Susan wrote on her postsession questionnaire, “When the therapist talked about becoming more aware in the moment of how we are speaking to each other, it was thought provoking and helped me to be cognizant of communication with my spouse.” The fourth pivotal moment was named Spouse as Friend (BS1 Spouse as Friend). The session included a discussion of Gottman’s Sound Marital House approach and building a foundation of friendship (1999). The therapist made a comment about how couples will often speak to each other very differently then they would a friend and how it would be more helpful to give your spouse the same consideration, patience and respect that one would give to a friend. Susan wrote on her post-session questionnaire, “The therapist’s analogy about treating your spouse differently than we would talk to our friends and how we should instead talk to our spouse the same as our friends stuck with me. It made a lot of sense.” Todd identified two pivotal moments during session one. The first was named Learning Softened Start Up (BT1 Learning Softened Start Up). Todd discussed that he found it very helpful to learn about starting a conversation in a soft way instead of

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starting with harsh criticism. The second pivotal moment was named Avoiding Defensiveness (BT1 Avoiding Defensiveness). Todd wrote on his post–session questionnaire, “It was very helpful to discuss and come to an understanding, how when we say something demanding to our partner we can cause them to go into defensive mode.” Part of this session included observing the couple discuss a problem they were experiencing. After the observation the therapist discussed the Four Horsemen of the Apocalypse identified by Gottman (1999) and how to avoid them (see Theoretical Framework in Chapter Three for discussion of these terms within the context of the model). Session two began with each partner individually and ended with a few minutes together. Each partner had been asked to create a Lifeline (See appendix C for a full description of the art directive and how this was linked to the Oral history of the Gottman model) The therapist reviewed the Lifeline drawings separately with each partner as part of Gottman’s Oral History (1999). Then each were seen together to reflect on each other’s Lifeline drawings and discuss family-of-origin issues and how they may be connected to current behaviors and choices. Post-session questionnaires were not filled out for this session. Due to time restriction, the therapist/ researcher asked the couple to complete the questionnaires at home and return them. The questionnaires did not get back to the therapist/researcher. During this session Susan discussed her childhood trauma of sexual abuse, when it occurred, how it affected her withdraw from gymnastics as well as relationships with men, and when she remembered the abuse and disclosed it to her parents. As she explained the images on her Lifeline she discussed the high and low points in her life, her faith and the protective spirit that was with her throughout her life. This spirit is symbolized with the yellow surrounding the images and is always there even in the most painful times. It is paramount to mention this as it becomes a point of reference in other sessions and artwork (see Figures 4.9-4.12 to reference Susan’s Lifeline). The following section from the transcripts begins to place the importance of this symbol in context. Susan: This is sexual abuse. I was in graduate school when I finally made the connection and talked about it, it was buried. It was kind of a shocker, I never

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really said anything, really connected what was wrong but I had an idea that something had happened. Therapist: Were you studying about sexual abuse at the time? Susan: Yes, I was…My sisters and mom, her whole life she never said anything and then when I came out, I think this happened, I don’t know who, she realized it was my grandfather. Therapist: Do you remember how old you were? Susan: Yeah, I was very young. I can actually go back and place it because I remember the haircut; I can remember it happening with my first haircut. My mom was real upset when I first started talking about. When she said it happened to her then it was like flood gates, flash backs about certain things. Therapist: Tell me more about how you remembered and what happened when you told your parents. Susan: I was dating a guy at a time and we were getting ready to leave, we were arguing about something and he whispered something in my ear, I don’t remember what is was but it totally set me off. At this time I was having nightmares, really bazaar nightmares. When he whispered he triggered me and I ended up hitting him. I tried to explain my reaction and told that I thought I might have been abused. That night he drove to all the way to my parent’s house and told my parents that I had been sexually abused. Which I couldn’t believe he did that. He said she thinks it’s by her grandfather. When he said that my parents immediately drove up and then when my mom said, oh my God that happen to me. She said I put my hands over my ears, saying no, it was very strange. Therapist: How did you deal with all of the issues, the pain. You never said anything until that day. Susan: I don’t know. I’ve always felt I have this protective spirit with me. I knew something was wrong, I had developed an eating disorder, not knowing why that I had these issues…I think I started having suspicions. We were in counseling to address my eating disorder, we had one family counseling session where they asked me if I had been abused and I said no, but I remember thinking that I might have. Looking back you can see all signs.

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Susan: (Pointing to her drawing) That was the part, it does effect our relationship now. There are things that trigger me. Todd is really wonderful, supportive. He gets upset when I say he reminds me of my grandfather and that really bothers him. He’s understanding. He’s very gentle. He will stop and not pressure me. Therapist: That sounds like a strength in your relationship. Susan: He’s known all along about that. Therapist: (Pointing to an image in the drawing). Tell me about this yellow line throughout and the areas where it is intensified. Susan: That symbolizes my spirit. That stays with me not matter what I go through and that was there, and that little girl, he didn’t touch that. Therapist: You draw strength from this spirit? Susan: I guess so. I have a strong faith. I’m Christian that is something that I have. There is a part of me that is missing but I know that my family loves me. My parents, my sisters, we are very close family.

Figure 4.9 (Susan’s Lifeline drawing from birth to 5th grade)

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Figure 4.10 (Susan’s Lifeline drawing from 5th grade to High School Graduation)

Figure 4.11 (Susan’s Lifeline drawing college years)

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Figure 4.12 (Susan’s Lifeline drawing from college years to present) During session two Todd discussed his upbringing with his mother, brother and grandparents. He talked about his father not really being involved in his life. Todd stated that he wanted to spend more time with his drawing however since these were done as homework he did not have as much time as he would have liked to include all the details. Todd discussed depression starting for him in high school and continuing through college and also somewhat in the present. The Lifeline included his first marriage and the dissolution of that marriage, his career as a police office and helping professional and his decision to leave this work behind and go into sales (see Figure 4.13 to reference Todd’s Lifeline drawing). He included how he met Susan at the time he was making the change to go into sales. Todd said that he ran out of time to include the time when their children were born and up to the present. A salient issue from this session was Todd’s connection to a misunderstanding early on in his relationship with Susan that corrupted her view of him and challenges the relationship ongoing. The following section from the transcript places this connection in context. Todd: Oh it just infuriates me. A lady that was Susan’s supervisor, I actually had worked at the agency where Susan was working before she did and I had gone out

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with a woman who worked there before I meet Susan. I didn’t know that this woman had shared some things with the supervisor about our physical relationship. Apparently Susan had shared with her supervisor that she went on a date with me, and I guess supervisor’s perception of me was that I was this player…… And then she throws in this whole thing about drinking and using drugs and all this. I have never been drunk my entire life. … Yeah, I use to go out, but I use to go out dancing, I would go to clubs or some place to dance. I don’t drink, never have done a drug in my life, never have smoked a cigarette. I had never done anything…I was the good kid that,… I’ve flirted and I played the field when I was single. I will never deny that, but I have never, no time in my entire life have I ever been unfaithful in a relationship. And see for me, it was just the opposite. I always felt used. I sought love through sex. I thought if a woman was having sex with me, she loved me, and I came to find out that it was the other way around. I was just being used. And it’s very odd for a man, men typically are on that side in using women, but I, my brother had always told me as a child that when people are in love, they have sex. And so therefore when I was having sex, I thought these women loved me. Well apparently anyway it goes back, this supervisor tells Susan all these things, I’m just a player, I’m this partier and I’m always up to something and after Susan and I had had this very intense date and everything, and we were very close…it changed after that conversation and I feel that Susan has always had doubts because of this.

Figure 4.13(Todd’s Lifeline drawing from birth to present) 81

In session three the Joint Picture was created (see Figure 4.14). The therapist asked Todd and Susan to create and integrated picture together without talking (see appendix C for a full description of the art directive and how it is used within the context of the Gottman model). Susan identified three pivotal moments during session three. The first was named Assessment to Goals (BS3 Assessment to Goals). Susan discussed how she found it helpful when the therapist shared her formulation of where the work needed to be done with the couple. The second pivotal moment was named Drawing Dynamics (BS3 Drawing Dynamics). For this pivotal moment, Susan discusses how the drawing exercise was used to identify personality traits and how they relate to the dynamics in the relationship. The third pivotal moment was named Cooperative Expression (BS3 Cooperative Expression). Susan identifies two of the five advantages of using art therapy with couples and the immediacy of doing a task together, the shared pleasure that picture making can provide for a couple (Wadeson, 1980). She wrote on her post-session questionnaire, “Seeing us cooperate together on a mutual task that was fun and expressive.” Todd identified two pivotal moments in session three. The first was named Recognized and Apologized (BT3 Recognized and Apologized). In the processing of the Joint Picture a discussion emerged regarding boundaries and personality traits. This pivotal moment relates to one of the five advantages of using art therapy with couples, the spatial expression of pictures (which can symbolically reveal the couple’s life space) (Wadeson, 1980). Todd expressed how he viewed the space of the picture. He felt that one side was his and one side was Susan’s. Susan felt the entire space was for both of them to work on. Todd stated that it didn’t bother him that she came into his space, although he discussed times when she had crossed boundaries with him that she knew he did not appreciate. Susan took responsibility for this and apologized to him for it. Todd wrote on his post-session questionnaire, “Susan apologized and recognized that she overstepped a boundary of mine.” The second pivotal moment was named Feelings Respected (BT3 Feelings Respected). Todd discussed how the processing of the image evoked genuine expression and showed him that Susan cared.

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Figure 4.14 (Todd and Susan’s Joint Picture) In session four the Have/Need Collage was modified to be used as the Dream Within the Conflict Collage (see appendix C for the specific art directive and how it was formulated to work within the Gottman model). Susan identified two pivotal moments from this session. The first was named Connected to Conflict (BS3 Connected to Conflict). Susan discussed how the making of the collage connected her childhood family-of-origin issues to her current marital conflicts. The second pivotal moment was named Recognize Impact on Dream (BS3 Recognize Impact of Dream). She wrote on her post-session questionnaire in reference to the making and sharing of her collage with her spouse, “Recognizing childhood issues and how it impacts my overall dream.” Todd did not fill out a post-session questionnaire for session four. Susan’s collage was processed for the most part in this session. A core ongoing issue for Todd and Susan was identified in this session. They continually disagreed regarding neatness and order and the differing perception that were tied to personality traits. Both partners appeared particularly critical of each other over this issue. It seemed to be the content of most of their arguments and the conflict that blocked their dream of being closer and

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more intimate. Processing continues with the collages in the next session (see Figures 4.14-through 4.17).

Figure 4.15 (Susan Dream within the Conflict Collage – Conflict side) During session five processing of the collages continued. Todd was given time to discuss his collage and to explain the meaning of the images. The disagreement on neatness/organization emerged again. Todd would describe Susan as ‘messy’; Susan would describe Todd as ‘compulsive.’ The therapist reviewed the importance of making a complaint and avoiding criticism and attacks on personality traits. Because this was such a prevalent issue the therapist suggested reframing the references to each other’s traits in a positive way. Susan viewed what Todd identified as messy as carefree. She discussed how this related to her dream of being carefree and happy and not having to worry that Todd would notice something small that she had overlooked and criticize her. Todd viewed what Susan identified as compulsive as observant. He related this back to his need for order in order to relax. His dream was also to be carefree and enjoy time together, however, he stated because he was by nature observant he could not ignore certain things. Todd and Susan agreed to refer to each other’s traits as ‘carefree’ and ‘observant’ from that point forward.

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Figure 4.16 (Susan’s Dream within the Conflict – Dream side)

Figure 4.17 (Todd’s Dream within the Conflict Collage- Conflict on left/Dream on right)

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During session five Susan identified three pivotal moments. The first was named Redirecting Flow (BS5 Redirecting Flow). She wrote on her post-session questionnaire, “The therapist helping us to talk to each other and guiding us through the processstopping us during dialogue and directing the flow.” The second pivotal moment was named State Feelings (BS5 State Feelings). Susan discussed how it was helpful for her to express what she was truly feeling to her husband in a non critical way when the therapist encouraged her to take her expression from intellectualizing to expressing her deeper emotion regarding the issue. The third pivotal moment was named Rephrase Terms (BS5 Rephrase Terms). Susan discussed how helpful it was to recognize the criticism in the terms they were using and to rephrase the terms that describe the personality traits in a more positive way. Todd identified one pivotal moment from session five named Rephrase Terms (BT5 Rephrase Terms). He also discussed that using more positive terms to refer to and describe personality traits as helpful. There had been a few weeks in between session five and six due to schedule conflicts. During session six there was a discussion of progress thus far and any changes in communication. There was a review of perpetual problems and solvable problems. The couple was asked to discuss a problem that they viewed as solvable. Todd brought up the problem of not getting enough affection and physical intimacy from Susan. The couple discussed this issue in such a different way. The following section from the session transcript illuminates the level of respect they gave each other on this issue. Therapist: You know both of you are showing so much love for each other right now. Here you are saying that you knew that he needed something and you were willing to let him have it because he wanted it so bad. Then here he is saying I can’t believe you were feeling like that and I don’t want you to feel like that, showing so much respect to each other. Susan: And I feel very safe. Even though we don’t have sex very often and maybe sometimes it is not like fireworks going off when we do, it is always a pleasurable close experience for us. It has never been anything bad or I have ever wanted to cry afterwards… I don’t think we have ever talked about sex and gotten into an

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argument. We have noticed differences or noticed areas that need to be worked on but we are not unpleasant to each other. Therapist: This is really great because what you are doing right now are using skills we talked about. There is a genuine respect to each other. Susan: I think the key word is respect. I do feel sex is a respected issue. Whereas any other issue I don’t think either one of us feel respected. Todd: Exactly. I have used that word a couple times that we have talked in the past. We don’t feel respected. I feel it is disrespectful to mess up something. To me and again because I tried to take care of certain items and I felt disrespected that they were not taken care of the way I would and she feels disrespected and I say something about I have taken care of an item. We do definitely feel disrespected. The couple was encouraged to build on this strength and use this respectful approach with other issues as they arise. The couple was also encouraged to be more affectionate without the expectation of sex and to develop a positive greeting ritual that was affectionate in nature. Susan identified three pivotal moments during session six. The first was named Building on Strengths (BS6 Building on Strengths). She discussed how it was helpful to recognize a problem that could be resolved with effective communication and to build on this strength and recreate the same type of communication toward other problems. The second pivotal moment was named Positive Greeting (BS6 Positive Greeting). She discussed that she felt developing a positive greeting would make a big difference in how they began their communication at the end of a long day. She related it back to how they greeted their children when they picked them up from daycare and how they were both loving and affectionate with their children and could do the same with each other. The third pivotal moment was named Regulating Conflict (BS6 Regulating Conflict). Susan discussed insight regarding recognizing just how damaging the conflict in her marriage is. She discussed needing to reframe it before it ruined the relationship. Todd identified two pivotal moments in session six. The first was named Building on Strengths (BT6 Building on Strengths). Todd wrote on his post-session, “ Applying the skills we use when we discuss intimacy to other topics… being carefree

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and observant.” The second pivotal moment was named Mutual Respect (BT6 Mutual Respect). He wrote in reference to this pivotal moment, “ Trying to use the same amount of respect for each other when we discuss the ‘mess’ issue as we do other times.” During session seven the couple processed a Torn Paper Solvable Problem Collage (see appendix C for a full description of the art directive and how it is linked to the Gottman model) (see figures 4.18-4.20 for art work associated with this session). These were created for homework and brought in by the couples. They were given the Matisse-like expressive figure stencils to take home and some construction paper. They were asked to think of an issue that frequently comes up in the marriage and express the issues using the materials. The issue chosen by the couple related to not being feeling accepted and loved. Each image created was powerful and contained graphic indicators which communicated both the intensity of emotion tied to these issues and the gridlock surrounding the issues. Susan identified four pivotal moments from session seven. The first was named More Work (BS6 More Work). She discussed that hearing from the therapist after the processing of the images that the couple would need to do more work to keep the marriage together was important. Later in subsequent sessions she shared how initially she was discouraged by the comment, however, it eventually motivated her to take action and show that her relationship was better and capable of coming through the challenges. The second pivotal moment was named Sharing Artwork (BS7 Sharing Artwork). Susan discussed how seeing the image express the issue was illuminating. She was able to grasp the intensity of the pain her husband was experiencing as well as to communicate her own strong emotions. The third was named Discussing Deeper (BS7 Discussing Deeper). Susan discussed how it through the images she and her husband were able to have communication at a deeper level regarding the meaning of the images and the feelings connected to the images. The fourth pivotal moment was named Reframe/Recognize (BS7 Reframe/Recognize). On her post session questionnaire Susan wrote, “It was very helpful when the therapist was able to reframe/recognize a situation and help explain to my husband.”

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Figure 4.18 (Front side of Susan’s Torn Paper Solvable Problem Collage)

Figure 4.19 (Back side of Susan’s Torn paper Solvable Problem Collage)

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Todd identified three pivotal moments from session seven. The first was named Expressing Pain (BT7 Expressing Pain). He wrote on his post-session questionnaire: “I got to share that I was ‘dying’ inside and got to show Susan how I am feeling through my art project.” The second pivotal moment was named Being Seen and Heard (BT7 Being Seen and Heard). He wrote on his post-session questionnaire: “Where sometimes I feel like Susan shuts down when I talk to her, the images on my art were able to reach her.” With this statement Todd was confirming one of the five advantages of using art therapy, the genuineness of unexpected material revealed in pictures (which may challenge old assumptions or beliefs that the couple holds onto firmly) (Wadeson, 1980). The third pivotal moment was named Shared Spirit (BT7 Shared Spirit). Todd discussed how helpful it was to see Susan’s image depicting her spirit dying in the relationship.

Figure 4.20 (Todd’s Torn Paper Solvable Problem Collage) During session eight the Bridge Drawing was created (see figures 4.21 and 4.22 to view art work created in this session). After a discussion of how the week had gone since the last session and some processing of insights from the last session, the couple was asked to think of the evolution of their marriage where is has been, where it is now and

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where is heading and to draw a bridge and place themselves on the bridge (see appendix C for a description of the art directive and how it used within the Gottman model). Susan identified three pivotal moments from session eight. The first was named Art Expression (BS8 Art Expression). Susan wrote on her post–session questionnaire, “It was helpful expressing feelings and ideas through painting that are difficult to verbalize.” The second pivotal moment was named Art Reflection (BS8 Art Reflection). Susan discussed how the process of painting, reflecting and then painting more was helpful to truly express the complex abstract feelings surrounding the evolution of the marriage. The third pivotal moment was named Reviewing (BS8 Reviewing). Susan commented on the helpfulness of the review of the week and the progress of the relationship as well as the insights gained from the last session. Todd identified two pivotal moments from session eight. The first was named Art Expression (BT8 Art Expression). He discussed how using an art image to show where the relationship currently is and is heading was insightful. The second pivotal moment was named Tangible/Abstract (BT8 Tangible/Abstract). He wrote on his post-session questionnaire, “Getting a (tangible) mental image to correlate with the abstract image of the state of our relationship.” With this statement Todd has also identified one of the five advantages of using art therapy with couples, the permanence encountered whereby the drawing provides a concrete object to study, react to, use for clarification/review (Wadeson, 1980). During session nine, the last session, processing of the Bridge Drawing and a review of all the art work created during therapy took place. The session began with a processing of the Bridge Drawings. Graphic indicators were present that showed a move from gridlock to progress (see Figures 4.21 & 4.23 for Susan and Todd’s Bridge Drawings). Susan identified three pivotal moments that occurred during this session. The first was named Review of Art (BS9 Review of Art). She discussed how helpful it was to go back to the art work created in earlier sessions and process it again and compare it to the current art work. The second pivotal moment was named Recognizing Growth (BS9 Recognizing Growth). She discussed how in reviewing the art work it was helpful and hopeful to see the evolution and recognize the growth in the marriage. The third pivotal

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moment was named Processing Comment (BS9 Processing Comment). Susan discussed how important it was to process an earlier comment made by the therapist and the effect it had on she and her husband as a couple. She commented on how different it was to review the images together instead of just explaining her image or listening to her husband’s. She felt that it more pleasurable to look back and discuss the issues after they had time to reflect. Todd identified four pivotal moments from session nine. The first was named Review of Artwork (BT9 Review of Artwork). He discussed how he found it insightful to review the art work made during the therapy. The second pivotal moment was named Reflection on the Past (BT9 Reflection on the Past). Todd commented on how useful it was to ‘see’ where they were through the artwork at the beginning of therapy. The third pivotal moment named Discussing Progress (BT9 Discussing Progress) was related to the second. Todd described how discussing the progress and seeing the art work that represented the progress was helpful and contributed to the next pivotal moment named Positive Future (BT9 Positive Future). He discussed that he could see in the Bridge Drawing that they were both focused on a positive future and could connect the path the lead them there through the artwork.

Figure 4.21 (Susan’s Bridge Drawing)

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Figure 4.22 (Todd’s Bridge Drawing) Summary of Case B Todd and Susan attended a total of nine therapy sessions. A total of 42 pivotal moments were identified by couple B. Todd identified 18 and Susan identified 24. Todd and Susan were consistent with therapy and made progress in on their therapeutic goals. Susan pre and post DAS score were about the same. She scored a 103 on her pre test and a 102 on her post test. Todd scored a 73 on the post DAS and a 96 on his post test. He increased his score by 23 points and moved closer to the nondistressed category. Patterns, Trends and Themes As the pivotal moments were identified they were assigned to a category. Seven categories emerged through the analysis of post session questionnaires, transcripts and artwork. These categories include recognizing familial patterns, communicating openly and freely with a neutral person, remembering good times, hearing positive feeling from spouse, being authentic with expression, reframing/being accountable for learning new skills, and art expression. Each category has been given a brief name for ease of reference. Recognizing familial patterns was named Family-of-Origin Insight (FOO Insight). This category

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refers to when the participant identified a pivotal moment that caused them to make a connection to their family-of-origin patterns and how they relate to current behaviors and/or choices. Communicating openly and freely with a neutral person was named Free Neutral. This category refers to when a participant identified a pivotal moment that related to being able to state their feelings to their spouse within the boundaries of the therapy session and being heard/validated by the therapist. Remembering good times was named Remembering Positive. This category refers to when a participant identified a pivotal moment the related to remembering good times in the past with their partner and this memory bringing hope. Hearing positive feelings from spouse was named Hearing Positive. This category refers to when a participant identified a pivotal moment that related to hearing their spouse state positive feelings about them or notice positive changes that they have made. Reframing/ being accountable for learning new skills was named Reframing. This category refers to when a participant identified a pivotal moment that relates to reframing their view in a way that they take some accountability for their part of the issue and learn new skills to approach an issue. The category Art Expression refers to when a client identifies a pivotal moment that related to the communicating through art, reflecting on the art and gaining insight and being “seen and heard” through the art without interruption or words getting in the way. Table 4.3 examines Susan’s identified pivotal moments by category and by session number. Susan identified three pivotal moments in Free Neutral, three pivotal moments in Hearing Positive, eight pivotal moments in Reframing, one pivotal moment in authentic expression and seven pivotal moments in Art Expression. Examination of the chart reveals more pivotal moments were identified after the third session once the assessment phase of therapy was completed and the issues began to be processed. Susan’s highest number of pivotal moments was in the category of Reframing with her second highest number of pivotal moments in Art Expression. Although Art Expression has a category of its own, many of the other pivotal moments were linked to the process of making art. Out of the 24 identified pivotal moments, seven were perceived by Susan to be directly linked to Art Expression. Table 4.4 examines Todd’s identified pivotal moments by category and by session number. Todd identified one pivotal moment in FOO Insight, three pivotal moments in

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Hearing Positive, four pivotal moment in Reframing, four pivotal moments in Authentic Expression and four pivotal moments in Art Expression. Examination of the chart reveals more pivotal moments were identified after the third session once the assessment phase of therapy was completed and the issues began to be processed. Todd’s highest number of pivotal moments identified was split among three categories Reframing, Authentic Expression and Art Expression. Several of the pivotal moments that were categorized in Hearing Positive and Authentic Expression were also linked to the category Art Expression. Out of the 17 identified pivotal moments, four were perceived by Todd to be directly linked to Art Expression. Table 4.3 (S=Session) Susan’s Identified Pivotal Moments FOO Insight

Free Neutral

S1

Remembering Positive

Hearing Positive

Reframing

Hope

Identify Problems Aware of Communication Spouse As Friend

Authentic Expression

Art Expression

S2 S3

S4

Assessment to Goals

Cooperative Expression

Drawing Dynamics

Recognize Impact on Dream

Connected to Conflict

S5

S6

Redirecting Flow State Feelings Rephrase Terms Building on Strengths Regulating Conflict

Positive Greeting

S7

Reframe Recognize

S8

Reviewing

S9

Processin g Comment

More Work Discussing Deeper

Sharing Artwork Art Expression Art Reflection Review of Art Recognizing Growth

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Table 4.4 (S=Session) Todd’s Identified Pivotal Moments FOO Insight

Free Neutral

Remembering Positive

Hearing Positive

S1

Reframing

Authentic Expression

Art Expression

Learning Softened Start Up Avoiding Defensiveness

S2 S3

Recognized and Apologized

Feelings Respected

S4 S5 S6

Mutual Respect

Rephrase Terms Building on Strengths

S7

Expressing Pain Being Seen and Heard Shared Spirit

S8

S9

Reflecting on the Past

Positive Future

Discussing Progress

Images Reached Her

Art Expression Tangible/ Abstract Review of Art

Qualitative Analysis of Case C “Janice and Terry” Demographics As of the commencement of marital therapy, Janice and Terry had been together for about ten years and had been married a little over one year. They had no children at the time of the study, however decided to marry with the hope of starting a family. Both were college educated. Both were Caucasian. Janice and Terry were lesbians. They had been to previous relationship counseling without success. Janice had been to previous individual therapy and Terry began individual therapy during the time they attended marital therapy. Janice was 35 and Terry was 27. Janice was professionally employed as

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a Licensed Clinical Social Worker. Terry was employed in the retail industry. Both Janice and Terry were very creative individuals. They both had a background in theatre and performance art and had met via this common interest. This was a first marriage for both of them. Pseudonyms were chosen to ensure confidentiality. Presenting Problem Janice and Terry entered therapy with the goal moving past gridlock on several issues. They reported that they were currently separated and living in different homes and were not spending very much time together. Janice asserted that she was looking for an answer from Terry as to whether she wanted to stay in the marriage or dissolve the marriage. Terry asserted that she wanted to stay in the marriage but needed time on her own to learn how to be a more equal partner. Janice reported a rather difficult abusive upbringing. Terry reported an ideal upbringing yet she felt she did not have the skills to deal with emotional issues appropriately. Both spouses took the Dyadic Adjustment Scale (DAS, Spanier,1976), a measure for assessing the quality of the marital dyad. Janice scored 68 on the pre test and 71 on the post test, Terry scored 83 on the pre test and 84 on the post test. Spanier classified couples scoring 101 and below as relationally distressed and those scoring above 101 and relationally nondistressed. Thus both spouses were in the distressed category both before and after participating in therapy. Pivotal Moments Identified During the first session the presenting problem was discussed and processed. The couple was observed in a discussion regarding a current problem to get a sense of their present communication style. There was not any artwork created in this session. Postsession questionnaires were not filled out due to the session running overtime. Salient from this session was the urgency of the need to get tot the issues. Janice was very distressed and unsure if she really wanted to continue due to the amount of emotional pain she was and had been experiencing for a long time. This following section of the transcript describes the intensity that Janice felt. Janice: I’m not sure if we are here for marriage counseling or divorce counseling because we are so many things are not moving forward. I don’t want to divorce at all but it’s just really tricky right now. I’m in so much pain that I’m

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having a really hard time with…..(crying)…I’ve tried for a really long time to make things better and there was a lot of resistance… its like I’m upside down on a car note right now….I’m struggling to stay involved. I keep coming up with these ideas like let’s go to this, let’s try this…. Terry seemed to be in denial that she could lose her partner. She did however admit right away that she avoided discussions that were needed to resolve issues because she had a low tolerance for emotional unpleasantness. She also stated that she knew that she was having a hard time separating from her family-of-origin. The following section from transcript reveals Terry’s struggles with differentiation. Terry: Yes it does make me uncomfortable. Intense feelings of any kind make me uncomfortable. Probably because of the way I was brought up. She has….knows all about my family and she’s part of the family now. Everybody is intertwined…one of the main issues that I’ve had and has been going since the beginning is I’m having trouble separating myself from my family. My family is like the Borge from Star Trek. Session two began with each partner individually and ended with a few minutes together. Each partner had been asked to create a Lifeline. (See appendix C for a full description of the art directive and how this was linked to the Oral History of the Gottman model) The Lifelines were created outside the session and the participants brought them in. This was done in an effort to have more time to process these images as they take a long time to create for most clients. The therapist reviewed the Lifeline drawings separately with each partner as part of Gottman’s Oral History (1999). Then each were seen together to reflect on each other’s Lifeline drawings and discuss familyof-origin issues and how they may be connected to current behaviors and choices. Postsession questionnaires were not filled out for this session due to the escalation of issues at the end of the session. Janice seemed to need to move to issues immediately. This first few sessions required assessment (see Figures 4.23-4.28 for Lifeline drawings related to this session). Terry shared her Lifeline in detail and gained insight into family-of-origin issues.

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Figure 4.23 (Janice’s Lifeline)

Figure 4.24 (Terry’s Lifeline – birth junior year of high school)

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Figure 4.25 (Terry’s Lifeline Senior year of high school through college

Figure 4.26 (Terry’s Lifeline 1999-2004)

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Figure 4.27 (Terry’s Lifeline 2004-2005)

Figure 4.28(Terry’s Lifeline 2005- Present)

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During session three the Joint Picture was created (see appendix C for a full description of the art directive and how it was used within the Gottman Model). Janice and Terry were asked to create an integrated picture together without talking. Janice identified two pivotal moments from this session. The first was named Safe Space (CJ 1 Safe Space). Janice discussed appreciating having a safe space to address their ongoing issues that were causing her great pain and uncertainty. The second pivotal moment identified by Janice was named Shared Holding (CJ1 Shared Holding). Janice wrote on her post-session questionnaire: Just being able to be ‘where I am’ and not holding all the ‘direction’ or ‘keys’ to where we are headed…actually being able to fall apart a bit and not expected to pull it back together immediately. It feels very basic right now, like I am just learning to walk. Terry identified two pivotal moments from session three. The first was named Drawing Dynamics (CT1 Drawing Dynamics). She discussed her surprise in gaining insight from noticing the dynamics of the relationship in the making of the Joint Picture. This coincides with one of the five advantages of using art using art in couples counseling sessions (Wadeson, 1980); the genuineness of unexpected material revealed in pictures (which may challenge old assumptions or beliefs that the couple holds onto firmly). The second pivotal moment identified by Terry was named Art Mirrors Life (CT1 Art Mirrors Life). She wrote on her post-session questionnaire: “Seeing how I interpreted what Janice was drawing and how I was trying to amend it, make it happier/better…at least in my eyes was very much like how we interact together in our daily lives.” This also coincides with on of the five advantages of using art in couples counseling sessions, the spatial expression of pictures (which can symbolically reveal the couple’s life space). During session four the Dream within the Conflict art activity was processed (see appendix C for a full description of the art directive and how it is integrated into the Gottman model). The couple was asked to create the art activity at home to have more time to process during session. Janice completed and brought hers to the session (see Figures 4.30 & 4.31). Terry had forgotten to bring her art work to the session. The session was spent processing the images that Janice had created. She also brought in

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some music to play along with the artwork that she had created. This session was particularly powerful; it provided insight that lead to decision making.

Figure 4.29 (Joint Picture) Janice identified four pivotal moments from this session. The first was named Reestablished Commitment (CJ4 Re-established Commitment). Janice discussed how it was comforting to hear her spouse state her feelings of commitment to the marriage and the actions she was willing to take to show her commitment. The second pivotal moment was named Sharing Artwork (CJ4 Sharing Artwork). Janice stated that using the ‘nonverbal medium’ made the difference in their communication. The third pivotal moment was named Showed Emotion (CJ4 Showed Emotion). Janice wrote on her postsession questionnaire: “Terry cried - she showed emotion – that showed me that she cared and feels emotionally connected to our marriage. The fourth pivotal moment is name Specific Plans (CJ4 Specific Plans). Janice discussed how helpful it was to have a concrete and specific plan for her partner’s self journey (decision to seek individual

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therapy) that would hopefully help her to be more comfortable discussing emotional issues and consequently help them to establish a way to regulate and resolve conflict. During session four Terry identified three pivotal moments. The first was named Understand/ Respond (CT4 Understand/Respond). She wrote on her post-session questionnaire, “The picture that Janice drew of our difficulties/barriers was very clear for me to understand and respond.” The second pivotal moment identified by Terry in session four was named Images Communicate (CT4 Images Communicate). She discussed how the art directive was very helpful because there were not any words to get the way of the deeper message. The third pivotal moment identified was named Insight to Decision (CT4 Insight to Decision). Terry discussed how processing the descriptive art created an awareness of a specific need and she made a decision to begin individual therapy.

Figure 4.30(Janice’s Dream within the Conflict image- conflict focused) During session five Terry brought in her completed Dream Within the Conflict image. She made a collage which focused only on the dream and on the back she placed the word insight. She created a second piece that was a drawing that depicted the conflict she has with processing deep and unpleasant emotions.

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Figure 4.31 (Janice’s Dream within the Conflict image- dream focused) Janice identified four pivotal moments from session five. The first was named Visual Honesty (CJ5 Visual Honesty). Janice discussed how Terry bringing in her images and explaining what the images symbolized provided an atmosphere of honesty and integrity. The Second pivotal moment identified was named Present/Open (CJ5 Present/Open). She wrote on her post-session questionnaire: “Terry was present and open during this session. I felt that I could be more open.” The third pivotal moment identified was named Practical/Useful (CJ5 Practical Useful). She discussed how she found the therapist suggestion to be practical and useful. The last pivotal moment was named Validation (CJ5 Validation). Janice stated that the therapist expressed concern regarding their living situation and making progress was validating to her. Terry identified two pivotal moments from session five. The first was named Heard and Understood (CT5 Heard and Understood). She wrote on her post session questionnaire, “The exploration of my drawing was the most helpful. To know that it was being understood in the way that I meant it was particularly helpful.” The second pivotal moment was named Effective Communication (CT5 Effective Communication). Terry discussed how she could truly communicate effectively through the picture (see Figure 4.32 for the image that Terry refers to for this pivotal moment).

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Figure 4.32 (Terry’s Dream within the Conflict – dream focus)

Figure 4.33 (Terry’s Dream within the Conflict – conflict focus)

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The following section of transcript elucidates the process and the intensity of the session that contributed to the pivotal moments identified. Therapist: Very interesting. Are those sharks? Terry: They’re sharks (laughing). Therapist: Tell us about this. Terry: I think that my main problem is I’m kind of on an island here. I’m afraid of all of these different things down here around me. And because I’m afraid of them I’m locked up behind this fence. Even though I see that there is a clear path to a brighter place, it still has an area were these things might come up but it’s not like this part. Therapist: And what about the atmosphere here, the clouds. Terry: Those are clouds of rain, storm clouds. I feel that even though I’m trying to avoid all of the sharks I still feel the high pressure system that has gathered around. Therapist: Your bridge looks really strong. Terry: Yes, but its like going down a rollercoaster that you haven’t been on before. You know that you won’t get hurt but you’re scared about event the chance of getting hurt. Therapist: So almost like you’re scared of even the illusion that you could be hurt. Terry: Yes. Any of that kind of stuff. Even though it’s fine there is still danger. Even though I made the bridge strong. Therapist: Tell about this yellow here. Terry: It’s a bright path. It’s bright because I will need that. I recognize that once I get across to this better place, all the things I am afraid of will still lurk about. Therapist: You are saying that you know these things represented by the sharks will always be there but you know that if you can get from here to there that you won’t feel so locked up and trapped. Terry: Right.

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Therapist: That’s interesting because that’s the first time I heard you say that you were in pain by not addressing those emotions that you’re uncomfortable with. Terry: I definitely feel stuck and I don’t like to hurt the others around me. Therapist: I had the impression before that you felt safe in your spot. But it doesn’t look safe. Terry: It is safe because I’m not only on an island away from all those things I’m behind a fence. It doesn’t look comfortable but it looks safe. Therapist: You’re not protected up here (pointing to the sky above in the picture) Terry: No. Because I still feel it but I’m not going to fall out into the ocean of anger, hurt, sadness, failure, loss, change… Therapist: Janice what do you see in this? Janice: Well I think it’s a very good depiction of the dynamics that I’ve been witnessing. Therapist: The symbolism, I think the sharks really tell me just how fearful you are. That’s how it feels to you, that strong. Terry: Right because the sharks can consume you, devour you and there floating around in just massive water and you can’t always see them. Like those two are above the water but the others are just swimming underneath and you don’t know when they are going to just come out. Janice: I’m curious that seeing it all here in front of you do you feel like you have a better way to contain it or does it feel better because you can look at it? Terry: Well it just feels like it’s easier for me to communicate it. I don’t feel any differently about it. When I did it I started from a place of a blank slate and kind of went with it. It seems hard to get from one place to the other. Therapist: But it doesn’t seem impossible. Terry: No, it doesn’t seem impossible. It’s funny, if I had more time I thought of making it into a board game. It would kind of be like the game of life where if you landed on one of these sharks you would have to go back but then you could get cards like hope ect. and keep going until you got to that happy place. Therapist: It sounds like how therapy is sometimes, you take a few steps forward and then you fall back. It really symbolizes the journey and that it won’t always

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be easy and it’s normal and natural to have setbacks. What’s clear to me is that you have a pretty realistic view of what you will have to go through and you’re aware of what the issues are. I didn’t really get that from you before. Terry: I’ve learned that these are things that I don’t like. And I’m afraid of it and I don’t want anything to do with that. Therapist: What about for you Janice. Is this clearer for you? Janice: There are two things that are significant about this for me. The first is that she did it, which is very good because I knew that if she did it we would get somewhere. When you sit down and actually do something, you are smart and creative and intelligent and when you are invested and present things do go on. The first piece to anything is to show up and be present. Number two is that I have been watching this dynamic in all the time I’ve known you and the last two years it has spun out of control and the part of me that has compassion can see it. I’m just glad that you also see that fear is at the route of it; if you can name that thing and put it somewhere then it’s a start. Some time had passed (about a month) between session five and six due to schedule problems. During this session the couple was asked to create a Marital Landscape to get a sense of where each partner was in the relationship and if things were progressing toward goals (see appendix C for a full description of the art directive and how it is used within the Gottman model) (see Figures 4.34& 4.35 artwork created in this session). Janice identified two pivotal moments from session six. The first was named Art Expression (CJ6 Art Expression). Janice discussed just having the medium of paint and canvas to express and communicate was helpful. The second pivotal moment identified was named Art Reflection (CJ6 Art Reflection). Janice discussed how the process of painting, pausing and reflecting, painting again and then processing was particularly helpful and insight inspiring. Terry identified three pivotal moments from session three. The first was named Art/ Insight (CT6 Art Insight). Terry discussed how the creation of her artwork contributed to insight. She wrote on her post session questionnaire, “Because of the art and my own personal musings of the day, I had an insight about time for myself.” The

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second pivotal moment named Insight Recognized (CT6 Insight Recognized) related to the first. Terry discussed how she communicated her insight through her explanation of her image and that she felt that it was heard by her spouse. The third pivotal moment was named Art as Expression (CT6 Art as Expression). Terry discussed how she is discovering that she is more comfortable communicating through art and feels as through she is able to clearly send a message and have it received in the way she intended when expressing creatively.

Figure 4.34 (Janice’s Marital Landscape) During session seven the processing of the Marital Landscapes continued. Janice identified three pivotal moments from this session. The first was named Validation (CJ7 Validation). Janice discussed how after she explained her image and expressed some deeper feelings she felt validation form her spouse as she listened and commented on the image. The second pivotal moment was named Therapist Recognized Need (CJ7 Therapist Recognized Need). Janice discussed how helpful it was when the therapist discussed the need for repair in the relationship to occur. Janice stated that she had been

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in pain for a long time and had felt abandoned by her partner. She seemed to need from her partner an acknowledgement of this time and a promise to be present in the relationship in the future.

Figure 4.35(Terry’s Marital Landscape) Through the discussion Terry agreed to create artwork that expressed her remorse and commitment and thank Janice for her patience as she learned to be more comfortable addressing deep emotions. The third pivotal moment identified by Janice is named Explore Perspective (CJ7 Explore perspective). She wrote on her post session questionnaire, “Going over the paintings and asking about Terry’s perspective and sharing my perspective was extremely helpful. We were able to ‘see’ how each other feels from our individual perspectives.” Terry identified two pivotal moments from session seven. The first was named Art/Reflection (CT7 Art Reflection). Terry discussed gaining additional insight from reflecting on the artwork and processing further. The second pivotal moment was named Art Mirrors Relationship (CT7 Art Mirrors Relationship). Terry discussed how the art work that each of them had created truly mirrored their relationship. She wrote on her

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post session questionnaire, “I got that we both really understand what is going on in her piece and thus in our relationship.” During the session eight when the couple entered the session there appeared to be tension and it seemed that something had happened to cause them to regress. The progress of the week was reviewed. There had been some setbacks and the couple was a gridlock once more regarding communication. Terry was avoiding discussions with Janice. The therapist reviewed the softened start up and avoiding criticism. Janice seemed to be at a point where she wanted to give up and expressed that even though there was some success communicating through the art that she feared that Terry would always end up avoiding important discussions. The couple agreed to begin the art expression planned for the session, however in the process of creating they began talking again and the discussion escalated to become very critical in nature. The therapist attempted to redirect the discussion. As the session continued Janice stated that she needed some time to think and decide if she could continue in the relationship. She agreed to call and if she decided to continue with marital therapy. At this point the couple completed the post DAS. Summary of Case C Janice and Terry attended a total of eight therapy sessions. A total of 27 pivotal moments were identified by couple C. Janice identified 15 and Terry identified 12. Janice and Terry were consistent with therapy and made progress in on their therapeutic goals. It seemed that Janice needed more progress to occur without set backs in order to continue. Her pre DAS score was in the lower end of the distressed range. Janice scored a 68 on her pre test and a 71 on her post test. Terry scored 83 on the pre DAS and 84 on his post test. Both partners remained in the distressed category at the termination of therapy. Patterns, Trends and Themes As the pivotal moments were identified they were assigned to a category. Seven categories emerged through the analysis of post session questionnaires, transcripts and artwork. These categories include recognizing familial patterns, communicating openly and freely with a neutral person, remembering good times, hearing positive feeling from

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spouse, being authentic with expression, reframing/being accountable for learning new skills, and art expression. Each category has been given a brief name for ease of reference. Recognizing familial patterns was named Family of Origin Insight (FOO Insight). This category refers to when the participant identified a pivotal moment that caused them to make a connection to their family-of-origin patterns and how they relate to current behaviors and/or choices. Communicating openly and freely with a neutral person was named Free Neutral. This category refers to when a participant identified a pivotal moment that related to being able to state their feelings to their spouse within the boundaries of the therapy session and being heard/validated by the therapist. Remembering good times was named Remembering Positive. This category refers to when a participant identified a pivotal moment the related to remembering good times in the past with their partner and this memory bringing hope. Hearing positive feelings from spouse was named Hearing Positive. This category refers to when a participant identified a pivotal moment that related to hearing their spouse state positive feelings about them or notice positive changes that they have made. Reframing/ being accountable for learning new skills was named Reframing. This category refers to when a participant identified a pivotal moment that relates to reframing their view in a way that they take some accountability for their part of the issue and learn new skills to approach an issue. The category Art Expression refers to when a client identified a pivotal moment that related to the communicating through art, reflecting on the art and gaining insight and being “seen and heard” through the art without interruption or words getting in the way. Table 4.5 examines Janice’s identified pivotal moments by category and by session number. Janice identified three pivotal moments in Free Neutral, one pivotal moment in Hearing Positive, three pivotal moments in Reframing, two pivotal moments in authentic expression and five pivotal moments in Art Expression. Examination of the chart reveals more pivotal moments were identified after the third session once the assessment phase of therapy was completed and the issues began to be processed. Janices’s highest number of pivotal moments were in the category of Art Expression with her second highest number of pivotal moments tied in categories Free Neutral and Reframing. Although Art Expression has a category of its own, many of the other pivotal

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moments were linked to the process of making art. Out of the fifteen identified pivotal moments, five were perceived by Janice to be directly linked to Art Expression. Table 4.5 (S=Session) Janice’s Identified Pivotal Moments FOO Insight

Free Neutral

Remem -bering Positive

Hearing Positive

Reframing

Authentic Expression

Art Expression

Re-established Commitment

Specific Plans

Showed Emotion Present/ Open

Shared Artwork Visual Honesty

S1 S2 S3

Safe Space Shared Holding

S4 S5

Validation

Practical/ Useful

S6

S7

Validation

Therapist Recognized Need

Art/ Expression Art/Reflection Explore Perspective

S8

Table 4.6 examines Terry’s identified pivotal moments by category and by session number. Terry identified one pivotal moment in FOO Insight, three pivotal moments in Hearing Positive, four pivotal moment in Reframing, four pivotal moments in Authentic Expression and four pivotal moments in Art Expression. Examination of the chart reveals more pivotal moments were identified after the third session once the assessment phase of therapy was completed and the issues began to be processed. Terry’s highest number was in the category of Art Expression. Out of the 12 identified pivotal moments, nine were perceived by Todd to be directly linked to Art Expression.

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Table 4.6 (S=Session) Terry’s Identified Pivotal Moments FOO Insight

Free Neutral

Remembering Positive

Hearing Positive

Reframing

Authentic Expression

Art Expression

S1 S2 S3

S4

Insight to Decision

S5

Heard & Understood Insight Recognized

S6 S7

Drawing Dynamics Art Mirrors Life Understand/ Respond Images Communicate Effective Communication Art /Insight Art As Expression Art/Reflection Art Mirrors Relationship

S8

Quantitative Analysis In order to examine changes in marital adjustment after participation in marital art therapy, participants DAS scores were subjected to the Wilcoxon Rank test. Due to the small sample size of this study there is not a normal distribution present. Therefore it is appropriate to use a nonparametric measure. The Wilcoxon Rank test is most appropriate for correlated groups (Agresti & Finlay, 1997). Since post test scores were not available for Couple A the missing values were substituted with 88. This score was the mean of the pre and post test scores for the four other participants. The Wilcoxon Rank test was computed to explore if a statistical difference between pre and post test scores on the DAS was present. In calculating the Wilcoxon Rank test statistic, all the different scores are placed in ascending order; then they were given ranks. Then to each, rank the sign of the difference was affixed. There were six participants in this study. Five participants had positive ranks and one

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participant had a negative rank. The mean for each group was calculated and the total sum of ranks for each group was calculated (See the table 4.7)

Table 4.7 Wilcoxon Signed Ranks Test Ranks N Post Test DAS score - Pre Test DAS score

1a 5b 0c 6

Negative Ranks Positive Ranks Ties Total

Mean Rank 1.50 3.90

Sum of Ranks 1.50 19.50

a. Post Test DAS score < Pre Test DAS score b. Post Test DAS score > Pre Test DAS score c. Post Test DAS score = Pre Test DAS score

Test Statisticsb

Z Asymp. Sig. (2-tailed)

Post Test DAS score - Pre Test DAS score -1.897a .058

a. Based on negative ranks. b. Wilcoxon Signed Ranks Test

The asymptopic significance found was found to be .058. Since this study is exploratory and had small sample size with mixed methods approach, the data is considered significant at less than .10 (90 times out of 100, results will be found)( Agrest & Finlay, 1977). The sum of the positive ranks (19.5 versus 1.5), indicated that there were more scores on the post test that were higher than the pre test scores; five scores on the post test were higher than the pre test scores. One could speculate form the data that marital art therapy could have a positive effect on DAS scores. DAS scores indicated an increase in reported marital adjustment from the beginning of marital art therapy to the completion of marital art therapy. To examine the relationship between the increase in the DAS scores and the number of pivotal moments identified by participants, several calculations were employed. For the first calculation using Spearman’s rho, the post DAS scores and the

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number of pivotal moments for each individual were used to run a bivariate correlation. Spearman’s rho is most appropriate since the level of measurement is considered ordinal (Agresti & Finlay, 1997).

Table 4.8 Spearman’s rho Calculation 1 Correlationsa

Spearman's rho

Number of pivotal moments Post Test DAS score

Correlation Coefficient Sig. (2-tailed) Correlation Coefficient Sig. (2-tailed)

Number of pivotal moments 1.000 . .716 .109

Post Test DAS score .716 .109 1.000 .

a. Listwise N = 6

In the table 4.8, since the correlation between the number of pivotal moments and post test DAS scores has a positive value (0.716), there is a positive correlation present. When one variable increases the other variable also increases. However, this correlation is not significant as the two tailed significance is .109 (it is greater than .05). For the second calculation Spearman’s rho was used including the average of the post test scores for each couple and the total number of pivotal moments identified for each couple (see data file variable 7 and 8 in table 4.9). The correlation was found to be significant (Spearman’s rho is equal to 1.000 significant at .01 two tailed) ( See table 4.9). Table 4.9 Spearman’s rho Calculation 2 Correlationsa

Spearman's rho

VAR00007 VAR00008

Correlation Coefficient Sig. (2-tailed) Correlation Coefficient Sig. (2-tailed)

VAR00007 VAR00008 1.000 1.000** . . 1.000** 1.000 . .

**. Correlation is significant at the 0.01 level (2-tailed). a. Listwise N = 3

For the third calculation, the net change in post test scores was compared to the total number of pivotal moments identified. For example if one partner had 23 points

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higher on the post DAS while the other partner was a negative 1 point, the net change is 22 points (See data file variable 9 in table 4.10). Pivotal moments for each partner were added to derive the total number of pivotal moments for the couple (data file variable 8). The spearman’s rho values was .500 and was not significant (p=.667). See the table below. Table 4.10 Spearman’s rho Calculation 3 Correlationsa

Spearman's rho

VAR00008 VAR00009

Correlation Coefficient Sig. (2-tailed) Correlation Coefficient Sig. (2-tailed)

VAR00008 1.000 . .500 .667

VAR00009 .500 .667 1.000 .

a. Listwise N = 3

Cross Case Analysis Through review of the transcripts, post-session questionnaires, charts of identified pivotal moments and DAS scores, and the artwork from each case; patterns, trends and themes emerged that were both universal to each case, unique to each case and unique to each participant. In this section the unique environments for each case will be discussed first and followed by the commonalities present for all three cases. Authentic communication emerged as the prime ingredient necessary for pivotal moments to occur for Case A. When art expression was linked to authentic expression, Case A would also be more likely to report a pivotal moment. Both had family backgrounds where expressing emotion was discouraged. The husband, John, tended to repress and minimize his emotions. As a result they manifested in depression. He would frequently shut down or stonewall his wife and this contributed to their gridlock. The wife, Marion, would not allow herself to show her vulnerable emotions because she viewed them as weak. She developed this as a survival skill from her upbringing. She would only allow herself to express anger. Not only did she view herself as weak for showing other emotions, she also viewed her husband this way and would become extremely critical with him when he was vulnerable which also contributed to their gridlock.

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When the couple was encouraged and validated for expressing their true feelings within the safe boundaries of the therapy session they experienced authentic, genuine expression and could move past gridlock. They showed progress of being able to recreate this environment at home, however seemed to become overwhelmed by their setbacks. Individually, John seemed to respond to hearing positive comments from his spouse. This most likely had to do with Marion holding back on being vulnerable to her husband. When she would communicate in the session something positive, or affectionate, her husband would report that a pivotal moment had occurred. Marion seemed to find reframing particularly helpful. She seemed more comfortable with cognitive shifts rather than emotional shifts. This matched with her report of how she excelled in school and leadership throughout her childhood when she was mitigating extremely emotional and traumatic situations in her home environment. Reframing emerged as paramount for Case B. They both seemed very aware of their feelings and could express them well. However, they had become stuck in a pattern of expressing in a negative way. They seemed to identify pivotal moments when they were able to break past this pattern and treat each other with respect. Todd and Susan possessed the skills to communicate effectively and could use them in many situations outside the marriage. They could also use them regarding certain issues in the marriage but not with issues that had a negative history and where gridlock was present. When they were encouraged to use these skills to communicate and when the artwork broke the pattern they were able to avoid criticism and move toward regulating conflict and making complaints specific to behavior rather than criticism of character/personality. Individually, Todd tended to identify pivotal moments when he heard something positive from his spouse or saw a positive image and when he felt his feelings were heard and respected. Susan tended to report pivotal moments that included a sense of hope for the future and when she gained insight into the dynamics that were keeping them in gridlock. Art Expression emerged as the salient feature present when Case C identified a pivotal moment. Terry stated from the beginning that she was very uncomfortable with unpleasant emotions to the point that she would avoid discussions that were important for

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the relationship with Janice to continue. Janice and Terry had been performance artists and were comfortable with expressing themselves creatively. Janice felt that she had been carrying the emotions for both of them in the relationship for so long that it was difficult for her to be patient, listen and refrain from criticism. Through artwork they were able to break the negative pattern. Terry was able to express her feelings clearly and Janice was able to hear them and have hope that Terry would continue to be present in the relationship and not to shut down (stonewall). Terry was able to feel that she was heard and understood and accepted without criticism. Individually, Janice seemed to identify pivotal moments when there was an atmosphere of validation for her long term toleration of Terry’s inability to address strong emotions and when Terry was present (showed emotion and was actively engaged in solving the conflict). Terry tended to identify pivotal moments when she gained insight and felt that she was heard and understood in the spirit of her intentions. All three cases identified pivotal moments when core issues tied to the presenting problem were discussed. Pivotal moments occurred following sessions that were emotionally charged and when cognitions relating to these emotions were reframed in a more positive light. Pivotal moments across all three cases tended to build on each other and occur within or relating to a particularly powerful sessions. Table 4.11 shows pivotal moments and DAS scores reported across all three cases. One of the goals of this study was to discern whether the number of pivotal moments identified correlated to an increase on the Dyadic Adjustment Scale (DAS). As discussed in the qualitative analysis, there was a positive correlation to the number of pivotal moments present and the amount of increase on the DAS. Although this correlation is not considered to be statistically significant, the data supports that when one score increases (number of pivotal moments) the other score also increases (number of points higher on the DAS). What also emerged as critical through the qualitative data that could not be discerned from quantitative data itself, is that when the couple was able to experience therapy with continuity (followed the treatment plan and came to scheduled appointments on a regular/consistent basis) more pivotal moments were identified thus more marital satisfaction was gained.

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Table 4.11 Cross case analysis of pivotal moments and DAS scores Couple

Pre Treatment DAS

A Partner 1 85 (John) A Partner 2 66 (Marion) B Partner 1 73 (Todd) B Partner 2 103 (Susan) C Partner 1 68 (Janice) C Partner 2 83 (Terry) * mean scores substituted

Post Treatment DAS

Not Available (88)* Not Available (88)* 96

Number of Pivotal moments identified by each partner 15

Total Pivotal Moments per couple A=27

12 18

102

24

71

15

84

12

B=42

C=27

Due to the size of the sample of this study and the method of choosing participants (convenience sampling), the study is limited and experimental in nature. There are several interesting trends that have emerged and merit further investigation. Chapter four will address the conclusions and recommendations for further research pertaining to the results of this study.

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CHAPTER FIVE SUMMARY AND DISCUSSION The purpose of this exploratory study was to provide an investigation which examined the use of art therapy techniques with couples in marriage counseling. Additionally, the researcher aimed to provide data that would strengthen the validity of using art therapy as a treatment modality for couples in therapy. Using both quantitative/ qualitative methods, pivotal moments in dyadic art therapy were identified by participants and marital adjustment was compared at the beginning and the conclusion of therapy with the pre and post administration of the DAS. Subsequently, the number of pivotal moments identified and the amount of increase on the DAS were assessed for possible correlation. In this chapter the interpretations of findings relevant to the objectives of the study as well as additional findings which occurred during the analysis of the data will be discussed. The limitations of the study addressed in Chapter One are readdressed in problems that occurred in the sampling procedures, data collection, and data analysis. Findings relating to current literature, clinical implications for the Marital Art Therapy treatment plan, modifications and suggestions for further research will also be discussed. Summary of Methodology and Response to Research Questions The setting for this study was at a Marriage and Family Counseling Center in Jacksonville, Florida. There were three couples participating in the study. The participants were administered a pre test and post test of the Dyadic Adjustment Scale (DAS) in order to address marital adjustment. Analysis of session transcriptions, postsession questionnaires and analysis of art work were employed to address pivotal moments. The participants meet for approximately eight sessions. Convenience sampling was used to select participants. Refer to Chapter Three for a thorough delineation of the methodology. This study addressed the following research questions: 1) Will the use of art therapy techniques with couples in counseling improve the quality of their relationship? 2) What significant or meaningful events in art therapy do the participants consider to be pivotal?

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3) How do participants account for the pivotal moments they experience in therapy? 4) Is there a relationship between the number of pivotal moments identified and the level of increase on the Dyadic Adjustment Scale (DAS)? In response to the first research question regarding art therapy improving the quality of the couple relationship, several indicators were present. In processing the post session questionnaires, participants reported art therapy techniques had increased their awareness and provided opportunities to gain insight. Participants reported different choices they made in the relationship as a result of session insights as well as conversations outside the sessions that were sparked from the content of the session. Participants described the environments that were present in order for the pivotal moments to occur; specific descriptions are available in Chapter Four. These environments were further examined through the session transcripts and the art work created in the sessions. Both art work and session transcripts lend support to the pivotal moments identified. Additionally, as discussed in Chapter Four, DAS scores indicated a statistically significant increase in reported marital adjustment from the beginning of marital art therapy to the completion of marital art therapy. Although the data suggested that marital art therapy could have a positive effect on DAS scores, the size of the sample diminishes the strength of this finding. Additionally, post DAS scores were not available for Couple A and instead the mean of the post DAS scores from the four other participants was used. Since the sample is small to begin with, using a mean score to fill in the gap is limiting and further weakens this finding. Recreating this study with a larger random sample size could provide more robust findings. In response to the second and third research question regarding significant or meaningful events in art therapy that the participants consider to be pivotal and how they account for them, analysis of pivotal moments revealed some common themes, trends and patterns. As discussed in Chapter Four, seven categories emerged through the analysis of post session questionnaires, transcripts and artwork. These categories include recognizing familial patterns, communicating openly and freely with a neutral person, remembering

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good times, hearing positive feelings from spouse, being authentic with expression, reframing/being accountable for learning new skills, and art expression. Each category has been given a brief name for ease of reference. Recognizing familial patterns was named Family-of -Origin Insight (FOO Insight). This category refers to when the participant identified a pivotal moment that caused then to make a connection to their family of origin patterns and how they relate to current behaviors and/or choices. Communicating openly and freely with a neutral person was named Free Neutral. This category refers to when a participant identified a pivotal moment that related to being able to state their feelings to their spouse within the boundaries of the therapy session and being heard/validated by the therapist. Remembering good times was named Remembering Positive. This category refers to when a participant identified a pivotal moment the related to remembering good times in the past with their partner and this memory bringing hope. Hearing positive feelings from spouse was named Hearing Positive. This category refers to when a participant identified a pivotal moment that related to hearing their spouse state positive feelings about them or notice positive changes that they have made. Reframing/ being accountable for learning new skills was named Reframing. This category refers to when a participant identified a pivotal moment that relates to reframing their view in a way that they take some accountability for their part of the issue and learn new skills to approach an issue. The category Art Expression refers to when a client identified a pivotal moment that related to the communicating through art, reflecting on the art and gaining insight and being ‘seen and heard’ through the art without interruption or words getting in the way. Although themes, patterns and trends were present through all three cases, there appeared to be favorable categories per couple as well as per individual participate. The researcher created several charts of pivotal moments for each participant as well as comparing each couple and individual. The session transcripts and art work were closely examined regarding the emerging patterns and used as cross references to the postsession questionnaires. Chapter Four provided detailed information about each pivotal moment identified, the environments which precipitated and followed the pivotal moment, and the art work associated with the pivotal moment. In summary, all three cases identified pivotal moments when core issues tied to the presenting problem were

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discussed. Pivotal moments occurred following sessions that were emotionally charged and when cognitions relating to these emotions were reframed in a more positive light. Pivotal moments across all three cases tended to build on each other and occur within or relating to a particularly powerful sessions. In response to the fourth research question which inquires whether there is a relationship between the number of pivotal moments identified and the level of increase on the DAS, the data was inconclusive. As discussed in Chapter Four, three calculations were completed using Spearman’s rho. For the first calculation, the post DAS scores and the number of pivotal moments for each individual were used to run a bivariate correlation. A positive correlation was found to be present, however, it was not considered to be statistically significant. For the second calculation the average of the post DAS scores per couple and the total number of pivotal moments identified for each couple was used. This calculation yielded a statistically significant result. For the third calculation, the net change in post test DAS scores was compared to the total number of pivotal moments identified. This calculation indicated a statistically insignificant result. Overall the data specified that when one variable increased (pivotal moments) the other (post DAS scores) also increased. Although a correlation was present in the calculations, the size of the sample limits these findings. Further research with a larger random sample could yield more conclusive findings. Findings as the Relate to Current Literature The patterns, trends and themes that emerged from this study correlated to several current outcome research studies in marriage and family therapy and art therapy. In this study pivotal moments occurred following sessions that were emotionally charged and when cognitions relating to these emotions were reframed in a more positive light. Specifically, as reviewed in Chapter Three, Johnston and Greenberg’s Emotionally Focused Therapy (EFT) study it was found that the most successful sessions were those which involved deep level self-disclosure and reprocessing of emotional experiences. This phenomenon of Authentic Expression became a category the emerged with high frequency across all three cases. Many times the identification of Art Expression as pivotal was correlated to the raw deep expression of the image.

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Helmeke and Sprenkle (2000) reported that pivotal moments tended to occur in discussions of topics relating to the presenting problem and those discussed in previous and subsequent session. Similarly in this study, pivotal moments across all three cases occurred when core issues tied to the presenting problem were discussed. They also tended to build on each other and occur within or relating to a particularly powerful sessions. Reframing became a category for pivotal moments in this study. As described in Chapter Four, this category refers to when a participant identified a pivotal moment that relates to reframing their view in a way that they take some accountability for their part of the issue and learn new skills to approach an issue. This category was present in each case and was particularly helpful for Couple B (Susan and Todd). As reviewed in Chapter Two, Christensen et al (1998) discussed their findings which correlate to Reframing as they report that change occurs through shifts in affect, cognition and communication. Several of Gottman et al (1998) claims such as, avoiding criticism, contempt, stonewalling and defensiveness as well as regulating conflict, and positive sentiment override, building a fondness and admiration system emerged in the categories of Hearing Positive From Spouse, Remembering positive, and Reframing. As discussed in Chapter Two, an art therapy outcome study by Saunders and Saunders (2000) addressed effectiveness and other specific questions including the number of art therapy sessions and their influence on program outcomes. The researchers found that the number of art therapy sessions had a positive correlation to favorable therapeutic outcomes. This was also the case with Couple B. They attended more therapy sessions and on a more consistent basis. The husband of the dyad had the highest increase on the DAS. Qualitative data supported the positive outcomes for both partners through comments on post-session questionnaires and the graphic indicators of moving out of gridlock and toward resolution of conflict. An outcome study by Ball (2002) which focused on moments of change in art therapy yielded results similar to this study regarding the emotional experience f therapy. As with the participants of this study, Ball found that the art therapy provided a way to symbolize experiences in images, to regulate emotions and to observe themselves through the tangible art product. The art provided a record of the progress. This also correlated

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to one of the five advantages of using art therapy with couples, the permanence encountered whereby the drawings provide a concreted object to study, react to, use for clarification/ review. Several of the five advantages were identified by participants of this study on the post session questionnaires. Additionally, participants discussed how the art made visible issues that were abstract and nebulous therefore difficult to express in words. This correlates to Riley’s (2003) discussion of art providing the lens in which to see the partner’s inner world. Particularly for Terry of Couple C, the art making was an easier form of expression. She was able to discuss through her images issues that she had not been able to speak of in the past. This correlated to Barth & Kinder’s (1985) statements regarding art as a valuable form of communication because if provides a device for clients who are unable or unwilling to speak about their issues. Limitations Financial resources were limited dictating a small study. This influenced the choice of convenience sampling instead of random sampling. The size and method of sampling caused this study to be quasi-experimental instead of experimental which limited the internal validity. There were challenges in finding couples willing to participate in the study at first. The procedures begin with informing clients that called the counseling center asking for marriage counseling of the study. If a couple indicated interest they would be contacted by the researcher. Several referrals were made to the researcher, however only one couple from this group of referrals completed more than three sessions. After some time the researcher asked if participants could receive free marital counseling. The administration agreed and a flyer describing the study and offering eight sessions of marital art therapy was put out through the North East Florida Social Work Network. The researcher received many calls immediately after the flyer went out; soon after the next two couples began the study. There were also several names on a waiting list in case participants discontinued therapy. The different ways in which the participants were selected could have affected the results. There were problems that occurred in the data collection. The researcher/ therapist needed to allow for time following the session to fill out the post-session questionnaires. There were several occasions when the researcher/therapist struggled

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with the needs of the client to extend the session and the need to complete the questionnaires. Art therapy can require a longer session due to the set up and clean up of art materials as well as the time it takes to create and process. The setting in which the study took place allowed for a 50 minute hour block of time. This was addressed with administration and modified as the study progressed. However before this modification there were some sessions were the participants did not fill out post-session questionnaires. More pivotal moments could have been identified if a questionnaire was filled out for every session. Only one couple, Couple B, completed the treatment plan from beginning to end. This couple identified more pivotal moments then the other two and had more of an increase on the DAS. They also came into the study in less distress then the other two couples. It is possible that having couples enter at different levels of distress skews the results of the study. It is notable to address this when planning any further research. Clinical Implications There were several changes in the treatment plan as information was collected and processed. The Gottman model (1999) typically uses the first three sessions as assessment. This became challenging for couples who were in distress. Some of the art directives were consolidated to get to the presenting problems more quickly. The most distressed couples have waited very long before coming into therapy and are in need of immediate intervention in order to even continue coming to therapy. Originally, the treatment plan (see appendix C) was designed to move sequentially through specific art directives. The researcher/therapist found this to be limiting and instead the art directives were modified and used when appropriate and specific to the need of the couple at the time regardless of which session they were in. Another salient observation was that couples in distress need more than an hour therapy session. Dyadic therapy presents the unique challenge of meeting the needs of each individual. Adding art creations into the session requires scheduling and hour and a half to two hours of session time in order to avoid “stirring things up” without session closure. With the session times expanded and adequate funds available, it would be helpful to bring more three dimensional media into the treatment plan. The art directives

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could be expanded by using clay to include family sculpting or to expand the genogram to symbolic figures. The treatment plan could benefit from using art directives in which the couple created together. Possibly Sand Tray art directives could also provide for more symbolic analysis of family-of-origin dynamic in correlation to the present family dynamic. The House of the Future art directive could be made using three dimensional media and could provide for a stronger cognitive resonance and symbolic reflective distance. Overall the treatment plan could improve if more media dimension variables were used. This would enhance the possibility of participants to move through the different levels of the Expressive Therapies Continuum (ETC) and have a greater chance of reaching the Creative level (Lusebrink, 1990) Research Implications This body of work represents preliminary investigation of a therapeutic modality that integrates art therapy and marriage and family therapy. While this investigation revealed that marital art therapy yielded positive results in most cases, it also points to the need for controlled outcome studies. The participation of other art therapist trained in marriage and family counseling studying larger populations of couples would reveal more information. Having a separate researcher and therapist would strengthen the study. Choosing participants through a random sampling would improve the internal validity. Results would be more powerful with a control group. Perhaps a control group of participants which received traditional verbal therapy only and a control group of participants who did not received marital counseling would make for interesting comparisons. It may also be helpful for the therapist to identify pivotal moments after each session. This could be done through the same type of post-session questionnaire. It may also be helpful for the art therapist to keep a reflective visual/verbal journal. The post-session questionnaires and journal kept by the art therapist could be included in the qualitative analysis. This study included the analysis of artwork as part of examining pivotal moments. Through examination of the artwork the researcher began to see possible graphic indicators of Gottman’s Four Horseman of the Apocalypse, Criticism, Contempt, Stonewalling and Defensiveness. Additionally positive indicators such as positive sentiment override, creating a shared meaning system, building the marital friendship

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were also observed in graphic form. Participant’s identified several of the five advantages of using art therapy through post session questionnaires (Wadeson 1980). Perhaps graphic indicators which revealed positive and negative markers for marriage could be explored as an additional advantage of using art therapy with couples in a follow up study. Participant’s comments on the post session questionnaires and the researcher/therapist observations provide support for this possible hypothesis. Conclusions This dissertation represented a first step toward an effort to explore the effectiveness of marital art therapy. It presented three couples’ perceptions of pivotal moments in marital art therapy and the comparison of pre and post measures of the DAS individually and collectively. Through the analysis of qualitative data, discernable patterns emerged in participants responses to the investigation. Art therapy techniques appeared to succeed in evoking new insights and new behaviors. Quantitative results argue for the effectiveness of marital art therapy as a treatment modality. While the individual cases argue effectiveness, the aggregated results provide more compelling arguments for further formal research.

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APPENDIX A Post-Session Questionnaire 1. What happened in this session that you feel was the most helpful or important for you personally? (It might be something you said or did, your partner said or did or something your therapist said or did.)

2. Please describe what happened that was helpful/ important and what you got out of it.

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3. How helpful was this particular event? Rate it on the following scale. (Put an X at the appropriate point; half point ratings are OK e.g. 7.5)

Not helpful-----------------------------------Neutral--------------------------------------Helpful 1

2

3

4

5

6

7

8

9

l------------l------------l-------------l-------------l------------l------------l------------l------------l

4. About where in the session did this event occur?

5. About how long did the event last?

6. Did anything else particularly helpful happen during this session?

YES

NO (a. If yes please rate how helpful this event was: ____ Slightly helpful ____ Moderately helpful ____ Greatly helpful ____ Extremely helpful

(b. Please describe the event briefly

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APPENDIX B Assessment Data Sheet Client #______

DOB: ________

Ethnicity_______________

1. Strengths/social support system_______________________________________

2. Highest level of Education____________________________________________

3. Employment history_________________________________________________

4. Legal history_______________________________________________________

5. Mental health history________________________________________________

6. Substance abuse history______________________________________________

7. Medical/developmental history_________________________________________

7. Child abuse/neglect history____________________________________________

8. Other salient family-of-origin issues/patterns/ concerns_____________________

_________________________________________________________________

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APPENDIX C A TREATMENT PLAN FOR MARITAL ART THERAPY: COMBINING GOTTMAN’S SOUND MARITAL HOUSE THEORY WITH ART THERAPY TECHNIQUES The literature pertaining to the negative effects of divorce and high marital conflict strongly validates the need for research on effective marital therapy techniques. It is paramount to closely examine what has been successful in helping couples and what has failed. In an article which reviewed advances in the field of marriage and family therapy in the 20th century and addressed the marital research agenda for the 21st century, Gottman and Notarius (2002) delineate five seminal research needs. These identified needs include; more observation in a naturalistic setting, continued focus on sequences or patterns of interaction, recognition of the importance of positive affect in relationships, revisiting the study of personality and its effect on the couple relationship, and the need to study the management of stress spill-over into the marriage. The Gottman model of marital therapy is based on long-term research with over 700 couples which specifically examines what makes a marriage successful and happy and what contributes to an unsatisfied marriage or one that eventually leads to dissolution (Gottman, 1999). Gottman’s findings form the basis of his Sound Marital House theory. The basic tenants of this theory include; a foundation of friendship, regulating conflict and creating a shared meaning system. The Sound Marital House model illuminates what to avoid in a marriage such as what Gottman identifies as the Four Horsemen of the Apocalypse: Criticism, Contempt, Defensiveness, and Stonewalling. This model embraces the need to for the therapist to mitigate discernment of unresolvable or ‘perpetual problems’ from solvable problems. Therapists using this model help couples

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move from gridlock to dialogue on perpetual problems. Solvable problems are more easily approached by strengthening the marital friendship and using the five fundamental skills of softened start-up, accepting influence, repair and de-escalation, compromise, and physiological soothing. Combining the Sound Marital House theory with art therapy techniques responds to the five seminal research needs mentioned above. Art expressions can greatly improve the likelihood of a positive outcome for couple therapy. A myriad of issues arise in a relationship which reflect beliefs from the past, roles that society has imposed, and the differing viewpoints of men and women. “These issues can be made visible through the use of art and, when made visible, transform abstract words into material that can be altered” (Riley, 2003, p.397). Art therapy techniques are valuable in uncovering potentially important intrapsychic characteristics of each individual within a couple undergoing therapy. There are five advantages for using art in couples counseling sessions (Wadeson, 1980): (1) the immediacy of doing a task together, (2) the genuineness of unexpected material revealed in pictures (which may challenge old assumptions or beliefs that the couple holds onto firmly), (3) the spatial expression of pictures (which can symbolically reveal the couple’s life space), (4) the permanence encountered whereby the drawing provides a concrete object to study, react to, use for clarification/review and (5) the shared pleasure that picture making can provide for a couple who no longer find themselves having fun together. In this treatment model the five advantages of using art therapy with couples are combined with the basic tenants of the Sound Marital House theory to form an 8 week treatment plan of marital art therapy. Each session will identify a specific treatment goal

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and objectives that reflect those of the Gottman treatment model. A list of materials needed and a specific art directive will be identified for each session. A discussion of processing the images created in each session will provide suggestions for identifying possible graphic indicators of strengths and weaknesses within the marriage as well as other issues that may arise pertaining to insight and awareness. Art therapy techniques for each session were developed using the goals for Gotman’s Sound Marital House Theory combined with techniques and modification of techniques from several prominent art therapists in the field. Originally the treatment plan was developed according to the session number however has been adapted after clinical application to be used as appropriate for each couple and the needs they present. The genogram is commonly used in marital and art therapy. The genogram art directive was developed using guidelines from the Handbook of Art Therapy (Malchiodi, 2003). The Marital Landscape was modified from Home is Where the Art is: An Art Therapy Approach to Family Therapy (Arrington,2001). The Lifeline in was developed using information from an article by Tracz and Gehart-Brooks (1999). The have/need collage in was developed by modifying a technique (the good news/bad news collage) used by B.J.Troeger (personal communication, February, 2001). This was also adapted for use as the Dream within the Conflict art activity. The Joint Picture technique was developed using guidelines from Conjoint Marital Therapy Techniques (Wadeson,1972). The Solvable Problems Collage with Matisse-like figure stencils was modified from a technique used by J. Spitzer (personal communication, October, 2000). The House of the Future directive was developed using guidelines from an article by Lantz and Alford (1995). The Bridge Drawing directive was modified for use with couples. The original

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source for the Bridge Drawing as a projective assessment was an article by Hays and Lyons (1981).

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Marital Art Therapy Treatment Plan Genogram (to be used as part of the Oral History) Treatment Goal: To get a sense of the family of origin dynamics, to elicit the couples’ narrative of their situation the history of their current situation and dilemma, and their hopes for the outcome of therapy. Objectives: Provide an art intervention to help the couples’ express their history and family of origin history and make connections to their current situation and dilemma. To bring to the relationship awareness that the two persons in the couple have a choice of how they wish to perpetrate the patterns they observe or choose new resolutions. To begin to identify the new culture of the merging union by creating shared meanings and honoring dreams. Materials: Large white paper, color pencils, markers. Directive: Make a genogram (family map) of three generations. Represent the emotional climate of your family. Be sure to include important connections and separations such as marriages, births, miscarriages, separations, divorce, and death. (The therapists will demonstrate how to use circles and squares for male and female and other symbols and color to represent closeness, distance, conflict ect.) Processing: Discuss the family history, the areas of strengths and weaknesses as well as the traditions/rituals that have been passed through generations. Ask specific questions regarding the history of their parents marriage, what it was like, how it is similar or different to their marriage. Discuss relationships of closeness and conflict with various family members and how this affects the couple relationship. Encourage the couple to identify patterns through the generations.

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Marital Art Therapy Treatment Plan Marital Landscape (As part of the Oral History assessment) Treatment Goal: To get a sense where each individual is in the marriage, the nature of the marital friendship, the nature of their conflict and its regulation, the nature of their sentiment override (positive or negative), to identify potential sources of resistance. Objectives: Provide an art intervention to help the couples’ express their history as a couple from the time they met and started dating through their decision to marry and the development of the marriage relationship. Materials: Large white paper, oil pastels, watercolor paints, brushes of various sizes, water. Directive: Create and emotional landscape of your marriage. It may be abstract using color, line and form or may be representational using manmade or natural structures to symbolically represent how you experience the progression of your relationship. Processing: Process the images having each member of the couple explain their image in front of the other. Include a discussion of how the couple met, their memories of their courtship and dating. Ask specific questions such as: How and when did you decide to get married? Were you ever in love? Was it a difficult decision to get married? What memories do you have of your wedding? How did you navigate transitions such as becoming parents? What stands out as really happy times? What stands out as difficult times? How did you get through difficult times? Why did you stay together? What is your philosophy for getting through difficult times? How is the marriage different from when you first got together? Look for connections to the images and the stories told by the couple.

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Marital Art Therapy Treatment Plan Lifeline (To be used as part of the Meta-Emotional Interview conducted with each individual separately) Treatment Goal: To identify both positive and negative events/ experiences that have shaped the personality development and attachment patterns of each individual in the couple. To gain insight into individual clients’ perspective of their life histories and family of origin experiences. Objectives: Provide an art intervention to help establish rapport with each client as an individual, identify personally significant life events and provide a catalyst for processing and working through unresolved emotion and conflict. To provide an opportunity to the couples to begin to recognize each other’s “love maps”, fears and dreams for the future and begin the process of building shared meaning. Materials: Large white paper, ruler, drawing pencils, color pencils, markers. Directive: Draw a line that represents your life from birth to present. Then draw a picture (symbol or image) of your birth and continue by indicating other life events along the line. Each mark along the lifeline is accompanied with a drawing of that event. (Developmental events such as walking for the first time, important life events such as divorce or death of family members). Processing: Discuss each event and identify areas of unresolved emotion or conflict that may be contributing to present day interactions in relationships. Once processed individually, have the couple come together and process each other’s lifeline.

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Marital Art Therapy Treatment Plan Have/Need Collage (to use with focus of turning toward instead of turning away and avoiding the four horseman) This art directive may also be adapted to with similar goals and outcomes as the Dream within the Conflict art directive. Treatment Goal: To identify what each individual in the couple is getting from the relationship and what each needs more of in the relationship. To educate about the pitfalls of the Four Horseman of the Apocalypse and discuss using a soft start-up, selfsoothing, and accepting influence to regulate conflict and create an emotional bank account. Objectives: Provide an art intervention that will illuminate areas of needs and wants. To identify and express these needs through images and make connections to meanings and dreams. Materials: Various sizes of white and color construction paper, scissors, glue, magazines, pre-cut images and markers. Directive: Make a collage using images and words from magazines to express the things that your spouse provides for you in your marriage that you need and enjoy. On the other side of the paper, create a collage in the same way expressing the things that you need more of or that your spouse is not providing for you in the marriage. Processing: Begin with discussing the positive about the relationship, what is being provided and is enjoyable. Discuss the importance of creating an emotional bank account of positive encounters to be drawn upon when facing negative feelings. Before processing the needs that are not being met, discuss the four horseman of the apocalypse (criticism, contempt, defensiveness and stonewalling). Discuss why it is important to avoid them “taking up residence” in the marital house and how to avoid them by using soft start-up, avoiding flooding, self-soothing, regulating conflict and accepting influence. Process the second collage emphasizing turning toward rather than turning away to get needs met.

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Marital Art Therapy Treatment Plan Joint Picture (to be used with the goal of accepting influence) Treatment Goal: To identify patterns of interrelating that occur within the life space of the couple (symbolically represented by the paper). To gain a clearer picture of the presenting problem and the communication patterns of the couple. Objectives: Provide an art intervention that will illuminate covert patterns of interaction and communication. To provide insight/awareness for the couple regarding ingrained patterns of relating. Materials: 18” X 24” white paper, thick chalk pastels in a wide variety of colors. Directive: Develop one well-integrated picture together without verbal communication. Processing: Discuss how each partner felt during the creation of the image. Explore the nonverbal communication or lack there of, how space was distributed among the couple, possible patterns of leading, following, ignoring, accepting influence, domination, retaliation, isolation or integration. Process the following questions: How effective do you think you were at influencing each other? Did either of you try to dominate the other, or were you competitive with each other? Did either of you sulk or withdraw? Did you have fun? Did you work as a team? How much irritability or anger did either of you feel? Did you both feel included?

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Marital Art Therapy Treatment Plan Torn Paper Solvable Problem Collage (Used to focus on compromise and accepting influence) Treatment goal: To identify a solvable problem that the couple is experiencing and provide an opportunity for them to accept influence from each other and develop a compromise. Objectives: Provide an art intervention that will provide an opportunity for the couple to visually and verbally express their feelings, needs and wants in regard to a specific problem that they are facing. To challenge the couple to come up with a creative compromise together that will address the needs of each in regard to this specific issue. To provide practice in using a soft startup, learning to make and receive repair attempts, soothing themselves, compromise and being tolerant of each other’s faults. Materials: Matisse-like figure stencils in various expressive positions, construction paper, markers, scissors, glue, scrap paper and other craft materials. Directive: Think of a specific problem/issue that frequently comes up in your marriage. Agree on the same issue to focus on for this art activity. Chose one or more of the figure stencils that express how you feel regarding this issue. Trace the stencil and then tear and cut paper to further express your feelings. When this image is completed and discussed, make a new image together that represents how you will each compromise to solve this issue. Use the part or all of each of the original images that you each created to make one image that represents the resolution. You can add to this second image as well. Processing: Process the images created independently first. Include a discussion of what each partner needs and what each is willing to compromise on. Give the second directive for the couple to create an image together. Process this image when completed. Comment on the process of them working together, discuss how this felt for each, make connections to letting go of the original images for the final integrated image an how this relates to accepting influence.

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Marital Art Therapy Treatment Plan House of the Future (to be used with overcoming gridlock and creating a shared meaning) Treatment Goal: To identify unsolvable problems that have lead the couple to gridlock and the underlying dreams and meaning attached to these issues. To accept each other’s differences and honor and support each other’s dreams. Objectives: To provide an art intervention that will illuminate goals and dreams that each partner has. To provide an opportunity to symbolically express these dreams along with the history and meaning that surrounds them and to learn to approach gridlock from a perspective of acceptance and honor rather than trying to change or take away a dream. Materials: Large white paper, tempura paint, watercolor paint, paint brushes in various sizes, oil pastels, thick pastel chalk and pencils. Directive: Using whatever materials you wish create an image of your ideal house of the future. Processing: Process each image separately allowing for the full attention to be on one member of the couple at a time. Encourage listening and observation of each individual’s goals, hopes, ideals and meaning potentials still to be actualized. Comment on goals that are shared and mutual hopes for the future. Discuss how each can accept, honor and support each other’s goals and the symbols that emerge that represent the couples shared meaning.

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Marital Art Therapy Treatment Plan Review of Artwork/ Bridge Drawing Treatment Goal: To review the artwork and reflect on the progress that has been made by the couple. To access how far the couple has come and whether therapy should continue or commence. Objectives: To provide an opportunity to look at the images as tangible representations of the progress they have made. To provide an art intervention that evokes insight and awareness of where the couple is in their journey and how much assistance they need to continue on a successful path. Materials: 11” x 14” white paper, color pencils, and markers. Directive: Each of you individually draw a picture of the two of you crossing a bridge going form some place to some place. Place yourself and your spouse on the bridge where you think you are. Indicate the direction that you are traveling. Processing: Comment on the strength and support of the bridge or lack there of, the images in the place they are coming from and going to, what is below and above the bridge, where each of them is on the bridge and the affect depicted on the faces. Process separately and encourage each spouse to make comments and ask questions to the other. Make connections regarding where the couple is on their path and ask them to decide if they think they need more guidance/ therapy or they think they are ready to continue on their own with a follow up session.

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APPENDIX D Informed Consent

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APPENDIX E Human Subjects Committee Approval Letter

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BIOGRAPHICAL SKETCH Curriculum Vitae DINA LEAH RICCO, M.A./M.S. PERSONAL INFORMATION 3387 Highland Mill Lane Orange Park, FL 32065 Phone: (904) 282-9982 (home) (904) 424-9193 (cellular) Email: [email protected] ACADEMIC QUALIFICATIONS 2004 MS. Art therapy 2003 Doctoral Candidate 2001 Registered as a state intern in pursuit of Mental Health Counseling License 2000 Started PhD in Art Therapy, Florida State University 1992 Qualified for Certification in Guidance and Counseling 1992 MA Counselor Education, University of South Florida 1988 BA Fine Arts, University of South Florida PROFESSIONAL AFFILIATIONS/ SCHOLARSHIPS/AWARDS Student member of the American Art Therapy Association Vice President of Florida State University Art Therapy Association 2003 Teaching Assistantship, Florida State University 2000-2002 National Collegiate Education Awards Winner, University of South Florida RELATED EXPERIENCE Presentations: American Art Therapy Association National Conference A Treatment Plan for Marital Art Therapy: Combining Gottman's Sound Marital House Theory with Art Therapy Techniques Atlanta, Georgia November, 2005 Music Therapy in Substance Abuse Conference

Symbolic Use of Animal Imagery in Group Art Therapy Tallahassee, FL June 2003

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Children’s Home Society United Way Presentation The Use of Art Therapy in the Sexual Abuse Treatment Program Tallahassee, FL

April 2003 Marriage and Family Therapy Center/ Florida State University Art Therapy Assessments with Couples and Families Tallahassee, FL March 2003 Florida Coalition Against Domestic Violence State Conference The Use of Animal Imagery with Abused/Neglected Children Orlando, FL February 2003 The Healing Arts Alliance History and Practice of Art Therapy Tallahassee, FL June 2002 The 2nd Annual PDS Colloquium College of Education/University of South Florida (USF) Results of the USF/ Sarasota Middle School PDS Partnership Tampa, FL July 2000 Speakers Bureau/ DACCO Substance Abuse Prevention/ Education Tampa, FL 1990-1992 TEACHING EXPERIENCE 2003-2005 Adjunct Faculty, Flagler College • Instruction ofART355A Introduction to Art Therapy 2001-2002 Adjunct Faculty, Tallahassee Community College ! Instruction of 1501 College Success 2000-2002 ! ! 1999-2000

Teaching Assistant, Florida State University Instruct graduate students Supervise practicum settings Adjunct Faculty, University of South Florida

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! ! 1999-2000 ! !

1994

Assist with instruction in the eighth grade literacy classroom at Sarasota Middle School as it began its first year as a Professional Development School Collaborate with and assist the PDS liaison with instruction of at risk students Assist with research, attitude surveys, pre/post testing, data analysis Adjunct Faculty, Pasco-Hernando Community College Instruction of three credit elective class, Individual Discovery Curriculum focused on interpersonal skills for college students

Art Teacher, Summer School, Land O’Lakes High School ! Instruction of Art 2-D elective class ! Curriculum focused on introduction to two dimensional drawing and painting ! Discussion involved applying terms to critique of art work

CLINICAL EXPERIENCE 2006-Present Family Therapist Family Foundations • Complete Psychosocial Evaluations and make recommendations • Provide individual, group and family counseling • Develop and execute behavioral intervention plans • Consult with faculty of schools illegible for Full Service Schools grant services • Provide case management and aftercare services • Write curriculum for the after school BLAST (Building Lives and Solutions Together) program • Train new staff • Provide clinical supervision to interns • Maintain confidential records of clients 2004-2005 Psychological Specialist Department of Corrections/Florida State Prison • Provide counseling and case management to 70 inmates in maximum management confinement • Complete confinement reviews monthly • Generate Individual Service Plans, Behavioral Risk Assessments and Bio-Psychological Assessments • Present assessments to the Multi-disciplinary Staffing Team • Coordinate with the community for End of Sentence planning

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2004

Provide suicidal and homicidal assessment to the emergency management team

Art Therapist Daniel Memorial Inc • Provide Group Art therapy to all clients in the State Institutional Psychiatric Program (SIPP) • Participate in treatment team meetings • Provide consultation to other therapists, residential counselors and behavior specialist regarding diagnosis, treatment goals and progress in the group setting

2002-2003 • • • • • • • 2001-2002 ! ! !

2000-2001 ! ! ! ! 1999-2000 !

Counselor IV, Children’s Home Society/Family Connections Program Provide crisis intervention, individual, family and/or group therapy Complete bio-psychological assessments with clinical diagnosis Develop treatment plans Review and monitor billing for clinical services Train direct care staff regarding components of the individualized treatment plan Act as a liaison with outside agencies and other organizations Assist in grant writing and re-accreditation preparation Case Specialist, Children’s Home Society/ Child Protection Team Coordination of Medical Examinations and Forensic Interviews Complete Psychosocial Evaluations and Specialized Interviews Summit written report of evaluations to The Department of Children and Families including risk factors and recommendations Counselor, Multidisciplinary Center, Florida State University Co-lead Art Therapy Groups for ESE students in the Taylor County School System Conduct individual art therapy sessions Develop treatment goals Consult with parents and teachers Coordinator of Student Services, University of South Florida, Florida Community Partnership Program Coordinate with Franklin Middle School, Hillsborough County School District and the University of South Florida regarding services received by students who quality for the GEAR-UP Grant

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! ! ! 1998-1999 ! ! ! ! ! ! ! ! !

1996-1998 !

1996 ! ! ! ! ! ! 1995-1996 ! ! ! ! 1990-1992 ! !

Develop assessments used by case mangers to target assets and /or deficiencies in students academic and /or social skills Facilitate the emersion of the Parent Leadership Academy and the Saturday Enrichment Program Leader in the Design Team for the Fine Arts Learning Community Case management of 125 seventh grade students at FMS Academic Advisor, Pasco-Hernando Community College (PHCC) Provide career counseling and curriculum advising Facilitate orientation presentations for new students Supervise Veteran’s Administration (VA) work study students Certify course selections for veteran students Coordinate dual enrollment for Zephyrhills and Land O’Lakes High Schools Serve on Zephyrhills High School Advisory Council Act as liaison for Criminal Justice programs for ZHS/PHCC Administer the CLAST and SAT Serve as East Campus Representative for the Florida Association of Community Colleges (FACC) Part time Academic Advisor, (PHCC) Assist student services in advising students during peak registration periods Family Therapist, Family Continuity Programs Complete family assessment Develop clinical formulation and treatment plan Visit the family home weekly to conduct family therapy Coordinate home visits for clients Document progress of clients Correspond with Juvenile Justice Department Treatment Alternative to Street Crime (TASC) Specialist, Drug Abuse Treatment Association (D.A.T.A.) Complete psycho-social evaluations and drug screens Submit written reports of evaluations and recommendations to juvenile court Facilitate the initiation of treatment Provide case management Alternative School Counselor, Drug Abuse Comprehensive Coordinating Office (DACCO) Complete psycho-social intake evaluations of all clients on caseload Provide individual, family and small group counseling

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Instruction of peer counseling classes Consult with school social worker and school psychologist

PASCO COUNTY SCHOOL SYSTEM 1996-1998 Guidance Counselor, Zephyrhills High School ! Provide individual and/or academic counseling ! Conduct parent-teacher conferences ! Consult with teachers ! Maintain student cumulative files ! Evaluate credits for graduation ! Register new students ! Instruct classroom guidance ! Staff students into Drop Out Prevention Program ! Team Member Fine Arts Academy ! Manage crisis intervention and conflict resolution ! Administer HSCT, FCAT and AP exams 1994-1995

! !

Part time Adult Education Counselor, Zephyrhills High School Evaluate student credits regarding the completion of an adult education diploma Advise for career academic planning Administer the Pre-GED and T.A.B.E.

! ! ! ! ! !

Guidance Counselor, Cox Elementary School Provide individual, group, and family counseling Instruct daily classroom guidance lessons Maintain Exceptional Student Education files Chair the Exceptional Student Education Committee Coordinate School wide student recognition Manage crisis intervention and conflict resolution

!

1994-1995

1992-1994 ! ! ! ! ! ! ! ! ! !

Drop Out Prevention Counselor, Land O’ Lakes High School Coordinate five drop out prevention programs Staff students into appropriate programs Maintain student academic files Provide individual, group, and family counseling Conduct parent-teacher conferences Instruct classroom guidance monthly Promote community involvement through the Youth Motivators Program Chair the Student Recognition Committee Manage crisis intervention and conflict resolution Administer SAT, ACT and HSCT exams

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COMMITTEES Federal Grant Review Committee Substance Abuse and Mental Health Services Administration (SAMHSA) Washington DC 2000 Learning Community Design Team Franklin Middle School Tampa, Florida 1999 Nursing Student Selection Committee Pasco Hernando Community College Dade City, Florida 1998 .Learning Community Design Team Student Discipline Committee Academy of Law studies/ Criminal Justice Advisory Committee Zephyrhills High School Zephyrhills, Florida 1997-1999 Exceptional Student Education Chair Student Discipline Committee Cox Elementary School 1994-1995

Student Recognition Committee Chair Land O’Lakes High School Land O’Lakes, FL 1992-1994

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SPECIALIZED TRAINING

American Art Therapy Association 36th Annual Conference -Atlanta, Georgia, November 16-20, 2005

• • • • • •

Expanding Creativity of Family Therapy: Theory, Assessment, and an InHome Practical Model The Critical Years: Art Therapy approaches to Aiding Young Children and Families The Science of Art Therapy Treatment for Chronic Multiple Trauma The Open Book: Books, Journals, and Collaboration in Art Therapy Breaking the Cycle of Violence: Creativity as a Changing Force with Youth Overcoming Obstacles: Measuring the Effects of Art Therapy On Prison Inmates

American Art Therapy Association 34th Annual Conference- Chicago, IL November 19-23, 2003 • • • • • • • • •

Witnessing Aggression and Violence – Responding Creatively Word Pictures: A Panel on the Poetry of Art Therapists The Draw-An-Animal Drawing as An Expression of Self-Concept in LatencyAged Children Expressive Therapies Continuum: A Treatment Planning Tool for SED/ Developmentally-Delayed Students One Year Later for the Witnesses: At Therapy with Neighborhood Children after 9/11 Making Art for Professional Training Art Therapy and Attention Deficit / Hyperactivity Disorder Art Therapists as Art Educators The Art of Youth as Witness to Our Culture

American Art Therapy Association 33rd Annual Conference -Washington, DC • • • • • • •

November 21-25, 2002

A Study of Attachment Behavior Between Abused Children and the Foster Parents in Art and Play Therapy Recent Developments in the Diagnostic Drawing Series Project What’s Beyond the Scribble? Art Therapy with Preschool Children Common Ground: Child Victims of Domestic Abuse Find Strength Through Artistic Expression Finding a Safe Place: Art Therapy with Adolescent Runaways The Creative Genogram: A Technique for Exploring Family Relationship Patterns The World Trade Center Children’s Mural Project

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American Art Therapy Association 31st Annual Conference- St. Louis, MO • • • • • • •

November 8-12, 2000

Words, Image, Action: Giving Meaning and Purpose Through Poetry, art, and Drama The Relationship Between Personality Type and Nonrepresentational Drawing Style: A Preliminary Study Computer supported Distance Art Therapy: New Possibilities for Medical Art Therapy Surviving Abuse: Innovative Approaches to Working With Child Victims of Domestic Violence An Insatiable Hunger: Attachment Dilemmas of Children in Foster Care I Won’t Draw Dad: Domestic Violence and Its Effect on a Family Brief Art Therapy as Crisis Intervention: Reducing PTSD Symptoms in Injured Children University of South Florida/ College of Education National Resource Center For Middle Grades Education GEAR-UP Middle Level Training Tampa, FL 2000 District School Board of Pasco County High School Learning Communities Training Zephyrhills, FL 9/96-3/97 Sexual Addiction Symposium Augustine House St Petersburg, Florida 1997 University of South Florida SCATT (Suncoast Area Teacher Training) Consultation Skills/ Performance Learning Systems Working Effectively with Interns and Beginning Teachers Tampa, FL 1996 Sexual Abuse Treatment Training Family Continuity Programs St Petersburg, FL 1996 G.I.S.T. (Gentle Intervention Strategies for Tots) Behavioral Management Training Pasco County School Exceptional Student Education Dade City, FL 1994

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