DBT-Informed

Art Therapy in Practice

 by the same author

DBT-Informed Art Therapy

Mindfulness, Cognitive Behavior Therapy, and the Creative Process
Susan M. Clark
ISBN 978 1 84905 733 2
eISBN 978 1 78450 103 7

of related interest

DBT Therapeutic Activity Ideas for Working with Teens

Skills and Exercises for Working with Clients with Borderline Personality
Disorders, Depression, Anxiety, and Other Emotional Sensitivities
Carol Lozier
ISBN 978 1 78592 785 0
eISBN 978 1 78450 718 3

Creating DBT Activities Using Music

Interventions for Enhancing Engagement and Effectiveness in Therapy
Deborah Spiegel with Suzanne Makary and Lauren Bonavitacola
ISBN 978 1 78775 180 4
eISBN 978 1 78775 182 8

Creative Arts Therapies and Clients with Eating Disorders

Edited by Annie Heiderscheit
ISBN 978 1 84905 911 4
eISBN 978 0 85700 695 0

Mindfulness and the Arts Therapies

Theory and Practice
Edited by Laury Rappaport, Ph.D.
ISBN 978 1 84905 909 1
eISBN 978 0 85700 688 2
DBT-Informed
Art Therapy
in Practice
Skillful Means in Action

EDITED BY SUSAN M. CLARK

 First published in Great Britain in 2021 by Jessica Kingsley Publishers
An Hachette Company
1
Copyright © Jessica Kingsley Publishers 2021
The Benedict Carey epigraph on page 73 is from The New York Times. © 2018
The New York Times Company. All rights reserved. Used under license.
Every effort has been made to trace copyright holders and to obtain
their permission for the use of copyright material where necessary
to do so. The author and the publisher apologize for any omissions
and would be grateful if notified of any acknowledgments that should
be incorporated in future reprints or editions of this book.
Front cover image source: A painted jigsaw puzzle by Muneca (pseudonym),
whose drawings appear in Chapter 9 “DBT Case Conceptualization
Featuring Art Therapy and Poetry Interventions” (Yvette Duarte).
All rights reserved. No part of this publication may be reproduced, stored
in a retrieval system, or transmitted, in any form or by any means without
the prior written permission of the publisher, nor be otherwise circulated
in any form of binding or cover other than that in which it is published and
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Disclaimer: The information contained in this book is not intended to replace the
services of trained medical professionals or to be a substitute for medical advice.
You are advised to consult a doctor on any matters relating to your health, and
in particular on any matters that may require diagnosis or medical attention.
A CIP catalogue record for this title is available from the
British Library and the Library of Congress
ISBN 978 1 78775 208 5
eISBN 978 1 78775 209 2
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 Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Part 1: DBT-Informed Visual Art Therapy in Practice

1. The Three Ms of DBT-Informed Art Therapy (Mindfulness,
Metaphor, and Mastery) As Translated Through the
Wisdom of a Dog . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Susan M. Clark

2. The Pause: Borderline Personality Disorder, DBT-Informed

Art Therapy, and the Construct of Emptiness . . . . . . . . . . . . . 21
Heidi Larew

3. Utilizing DBT, Mindfulness, and Art Therapy in Today’s

Healthcare Environment . . . . . . . . . . . . . . . . . . . . . . . . . 37
Jane DeSouza

4. My Journey as an Art Therapist Focusing on DBT

and Art Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Megan Shiell

5. Inspiring and Sustaining Hope: Treating Suicidal Behavior with

DBT-Informed Art Therapy . . . . . . . . . . . . . . . . . . . . . . . 73
Jane DeSouza

6. DBT in Action: Art Therapy and DBT Skills Training in

Treating Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . 89
Susan M. Clark

7. DBT-Informed Ceramic-Based Art Therapy Groups for

Adolescents: Educating the Community About the Impacts of
Sexual Abuse Through Public Exhibition and Social Activism . . . 112
Shelley Kavanagh

8. From Hatch to Handshake: Combined Art Therapy and

DBT Skills Training in a High-Security Learning Disability
Treatment Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
Emma Allen and Anthony Webster
Part 2: Multi-Modal DBT-Informed Approaches
9. DBT Case Conceptualization Featuring Art Therapy and Poetry
Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Yvette Duarte

10. Group InCircle: Development and Implementation of a Novel

DBT-Informed Creative Arts Therapy Group for Veterans with
Serious Mental Illness in a Large Hospital Setting . . . . . . . . . . 173
Jeremy Steglitz, Scott Levson, Melanie Paci, and Tracela M. Zapata

11. Creative Mindfulness: DBT Skills-Oriented Intermodal

Expressive Arts Therapy for Populations with Severe
Emotion Dysregulation . . . . . . . . . . . . . . . . . . . . . . . . . 197
Karin von Daler

12. Toward a Distress Tolerance-Informed Expressive Arts Therapy

Protocol with Vulnerable Populations Experiencing Multiple,
Persistent Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216
Chloe Sekouri

13. Queering DBT: Critical DBT-Informed Art Therapy

with the LGBTQIA+ Community . . . . . . . . . . . . . . . . . . . 233
Mary Weir

14. Integrating DBT-Informed Psychoeducation with Visual

Journaling: Practical Considerations . . . . . . . . . . . . . . . . . . 255
Penelope James

Author Biographies . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274

Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280

Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285

 Introduction

This volume builds upon the foundation of DBT-Informed Art

Therapy: Mindfulness, Cognitive Behavior Therapy, and the Creative
Process (Clark 2017). My goal for that book was to provide readers
with strong overviews of both dialectical behavior therapy (DBT) and
art therapy, as well as describe how such differing interventions might
come together to assist in the treatment and recovery of individuals
with significant emotional and behavioral instability. DBT-Informed
Art Therapy contains plentiful theoretical information, as well as
creative visual exercises for developing competency with DBT’s four
skills training modules: core mindfulness, interpersonal effectiveness,
emotion regulation, and distress tolerance (Linehan 2015a, 2015b).
The art therapy activities in DBT-Informed Art Therapy are suitable
for both adult and adolescent clients, and I wrote at length about
my experiences working in varied treatment settings (including a
community mental health agency, a residential center for addictions,
and an intensive outpatient eating disorder program). However, I was
also aware of my natural limitations as one individual clinician, which
is why I actively sought out other DBT-informed creative arts therapy
practitioners. A few of those individuals, who were kind enough to
answer my questions and/or donate intervention(s) for the first book,
have written chapters in this one.
DBT-Informed Art Therapy in Practice: Skillful Means in Action
describes practical applications of the DBT-informed arts therapies
within a wide range of settings. The authors hail from the United
Kingdom (England), Canada, Australia, New Zealand, Denmark,
and the United States. Many possess decades of clinical experience.
Some are accomplished instructors, trainers, and presenters. All have
great enthusiasm for this novel approach and contribute valuable
perspectives resulting from their diverse interests and backgrounds. My
hope is that readers become inspired to apply what they learn to their
own work. Perhaps some will even pursue opportunities to formally

7
8 DBT-INFORMED ART THERAPY IN PRACTICE

research the efficacy of DBT-informed art therapy (and, ideally, publish

their findings in peer-reviewed journals).

What is “skillful means in action”?

According to DBT’s developer, Marsha Linehan, PhD, skillful means
comes from Zen Buddhism and “refers to any effective method that
aids a person to experience reality as it is, or, in DBT terms, to enter
fully into wise mind” (Linehan 2015a, p.223). It is the heart and spirit
of participating effectively, that is, throwing oneself into the present
moment and acting as skillfully as possible in order to pursue one’s
goals: “Do what is needed for the situation you are in,” Linehan
explains, “not the situation you wish you were in; not the one that is
fair; not the one that is more comfortable” (2015b, p.60). By integrating
their own unique versions of DBT-informed arts therapy into their
respective clinical environments, the authors demonstrate how to
assist individuals in acquiring, deepening their understanding of, and
applying these important cognitive and behavioral strategies across
all aspects of their lives. Such a process is, essentially, skillful means
in action.

How this book is organized

The book is divided into two parts. The first, “DBT-Informed Visual
Art Therapy in Practice,” contains eight chapters that emphasize more
traditional one- and two-dimensional visual art therapy approaches.
In Chapter 1, I illustrate the Three Ms of DBT-informed art therapy
(mindfulness, metaphor, and mastery) through a fictionalized
portrayal of a therapy participant. The Three Ms are discussed at length
in my first book, but in a much more instructional style. This piece
intends to show, rather than merely tell (i.e., describe), these concepts
as they might play out in real clinical situations. In Chapter 2, Heidi
Larew considers the chronic internal emptiness that plagues many
individuals who struggle with borderline personality disorder (BPD).
She encourages therapists to reconsider emptiness as a potential source
of strength and/or wisdom, and suggests some creative activities to help
both clients and therapists view the phenomenon from an alternate
perspective. Jane DeSouza writes about her efforts with combining
art therapy and DBT within managed care settings in Chapter 3.
 Introduction 9

She explains how motivated creative arts-based therapists might inte­

grate their experiential methods with empirically founded practices.
Chapter 4 highlights Megan Shiell’s decision to re-career as an art
therapist at age 50. Within a handful of years she became a highly
respected DBT therapist, skills trainer, and pioneer in DBT-informed
art therapy who had designed a novel online skills training program
for use by both clients and treatment providers.
Chapter 5, Jane DeSouza’s second offering, presents the unique
aspects of DBT-informed art therapy that may contribute to its observed
strengths when applied to the treatment of persistently suicidal
individuals. In Chapter 6, I describe an art therapy-based DBT skills
training curriculum for individuals with eating disorders. A version
of this chapter first appeared in the 2016 Jessica Kingsley Publishers
(JKP) book Creative Arts Therapies and Clients with Eating Disorders
(A. Heiderscheidt, editor). Art therapist and ceramic artist Shelley
Kavanagh writes about her ceramic-based DBT-informed art therapy
groups for young survivors of sexual abuse in Chapter 7. Housed in a
museum, these groups empower participants to become social activists
as they prepare to publicly exhibit their creative works. In Chapter 8,
co-authors Emma Allen and Anthony Webster share their work with a
troubled young man living in long-term seclusion within a high secure
treatment unit for mental illnesses and learning disabilities. This hands-
on, collaborative intervention proved essential to his development of
emotion regulation skills and, ultimately, an ability to achieve and
maintain appropriate and rewarding relationships with others.
Part 2, “Multi-Modal DBT-Informed Approaches,” comprises six
chapters that feature unique fusions of DBT-informed visual art therapy
and one or more other modalities (e.g., creative writing, movement,
drama). Chapter 9 highlights Yvette Duarte’s work with a client who
used poetry, drawing, and painting to both deepen their grasp of the
DBT skills they learned in program and foster their identity as a person
in recovering from mental illness. Duarte presents this individual’s
story in a DBT case conceptualization-style format. In Chapter 10 we
are introduced to “Group InCircle,” a creative arts-based intervention
that showed promise with helping military veterans acquire, retain,
and generalize the DBT skills they received in an outpatient mental
health treatment program. This piece’s primary author, Jeremy
Steglitz, was a postdoctoral fellow at the Veterans Administration
Medical Center (VAMC) in Washington, DC. Next, in Chapter 11,
10 DBT-INFORMED ART THERAPY IN PRACTICE

Karin von Daler reintroduces the “creative mindfulness” approach,

which she and colleague Lori Schwanbeck first wrote about in JKP’s
Mindfulness and the Arts Therapies: Theory and Practice (2014; Laury
Rappaport, editor).
In Chapter 12, Chloe Sekouri describes her work in an urban drop-
in center, where she provided short-term—often single-session—DBT-
informed creative therapy interventions to a particularly vulnerable
clientele. Art therapist Mary Weir introduces readers to her concept of
“Queering DBT” with the LGBTQIA+ population in Chapter 13, and
challenges us to expand our understanding of, and appreciation for, the
myriad manifestations of gender identity and sexuality. And, finally, in
Chapter 14 art therapist Penelope James explores one effective approach
for implementing a visual journaling (combined art and writing)
technique to enhance participants’ experiences in a psychoeducational
day treatment program.

How to use this book

As in the previous volume, I urge readers who are less familiar with
DBT to (at minimum) read the second edition of the DBT Skills Training
Manual (Linehan 2015a) and DBT Skills Training Manual: Handouts and
Worksheets (Linehan 2015b). For those who wish to go a bit deeper, the
original treatment manual, Cognitive-Behavioral Treatment of Borderline
Personality Disorder (Linehan 1993), is essential. Newer offerings from
experts in the field include Doing Dialectical Behavior Therapy: A
Practical Guide (2012) by Kelly Koerner, and DBT Principles in Action:
Acceptance, Change, and Dialectics (2016) by Charles Swenson.
This volume is not a substitute for proper training in a mental health
treatment discipline (e.g., professional counseling, clinical psychology,
social work, and so on), one or more creative art therapy modalities,
and/or DBT. The information contained within each chapter is meant
to provide ideas and inspiration around the use of DBT-informed art
therapy; however, please exercise discretion with implementing any of
the described interventions. Even fully credentialed treatment providers
may seek out additional training, consultation, and/or supervision prior
to using some of the techniques presented here.
 Introduction 11

A word about language

Each chapter contributor possesses their own beliefs and preferences
regarding how they refer to the people with whom they work.
Depending upon an author’s educational and professional background,
as well as the clinical setting described in their chapter, identifiers
such as “clients,” “patients,” and “participants” typically appear. Gender
pronouns vary from feminine to gender-neutral (e.g., they, them, their).
In this age of expanding understanding of, and sensitivity toward, the
rich range of human identities, my colleagues and I made every effort
to balance the many practical aspects of writing for publication with a
heartfelt desire to validate and affirm others. Although the results are
no doubt imperfect, we offer this book in the spirit of inclusion and
respect.

References
Clark, S.M. (2017) DBT-Informed Art Therapy: Mindfulness, Cognitive Behavior Therapy, and
the Creative Process. London: Jessica Kingsley Publishers.
Heiderscheidt, A. (ed.) (2016) Creative Arts Therapies and Clients with Eating Disorders.
London: Jessica Kingsley Publishers.
Koerner, K. (2012) Doing Dialectical Behavior Therapy: A Practical Guide. New York, NY:
Guilford Press.
Linehan, M.M. (1993) Cognitive-Behavioral Treatment of Borderline Personality Disorder.
New York, NY: Guilford Press.
Linehan, M.M. (2015a) DBT Skills Training Manual (2nd ed.). New York, NY: Guilford Press.
Linehan, M.M. (2015b) DBT Skills Training Manual (2nd ed.). Handouts and Worksheets.
New York, NY: Guilford Press.
Rappaport, L. (ed.) (2014) Mindfulness and the Arts Therapies: Theory and Practice. London:
Jessica Kingsley Publishers.
Swenson, C.R. (2016) DBT Principles in Action: Acceptance, Change, and Dialectics. New
York, NY: Guilford Press.
von Daler, K. and Schwanbeck, L. (2014) ‘Creative Mindfulness: Dialectical Behavior
Therapy and Expressive Arts Therapy.’ In L. Rappaport (ed.) Mindfulness and the Arts
Therapies: Theory and Practice. London: Jessica Kingsley Publishers.
 Part 1

DBT-Informed Visual
Art Therapy in Practice
 Chapter 1

The Three Ms of DBT-Informed Art

Therapy (Mindfulness, Metaphor,
and Mastery) As Translated
Through the Wisdom of a Dog
SUSAN M. CLARK

This chapter illustrates DBT-informed art therapy’s Three Ms

(mindfulness, metaphor, and mastery) through a fictionalized portrayal
of an adult therapy participant. Its intention is to suggest how these
somewhat abstract concepts might play out within actual clinical
situations. Rather than simply describe each concept/practice in the
typical academic manner, I show how the Three Ms could manifest and
develop throughout an individual person’s unique recovery journey.

Mindfulness
The artist inhales and runs his palms over the watercolor paper. Its
surface is rough and somewhat bumpy. He enjoys looking at the many
irregularities, especially the edges, which are uneven, almost ragged.
This is a large piece of paper (18 × 24 in.). It is quite thick, as well, and
rather heavy. The artist picks it up with both hands, feels the heft, shakes
it slightly, and listens to the sound produced, a rustling…no, a ruffling,
of sorts. Soothing. He shakes it again, this time with a bit more force.
He smiles. Before returning it to the table, the artist brings the paper
close to his face. He breathes in again, more deeply, enjoying the faint
cottony odor. Since no one is around to see, the artist turns his head
slightly and allows the paper to rest against his left cheek. He is perfectly
still for a moment. All that exists is the silence of the room, the paper’s
scent, and its faint, flat pressure against his skin.
15
16 DBT-INFORMED ART THERAPY IN PRACTICE

Once the sheet of watercolor paper is back resting on the table, the
artist takes in its crisp white surface once more. It will never again
look this way: unmarked, blank, somehow limitless. He reaches for
his sponge, which he dips into the small pan of water. Intentionally
not squeezing out any excess, he wets the paper’s surface thoroughly.
Now, it is glistening. He clears his throat, puts down the sponge, and
immediately takes his favorite brush, touching its tip to the small dollop
of blue pigment—then places it against a spot near the sheet’s center.
Vibrant blue practically leaps from the brush onto the paper, carried
effortlessly by vibrating water molecules. It is beautiful. The artist
observes how the color feathers out for several inches beyond the
original point of contact. He notices that there is a subtle migration
toward the right, which means that his table (or the floor) is slightly
uneven. He chuckles. So much for perfection.
There was a time when this kind of thing would challenge his patience
until he’d slam his fist onto the paper (or tear it into several pieces before
crumpling everything up and hurling it all into the trash can). He is not
certain why he continued to experiment with art. It would have been
easier to just quit. But he kept coming back. Especially to the watercolor.
What is it about this stuff? The crap’s not easy to work with. It so
rarely does what he wants it to do or goes where he intends for it to go.
But once he gave up trying to force his will upon the process, things
started going much better. It felt a lot better then. He could just do
something, anything really, and then calmly watch whatever happened.
The trick is really in the giving up of control, trusting the process and not
freaking out if things don’t end up being very pleasing to the eye. After
all, this is just a piece of paper and some ordinary tubes of watercolor.
Nice enough, but not expensive. There is truly nothing to lose.
The artist scratches his forehead. The room is so quiet that he believes
he can hear his heart. He drums a few fingers against the table to break
the silence. He coughs once. Then sighs. It’s time to add purple. But not
the one in the tube. He will make his own, using some ultramarine blue
and cadmium red. The artist suddenly becomes aware of feeling eager,
kind of excited about mixing colors. It’s fun.

Metaphor
About a half an hour has passed, and the artist is truly in the thick of
things. He has no idea how it happened, but he finds himself working on
 THE THREE MS OF DBT-INFORMED ART THERAPY 17

a portrait of a dog, a large, German shepherd-like creature. While the dog

itself looks enough like a dog, the coloring isn’t realistic because he has
been working with blue, purple, and now gray. He is fighting a strange
urge to make its eyes bright orange, like autumn pumpkins. “How weird
is that?” he whispers to no one in particular, and chuckles again.
The artist has been working with metaphors a lot lately. His therapist
says that they are powerful because they can be so deeply personal,
especially when they appear in one’s artwork. So far, he has found this to
be true. A single image can mean many different things, but sometimes
it has no meaning at all, which is also sort of meaningful. He regards
the dog and has an interesting thought: My dog is not a fighter. Okay,
so perhaps this one does have meaning, but does this mean that it’s
meaningful because of what it isn’t? Hmm.
The artist gives in to temptation and applies a thin, translucent orange
glaze over one of the eyeballs. He is careful to allow some white paper to
remain and show through, mimicking reflected light. He pauses, takes
in his work. It may appear strange, but it feels good and right. The artist
turns to the other eye. A moment later, when he is finished, the dog
suddenly seems animated. Almost as if he is real and has a soul. The
artist feels something like trepidation. What the hell kind of dog is this?
Again: My dog is not a fighter. All right. Why not, then? The artist
sniffs, regards the canine’s prominent head, scowls a little. This dog is
certainly big. Masculine. Extremely strong looking. If he existed, he
could tear someone apart if he wanted to.
Why doesn’t he want to?
That is the question, it seems. The artist’s eyes are filling up with hot
tears. Oh…shit. Not this again. Great. He awkwardly wipes his face on a
shirt sleeve and then reaches for paper towels. Blows his nose. Wonders
if he should wait on this, save it for next time he is with the art therapist.
That dog is staring at him, though. My dog. Who isn’t a fighter.
At least not that kind of fighter.
What do you WANT?
The artist places his brush into the soaking water and takes out his
notebook and pen. He opens to a blank page and adds the day’s date to
the top. For the next few minutes, he writes, stream-of-consciousness
style.
Again: My dog is not a fighter.
And then, a slew of metaphors:
My dog is a rose. A butterfly. A cloud. A secret.
18 DBT-INFORMED ART THERAPY IN PRACTICE

My dog is a song. A dance. A beginning. And an ending…

Oh, good grief. Here we go. He continues to write.
The artist finally closes its front cover with a decisive snap and tosses
his book onto the far end of the table. He looks down at the orange-eyed
dog, who seems to be gazing back at him…almost daringly.
Daring what?
And again: Not a fighter.
He remembers the dog he had had as a child, Rusty. What a typical
name. But that animal was unique. Rusty was…
It is difficult—very difficult—to think about this. He doesn’t want
to, but he knows well enough about the consequences of not allowing
oneself to “feel the feels,” as his art therapist likes to say. He sighs. And
then, another thought:
This dog does not want to be a fighter. He is what he is. I’m gonna quit
trying to make him into something he isn’t and never will be. Need to stop
now. Stop fighting. Stop fighting reality.
Radical acceptance. Ugh.
After he gets home, he takes out a box of old photos and finds Rusty.

Mastery
The artist started to call himself an artist, at least in his own mind,
several months ago. This was after realizing that he had drawn or
painted nearly every day for over an entire year. He wasn’t supposed
to focus on the quality of his artwork; however, over time it became
impossible not to notice how much he had improved. He was building
up skill. He started to feel something that might have been pride.
Since then, the artist has consistently thought of himself as an
artist and allows other people to refer to him as such, if they wish to.
Sometimes he works for pure enjoyment. Occasionally his intention is
to experiment with new techniques and further develop his abilities.
Most of the time, though, he is doing inner work. The nice thing
about having skill is that you are more able to make an image close to
whatever is in your head (or your heart). Instead of speaking a language
but only possessing a minimal number of words to express himself
with, the artist’s vocabulary has expanded to the point where he is quite
articulate. So, if one day his loneliness feels like an empty hand, he’ll
draw that hand and it will look as desolate and as lost as can be.
There is power in making our selves known, even if just to ourselves.
 THE THREE MS OF DBT-INFORMED ART THERAPY 19

***
It took quite a while before the artist realized that the dog with the
orange eyes was his own wise mind. Frankly, wise mind had never made
much sense. He wasn’t even really sure it existed. His therapist argued
about how we can know that we have lungs, kidneys, or whatever
without seeing them. Wise mind is there, somewhere, too, whether we
have directly experienced it or not. The artist just shook his head and
went on about his work.
Gradually, however, the idea began to sink in, especially as he grew
less tense and more at peace with himself and his life. The anger was
no longer constantly around, and its increasing absence left space, and
energy, for other things. He found himself with a desire to explore what
this wise mind concept might mean to him (if anything).
The artist began drawing, painting, and sculpting dogs of all breeds
and sizes. Some arrived with names, while others did not. But they
were all unique, just as Rusty had been. Another commonality was an
essential dog-ness: loyal, faithful, protective, instinctual, pure. Dogs are
themselves. They know what (and whom) they like, as well as what (and
whom) they do not like. The artist believed the saying that if your dog
appears to mistrust someone, you should take it to heart.
He sensed that he needed to start trusting himself. For as long as he
could remember, he had rejected his hunches and intuitions. That sort
of tripe was just for girls and women. Truth was, he did not know what
to think or feel. His parents had constantly said that he shouldn’t feel
the way he felt (or at least refrain from talking about it). He was overly
sensitive. Everything bothered him too much. Basically, he was weak.
He needed to toughen the hell up.
The dog with the orange eyes, however, did not seem even slightly
concerned about any of that. The dog with the orange eyes simply
was. He quietly held whatever he knew and waited. Weeks passed
uneventfully. The artist continued to live his life. He even tried a few
new things.

***
One day the artist mounts the watercolor on some foam board and later,
on a whim, hangs it up in his kitchen. At first, he is uncomfortable with
20 DBT-INFORMED ART THERAPY IN PRACTICE

how the dog seems to watch him. He can almost feel those autumnal-
hued orbs resting their gaze upon the back of his head as he boils water
or fries eggs. The man knows that it’s merely flattened wood pulp stained
by various mixtures of pigment and gum arabic (and perhaps some
glycerine or honey). He isn’t going mad; the dog is not real. And, yet.
A couple of months later the artist suddenly realizes that he is happy.
This strange recognition arrives as some sort of epiphany just as he
finishes his morning coffee. Things aren’t bad anymore. He had been
so busy for so long, working hard trying to build what the DBT people
called “a life worth living,” that it virtually snuck up behind him. He is
okay. Finally. This existence no longer appears to be just about existing.
The artist’s breath catches in his chest. He recognizes the
accompanying emotion as fear. Can I trust this? he asks himself, and
reflexively glances over at the dog (whose eyes glow with an odd but
comforting warmth). YES, he says. Trust in this.
 Chapter 2

The Pause
Borderline Personality Disorder, DBT-Informed
Art Therapy, and the Construct of Emptiness
HEIDI LAREW

Emptiness enveloped her like blankets of white snow,

embracing and comforting her in familiarity.
She sat in quiet stillness and felt gratitude for emptiness.
It was quiet and pleasant and safe,
unlike the emptiness
that had consumed her during the in-between years.
There were the first years: Zero, one, two, three, four.
Sunlight poured over her in year four.
She felt the warm breeze, the wide-open space,
the emptiness,
and something of safety,
so safe that there was no need for the word safe.
This was before her tender ways
and her tragic awareness of human suffering collided.
There were the in-between years.
The overwhelm, the loud, the clutter, the emotion,
and words all coming at her
and meanings and sounds
flooding.
And then the unlearning, finally.
And now,
The present. Again, with emptiness,
She could feel it and treasure it,

21
22 DBT-INFORMED ART THERAPY IN PRACTICE

Be in this moment
With no extra meaning.
Just emptiness.
Just as it was.
—H. Larew

Figure 2.1 Contentment (acrylic painting by the author)1

Introduction
Emptiness in the context of borderline personality disorder (BPD)
Feeling empty is a uniquely human phenomenon, one that many have
experienced on occasion. Like loneliness and isolation, emptiness is
uncomfortable—even painful. It implies a container that lacks fullness,
something incomplete. For most people, a sense of emptiness only
occurs during difficult periods and may accompany emotional states
such as sadness and/or grief. However, emptiness can be more persistent
for those who suffer from BPD, a mental illness characterized by severe
emotion regulation problems (American Psychiatric Association 2013).
 THE PAUSE 23

Emptiness is highly subjective and therefore difficult to measure; it

has not been the focus of extensive quantitative research. Clinicians and
clients alike struggle to adequately describe this experience, although
Widiger et al. (1995) offer the definition “without meaning, purpose,
or substance” (p.99). Gunderson and Links (2008) note that emptiness
may include “a visceral feeling, usually in the abdomen or chest” (p.12).
Klonsky’s (2008) study found a close relationship between emptiness
and “pathologically low positive affect and significant psychiatric
distress,” specifically hopelessness, loneliness, isolation, depression, and
suicidal thoughts (p.418).
A defining characteristic of BPD is “chronic feelings of emptiness”
(American Psychiatric Association 2013), and the diagnostic criteria
also include “frantic efforts to avoid real or imagined abandonment”
(p.663). Most individuals with BPD have intense and unstable
interpersonal relationships. They tend to view other people in extremes,
vacillating between idealization and devaluation. The intensity of their
emotions can be overwhelming (Mason and Kreger 2010). Mood
lability, an unstable sense of self, difficulty regulating anger, self-harm
behaviors, suicidal gestures, suicide attempts, and highly impulsive acts
can create distress for others as well. At times, those closest to these
individuals may pull away, thereby reinforcing fears of abandonment
(and furthering the potential for deeply painful experiences of
emptiness).
Coping with emptiness can seem overwhelming, an insurmountable
task. Its chronic presence frequently contributes to other BPD symptoms
as individuals attempt to distract themselves or fill the sense of inner
void with compensatory and “potentially self-damaging” behaviors
(American Psychiatric Association 2013, p.663). These could include
substance abuse, binge eating, overspending, sexual activities, and
reckless driving.
This chapter reflects on the construct of emptiness and explores
alternative responses, including radical acceptance (Linehan 1993,
2015a, 2015b), which might involve regarding emptiness from a variety
of creative angles and contemplating other, nonjudgmental, viewpoints.
It is entitled “The Pause” because emptiness itself is a form of a pause,
a space between. My intention is to allow readers to reflect on, and
perhaps, consider a different understanding of the cumulative effect
of BPD symptoms. Just as negative experiences and interpretations
can multiply in a downward trend, so also positive experiences and
24 DBT-INFORMED ART THERAPY IN PRACTICE

interpretations can have an upward propulsion, an overall movement

toward a more rewarding life.
The chapter also describes dialectical behavior therapy (DBT)
and explains how a dialectical view of emptiness (as well as several
other traits associated with BPD) can help reduce shame and stigma
in the people we treat. Using language that conveys respect as well as
a desire to understand and support these individuals may alleviate
their suffering. Word choice should focus on validation of emotional
pain as well as communicating clearly, with precision and compassion.
The chapter includes a brief introduction to art therapy as a potential
valuable method for exploring emptiness dialectically. To this end, I
offer ten creative exercises for the reader’s consideration.

A domino effect
According to DBT developer Marsha Linehan’s biosocial theory
(1993), persons with BPD often possess an inherently sensitive
emotional temperament as well as a history of having experienced at
least emotional invalidation, if not trauma/abuse, during childhood.
Validation communicates that the individual’s “responses make sense
and are understandable within their current life context or situation”
(Linehan 2015a, p.88). In the case of invalidation, such responses are
not accepted as reasonable, and may even be discounted or trivialized.
The message one receives from others, through direct feedback and/or
nonverbal signals, communicates that one’s perspective is inaccurate
or inappropriate. When a person is repeatedly distanced from others
through invalidation, feelings of alienation can occur. Social isolation
and social rejection contribute to depression (Matthews et al. 2016).
An accumulation of problematic factors may result in other unde­
sirable outcomes. For example, if an individual has already experienced
recurrent invalidation, and then also contends with substance use and
relationship issues during adulthood, there can be a chain reaction type
of impact. Just as one domino tips onto another, causing a cascade of
falling tiles, so one emotional problem occurs, then other factors are
added, and consequences become exponentially more troublesome.
Broken relationships can result in a gradual decline in self-confidence.
Chronic environmental invalidation reinforces the idea that the individual
is alone (which, again, may contribute to feelings of emptiness). However,
while dominos can tumble in negative directions, a positive accrual of
 THE PAUSE 25

life-affirming and healing experiences is also possible. The key is patience.

Individuals in therapy must be willing to consider their experiences from
other vantage points. It is also important to develop adaptive coping
skills, which often do not provide as much immediate relief as unhealthy
choices. Given that impulsivity is such a salient aspect of BPD, developing
mindful restraint, while not impossible, is challenging.

DBT
DBT, a familiar evidence-based intervention for BPD, can reduce
suicidal ideation, suicide attempts, psychiatric hospitalizations, self-
injury, and other destructive acts (Linehan 1993, 2015a, 2015b). DBT is
a form of cognitive behavior therapy (CBT) that incorporates concepts
from Zen Buddhism and dialectical philosophy. It emphasizes meeting
the client wherever they are while working toward the behavioral
changes necessary for safety and an improved quality of life. DBT’s
psychoeducational component includes four modules: mindfulness,
interpersonal effectiveness, emotion regulation, and distress tolerance
(Linehan 2015a, 2015b). Through skills training clients learn to
cultivate mindful awareness of their own emotions and/or other
internal experiential states (like emptiness). DBT participants also
develop capabilities for asserting their personal needs in relationships
and effectively managing intense emotions, as well as accepting and
tolerating occasions when they are not able to immediately experience
emotional relief, resolve pressing problems, and so on.

Emptiness viewed from other perspectives

One can conceptualize emptiness in various ways. The person may
experience shame for being lonely while surrounded by loved ones,
or for not feeling full, complete, whole. Further, given the persistence
and degree of emptiness in individuals with BPD, any encouragement
to reframe it as a positive experience could feel like more invalidation.
Individuals who suffer from chronic emptiness can perceive other views
as Pollyanna-ish (i.e., excessively or blindly cheerful/optimistic).
DBT, with its focus on dialectics (described below), strives to balance
“the tension between seeking change in a person and encouraging them
to embrace acceptance” (Linehan 2020, p.226). In the case of distressing
sensations like anxiety, depressed mood, identity disturbance, and
26 DBT-INFORMED ART THERAPY IN PRACTICE

feelings of emptiness, this is no small feat. Individuals understandably

wish to push away and/or anesthetize themselves from such experiences.
However, the dialectical approach asks that both client and therapist
entertain a novel idea:
Dialectics allows opposites to coexist: you can be weak and you can
be strong, you can be happy and you can be sad. In the dialectical
worldview, everything is in a constant state of change. There is no
absolute truth, and no relative truth, either; no absolute right or wrong.
Truth evolves over time. Values that were held in the past might not
be held in the present. Dialectics is the process of seeking truth in the
moment, drawing on a synthesis of opposites. (Linehan 2020, p.227)

Reconsidering words and meanings

To balance considering emptiness through a less pejorative lens while
attempting to avoid unnecessary invalidation, we might examine
other words that commonly describe aspects of the BPD experience:
manipulative, anxious, attention-seeking, avoidant, impulsive, isolative,
ruminating, and numb. These adjectives, while at times accurate and
even productive, are potentially hurtful, as well. I again advise taking
a dialectical view. From one perspective, an attribute is seemingly
unbecoming; however, from another angle one may see that same
quality as functional.
The case can be made that in the minds of professional caregivers,
these terms are not pejorative; indeed, that might be true. However, it
seems to me that such…terms do not themselves increase compassion,
understanding, and a caring attitude for borderline patients. Instead, for
many therapists such terms create emotional distance from and anger at
borderline individuals. At other times, such terms reflect already rising
emotional distance, anger, and frustration. One of the main goals of
my theoretical endeavors has been to develop a theory of BPD that is
both scientifically sound and nonjudgmental and nonpejorative in tone.
The idea here is that such a theory should lead to effective treatment
techniques as well as to a compassionate attitude. Such an attitude is
needed, especially with this population: Our tools to help them are
limited; their misery is intense and vocal; and the success or failure of
our attempts to help can have extreme outcomes. (Linehan 1993, p.18)
 THE PAUSE 27

• Manipulative versus resourceful: A manipulative person finds

ways to exert control over others without communicating
directly. The individual is resourceful but not forthright. This
behavior is understandably unsettling to those who feel deceived.
However, Linehan (1993) contends that the assumption that
individuals with BPD attempt to affect the people around them
“by indirect, insidious, or devious means” (i.e., manipulation) is
misleading: “Indeed, when they are trying to influence someone,
borderline individuals are typically direct, forceful, and, if
anything, unartful” (p.16). DBT’s interpersonal effectiveness/
assertiveness training module teaches them how to express their
wants and needs more skillfully (Linehan 2015a, 2015b)—in
other words, how to be resourceful in ways that do not negatively
impact important relationships.
• Anxious versus eager: My experience as a treatment provider
has been that mental health services clients often pathologize
themselves. As they recover, however, they sometimes continue
to express feeling difficult emotions such as anxiety (when it may,
in fact, not be the case). Hence, one might ask whether they are,
instead, eager. For example, the person may be excited about a job
interview or enthusiastic about a new relationship—two emotional
states that can feel like anxiety. It is important to consider this
possibility, rather than immediately assume the negative.
• Attention-seeking versus human and in need of connection: An
attention-seeking individual may pursue their goal in ways that
are upsetting to others. They could even require more attention
than others can give. The desire itself should not be a source
of embarrassment; humans need to receive recognition and
care. And yet those with BPD may unintentionally deplete the
resources of their support systems. Perhaps the attention-seeking
individual is in fact searching for connection. The observer’s
critical assumption is not helpful. What is beneficial is helping
the individual to identify their need, meet it (if possible), or
tolerate times when they cannot obtain the degree of attention
that they so strongly desire.
• Avoidance versus intentional diversion: People make countless
choices each day: “Should I plan my commute intentionally to
28 DBT-INFORMED ART THERAPY IN PRACTICE

avoid traffic?” Yet what if I were to take this further, and work
to prevent spending time with someone whose ways do not
enhance my life? The word avoidance itself, like the others noted
here, is not completely problematic. However, its tone implies a
fearful skirting away when an individual may be making highly
proactive decisions. Intentional diversion indicates mindful and
empowered choice. Someone with a strong sense of their own
independence, or those who are more introverted, may redirect
away from people and situations that deplete their energies. This
choice to change course can be quite healthy and powerful.
• Impulsivity versus choice: Impulsive decisions lack forethought—
for example, suddenly buying a candy bar in the grocery store
line for a screaming toddler (or for oneself). It is the spontaneity
and absence of attention to probable consequences that make
said behaviors impulsive. Likewise, an unpremeditated leap from
a vacation spot’s skyline viewing area is an impulsive decision,
unlike pondering suicide for days and creating an organized plan
to kill oneself. It is important for the person with BPD to be honest
with themselves (as well as with their treatment providers and
any other trusted individuals) about the potential for destructive
behaviors. Justifying such acts as impulsive when they are not is
disempowering and erodes one’s sense of mastery over time.
• Isolation versus choice of solitude: The term isolation describes
lack of contact with others. Individuals who have been warned
against isolating may require encouragement to remain socially
involved, supported, and able to contribute to their communities.
Isolation is both a potential trigger for depression and one of its
symptoms. However, individuals with a history of isolation can
feel shame around preferring time to themselves. They may be
people who do not require as much daily interpersonal contact.
Given the opportunity to reconsider their conceptualization of
this, they may identify as introverted. It is not maladaptive to
possess a deep sense of one’s own independence and personal
dignity without a need to conform to others’ expectations. For
such individuals, time alone is spent treasuring solitude.
• Ruminating versus problem-solving or engaging in a creative
process: A common feature of both anxiety and depression is
 THE PAUSE 29

rumination, a pattern of obsessively and repetitively dwelling

on the causes, circumstances, and/or outcomes of one’s negative
emotional experiences (Nolen-Hoeksema and Morrow 1993).
The propensity for viewing an obstacle from various angles
and considering numerous possibilities for overcoming it is
not necessarily undesirable. Creative thinkers often mull over
many approaches before tackling an issue head-on. However,
rumination lacks focus. It is important for the individual to
consider his or her manner of thinking and problem solving.
External processers are verbal thinkers (Williams and Tappan
1995); therefore, it may be most effective for them to brainstorm
aloud with similarly inclined people. Problem solving can be
a stimulating exercise for a group that enjoys open-minded
collaboration.
• Numb versus content: Individuals participating in DBT record
their emotions and other internal subjective experiences on
preprinted tracking tools called diary cards, which typically
include some general emotion terms such as joy, anger, anxiety,
and depression. Numbness is often an option, as well. But what
about more subtle affective experiences, such as contentment?
Given only a few basic choices, the individual may inappropriately
check off numbness. Individuals with BPD, who tend to think in
black-and-white/all-or-nothing terms, frequently struggle with
this. However, most diary cards do allow clients to fill in items
and add numerical ratings to better capture their subjective states.
Each person must identify for herself exactly which terminology
to use and how to measure progress. As one can never completely
understand another’s experience (e.g., a headache that stings
versus one that feels dull), these must be individually described
and defined.

DBT-informed art therapy

DBT’s focus on acceptance of emotions is present in art therapy (Abbing
et al. 2019), a mental health treatment intervention that allows clients
to identify and process their feelings through various forms of visual
media (i.e., the materials/tools used to make an art product). Examples
of media include drawing paper, pencils, paint, oil pastels, and clay.
30 DBT-INFORMED ART THERAPY IN PRACTICE

Clients use these as vehicles for expressing themselves in a symbolic

manner. They may then observe the resulting art product and reflect
on the conveyed emotions.
DBT concepts and skills may be combined with art therapy in numerous
ways (Clark 2017). While experimenting with a range of techniques,
clients cultivate mindfulness of the chosen materials (e.g., paying close
attention to tactile sensations, colors, and so on). They can create objects
with visual symbolic reminders of interpersonal effectiveness skills, as
well as written words of encouragement and assertiveness statements.
DBT-informed art therapists combine psychoeducation about emotions
with artistic expression, allowing clients to paint, draw, or sculpt their
feeling states. Techniques and media that are difficult to control (such as
watercolor) allow for practice of distress tolerance.

Empty space, positive and negative space,

and emptiness in experience and in art
Feeling empty, as we have established, is a deeply troublesome
BPD symptom. However, it is possible to broaden one’s view of this
phenomenon by exploring it in novel ways. For example, Linehan
(2015a) states that mindfulness can, over time, elicit a shift in
experiencing emptiness “as liberating and joyful rather than painful
and constricted” (p.215). An idea for consideration:
The therapist places rocks or other items such as cotton balls into
a jar until these objects reach the rim. She then asks the client: “Is the
jar full?” Next, the therapist adds much smaller items into the jar (e.g.,
gravel, tiny seeds) and asks again: “Is the jar full?” Finally, the therapist
adds water and asks one last time: “Is the jar full?”
The jar and its contents are a reminder of the empty spaces that
exist between everything. Consider the tiny grain of sand, or the spaces
between and within particles of matter. Consider the atom—a millionth
the size of a grain of sand—as well as subatomic particles, an electron,
a proton, a nucleus. The quark, a subatomic particle carrying a fraction
of an electrical charge, has a radius smaller than 43 billion-billionths of
a centimeter.
That’s 2,000 times smaller than a proton radius, which is about 60,000
times smaller than the radius of a hydrogen atom, which is about
forty times smaller than the radius of a DNA double-helix, which is
 THE PAUSE 31

about a million times smaller than a grain of sand. Quarks (along with
electrons) remain the smallest things we know, and as far as we can tell,
they could still be infinitely small. (Butterworth 2016)
While quarks are too small to be directly observed, scientists have
proven that they exist. The spaces between seem endless. The empty
areas separating objects touch each object, and therefore, bridge them.
Throughout our daily lives we experience times when we are busy and
productive, as well as moments during which we are still…when we
pause. The pause is necessary emptiness. In art, positive space refers to
the solid area on which the eye focuses. It is the mass of the depicted
object. Negative space is the remaining area, the emptiness that surrounds
the object or that rests between objects (Edwards 2012). Without
negative space, there is clutter; lines, shapes, colors, and objects would
run together chaotically. Our minds require such in-between places to
discern an image.
In terms of mental health, the human mind needs something
similar. It must occasionally pause, rest, experience solitude and quiet.
For those diagnosed with BPD, however, such still, empty spaces can
feel all-consuming. In being present alongside clients during therapy
sessions, we can pause and allow for these necessary silences. We can
model a tolerance of, and respect for, emptiness.
Music, like visual art, offers powerful analogies for emptiness.
Rests are intervals of silence. With no rests, no occasional absence of
sound, cacophony occurs. Emptiness, silence, is of great importance.
Consider these words attributed to French composer Claude Debussy:
“[M]usic is the space between the notes” (Barton 2014). A pause brings
vitality to the sounds surrounding it. A rest of just a beat or two allows
for a suspenseful build-up of energy. At the close of a piece of music,
the instruments recede momentarily, which accentuates the climax,
following as it does this brief quietness.

DBT-informed art therapy and other creative

emptiness-related interventions
Clients may engage with the following ten exercises on their own or
with a therapist.
1. Subjective emptiness artwork: The directive is simply to create
an image of what emptiness feels like. By using art materials
32 DBT-INFORMED ART THERAPY IN PRACTICE

to depict this individual and somewhat vague experience, the

person may gain better understanding. Research suggests that
the act of identifying an affective state helps to reduce its intensity
(Lieberman et al. 2007). The resulting two-dimensional image
can be a visual container for improved emotional regulation.
2. “Dear Emptiness” letter: This therapeutic journaling exercise
can be particularly effective for increasing distress tolerance. It
involves personifying the experience and expressing thoughts
and feelings directly to the character of Emptiness. The letter
facilitates externalization of difficult emotional content.
3. Mindful music experience: The individual carefully listens to a
song that she enjoys and is especially mindful of the musical
rests/pauses. Possible prompts for writing and reflection include:
“What do the rests/pauses communicate to you?”; “What are your
thoughts and emotions in response to the rests/pauses?”; and
“What specific bodily sensations do you notice while listening
to this music?”
4. Opening the Space2: This is an imaginative technique for exploring
the concepts of space, emptiness, and fullness. Provide the client
with a sheet of black paper as well as a sheet of white paper of the
same size, a glue stick, some colored pencils, and scissors. She
will first cut a circular hole (i.e., empty space) into the middle
of the black sheet of paper. The client then glues the black sheet
over the white sheet. Encourage her to imagine that the resulting
white space is her experience of emptiness. Instruct the client to
use colored pencils to draw and/or write healthy ways of feeling
full. This intervention facilitates a concrete, physical act of creating
that helps the client to accept emptiness while, at the same time,
consider strategies for changing the internal subjective state.
5. Mindfulness of darkness and light: This therapeutic approach
allows the client to be present with her experience of emptiness,
to depict it on the paper, and to reflect about her own emotional
resilience. The therapist encourages the client to gaze upon a
sheet of black construction paper and imagine the feeling of
emptiness. Next: “Draw a tiny speck of light and then use your
pencil to physically expand the drawing out from that, using
shading. Symbolize your source of strength. Where do you get
 THE PAUSE 33

that strength? Even if this seems unreachable, allow yourself

to consider that even though you may not feel it, you do have
strength that has gotten you this far.”
6. Box of hope: The therapist provides the client with a small
box to decorate in a pleasing manner. Inside this container
the client places a note of self-encouragement. When feeling
empty, she may open the box and re-read and reflect upon
her words. This is an example of the DBT distress tolerance
“IMPROVE the Moment” skill “With Self-Encouragement and
Rethinking the Situation” (Linehan 2015b, p.336). Similarly, the
person can identify someone else who needs support. She could
send an uplifting greeting card or postcard to that individual.
This is an example of the distress tolerance “With Contributing”
strategy, part of the “Wise Mind ACCEPTS” distraction skills
(Linehan 2015b, p.333).
7. M.C. Escher/tessellations: Invite the individual to consider Escher’s
artwork (Locher 2013) as well as other examples of tessellations
(Stephens and McNeill 2001). A tessellation is a repeated pattern/
arrangement of flat shapes, such as polygons, that interlock with
no overlapping or gaps between them. Mindful observation of
the positive and negative spaces (“How do they work together?”)
allows the client to engage in a delightful experience of curiosity
and reflection.
8. Georges Seurat: Invite the individual to view some of Seurat’s art
(Düchting 2017). Provide a small piece of canvas or art paper
(even just 4–6 in. in size) and some fine-tipped markers of various
colors. The client may make their own pointillistic drawing after
which the clinician can ask: “Consider the spaces between the
dots and the sense of connection that those spaces convey. In
what ways are we connected to one another?”
9. Interconnectedness artwork: This artistic therapeutic intervention
allows the client to both explore interpersonal effectiveness in
relationships and consider concepts of emptiness and space. The
therapist teaches the client to make folded cut-out shapes such as
hearts and chains of united people (i.e., paper dolls). These one-
dimensional creatures can then be used as is, or the therapist may
teach the client how to produce prints using rollers and paint.
34 DBT-INFORMED ART THERAPY IN PRACTICE

The therapist points out the positive and negative spaces and
asks thought-provoking questions such as “How do the negative
spaces add to the composition?” The client and therapist also
may explore concepts such as emptiness and space—as well as
connection and boundaries in both artwork and in relationships.
10. Values mountain3: DBT highlights the importance of integrating
one’s personal values into mental health recovery. Linehan calls
this process building a life worth living (2015a, 2015b, 2020).
The therapist directs the individual to draw a simple image
of a mountain. At its peak, the client adds a symbol repre­
senting a current high-priority value. For example, she may
create a symbol for valuing family; she will also draw a path up
the mountain on which she adds both potential obstacles and
potential tools. The therapist can help the client to consider this
in the context of finding meaning and purpose in life. They may
discuss how working toward a life worth living might help to
ameliorate and/or reconceptualize emptiness.

Conclusion
The subjective experience of emptiness can be intensely painful, so
much so that individuals with BPD often react with behaviors that
are disruptive to their quality of life and relationships. As therapists
it is important that we consider clients’ experiences and respond with
supportive and validating actions, including the language we use. Their
pain and resilience deserve our respect. It is challenging for clients to
consider other perspectives regarding emptiness; however, alternative
viewpoints may prove beneficial, especially over the course of long-term
treatment. DBT-informed art therapy and other expressive modalities
offer potential ways to reach clients and assist them in finding peace.
My hope is that readers will be inspired to explore, and perhaps expand
upon, these ideas in the spirit of strength-based mental health recovery
and wellness.

Endnotes
1 Figure 2.1 depicts Contentment (12 × 24 in. canvas, acrylic paint, and minor assemblage
materials). During the Covid-19 pandemic, I painted an initial image to submit for
this text. I was pleased with the painting, as I had used the opportunity to focus on the
 THE PAUSE 35

concept of emptiness in art making. However, I was unsure whether it would have the
visual distinction needed for publication in black and white. I began this second piece
by using the same size canvas, black and white acrylics, and print making objects around
my home. At that time, having been home for eight weeks providing teletherapy, I was
profoundly aware of my own experiences of solitude and isolation, as well as gratitude
for my well-being.
I began by wrapping the canvas in twine to create a slight rise in texture; I then
added tissue paper and layered paint. As I explored the media, I initially intended to
duplicate the first art piece, but instead, I adapted. I thought of the black and white
paint, and the years of work I had done with clients addressing their “black and white
thinking.” I reflected on the world news—hearing one set of public health guidelines
one day and another set the next. I was aware of the intensity of emotion, the desire of
many people to support one another, and simultaneously the chaotic relationships and
emotions I observed through television, the radio, and the internet. Crisis had become
a source of human divisiveness, and, also, a source of human connection.
In the first painting I had embraced, explored, and expressed the concept of
emptiness. But now, in working on this piece, my thoughts and feelings took off in many
directions. Despite awareness of the pandemic, I found myself experiencing acceptance
of the moment and contentment in this one day. The creative process brought me an
opportunity to fully experience my internal processes in a new way. I had a heightened
awareness of gratitude for my health and for those I cherish.
2 The author would like to credit Nancy Nierman-Baker for this intervention.
3 The author would like to credit Vicki Lynn Milnark for this intervention.

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Linehan, M.M. (2020) Building a Life Worth Living: A Memoir. New York, NY: Random
House.
Locher, J.L. (2013) The Magic of M.C. Escher. London: Thames and Hudson.
Mason, P.T. and Kreger, R. (2010) Stop Walking on Eggshells: Taking Your Life Back When
Someone You Care About Has Borderline Personality Disorder (2nd ed.). Oakland, CA:
New Harbinger Publications. (Original work published in 1998.)
Matthews, T., Danese, A., Wertz, J., Odgers, C.L. et al. (2016) ‘Social isolation, loneliness and
depression in young adulthood: A behavioural genetic analysis.’ Social Psychiatry and
Psychiatric Epidemiology 51, 3, 339–348.
Nolen-Hoeksema, S. and Morrow, J. (1993) ‘Effects of rumination and distraction on
naturally occurring depressed mood.’ Cognition and Emotion 7, 6, 561–570.
Stephens, P. and McNeill, J. (2001) Tessellations: The History and Making of Symmetrical
Designs. USA: Crystal Productions.
Widiger, T.A., Mangine, S., Corbitt, E.M., Ellis, C.G., and Thomas, G.V. (1995) Personality
Disorder Interview—IV: A Semistructured Interview for the Assessment of Personality
Disorders. Professional Manual. Lutz, FL: Psychological Assessment Resources.
Williams, L. and Tappan, T. (1995) ‘The utility of the Meyers-Briggs perspective in couples
counseling: A clinical framework.’ American Journal of Family Therapy 23, 4, 367–371.
 Chapter 3

Utilizing DBT, Mindfulness,

and Art Therapy in Today’s
Healthcare Environment
JANE DESOUZA

Introduction
In their efforts to lower the considerable costs of treatment, regulating
and reimbursement bodies have increasingly scrutinized mental health
services. As a result, interventions with proven beneficial outcomes,
that is, evidence-based practices (EBPs), are now the norm. EBPs
offer significantly more dependable methods of facilitating improved
functioning and long-term recovery than do their non-empirically
founded counterparts, which “typically rely on tradition, convenience,
clinicians’ preferences, political correctness, marketing, and clinical
wisdom—none of which is consistently related to improving outcomes”
(Drake et al. 2001, p.181). Hence, to receive financial compensation,
providers must demonstrate that the treatments they offer to their
clients result in necessary skill acquisition as well as measurable progress
toward greater self-sufficiency. This is sometimes called outcome-based
reimbursement (Kilbourne et al. 2018, p.33), or value-based payment
(p.34). EBPs, many of which involve comprehensive approaches for
achieving and maintaining psychiatric stability and well-being, are
today among the interventions of choice in managed care settings.
It is challenging to ensure that behavioral health services engage
recipients while also consistently producing desirable outcomes. What
treatments are most effective for moving clients toward recovery? Over
the past 40 years I, the author, have worked primarily in one psychiatric
hospital setting where I provided clinical art therapy—an intervention
that (at the time of this writing) does not enjoy a strong research base in

37
38 DBT-INFORMED ART THERAPY IN PRACTICE

spite of its observed strengths. This chapter describes my experience as

an art therapist who possesses competence with some EBPs, dialectical
behavior therapy (DBT) in particular. I present art therapy as not
merely a supportive or supplemental service, but as a useful method for
delivering DBT’s psychoeducational skills training component (itself a
proven tool for promoting client self-efficacy and wellness).

What is EBP?
Sackett et al. (1996) define EBP as an “integration of clinical expertise,
patient values, and the best research evidence into the decision making
process for patient care” (p.71). Rather than relying solely on individual
instinct or judgment, practitioners balance solid empirical data with a
knowledge of clients’ unique characteristics (e.g., personal preferences,
values, environment, culture, and so on) for the purpose of achieving
the best possible outcomes. Treatment responses include measurable
results based on the goals and expectations of therapy while taking into
consideration a client’s level of engagement (Sackett et al. 1996).

DBT as EBP
Research on DBT goes back nearly three decades in the form of multiple
randomized, controlled studies (Linehan et al. 1991; Stoffers et al. 2012).
This adapted, mindfulness-based cognitive behavior therapy (CBT) is
a gold-standard treatment for borderline personality disorder (BPD)
(Chapman 2006). BPD is a complex psychiatric condition characterized
by “a pervasive pattern of instability of interpersonal relationships,
self-image and affects, and marked impulsivity beginning by early
adulthood and present in a variety of contexts” (DSM-5; American
Psychiatric Association 2013, p.663). Its diagnostic criteria include
enduring feelings of emptiness; recurrent suicidal thoughts, attempts,
gestures, and/or threats; nonsuicidal self-injurious behaviors (NSSI);
and extreme fears of abandonment (actual or imagined) (DSM-5;
American Psychiatric Association 2013).
Individuals who suffer from BPD require a high level of care for
such intense symptoms, and therefore tend to consume substantial
mental health resources in their communities. Problems/limitations
include the length of time necessary for adequate treatment, significant
expense, and a lack of availability of specialized programs (Parker,
 DBT, Mindfulness, and Art Therapy in Today’s Healthcare 39

Boldero, and Bell 2006). The instability and unpredictability of this

disorder make treatment difficult to manage (Paris 2008), and clients
often need interventions from a variety of modalities (Paris 1994).
DBT builds clients’ emotion regulation capacities so as to reduce
suicidal ideation and self-injurious behaviors (Paris 2008), which, in
turn, decreases emergency room visits and the need for costly inpatient
hospital admissions (Linehan et al. 1991). In a journal article reviewing
five separate studies, Panos et al. (2013) concluded that DBT is effective
in improving patient treatment compliance, as well as in stabilizing
and managing self-destructive behaviors. Although most early research
focused exclusively on BPD, the addressed symptoms exist within a
variety of clinical populations where children and adults struggle
with significant affect dysregulation and negative thought patterns.
Indeed, DBT has shown promise in treating individuals with comorbid
substance abuse disorders, eating disorders, depression, and anxiety
disorders (Chapman 2006).
DBT’s comprehensive treatment approach emphasizes the ac­
quisition of psychiatric and emotional/behavioral stability through
mindfulness, or “paying attention in a particular way: on purpose, in
the present moment, and nonjudgmentally” (Kabat-Zinn 1994, p.4).
Mindfulness originated from ancient Buddhist practices, and over the
past two decades has shown efficacy in alleviating a variety of physical
and mental conditions (Brown, Cresswell, and Ryan 2015). DBT teaches
strategies to replace impulsive, mood-dependent behaviors with mindful
awareness, leading to options for alternative, more adaptive responses.
Skills trainers utilize a detailed instruction manual (Linehan 2015a,
2015b). The curriculum is organized into four psychoeducational
modules: mindfulness, interpersonal effectiveness, emotion regulation,
and distress tolerance. However, the skills comprise only one component
of a true DBT approach to recovery. Comprehensive DBT, the form
shown most effective in numerous randomized clinical research
trials, also includes weekly individual therapy sessions and outside-of-
treatment skills coaching calls. Perhaps the most crucial component is
support for DBT clinicians themselves: the peer consultation team, where
practitioners discuss progress, brainstorm interventions, obtain help with
maintaining treatment fidelity, and address their emotional reactions to
clients (thus preventing therapist burn-out) (Linehan 1993).
Without all four components—individual psychotherapy, skills
training, phone coaching, and peer consultation—DBT would likely
40 DBT-INFORMED ART THERAPY IN PRACTICE

be less effective. Clients may find it easier to avoid full engagement, and
they often struggle to grasp the benefits given their habitual maladaptive
ways of viewing and interacting with the world around them. Further,
clinicians are less able to sustain an appropriate therapeutic stance if
they lack necessary professional structure and support. The intensity
and drama of DBT clients’ lives can be exhausting to everyone around
them (including the clients themselves).

DBT skills training as an EBT

There is, however, some evidence that DBT skills training can be a
valuable sole/stand-alone or primary intervention (Linehan 2015a;
Linehan et al. 2015). The people I work with often make comments
such as Why didn’t I learn these skills before? and They should teach
these skills in school! Age does not seem to be a factor. Older clients
are often highly motivated to find a way out of lifelong distress, and
young adults respond well to skills training because it is empowering.
The psychoeducational materials do not dictate specific responses, but
rather emphasize personal choice and effectiveness.
My program has adapted DBT for clients with developmental
disorders who must have a slower, more concrete learning process. In
other departments, modifications exist to meet the needs of the various
milieus (e.g., inpatient units providing introductory skills training as an
engagement tool, DBT-informed intensive day program curriculums,
and follow-up groups for reinforcing and encouraging clients’ long-term
use of skills). Most relevant for creative arts therapists, some clinicians
have integrated nonverbal expressive modalities into skills training as
a means of increasing participants’ understanding and application of
DBT concepts/strategies into their daily lives (DeSouza et al. 2015).

DBT core concepts

DBT is grounded in dialectics, mindfulness, validation, and acceptance
(Linehan 1993).
• Dialectics refers to the countless opposing forces that are a part
of life and features the notion that two highly different ideas or
positions can be true at the same time. Individuals with distorted
cognitive processes and ineffective behavioral styles are in
constant conflict with themselves and their environments. On
one hand, it is often clients’ polarized (all-or-nothing, black-
 DBT, Mindfulness, and Art Therapy in Today’s Healthcare 41

or-white, right-or-wrong) thinking that creates such chaos. On

the other, their “extreme life problems and unstable emotions
result in cognitive rigidity at the exact times when clear, balanced
thinking is most needed” (Clark 2017, p.32). This is an example
of a dialectical dilemma.
A life worth living contains positive and negative aspects, joy and pain.
It is important for clients to grasp that avoiding the negative and
undesirable aspects also restricts the positive and rewarding elements.
The recovery process will not prevent or remove hurtful events, change
the people around us, or make up for a traumatic past. However, it does
provide tools for better managing each new moment as it arises, as well
as tolerating the imperfections of that moment, of ourselves, and others.
Dialectics allows for a balance between acceptance and change,
both of which are necessary for establishing fulfilling lives. A dialectical
stance does not seek compromise; rather, it looks for the truth in all
points of view. It asks: How do these things go together?; as well as: What
is being left out of my understanding of what is happening? Marsha
Linehan (2015c) explains that dialectical thinking would perceive the
combination of black and white not as gray (i.e., compromise), but
as plaid, an interweaving of the two that eliminates neither (Linehan
2015c). Further, it is interested in any transactions occurring between
them—because this is where change takes place.
• Mindfulness provides the foundation where other DBT skills are
built. Mindfulness is a deliberate and nonjudgmental awareness
of what takes place in the present. Both internal and external
stimuli tend to distract us from full awareness of now. DBT is
based on the idea that our feelings, thoughts, behaviors (as well as
the environmental cues that trigger them) often go unrecognized
(Linehan 1993), and this ignorance can precipitate crises. For
example, when a person is not paying attention to their escalating
emotions, impulsive behaviors such as self-harm may result.
The ability to objectively observe oneself in the world is challenging
because it requires the conscious interruption of countless habitual
impulsive reactions. I liken this to attempting to turn off an automatic
pilot system without knowing the location of the control button.
My clients have reported that once they truly grasped the concept
of mindfulness, however, the other skills became much easier to
understand and operationalize.
42 DBT-INFORMED ART THERAPY IN PRACTICE

• Validation is conveying to a person that their “responses make

sense and are understandable within their current life context or
situation” (Linehan 2015a, p.88). One assumes that all behaviors
have a reason/purpose and are not wrong, per se (although
they could have harmful consequences, or simply be ineffective
in achieving a goal). Validation of emotional responses in the
context of a given situation requires the therapist to identify
when the client’s maladaptive behavioral choices are based on
appropriate emotional responses.
DBT’s emphasis on validation addresses the fact that many individuals
experience standard CBT, which is highly change-focused, as
invalidating. Individuals with BPD frequently perceive their treatment
providers’ feedback and/or recommendations as harshly negative
and judgmental, which can lead to resistance (and, sometimes,
even withdrawal from therapy). I highlight to my clients that, while
maladaptive behaviors were once helpful for survival during difficult
times, they are no longer appropriate and may even be quite destructive.
Another important dialectical dilemma: I am doing the best that I can,
AND I need to do better, do more, or do something different.
• Acceptance is an essential DBT skill. Radical (i.e., total) acceptance
means letting go of all resistance to reality (Linehan 2015a). It
does not involve agreeing with, or liking, or approving of the way
things are; rather, it simply means to stop fighting against what
cannot be changed. Acceptance is the alternative to denying reality,
wishing that it were different, or fixating on how it should be. Pain
is inevitable, but misery is not. Suffering results from how we
respond to pain. The more we hold onto the should, the more likely
we are to experience negative emotions over a prolonged period,
and the more difficult it becomes to determine how to process and
move through life’s unavoidable hurts and discomforts.

Where does art therapy fit into the EBP model?

As previously mentioned, art therapy is not currently an EBP. Hence its
reimbursement is restricted by many managed care companies. While I
have seen some art therapists thrive within certain treatment settings,
regulatory and financial bodies typically relegate us to very narrowly
defined roles across the spectrum of behavioral health services. Because
 DBT, Mindfulness, and Art Therapy in Today’s Healthcare 43

outpatient community mental health agencies are dependent on third-

party payment, the types of clinicians these providers are willing to hire
are contingent on financial compensation.
A possible solution to this predicament would be to collect empirical
data supporting art therapy. However, in the introduction to her 2006
book Art Therapy, Research and Evidence-Based Practice, Andrea Gilroy
notes a problematic “tension in the process of art therapy becoming
evidence based…(that is) between the discipline and the systems in
which it operates” (p.2). Some art therapists believe that rigorous
research demands conformity and rigidly followed interventions
(Dean 2010).
Fast-forwarding to 2015, Bauer et al. state that “Despite its
widespread coverage in general literature, EBP is barely addressed by
the art therapy field. It is only recently that art therapists have begun to
address the controversies, and much of the literature originates from
the UK and Australia” (p.17). With regard to any available documented
evidence base for art therapy’s efficacy, the authors comment: “The few
articles that do exist lack cohesion, and the research methodologies did
not appear to build upon previous work” (p.43)—the latter of which,
replicability, is crucial for determining an EBP (Sackett et al. 1996).

My experience
During the early 1990s, at which time I had already practiced art
therapy for ten years in New York State, a new psychiatrist brought DBT
to the hospital where I worked and trained the entire inpatient unit
staff. I integrated what I learned into my groups and immediately saw
increased client engagement. Further, the combination of art therapy
and DBT seemed natural to me and suited my therapeutic style.
While change is often anxiety provoking, I, unlike some of my
colleagues, have experienced the evolution of New York’s services
for the mentally ill as positive overall. The focus on EBPs strives to
constantly improve clients’ potential for recovery while juggling
the need to meet those third-party reimbursement requirements (a
challenge I sometimes refer to as contending with a multi-headed
monster). I also became familiar with other EBPs by participating in
substance abuse trainings, as well through my work with the New York
State Office of Mental Health’s initiative for Personalized Recovery
Oriented Services (PROS).
44 DBT-INFORMED ART THERAPY IN PRACTICE

The incorporation of empirically founded approaches has felt neither

restrictive nor devaluing of my art therapist identity; rather, I believe
that it has enhanced my expertise in providing high-quality treatment.
In addition, fluency in the language of EBPs augments my ability to
communicate with clinicians from other disciplines, document in a
more concise manner, work collaboratively with clients, and effectively
advocate for the creative arts therapies within such an increasingly
managed care setting.
Over the course of many years I have seen our job titles evolve in
prestige from activity leaders to activity therapists, then to rehabilitation
therapists—to, now, creative arts therapists. In the hospital’s day
treatment program creative arts therapists are primary clinicians,
along with social workers and mental health counselors. I became
the director of the outpatient program in 2011 and, in the clinic,
accommodations were made to utilize me for DBT services despite
reimbursement restrictions. Art therapists have even been hired for
team leader positions! These accomplishments resulted from clear,
consistent demonstrations of art therapy’s effectiveness and versatility.
To this end, I applied the following strategies:
1. Obtained formal training in EBPs.
2. Carefully integrated art therapy into the use of those EBPs.
3. Displayed professional value based on client engagement
(as measured by their attendance/participation as well as via
standardized satisfaction surveys).
4. Developed relationships with other clinicians and agencies by
communicating in the common language of EBP, i.e., via written
documentation as well as verbal communication (e.g., rounds
meetings, in-services, case presentations, and so on).
To prevent or reduce professional resistance created by fears of conformity,
art therapists must believe that good research offers an effective method
for demonstrating their discipline’s capacity to promote positive outcomes
while not rigidly dictating its practice. I propose that art therapy is no
more of an EBP than are social work, mental health counseling, nursing,
and psychiatry. However, all techniques should be directly informed by
existing empirical evidence. EBP ensures that clinicians “are practicing
to the best of their abilities through constantly reviewing, updating
 DBT, Mindfulness, and Art Therapy in Today’s Healthcare 45

and adjusting…according to the latest research findings” (Sackett et al.

1996, p.71). EBP creates the groundwork upon which an art therapist’s
interventions can best meet clients’ needs, values, and treatment plans.
While nothing will replace the necessity for sound research, I feel that, in
the meantime, carefully combining an EBP with one’s art therapy skill set
is an avenue for gaining recognition as a value-based treatment.

Art therapy as a component of the DBT

skills training curriculum
This section describes how I have integrated art therapy into my
teaching of the four DBT skills modules.

Mindfulness skills
The mindfulness module starts with introducing states of mind that we
all experience at different times and to varying degrees. Reasonable mind
involves the cool, logical process of doing math, following directions,
and using only facts or an end-goal to guide decision making. Values and
feelings are irrelevant. In the extreme, this would be a robotic approach
that never allows for flexibility based on interests, enjoyment, or
spontaneous opportunities. It could also involve being so engrossed in
one’s objective that one fails to consider the wants and needs of others.
Emotion mind, reasonable mind’s dialectical opposite, is a state in which
thought processes and actions are overly influenced by extreme emotions.
It includes a loss of control to the point that intense, dysregulated
affects “crowd out reason and effectiveness” (Linehan 2015a, p.168) as
well as a reduced appreciation for possible undesirable consequences.
Emotion mind results in the impulsive/reactive, mood-dependent, and
maladaptive actions typical of BPD (American Psychiatric Association
2013; Linehan 1993). One should stress, however, that feelings are
essential; they motivate us to do important, often difficult things. Further,
our creativity, passions, and empathy are inextricably linked with strong
emotions.
Wise mind is a dynamic integration, a synthesis, of reasonable
mind and emotion mind. This state is flexible, intuitive, and allows us
to attend to the needs of the current moment. Wise mind is the ideal
place from which to make important choices and decisions because
it fosters “consider[ation of ] both emotional and rational/logical
options for responding, as well as novel…solutions” (Clark 2017, p.86).
46 DBT-INFORMED ART THERAPY IN PRACTICE

Participating effectively, or using skillful means, is mindfulness of the

present moment while doing just what is needed in that moment.
Skillful means refers to “any effective method that aids a person in
experiencing reality as it is, or, in DBT terms, to enter fully into wise
mind” (Linehan 2015a, p.223).
My introduction to one art therapy directive compares the recovery
process to a road trip. Mindfulness requires that we slow down so
we can remember our goals while we identify available choices. If we
always use cruise control we risk blowing past stop signs, running into
dangerous intersections, and colliding with other drivers. I further
explain that, when we neglect to keep our destination at the forefront
of attention, we are much more likely to get lost. Because the roads of
life are often winding and indirect, decision making is difficult without
a map. Figure 3.1 shows a client’s response to imagining her recovery
journey on a road map. Notice how she identified specific “obstacles”
and “positive pit stops.” The client shared how she was beginning to
visualize her change process (as seen in the review mirror) while also
staying aware of and looking out for potential problems. This is the
essence of using skillful means.

Figure 3.1 Recovery road map with

“positive pit stops” and “obstacles”

Art therapy promotes moving away from intellectualization and toward a

more holistic view of one’s experiences. Commencing each skills training
 DBT, Mindfulness, and Art Therapy in Today’s Healthcare 47

session with a mindfulness exercise allows clinicians to customize their

directives around that particular lesson (as well as the needs of both
the group and its individual members). I always provide a structured
activity, for example a simple game such as throwing around a nerf ball or
asking each person to name an object they see in the classroom without
repeating anything that was previously identified by others. Sometimes
I have participants color in a simple preprinted design, for example a
mandala, a shield, or—in the case of Figure 3.2—a bird.
The instruction is always to observe and rate one’s anxiety level (on a
scale of 1–10, 10 being the worst anxiety ever felt) both before and after
the mindfulness activity. I encourage clients to practice suspending any
judgments and/or resistance with the assurance that it is just an exercise:
“Be in the moment for the next ten minutes and also try to notice your
inner experiences.” After the activity ends and they have rated their
anxiety levels, group members share observations. Regarding the image
in Figure 3.2, the participant stated that he was able to completely focus
on coloring. In fact, he found the process so relaxing that his anxiety
rating decreased by several points.

Figure 3.2 Structured mindfulness exercise (coloring)

Clients are usually quite apprehensive at first; in many cases, their

anxiety ratings actually go up! However, after a few additional sessions,
they tend to relax. At that point participants can describe positive
changes (such as feeling calmer or better able to let go of any distress
that they had brought with them into the session).
48 DBT-INFORMED ART THERAPY IN PRACTICE

Interpersonal effectiveness skills

These skills involve asking for what one wants, as well as declining
undesired requests. The client ranks the relative priority of each: the
objective (accomplishing her goal), the relationship (how she would
like the other person to feel about her after the interaction), and self-
respect (how she wants to feel about herself afterward). As lessons
progress through this module, the art therapy directives become less
structured and sometimes last for an entire session. These directives are
designed to assist participants with conceptualizing how their internal
precepts impact social interactions and relationships (and also lay the
foundation for role playing activities through which clients practice
assertiveness strategies in simulated real-life interactions). Examples
of some directives include:
• Create images exploring what it feels like to be angry and still
impulsive versus angry but able to use skills.
• Make a symbolic self-portrait of what one would feel like after
being interpersonally effective, even if the other person responds
negatively.
• Collaborative group activity: Without drawing any human
figures, all group members illustrate one of their important
relationships. Participants then pass the papers around and add
to each original image. The artists will observe/describe their
experience seeing others work on the drawing they started or
feel some attachment to.
• Collaborative group activity: Participants plan a supportive
community as a mural (once, when I had an art therapy student
to help, we actually built a village with clay).

Emotion regulation skills

Although all modules require substantial effort to master (and many
report that mindfulness is the most difficult), I consistently observe
how clients struggle to grasp, as well as understand how to appropriately
use, emotion regulation skills. The idea that they could experience
any intense emotions in a controlled, tolerable manner seems too
overwhelming—even terrifying—at first. This module commences with
a discussion about emotions as a communication system and how each
emotion’s message helps to organize a valuable behavioral response. It is
 DBT, Mindfulness, and Art Therapy in Today’s Healthcare 49

important to explain how such messages can be distorted because this

validates clients’ current functioning. The emotion regulation module
includes a model for how emotions work. It is crucial that clients learn
how to examine the connections between their thoughts and action
urges, as well as ultimately identify the resulting emotion. This skill
leads to the identification of methods for changing and/or replacing
maladaptive behaviors (i.e., by learning how to conduct a behavioral
chain analysis) (Linehan 2015b).
Many of the creative directives I employ involve participants exploring
their personal experience of emotions and connecting each, as well as any
related thoughts, to a particular trigger/prompting event. Guided imagery
exercises that evoke an emotional response can help clients identify
their internal sensory experience of that feeling, which they are later
asked to illustrate. Sometimes this leads to an ability to catch cognitive
distortions in the moment and better appreciate how all-or-nothing
thinking perpetuates emotional dysregulation. Figure 3.3 shows one
person’s experience of learning to manage anger. The directive was: Pick
an emotion that you are beginning to learn to regulate, and then illustrate
how that has changed things for you. This client was constantly wracked
with intense anger that resulted in suicidal urges and frequent explosive
outbursts. After having learned and practiced emotion regulation skills
for a while, she felt less and less overwhelmed. Further, she was no longer
as self-destructive and could express frustration without exploding. At
the time of this image, the client was not yet satisfied with her progress;
however, she acknowledged that stomping her feet or yelling was
preferable to trying to kill herself or raging and scaring everyone away.

Figure 3.3 Using skills to manage anger more effectively

Distress tolerance skills

This final skills module focuses on learning to endure painful
events and emotions without making things worse by reacting with
50 DBT-INFORMED ART THERAPY IN PRACTICE

impulsive, destructive actions. Its crisis survival strategies include

various distraction and self-soothing behaviors. Later lessons involve
the importance of reality acceptance and willingness in successfully
navigating distressing situations.
We do a variety of fun activities for this module, including playing
Jenga, sharing music with one another, and decorating distress tolerance
kit toolboxes. This is also where the more long-term projects take place.
DBT skills training sessions have significant time constraints, but we
talk about what can be done and how to get involved. I encourage
clients to take other groups that support skills practice. Some of the
group choices include a (separate) art therapy group, DBT-informed
movement therapy, understanding anxiety and depression, exercise,
sports, nutrition, and building self-esteem. There are various
mindfulness-based activity groups, as well (e.g., gardening, arts and
crafts, journaling, musical jam session).
At this phase therapists review their clients’ treatment goals with
them, and staff members reinforce the value of using the program to
practice positive experiences. Related art therapy directives include:
Imagine what it will be like to achieve one’s long-term goals and Visualize
building/rebuilding one’s motivating hopes and dreams. This is also a time
for normalizing clients’ emotions and encouraging them to believe
they can take control of their choices, behaviors, and lives. In addition,
sharing relevant quotes, poems, and song lyrics reminds everyone that
life struggles are universal and bad things do happen to good people. At
the end of the four modules clients use art to depict how far they have
traveled on their recovery paths.

DBT-informed art therapy

Why art?
DBT encourages wellness, self-management, exploration of one’s
own values, and a “big picture” view of life (while simultaneously
paying attention to the details—yet another dialectic). Generalization
of DBT skills, that is, the ability to use them independently outside of
the classroom, is a key to recovery. Clients often ask me, “What do
I do when _____?” I am a sports fan, and so I utilize the analogy of
preparing for a sporting event to illustrate this: Although we cannot
foresee the best/perfect action to take in any given situation, as the
game develops we need to feel prepared to handle unpredictable events
 DBT, Mindfulness, and Art Therapy in Today’s Healthcare 51

with confidence, flexibility, and spontaneity. Like athletes, clients must

practice every day to be ready for whatever challenges they encounter.
The art therapy studio provides bountiful opportunities to use DBT
skills in the moment. Involvement with lengthier projects allows clients
to plan, make aesthetic choices, and alter or revise their artwork—all of
which require skillful behavior (Huckvale and Learmonth 2009). Many
individuals with BPD do not possess an ability to soothe themselves
and are therefore vulnerable to self-mutilation and other impulsive
acts (Linehan 1993). Art making can aid in self-regulation, particularly
through repetitive motions, exposure to pleasing colors, and mindful
attention. Art therapy might also help clients to develop an internal
sense of self-soothing that can be translated to situations outside of
therapy (Huckvale and Learmonth 2009; Lamont, Brunero, and Sutton
2009; van Lith 2008).
I frequently emphasize preparation through practicing—that is,
“repetition, repetition, repetition.” Recovery is not linear; rather, it is
a process of experimentation followed by numerous failures as well
as successes. I argue that this journey is more akin to rock climbing
than an escalator ride: sometimes the best way to move up involves
first finding a firm hold that is perhaps slightly lower and to the side.
DBT-informed art therapy allows for an alternative perspective that
personalizes recovery while accepting the dialectical phenomena of
acceptance/change, trial/error, and so on.
Although the DBT skills training modules include homework
assignments, my experience has been that only already highly engaged
clients—and/or those more advanced in the curriculum—are willing
to practice outside of treatment. Including creative activities as part
of lessons provides another means for skills generalization because
they promote engaged participation in a nonthreatening arena, with
extra opportunities to learn self-monitoring techniques, practice
consequential thinking, etc.

Creative engagement
The Substance Abuse and Mental Health Services Administration
(SAMHSA) identifies ten principles as essential components of mental
health recovery: self-direction, individualized and person centered,
empowerment, holistic, nonlinear, strengths-based, peer support,
respect, responsibility, and hope (SAMHSA 2012). For many individuals
52 DBT-INFORMED ART THERAPY IN PRACTICE

entering a recovery-oriented setting, these concepts are foreign. Clients

with serious mental illness (SMI) often have long histories within
medical model-based behavioral health systems (where treatment was
done to them rather than in collaboration with them). Hence, they may
have grown dependent on providers to make decisions because they
were considered noncompliant if they failed to follow recommendations
or respond in a positive manner. Some clients might even present as
disheartened, passive, or rebellious, making it difficult to enter a new
treatment setting with expectations of anything being different.
The first task in engaging clients may be to disrupt their assumptions
concerning mental health care and educate them about the recovery
process, thus reigniting their imagination and ability to consider new
dreams and goals. Marsha Linehan (1993) refers to the therapist’s role
in this disruption as irreverence. DBT-informed art therapy puts the
client in an active and empowered position that promotes more effective
learning than does just listening to yet another person tell her what to do:
Over the years I have always thought the important contribution I
brought…was being creative, spontaneous, thought-provoking, and
consistent. I have been practicing being the “irreverent therapist,”
openly telling clients [when] it is time to turn over the apple cart.
Surprising clients, creating the experience that moves them out of their
comfort zone, has been challenging and invigorating. Marsha Linehan
encourages therapists to use metaphors and stories to help clients grasp
the concepts of the skills. This has required creativity and risk-taking
but has become a rewarding aspect of the treatment because clients
respond and more easily connect to the skills. My expressive therapy
groups utilize many varied modalities to stimulate clients’ ability to
communicate more effectively and imaging a different way to respond
to their illness, trauma, and painful emotional experiences. Mindfulness
has become the core of the groups, requiring clients to practice being
“conscious” in their own lives. (DeSouza, in Clark 2017, p.136)
Since clients with severe emotion dysregulation often exhibit extreme
thoughts and behaviors, using creative expression to bring these out
into the open can be surprising enough to get them to pay attention.
Emphasizing the drama in life can make them laugh and ease self-
judgment. Art therapy is particularly effective in satisfying clients’ need
for attention by providing a safe space to look at their inner beliefs and
myths as well as to create bigger-than-life projects. Art therapy affords
 DBT, Mindfulness, and Art Therapy in Today’s Healthcare 53

the ability to explore at one’s own pace. It allows for self-discovery,

and bypasses resistance or the embarrassment of being told by others
that change is needed. In addition, the group provides opportunities
to normalize participants’ thoughts and fears by connecting with peers
who have had similar experiences.
It may feel like a dangerous leap of faith to attempt something new,
to be vulnerable and open to the unknown in the hope that it will result
in positive change. Integrating creativity into skills training gives clients
the space to explore what it could be like to take a more self-directed
approach to their recovery. Because hope is a difficult concept for many
seriously mentally ill individuals, this can be the most challenging and
labor-intensive phase. Any small disappointment or perceived threat
might cause a client to regress to old habits. The experience of learning
skills and exploring the relationship between thinking, physical
sensations, emotions, and behaviors is new and can be confusing. Art
interventions facilitate this process by helping clients to visualize how
skills could practically apply to their own lives.
In dialectical thinking and mindfulness, there is a conscious intent
to build awareness of one’s behavioral choices. Systems (whether
families, work organizations, or social circles) are resistant to change.
A balancing of acceptance and change is important not only during
therapeutic interactions, but outside of the clinical environment where
life may still feel invalidating. Clients also come to appreciate that each
movement can have ripple effects that are not always positive.
Within the individual therapy sessions DBT clinicians employ
validation strategies as their clients struggle to learn self-acceptance
and skillfulness. However, specifically to group art therapy, validation
becomes broader as cohesion develops and clients’ witnessing of
each other’s artwork promotes the capacity to challenge invalidating
experiences among themselves. For example, a client can practice self-
validation by processing with the group when feedback is difficult to
hear. She may come to realize that she has the power to decide how
much to share at any given time, which in itself cultivates a sense of
self-efficacy and mastery.
Art therapy experientials can help participants appreciate that seeing
the world from different angles results in multiple viewpoints—and
none of these perspectives are incorrect or invalidating of the others.
Such realizations may open discussions about the pros and cons of their
rigid, nondialectical thinking, as well as how to challenge these patterns
if desired.
54 DBT-INFORMED ART THERAPY IN PRACTICE

Conclusion
This chapter introduced readers to EBPs such as DBT and described
their significant role in today’s managed care mental health treatment
environment. Although art therapy is not at present an EBP, I have
found over the course of many years that its thoughtful integration with
DBT skills training frequently results in more active client participation.
Within my treatment setting, better engagement is demonstrated by
higher attendance and retention rates; further, clients report satisfaction
with their progress in both verbal remarks to staff and standardized
surveys.
Additionally, other clinicians convey recognition of the effectiveness
of the integrated approach through their increased referrals to skills
training as well as via requests for consultation and/or supervision
with DBT-informed art therapists. While it is clearly essential that
we pursue solid research evidence for the efficacy of art therapy in
supporting—and, perhaps, even enhancing—DBT’s skills training
protocol, I suggest that, in the meantime, a thoughtful combination
of the two interventions is an avenue for art therapy’s recognition as a
value-based treatment.

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Association 25, 1, 24–31.
 Chapter 4

My Journey as an Art Therapist

Focusing on DBT and Art Making
MEGAN SHIELL

Introduction
This chapter explores the notion that certain art therapy interventions,
when combined with the skills training component of dialectical behavior
therapy (DBT), can assist clients who experience emotional regulation
problems. I, the author, describe how I was first exposed to DBT while
studying to become an art psychotherapist. During a student internship
placement, I developed an introductory DBT-informed program that
included specialized art making activities. My curiosity was awoken as
I witnessed how many individuals with borderline personality disorder
(BPD) became more engaged with the skills training process; further,
they appeared to better understand/retain DBT concepts and techniques
after participating in the creative exercises.
As I continued my career in the northeast corner of New South
Wales, Australia, I became aware of the dearth of local empirically
founded treatment services for BPD (and for mental health consumers,
in general). I resolved to become a DBT trainer and educate as many
therapists as possible about this model. The frustration I felt as a
helping professional with scarce treatment resources and inconsistent
care led to my development of the online ME (Managing Emotions)
self-study DBT program. ME, which includes several art projects, is a
popular aspect of the services I offer and consists of two versions: one
designed for clinicians’ continuing education, the other for clients’ skills
training needs.
The chapter describes how I discovered my interest in DBT-informed
art therapy and ultimately developed the virtual ME program. I explain
how I incorporate therapeutic art interventions into both individual

56
 My Journey as an Art Therapist Focusing on DBT and Art Making 57

DBT sessions and skills training. Further, I present two brief case
examples to provide readers with an understanding of how creative
expression through visual art activities may assist clients with their
learning, retention, and implementation of DBT skills. The chapter
concludes with suggestions for further inquiry.

Background
My journey began with a visit to Perth, Western Australia, in 2003.
Over a weekend with a wise friend, I explored career options as a person
approaching 50 years of age. We discussed the fact that I had long
gained satisfaction from engaging in my own creative processes. I also
very much enjoyed listening to other people’s stories. This conversation
ultimately led me to the local library, where I strolled through aisles of
art books, then sat at a computer station and did a combined internet
search using the key words art and therapy. Among the results was
information about the University of Western Sydney’s graduate art
therapy program. This was an exciting discovery. As I investigated the
prerequisites for matriculation, however, self-doubt crept in.
How realistic was this dream? I had only completed year ten in
secondary school, and most of my employment experience was in the
corporate world! However, I had, over the course of more than 30 years,
consistently made art. The resulting creative pieces represented various
aspects of my life: working, having a family, and all the related emotional
and psychological experiences. Hence, I already had a portfolio of
around 30 pieces (an admission requirement of the art therapy program).
Additionally, while rearing my children I had held down several volunteer
positions; each involved facilitating workshops in which I taught
individuals of all ages how to make art for their personal self-expression.
And, so, I decided to submit an enrollment application.
After completing the interview process, I was accepted to pursue
the University of Western Sydney’s graduate diploma in expressive
therapies. I eventually obtained admission into its masters of art therapy
degree program, which included two student internship placements.
The first was in a residential service for differently abled individuals.
During this experience I learned to deeply appreciate the value of art
therapy, particularly in my work with one client who contended with a
serious brain injury. The second internship site was a private psychiatric
hospital in Sydney. This facility contained an outpatient comprehensive
58 DBT-INFORMED ART THERAPY IN PRACTICE

DBT program (i.e., adherent to the evidence-based model of DBT

designed and researched by Marsha Linehan, PhD). I was involved in
all facets of the program.

The efficacy of DBT for BPD and other

disorders of emotion regulation
The most effective treatments for BPD are highly structured (Paris
2008), and DBT has proven to be the gold standard. Sneed et al. (2012)
write that,
[b]ecause DBT has been shown to be efficacious by three independent
groups […] it is the only treatment meeting criteria for a well-
established treatment for BPD… DBT has the most consistent support
in reducing suicidality and parasuicidality compared to other leading
BPD treatments. (p.9)
Numerous randomized controlled trials (RCTs) have established that
DBT, compared with treatment-as-usual, is more effective not only
for BPD but also for some eating disorders (Courbasson, Nishikawa,
and Dixon 2012; Safer and Jo 2010), substance abuse (Dimeff and
Linehan 2008), depression (Harley et al. 2008), bipolar disorder (Van
Dijk, Jeffrey, and Katz 2013), attention deficit hyperactivity disorder
(Hirvikoski et al. 2011), and posttraumatic stress disorder (Bohus et al.
2013). Any of the conditions mentioned above share diagnostic criteria
with BPD, such as impulsivity, suicidal behavior, and interpersonal
difficulties. Perhaps this explains how DBT’s efficacy spans such a wide
range of conditions (May, Richardi, and Barth 2016).

DBT treatment structure

Comprehensive DBT includes four treatment arms (Linehan 1993,
2015a): individual therapy sessions, DBT skills training (usually
delivered in a group format), in vivo phone coaching, and peer
consultation team meetings for providers. The DBT skills training
curriculum consists of four modules (Linehan 2015a, 2015b).

Mindfulness
This core skill set of DBT involves an intentional, nonjudgmental
awareness of the present moment, which includes observing one’s own
reactions to events and situations.
 My Journey as an Art Therapist Focusing on DBT and Art Making 59

Distress tolerance
These skills assist clients in surviving emotional crises without
making them even worse by engaging in impulsive, mood-driven acts.
Distress tolerance skills are designed to effectively manage urges to use
maladaptive behaviors.

Emotion regulation
These skills enable clients to better understand and modulate their
emotional responses. They also assist in teaching how to improve
resilience to stressors.

Interpersonal effectiveness
These skills help clients increase the likelihood that their own wants and
needs will be met by making assertive requests. They also instruct how
to say “no” when necessary.

Art therapy and DBT

During my internship in the private psychiatric hospital I noticed how
many clients engaged in creative expression and shared their work with
their peers and individual therapists. The DBT program coordinator
asked me to develop some art therapy interventions to incorporate
into the skills groups. Clients had commented that, at times, it was
difficult for them to concentrate on the standard didactic skills training
curriculum. Some felt that another form of instruction might help
maintain their attention and interest.
In response, I designed several structured art making exercises. The
outpatient clients were enthusiastic about the addition of creativity
to their DBT skills training groups. I noticed that when they shared
at the end of a session, they were better able to communicate how
their artwork reminded them of the skill they had just learned. It
was paramount to ensure that clients felt emotionally contained and
comfortable during this verbal processing time. The theme-focused art
therapy approach achieved and maintained a sense of safety. Huckvale
and Learmonth (2009) write that “working with chaos, deep distress,
acute disturbance and imminent life-threatening danger to the person
demands containing structures” (p.62). Further, the art therapist,
working
60 DBT-INFORMED ART THERAPY IN PRACTICE

in conjunction with the place itself, can offer a unique setting […] where
battles may be fought in a contained therapeutic space. Boundaries of
time, and the use of materials, can offer a structured space to a client
with BPD wherein the Art Psychotherapist can make observations of
behaviour and anxiety levels in a non-judgmental environment. (Shiell
2008, p.59)
After years of academic study and the many challenges that came
with it, I was finally an art therapist. Following graduation from the
University of Western Sydney in 2006, the journey continued through
my work in private practice as well as for numerous hospitals. I became
increasingly intrigued by the combination of concrete DBT skills and
artistic expression, and I wanted to continue to pursue its possibilities.
DBT-informed art therapy seemed to build a sense of connection,
a verbal and nonverbal bridge of sorts, toward what the skills could
potentially mean for clients. By creating original artwork in response
to the formal psychoeducation-based lessons, they could more fully
articulate DBT concepts in ways that made personal sense to them.
In 2007 I was hired by The Sydney Clinic (in Bronte, New South
Wales) to co-facilitate its DBT programs; by 2008, I had become
coordinator of DBT there. Every member of the treatment team,
including myself, had completed intensive training with Dr. Linehan’s
company, Behavioral Tech. We developed, as closely as possible, a
comprehensive four-armed model. The demand for adherent DBT was
high, and waiting lists were long; this necessitated the creation of two
identical 12-month DBT programs that both met two days each week
(for five hours per day).
The Sydney Clinic also offered two eight-week introductory DBT
programs conducted for three hours on two separate days. The shorter
curriculum assisted staff in assessing whether clients were suitable for
groups or ready to commit to the 12-month program. Wishing to build
upon the work I had started during my graduate internship, I asked
management if we could incorporate art making.
It became a requirement that all participants complete the eight-
week DBT course prior to entering the 12-month program. Outcome
data revealed that 76 percent of those clients who had finished the
introductory course completed the longer program, as well. However,
the 12-month DBT program did not include any art making groups
(and many clients had expressed the wish that it had).
 My Journey as an Art Therapist Focusing on DBT and Art Making 61

Individual DBT sessions including art

making in private practice
During the time that I worked at The Sydney Clinic I also offered DBT
within my private psychotherapy practice. The individual therapy
sessions were highly structured via the evidence-based DBT protocol,
including diary cards (DCs) and behavior chain analysis (BCA)
(Linehan 1993). Clients use DCs to record any problematic behaviors
that occurred during the previous week, as well as the intensity of
their behavioral urges and various emotional states. DBT’s hierarchy
prioritizes target one/life-threatening behaviors (e.g., serious suicidal
ideation and/or attempts, self-injurious behaviors), followed by target
two/therapy-interfering behaviors (e.g., missing individual therapy
and/or skills group, failure to complete DCs), and, finally, target three/
quality of life-interfering behaviors (e.g., co-occurring mental health
and/or substance abuse conditions, financial issues, serious relationship
problems). If the individual engages in a behavior that was identified
during the initial assessment, the next step is to conduct a BCA, which
explores the sequence of events, thoughts, emotions, and actions
leading up to said behavior.
After completing a BCA, I teach the client a DBT skill that might help
her to avoid a similar behavior in the future. I then allow approximately
20 minutes for the client to create an object or image that directly relates
to the skill. She shares the resulting image; then we engage in a grounding
exercise and verbally commit to continue working together. I believe that
this structured format creates a safe, contained therapeutic environment
within which many clients are better able to process highly emotional
material. Further, the method of discussing art images metaphorically—a
less threatening approach for some—seems to increase clients’ willingness
to share their distress more openly. Huckvale and Learmonth (2009) posit
that making art allows clients to experience a variety of behaviors, and
therefore feelings and emotions, within a very particular container. They
also discuss that the right kind of therapeutic relationship is crucial and
allows clients to take appropriate risks: “Acceptance was embraced in
the session structure and the relationship. The possibility of change was
explored through the art materials. A dialectic between them was opened
up for reflection” (p.56).
It will be in the moving between being contained and being uncontained
in the therapeutic relationship that the client’s confidence will grow.
62 DBT-INFORMED ART THERAPY IN PRACTICE

This replicates the philosophy of DBT, the constant moving between

acceptance and change through all the modules of skills training. (Shiell
2008, p.62)
Although the pieces that clients made during their individual therapy
sessions directly related to a DBT skill, they could bring to the artwork
whatever they wished. Art was a way to enlarge their emotional and
psychological sense of self. As I witnessed my clients’ creative processes,
I became very aware of the struggles and difficulties individuals with
BPD face every day.

MIRANDA
Miranda was a 42-year-old single Australian woman who had been
diagnosed with BPD. She struggled with extreme, chronic emotional
instability (the result of a series of sexual abuse incidents during early
childhood to age 12). At the time of her initial interview for admission
into an outpatient DBT program, Miranda could maintain neither steady
employment nor trusting interpersonal relationships. And, owing to
significant social anxiety, she was not considered group-ready. However,
given my extensive training and experience as a DBT clinician and skills
trainer, I could offer her alternative options for participating. Miranda chose
to work with me in individual therapy. She was extremely dedicated to
the recovery process, and diligent with completing DCs and homework
assignments. She would even write up her own BCAs and bring them to
our sessions.
Miranda greatly enjoyed making art while learning the DBT skills. She
once commented that having an image to reflect on afterward assisted her
with retaining the information. She mentioned how she referred to some
of her earlier pieces during times of overwhelming stress and explained
that the process allowed her to reconnect with DBT skills she had explored
through those previous artworks.
During one of our sessions Miranda shared confusion about whether she
should continue to attend Bible study meetings. Miranda’s abuse history
included sexual molestation by her father. As a result, she possessed a
great deal of anger toward her religion because it had not protected her
from harm.
In response to Miranda’s confusion issue (which was accompanied by
significant emotional dysregulation), I taught her the distress tolerance/
 My Journey as an Art Therapist Focusing on DBT and Art Making 63

crisis survival strategy “pushing away” (Linehan 2015b, p.333). This skill
is applicable when the individual cannot immediately solve a problem
situation and wishes to reduce their current level of emotional intensity.
It involves mentally placing the issue “in a box…on a shelf” (Linehan
2015a, p.441) to address at a later, more appropriate time, and therefore
temporarily distancing themselves from worries and negative ruminations.
The collage below (Figure 4.1) expresses Miranda’s feelings about
attending Bible study during that time in her life: “I feel like a battered
bulldog and I am not going to get pulled into the fishing pond. I say ‘Stop!’
with my hands up, in front of the church; I say ‘No, I will not go to Bible
study anymore.’”

FIGURE 4.1 COLLAGE EXPRESSING THE DBT “PUSHING AWAY” SKILL

Miranda said that the empty crossword puzzle conveyed how she “just
does not get the meaning of the words that people speak sometimes.”
A featureless human figure in the top right-hand corner symbolized her
desire “to stay invisible in the crowd.” Miranda explained that the collage
reflected how, if she made decisions based on the problems and issues she
could actually solve/change, she would not return to Bible study. She might
then become capable of accepting and moving past the anger she felt, and
continued to feel, concerning her childhood trauma. Miranda reported that
the process of making this collage helped her to recognize that she could
use pushing away without growing more dysregulated until she could solve
her problem.
Figure 4.2 is a painted mask created by Miranda around four years later
in therapy. As I was preparing to move interstate, our work together had
64 DBT-INFORMED ART THERAPY IN PRACTICE

to come to an end. Over the course of the treatment I witnessed Miranda’s

sense of identity and confidence gradually develop. By the end of DBT she
reported that she had greater self-awareness and could see when issues
were brewing. She also made more effective choices concerning work,
her relationships, and communicating wants and needs to others. Miranda
believed that the combined art psychotherapy and DBT approach allowed
her to gain better insight into her behaviors, as well as develop the inner
strength and courage necessary for overcoming BPD.

FIGURE 4.2 MIRANDA’S PAINTED MASK: WHAT IT’S LIKE TO BE ME

The left side of my face is painted blue, as some days I see a blue sky
with clouds passing by. But even though I can sometimes feel calm (green
representing calm on the lower left side of my face), I often have emotions
(yellow tears) that I cannot control. The right side of my face represents
the deep fears and confusion I experience. It is often terror one minute (the
red and black lines crossing my eye), then a feeling of emptiness in the next
(blank blue on the lower right side of my face).

These experiences with Miranda had piqued my interest around how

art therapy might be applied to DBT skills training. The combined
interventions seemed to help her to better understand, retain, and apply
the skills to her life outside of therapy.
Art psychotherapy can offer another dimension to the skills-based
DBT program since the making of objects and images can substantially
support the understanding of the strategies and techniques offered by
DBT in supporting clients… It enables clients to find their observer-self
 My Journey as an Art Therapist Focusing on DBT and Art Making 65

and repair the chronic feelings of emptiness that they often felt in their
lives. (Shiell 2008, p.51)
The concept of an observer-self mirrors the first of DBT’s mindfulness
“what” skills, observe (Linehan 2015b, p.53). Rathus and Miller (2014)
describe observe as “[w]atch[ing] wordlessly. Just notic[ing] your
experience in the present moment” (p.106). Rappaport (2014) states
that to observe is to cultivate an “awareness of one’s moment-by-moment
internal and external experience” (p.242). Further, she suggests that
movement and visual art activities may allow clients to experience the
observe skill more readily.

Sea change
In 2011 my family and I moved from Sydney to the northern coast
of New South Wales. Here I have continued to pursue my passion of
working with DBT and art psychotherapy in private practice. However, I
was shocked to learn that, in this new location, many mental health care
professionals had never heard of DBT. Others provided the treatment
without appropriate training. I took it upon myself to develop a two-day
DBT-informed workshop for clinicians. My goal was to offer the course
throughout Australia to educate providers about DBT and explain how
its comprehensive model is conducted.
On the first day I introduce the theory and components of DBT as
well as the delivery of both individual therapy and skills training. The
second day involves a more extensive lesson on how DBT skills training
sessions should be structured/delivered, and I teach as many of the skills
as possible. I also describe the value of combining art making with DBT
skills instruction and provide participants with an opportunity to create
an image of their own to experience that process.
As of March 2021 I have trained over 2500 clinicians in Australia.
This number includes the online programs I developed due to the
Covid-19 pandemic. Many of my workshop attendees have described a
general lack of knowledge of DBT among their colleagues. They shared
that, if DBT was offered in their places of employment (and/or within
the larger service areas), it was usually only skills training. Living in a
regional area of Australia myself, I became frustrated by the fact that
many individuals who suffer with severe emotional dysregulation are
unable to access DBT and other effective treatments.
66 DBT-INFORMED ART THERAPY IN PRACTICE

Australia’s public sector only occasionally offers DBT (and not

always the research-validated version). Existing programs, typically
in major cities, have extremely long waiting lists. Approximately
one quarter of emergency mental health presentations and inpatient
psychiatric admissions are for individuals with personality disorders
and associated problems including self-harm and substance
dependence (Grenyer 2014). A few comprehensive DBT programs
operate within nongovernment organizations and private health
care providers; however, these are difficult to access. In the private
sector, free-standing DBT skills training groups are typically the only
available option.

Developing the ME online skills program

with an art component
In 2017, in response to my professional concern with the lack of DBT
knowledge and training for DBT in Australia’s health sector, I created a
ten-session virtual self-study DBT-informed skills training curriculum
for local and global health care professionals. The ME program includes
a summary of DBT’s theory and techniques. It also contains guidelines
for structuring individual DBT sessions.
I created a similar ten-session ME self-study program specifically
tailored for clients that can serve as an introduction to DBT or as a
refresher for those who have completed a comprehensive program.
The curriculum consists of ten skills training videos, each around
20–30 minutes in length. Session nine shows how to complete a DC
as well as how to conduct a BCA. I produced a 59-page manual to
accompany each of the ME sessions. It is recommended that individuals
view one video per week, which allows for ample skills practice time
in between sessions. This mirrors standard DBT skills training groups,
which typically introduce one skill per week. Art making is optional.
One of the ME program’s strengths is that users maintain permanent
access to the online curriculum after completion. Hence, they can go
back and refresh their DBT skills knowledge at any time.
I suggest that if clinicians are going to work through the self-study
online program with clients face to face, and the client wishes to create
an image, they ask two questions:
• What did it feel like to create this image?
 My Journey as an Art Therapist Focusing on DBT and Art Making 67

• How does the image relate to the skill you have just been taught?
It is essential to explain that, while there is certainly a strong therapeutic
element involved in talking with clients about their art images, the
process I describe is not art psychotherapy as practiced by trained,
experienced art therapists. My goal is to make it possible for all mental
health clinicians to use creativity as part of their DBT-informed work.
However, there is no profound exploration into visual symbolism and
emotional content. This is described with somewhat greater detail later
in the chapter.

DBT-informed art therapy interventions

in action: Exploring the wise mind
The first session of the ME program explains DBT’s wise mind, an
“inherent wisdom that each person has within” (Linehan 2015a, p.166),
“the part of each person that can know and experience truth. It is where
a person knows something to be true or valid. It is where the person
knows something in a centered way” (Linehan 2015a, p.170).
…When teaching about the Wise Mind (Linehan 1993b) we found
that many clients understood the concept but did not have access to
the state. We hypothesized that the experiential and imaginal realms
needed to be involved in order for clients to access such resources. (von
Daler and Schwanbeck 2014, p.238)
Direct the client with a positive instruction; for example, “What could
wise mind look like for you? Would it be a place where you may feel
calm or a color you associate with a sense of being grounded?” It is
important that the instruction to create an image or object directly
relates to the skill being taught that day.
The suggestion for the artwork is to create an image using crayons,
colored markers, or colored pencils that could represent wise mind.
I purposely choose the materials for each art exercise to provide an
opportunity for the client to simply create without feeling pressure to
decide on a specific medium. I want them to feel especially comfortable
in the art making by allowing them to freely experiment with self-
expression using the given materials. We do not necessarily even
process the resulting image(s).
68 DBT-INFORMED ART THERAPY IN PRACTICE

BARBARA’S WISE MIND

Barbara was a 35-year-old Australian woman diagnosed with BPD. Figure
4.3 shows her representation of her wise mind.

FIGURE 4.3 MY WISE MIND IMAGE, BY BARBARA

I always ask the following two core questions after the art piece is
completed (Barbara’s responses are in italics):

1. What did it feel like to make that image?

At the beginning I was stumped and scared of the white page. I had
to really think hard.

2. How does this image represent wise mind for you?

Well I always look at old huge trees in the rainforest. They have been
there for so long that they are huge, wide, and must have a big root
system. I put the eyes on the tree to show that a wise tree is always
looking around, taking information in. There are many roots to the
tree so that it is solid underground and will not fall over. That is how
I want to be—solid, aware, and wise.

It is interesting to note that over many years I have seen numerous similar
images (trees) and descriptions in response to this prompt.

Art in the ME program

For eight of the video sessions I suggest an art exercise that can
mirror the skill that has been taught in any particular week. Table 4.1
describes the artwork themes and materials:
 My Journey as an Art Therapist Focusing on DBT and Art Making 69

Table 4.1 ME program DBT skills/art activities

DBT skill topic Related art activity Materials provided
“What is Wise What could wise mind Drawing paper and
Mind?” look like for you? colored pencils (a simple,
(Video session 1) nonthreatening medium)
“Mindfulness” What does it feel like Watercolor paper/
(Video session 2) when you are in the watercolors (because a
present moment? mindful state often feels
uncontrolled and flowing)
“The Distress Try to identify what Collage images/
Tolerance Wise Mind kind of distress tolerance magazines, paper, pens,
ACCEPTS and Self- strategies may help you scissors, and glue (to
Soothing Skills” create a concrete visual
(Video session 3) list of distraction and self-
soothe ideas)
“The Distress Create an object or Found objects and glue,
Tolerance IMPROVE image representing for building/constructing
the Moment/Self- your inner cheerleader a tangible representation
Encouragement to encourage yourself of your own cheerleader
(‘Cheerleading’) Skill” during difficult moments
(Video session 4)
“Radical Acceptance Create representations Drawing paper and
Willingness-vs- of a willing hand and a colored pens. Trace
Willfulness/‘Willing willful hand around both one’s closed
Hands’ Skill” and open hand, then
(Video session 5) write/draw on the hands
to describe how willing
and/or willful you are
(this can reveal the client’s
inner values)
“How Can You Create a collage to Collage images/
Become Emotionally describe all the tools you magazines, paper, pens,
Strong?” can use to become/stay scissors, glue, and crayons
(Video session 7) emotionally well. Sleep,
exercise, diet, staying
away from “drama,” and
so on
Cont.
70 DBT-INFORMED ART THERAPY IN PRACTICE

DBT skill topic Related art activity Materials provided

“Communication “How do you look?” Papier-mâché masks and
Skills” (when you are oil pastels
(Video session 8) communicating
effectively)
Decorate a mask
to convey a facial
expression that
communicates a certain
emotion
Walking the middle Build a skills box Glue, scissors, cardboard
path. Review all skills boxes, objects, pens.
and develop a list of Provide clients with a list
the best skill for you of DBT skills learned in
to use program
(Video session 10)

A caveat
The sole function of art making in the ME program is to reinforce the
learning and retention of DBT skills. An art object provides the client
with a succinct nonverbal reminder of the value of the related skill, as
well as its general application. This is not art psychotherapy, which is a
specialized discipline. Individuals in treatment will often try to express
their deep feelings in response to any suggestions from a clinician. Only
credentialed art therapists can appropriately witness and safely contain
the dysregulation that can occur if the creative process provokes a
strong emotional reaction.

Conclusion
My professional journey—from brainstorming with a friend about
later-in-life career possibilities, to becoming a credentialed art
psychotherapist and DBT specialist—has been an extremely fulfilling
endeavor. Who would have guessed that a student internship in a DBT
treatment milieu would ultimately inspire me to develop two online
self-study programs, one to inform clinicians on how to use DBT, and
the other tailored to provide clients with DBT skills (both with an
optional art making component)?
 My Journey as an Art Therapist Focusing on DBT and Art Making 71

The joining of a manualized verbal therapy and an experiential,

creative approach provides clients with opportunities to experience DBT
in a novel manner. Making artwork not only summarizes the didactic
material, it also facilitates a unique, personal connection. The clients can
quickly refer to their image(s) regarding how to proceed with managing
difficult emotion(s). In addition, they receive opportunities to identify
what skills they find most helpful by discussing and exploring the
metaphors present in their artwork.
The journey started with an internet search and evolved into an
online course to help clients reach their potential in coping with
emotion dysregulation. I remain driven to make DBT more accessible
to anyone who wishes to attain or improve mental wellness. A lack of
adequate training for clinicians fueled my resolve to offer education
to professionals both face to face and within a virtual domain. Among
my future goals is to explore methodologies for evaluating the efficacy
of the art making components in both versions of the ME online DBT-
informed skills course.

References
Bohus, M., Dyer, A.S., Priebe, K., and Kruger, A. et al. (2013) ‘Dialectical behaviour therapy
for post-traumatic stress disorder after childhood sexual abuse in patients with and
without borderline personality disorder: A randomised controlled trial.’ Psychotherapy
and Psychosomatics 82, 4, 221–223.
Courbasson, C., Nishikawa, Y., and Dixon, L. (2012) ‘Outcome of dialectical behaviour
therapy for concurrent eating and substance use disorders.’ Clinical Psychology and
Psychotherapy 19, 5, 434–449.
Dimeff, L.A. and Linehan, M.M. (2008) ‘Dialectical behavior therapy for substance abusers.’
Addiction Science and Clinical Practice 4, 2, 39–47.
Grenyer, B.F.S. (2014) ‘An integrative relational step-down model of care: The project
air strategy for personality disorders.’ The Acparian: Australian Clinical Psychology
Association Journal 9, 8–53.
Harley, R., Sprich, S., Safren, S. and Jacobo, M. et al. (2008) ‘Adaption of dialectical behavior
therapy skills training group for treatment-resistant depression.’ Journal of Nervous and
Mental Disease 196, 2, 136–143.
Hirvikoski, T., Waaler, E., Alfredsson, J. and Pihlgren, C. et al. (2011) ‘Reduced ADHD
symptoms in adults with ADHD after structured skills training group: Results from a
randomized controlled trial.’ Behavior Research and Therapy 49, 3, 175–185.
Huckvale, K. and Learmonth, M. (2009) ‘A case example of art therapy in relation to
dialectical behaviour therapy.’ International Journal of Art Therapy 14, 2, 52–63.
Linehan, M.M. (1993) Cognitive-Behavioral Treatment of Borderline Personality Disorder.
New York, NY: Guilford Press.
Linehan, M.M. (2015a) DBT Skills Training Manual (2nd ed.). New York, NY: Guilford Press.
(Original work published in 1993.)
Linehan, M.M. (2015b) DBT Skills Training Manual (2nd ed.). Handouts and Worksheets.
New York, NY: Guilford Press. (Original work published in 1993.)
72 DBT-INFORMED ART THERAPY IN PRACTICE

May, J.M., Richardi, T.M., and Barth, K.S. (2016) ‘Dialectical behavior therapy as treatment
for borderline personality disorder.’ Mental Health Clinician 6, 2, 62–67.
Paris, J. (2008) Treatment of Borderline Personality Disorder: A Guide to Evidence-Based
Practice. New York, NY: Guilford Press.
Rappaport, L. (ed.) (2014) Mindfulness and the Arts Therapies: Theory and Practice. London:
Jessica Kingsley Publishers.
Rathus, J.H. and Miller, A.L. (2014) DBT Skills Manual for Adolescents. New York, NY:
Guilford Press.
Safer, D.L. and Jo, G. (2010) ‘Outcome from a randomized controlled trial of group therapy
for binge eating disorder: Comparing dialectical behavior therapy adapted for binge
eating to an active comparison group therapy.’ Behavior Therapy 41, 1, 106–120.
Shiell, M. (2008) ‘Art psychotherapy, dialectical behaviour therapy, and borderline personality
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Sneed, J.R., Fertuck, E.A., Kanellopoulos, D., and Culang-Reinlieb, M.E. (2012) ‘Borderline
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Van Dijk, S., Jeffrey, J., and Katz, M.R. (2013) ‘A randomized, controlled, pilot study of
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 Chapter 5

Inspiring and Sustaining Hope

Treating Suicidal Behavior with DBT-Informed Art Therapy
JANE DESOUZA

Crisis hotlines can save lives; so can psychiatric treatment. But

suicide is such an unpredictable, often impulsive act that no single
intervention has proved sufficient.
Benedict Carey (journalist, The New York Times), 2018

Introduction
Dialectical behavior therapy (DBT)-informed art therapy may assist
suicidal individuals in developing the capabilities and motivation
necessary to build what DBT’s inventor, Marsha Linehan, calls a life
worth living (2015a, 2020). This chapter describes some common
problematic thought patterns experienced by people struggling with
suicidal ideation and explores how such beliefs can be effectively
challenged and replaced. In addition, it highlights the importance of
cultivating a dialectical stance, “which holds that reality is dynamic and
ever-changing—a complex system of countless interrelated yet polarized
elements” (Clark 2017, p.32). Through two case studies illustrating art
therapy within an intensive DBT day treatment program, I, the author,
demonstrate how a dialectics-based creative approach might help to
reduce our most vulnerable clients’ severe emotion dysregulation and
support them in creating an enduring sense of hope.

73
74 DBT-INFORMED ART THERAPY IN PRACTICE

The problem of suicide

Suicide is a controversial and often taboo area of human behavior. It is
also a significant public health concern. According to the most recent
reports from the National Institute of Mental Health (NIMH) (2017)
and the Center for Disease Control (CDC) (2018), suicide was the
tenth leading cause of death in the United States, and there were more
than twice as many suicides as homicides. The first center for suicide
prevention was established in California during the 1950s (UDHHS
2012); in the years that followed, substantial literature was published
with recommendations for reducing suicide rates. Yet, despite such
efforts, its prevalence continues to rise. The latest statistics report that
since 2001 the total suicide rate increased by 31 percent, and 47,000
Americans died in 2017 by suicide (CDC 2018; NIMH 2017).
The NIMH and CDC data also indicate that suicide is the second
most frequent cause of death in individuals aged 10–34 years old. The
highest rates are for men over 65 years old. Although women attempt
suicide twice as often as men, men succeed in killing themselves
twice as often as women (NIMH 2017). Other high-risk groups
include American Indian and Alaskan Native youth and middle-aged
individuals (followed closely by non-Hispanic white middle-aged and
older adult males), those in the justice and child welfare systems, those
who identify as LGBTQIA+, members of the armed forces, military
veterans, individuals struggling with mental illness and/or substance
use disorders, and people with certain medical conditions. Risk factors
include a family history of suicide, maltreatment during childhood or
other interpersonal trauma, previous suicide attempts, bereavement due
to another person’s suicide, intentional nonsuicidal self-injury (NSSI),
substance abuse, frequent impulsive behaviors, irrational thinking,
insufficient social support, the presence of an organized suicide plan,
access to lethal means (especially firearms), and diminished optimism
for the future (CDC 2018).
If you think about the cost society pays due to undiagnosed mental-
health conditions, due to emotional crises and stressors leading to loss
of function and ultimately to suicide and how many lives are directly
affected by suicide…when you think about all that, this is a public
health crisis. (Healthcare News 2018, p.2)
 Inspiring and Sustaining Hope 75

Understanding suicidal thinking and assessing for risk

It is not enough just to provide clients with empathy and support;
we must identify their underlying thought patterns to assist with
changing their approach to solving painful life realities. An individual
considering suicide typically suffers from a pervasive sense of being
trapped and despairing. Further, they may not possess the necessary
skills to effectively contend with difficult situations. Rudd, Joiner, and
Rajab (2001, p.29) identify three common suicidogenic beliefs:
• unlovability (I don’t deserve to live)
• helplessness (I can’t solve my problems)
• poor distress tolerance (I can’t stand the pain anymore).
Over the years while treating suicidal individuals, I have repeatedly
observed an assumption that there is no other option. Killing oneself
becomes the solution when distress increases to a certain level. A
crucial clinical skill is assessing for immediate suicide risk. One must
ascertain the level of danger to self, which includes distinguishing
between true suicidal intent and destructive and/or self-mutilating
behaviors (i.e., NSSI). Risk factors themselves are not determinants of
imminent suicide; however, the number of risk factors, combinations
of risk factors, and the current status of each must be considered when
determining potential lethality. Therefore, assessment is three-pronged:
evaluating the client’s risk factors, their current attitude toward suicide
(intent/plan), and professional judgment based on one’s knowledge and
experience with the client (Shea 2002).
Clinicians should differentiate between true suicidality and
parasuicidal ideation. The latter involves apparent suicidal behaviors
or attempts without the goal of death (and may include NSSI). When
a person is going down the dark tunnel of suicidal thinking, they can
easily become stuck and see no benefit to resisting their urges, even
when they don’t really want to die. Indicators of possible parasuicidal
ideation include comments such as I’ll show them; They’ll be sorry;
Nobody cares; It’s their fault; Nobody ever listens to me. However,
clinicians must keep in mind that impulsivity, impaired judgment, and
intense emotional dysregulation increases the danger of the person
going too far with suicidal gestures, perhaps resulting in unintentional
death. Authentic suicidal ideation may be accompanied by thoughts or
76 DBT-INFORMED ART THERAPY IN PRACTICE

comments including This is the best way; I just want to get away from
the pain; I don’t have any choice; There is no reason to go on.
When clients are guarded and/or have difficulty communicating,
simple art therapy prompts can offer opportunities to assess intent.
One does this by discussing the resulting imagery. Asking clients to
illustrate how they are feeling right in that moment, or to draw the
present distressing situation, may elicit important information that
they are unable (or unwilling) to verbalize. Scribbling/doodling can
also serve as a self-soothing or grounding activity.
If the person is deemed to be in imminent danger, crisis intervention
must follow, the goals of which are “immediate symptom relief, ensuring
the person’s safety, and active problem solving” (Rudd et al. 2001,
p.150). In order to achieve these, it is essential to establish basic rapport
with the person (or, if possible, bring in someone with whom they
already have a relationship). Attempt to defuse the crisis by reviewing
their ability to regulate their cognitive, behavioral, physiological, and
affective systems. Identify relevant skills, create a lucid crisis plan, and,
finally, assess for a need for supervision.
Once physical safety is ensured, art therapy can provide an objective
space for exploring what may be triggering symptoms. Creative
activities allow the time and distance for individuals to re-regulate
and reframe their thinking by identifying alternative interpretations
of events, as well as other possible solutions. Two directives that are
helpful when safety planning include making a crisis survival toolbox
(containing various skills card reminders, distracting activities, and/or
self-soothing products) and drawing one thing that, if changed, would
allow the individual to consider staying alive.
What happens after the crisis of imminent danger has passed?
Until both therapist and client can fully trust the client to not kill
themselves, treatment must revolve around decreasing factors that lead
to risk for suicidal thoughts and behaviors and increasing factors that
help strengthen, support, and protect the individuals from acting on
future suicidal urges (Rudd et al. 2001). DBT skills training and DBT-
informed art therapy interventions address these goals by identifying
maladaptive cognitions and behavioral patterns, as well as providing
effective replacement strategies.
 Inspiring and Sustaining Hope 77

DBT
DBT, an empirically founded cognitive behavioral treatment, reduces
suicidal ideation and behavior in many individuals (Linehan 1993). It
was originally developed for women who met the diagnostic criteria
for borderline personality disorder (BPD). DBT has five functions
(Chapman 2006): (1) to enhance the client’s capability through increasing
their skillful behavior; (2) to improve and maintain the client’s motivation
to change and to engage in the treatment; (3) to ensure generalization
of change; (4) to enhance the therapist’s motivation and capability to
deliver effective treatment; and (5) to help the client change or restructure
their environment “in such a way that it supports and maintains progress
and advancement toward goals” (Linehan 2015a, p.13).
DBT is a highly structured, language-based treatment model. Some
clinicians believe that combining creative arts therapies with its didactic
skills training component can expand certain individuals’ capabilities
more than standard DBT alone—and better help them to identify
erroneous thought patterns, replace maladaptive behaviors with healthy
ones, and design a life worth living that is congruent with their important
personal values (von Daler and Schwanbeck 2014). This may especially
be the case for clients with nonverbal learning styles (Clark 2017).
According to Rudd et al. (2001), three areas for effective suicide
treatment are symptom management, skill building, and personality
development. Symptom management and skill building interventions
occur within a time-limited framework. The process of personality
development is a much lengthier and more arduous journey, although
I believe that it is possible to achieve through the mastery of the DBT
skills. Effective long-term symptom management is contingent upon
the client’s improved self-awareness, and skills development requires
knowledge of (and insight regarding) one’s symptoms. Art therapy can
play a role in all three aspects; however, the following case studies focus
primarily on skill building (specifically, DBT skills).

Case studies
The following clinical case studies come from my work in a long-
term DBT day treatment program for severely mentally ill individuals
(pseudonyms protect client confidentiality).
78 DBT-INFORMED ART THERAPY IN PRACTICE

MARY
Mary’s story illustrates how cognitive distortions can have a profound
negative impact on a person’s functioning and hope for a future. She was
37 years old when she entered the intensive DBT day program. Suffering
from posttraumatic stress disorder (PTSD), the result of extensive
childhood physical and sexual abuse, Mary had not been in contact with
her family since age 14 (she spent several years in a detention center for
adolescents). Her suicidal thoughts emerged quite early. At one point, after
breaking up with a girlfriend, Mary had stood on the edge of a bridge with
the intention of jumping off. As an adult she exhibited all the symptoms of
depression yet tried very much to present a tough exterior to the world.
However, Mary also recognized that it was becoming increasingly
difficult to tolerate her emotional distress and dissociative episodes. She
had never attended group treatment before and she had only started
individual counseling one year prior to entering this five-day-a-week
program. Mary requested DBT because she was making little progress
with her therapist; further, her functioning was significantly impacted by
the PTSD symptoms. Some people she knew who experienced similar
problems had said that they benefited from DBT.
At the time of Mary’s admission, I taught DBT skills groups every day
and facilitated an accompanying weekly art therapy session. I was assigned
as Mary’s primary program therapist. Because of her intense distrust of
others, nearly a year passed before she would participate to any significant
degree in group discussions (or even engage with doing artwork). Yet she
was consistently alert and attentive. Only in individual therapy would Mary
share about her difficulties tolerating treatment, the group living situation
she was in, and so on. She expressed feeling as if she was always in danger;
her early experiences had taught her that there was no one she could trust.
Mary believed that things would never get better because she was
defective in some essential way. Her thinking was consistently rigid and all-
or-nothing. She assumed, since she was so competent at walling off painful
feelings, that there was no good reason to risk trying something different.
Anger was the only emotion she expressed, which understandably resulted
in frequent altercations at the group home. Mary also had a low tolerance
for the company of others and chose to keep to herself most of the time.
Aggression was an effective way to hold people at a distance.
Slowly, however, Mary began to understand that these behavioral
patterns were in reaction to her fears of being hurt by relationships. As
she became more engaged in DBT she struggled to navigate the dialectical
 Inspiring and Sustaining Hope 79

dilemma of an intense desire for safety versus the growing emotional

connection between herself and her therapists (as well as with other
program participants). Dialectics tells us that everything in existence has
its opposite and that even highly “opposing points of view can both be
true” (Linehan 2015a, p.286). Many people—those with severe emotional
dysregulation problems, in particular—perceive the world around them
in an extreme, dichotomous manner that creates inflexible, ineffective
thoughts and behaviors. DBT’s goal of cultivating a dialectical stance isn’t
to teach clients “to view reality as a series of grays, but rather to help them
see both black and white, and to achieve a synthesis of the two that does
not negate the reality of either” (Linehan 2015a, p.291).

DBT conceptualizes the client’s difficulties as a series of dialectical dilemmas

wherein the client and the therapist struggle to reconcile opposing forces.
Borderline Personality Disorder…can be viewed as stemming from failure to
integrate opposing views. In DBT, the therapist helps the client to recognize
these conflicting forces and helps the client to reconcile these into a more
balanced view. (Chapman, Turner, and Dixon-Gordon 2011, p.172)

Timing is everything and, at just the right moment, a graduate art therapy
student joined the intensive day program’s treatment team. Because of
this increase in staff Mary received more individualized attention than she
otherwise would have, and it seemed to make a difference. Eventually
she began to make art. Mary’s first piece, created during a private session,
was in response to the directive to express what she was feeling in
that moment. The painting (“I HATE ART!”) was Mary’s statement about
her attitude toward treatment, her use of anger for self-protection, and
the trepidation she felt around sharing her inner world. This was her
first attempt at communication through a means other than the typical
aggressive acting out. Mary took a risk to see what kind of reaction she
would provoke in the clinical team. I used the opportunity to validate how
hard it must have been to express herself so honestly considering the
abuse she had experienced over the years. Both the art therapy student and
I strongly reinforced Mary’s willingness to convey such intense emotions
despite the possibility of offending us. This marked a significant turning
point: She chose to participate actively in treatment going forward.
Mary reported that she had started practicing DBT skills outside of
program but was frustrated with the outcomes. She blamed other people
when things did not go well rather than acknowledge that she needed to
make more of an effort to master the behavioral techniques. In response, I
80 DBT-INFORMED ART THERAPY IN PRACTICE

would refer to the “Model for Describing Emotions” handout (Linehan 2015b,
p.213) and ask her to consider alternative (i.e., neutral) interpretations
whenever results were less than satisfactory. I also pointed out specific
times when she had been effective in using the skills during treatment. As
Mary became more competent, she grew more trusting of the program.
She could view other people’s reactions from different perspectives, as
well. This also increased her anxiety somewhat as she began to identify,
and allow herself to experience, a variety of emotions instead of avoiding
them with angry outbursts.
As the months passed Mary’s engagement in group discussions
evolved, as well. However, her most significant progress took place
through the artwork she made during individual sessions. I witnessed her
become much more open about her emotional distress. Figure 5.1 shows
a large painting that she described as “original pain.” The directive was
to illustrate what being in relationships felt like. During our discussion, I
challenged Mary’s rigid belief that closeness with others always results in
suffering by identifying ones she had recently developed that were healthy
and rewarding.

FIGURE 5.1 MARY’S DEPICTION OF HER ORIGINAL PAIN

Mary struggled with profound guilt and remorse over some of her past
behaviors. She eventually disclosed that she had been engaging in cutting
and other self-destructive acts since entering the DBT program. However,
at that point she was able to verbalize how a negative self-image and sense
of worthlessness triggered those urges. During her second round in the
 Inspiring and Sustaining Hope 81

mindfulness skills module, the core theme in art therapy was illustrating
one’s mindful observations of thoughts and feelings (as an alternative to
maladaptive, impulsive outbursts). In response to the directive Show what
it feels like when you are experiencing an intense emotion, Mary built a
volcano to express how she felt like exploding whenever she was angry.
Our discussion explored the consequences of erupting with out-of-control
behaviors versus dealing with emotions skillfully as they arise.
During another individual session, as we were practicing some reality
acceptance exercises to help her to make peace with her past, I asked
Mary to consider why she was given such a beautiful name with so much
potential for good (i.e., Mary, the mother of Christ). She was stunned
that I would compare her to a religious figure—and, for a moment, she
experienced a radically different view of herself. Someone might have given
her a beautiful name because there was love that could not be expressed
any other way. Mary was making room for hope and self-tolerance. She
realized that change could be positive rather than always a threat.
During the distress tolerance skills training module art therapy
participants construct their own crisis survival toolboxes. Mary was
still not doing much work in groups; however, one of her first directives
around that time within individual therapy sessions was to illustrate
how she presently reacted to distress, and identify what helped her to
cope effectively (versus what made things worse). Mary built a concrete
container, which she covered with black industrial plastic bags and heavy-
gauge wire. She explained that she had no intention of letting anything in
or out because she believed that this protected her from emotional pain.
In our post-art making discussion, Mary reported she was growing
increasingly satisfied with her ability to express herself—and she felt
a new sense of optimism that she could change. She was also able to
acknowledge the following dialectical dilemma: the container not only
blocked her pain; it also separated her from any possible pleasant
experiences. Mary verbalized an insight that she had never developed her
own identity because she was always worrying about protecting herself.
She could not name any interests and goals.
Over the months that followed I witnessed Mary discover that she
was lovable, that she was strong, and that she could solve her own
problems. She was cutting less frequently and had started to take care
of her medical issues. She reported that her depressive symptoms were
gradually decreasing. She even found it a bit easier to interact with her
peers. Mary was building a new approach to the world. She cultivated the
82 DBT-INFORMED ART THERAPY IN PRACTICE

willingness and skill to appreciate other people’s differing perspectives

without absorbing their emotions.
Mary attended the intensive day treatment program for nearly two years.
Over that time DBT and art therapy helped her to trust herself and others,
explore and change patterns of rigid thinking, and safely communicate
overwhelming emotions. Mary was ultimately able to generalize skills
outside of the therapeutic environment, make new friends, and enjoy
activities. During her final months in the program Mary talked about wanting
to share her story. She saw this not just as a way to connect with others,
but also as a means of accepting and resolving her past. Mary created her
final piece in response to the art therapy group’s directive Illustrate your
progress made so far. Mary presented a bright-colored poster, made for
the program itself, which stated her belief that “DBT WORKS!”
It has been many years since Mary’s discharge from the day treatment
program, yet she continues with individual trauma-informed therapy at our
agency’s outpatient clinic. When we pass each other in the hallways she
greets me with a smile and reports that she is doing good work. Mary has
neither made any suicide attempts nor been psychiatrically hospitalized
since completing DBT. She sustains hope by trusting in her skills and with
the support of ongoing treatment.

TANDY
Tandy, a 43-year-old woman whose primary diagnosis was BPD, entered the
DBT day treatment program after her most recent inpatient hospitalization.
During our initial individual therapy session, she reported that she had been
hospitalized at least 15 times over the years due to recurrent suicidal ideation
and attempts. Further, she habitually used self-injury (cutting) to relieve
anxiety. Tandy had difficulty tolerating change. The fact that she was not able
to return to her previous agency and therapist made her very distraught,
even though she had only worked with the therapist for a few months.
Tandy reported feeling different from other people at a young age. She
had been in therapy most of her life and spent 13 years in a residential
treatment facility (where she reportedly endured both physical and sexual
abuse). Despite having received some DBT skills training prior to entering
the day treatment program, Tandy was ambivalent about the change
process, and, like Mary, avoided considering how her own behavior had
impacted her life. However, during the initial evaluation Tandy agreed
 Inspiring and Sustaining Hope 83

that, in order to reduce the frequency of psychiatric hospitalizations, our

treatment plan should focus on emotion regulation skills.
Tandy had a very conflictual relationship with her mother, who also
struggled with psychiatric issues. She lived in a group home at the time of
her admission and believed that it was preferable to staying with family.
Tandy’s father had been a successful businessman prior to his retirement.
Since that time, her parents traveled a great deal. Tandy always became
more anxious when they went on extended trips.
Tandy’s suicidal behavior was driven by an intense emotional
vulnerability. At the beginning of DBT she required daily individual attention
(in particular, right before the weekend when she needed coaching around
how to implement self-soothing skills). Although she was highly intelligent,
Tandy had a childlike demeanor, especially when relating to female
clinicians. She would often stand outside of my office door and wait for me
to come out.
Tandy was isolative in groups and wanted to interact only with the
therapists. She rejected constructive feedback but was apologetic when
others became frustrated with her. In contrast, during art therapy sessions
she was very expressive. It was there that she began to communicate
her emotional pain and internal struggles. In response to the directive
Illustrate opposing (dialectical) emotional forces, Tandy produced two
images: a human baby crying for love, and a large open mouth spewing
out a wave of black and red material. Together, the drawings convey how
Tandy vacillated between infantile desperation for emotional nourishment
and anger so intense that it felt as if she was expelling explosive vomitus
of rage.
Although Tandy had some additional psychiatric hospitalizations during
her time in the DBT program, such episodes became less frequent. I, as her
individual clinician, worked hard to maintain therapeutic consistency as well
as manage my reactions to her help me/I don’t want to change approach to
treatment. Tandy was eventually better able to consider how her behaviors
impacted other people and this sometimes resulted in negative responses
(which, in turn, triggered more self-destructive urges). At one point she
portrayed her internal struggle concerning her ambivalence about recovery:
“If I change and become more self-sufficient, will I be alone or will life be
better?” The directive was to Draw the likely pros and cons of implementing
DBT skills (Figure 5.2). Tandy appreciated the ineffectiveness of her current
coping strategies. Further, by illustrating nascent hope for the future, she
could affirm the possibility of a rewarding life.
84 DBT-INFORMED ART THERAPY IN PRACTICE

FIGURE 5.2 TANDY: THE PROS AND CONS OF USING DBT SKILLS

Tandy continued to experience emotional overwhelm whenever I went on

vacation or her parents left for/returned from one of their seasonal trips.
But she was doing better, and during our individual sessions she could
finally accept feedback concerning her progress. I encouraged Tandy to
utilize the groups by talking more about ambivalence. She worked with me
on a crisis survival skills toolbox for the weekends yet remained unwilling
to give up cutting (as she believed that it was the only way to relieve
anxiety/tension). She conceptualized the purpose of self-injury around her
belief that she could tolerate physical pain but not emotional pain.
As described by Southwick et al. (2008), lack of resiliency is a major
component of rigid or repetitive behavioral reactions, and adequate
supports are necessary to maintain it in the face of trauma. The creative
process allows clients to express a sense of hopelessness and helplessness
without re-enacting traumatic cycles via maladaptive behaviors. Thus, they
are more capable of problem-solving, which ultimately reduces the factors
that contribute to suicidal thinking.
During the mindfulness module Tandy also explored walking the middle
path in art therapy. This skill teaches dialectical thinking—in particular,
balancing acceptance and change (Linehan 2015a, 2015b). For Tandy, the
middle path meant rejecting suicide as a solution, although she still was
not ready to give up cutting. Walking the middle path also involved being
more present as a group member, even as she remained quite impulsive in
her interactions with peers. During our individual sessions I often pointed
 Inspiring and Sustaining Hope 85

out my observations of Tandy’s various dialectic dilemmas while the art

therapy component explored what might happen if she fully committed
to using the DBT skills. Figure 5.3 shows her response to the directive to
visualize a skill that could help put her on the middle path. Tandy chose the
distress tolerance module’s STOP skill: Stop, Take a step back, Observe,
and Proceed mindfully (Linehan 2015b, p.327). STOP was effective for
slowing her mind down and making more thoughtful decisions (instead of
just reacting impulsively).

FIGURE 5.3 TANDY: VISUALIZATION OF WALKING THE MIDDLE PATH (STOP SKILL)

While she was never able to make friends in the DBT day treatment
program, Tandy became significantly more interactive during groups;
further, she could accept her peers’ positive comments on how she used
art to communicate concepts. Tandy had also developed a more objective
perspective regarding her relationship with her mother, although she still
very much wanted approval and was deeply hurt whenever she received
criticism from her.
Art making was a powerful avenue for Tandy to communciate her
emotions and distress. With the addition of DBT-informed art therapy
to the treatment-as-usual, Tandy could better generalize the skills she
learned into her daily life (which eventally reduced the frequency of cutting
episodes and hospitalizations).
Tandy began to talk about leaving the DBT program because she felt
too attached. This was the first time she had made a thoughtful decision.
She finally felt hopeful that she would no longer need to be taken care
86 DBT-INFORMED ART THERAPY IN PRACTICE

of on a daily basis. After considerable discussion about how to continue

progressing with the skills, Tandy stated that she was ready to step down
to weekly individual sessions. She also asked me to refer her to a DBT
therapist. Figure 5.4 is her final art project before discharge. Tandy at last
could visualize herself as a competent person with a hopeful future. She
continues to make art and often brings drawings into therapy sessions.
When I see her in the hallways she is able to say hello and only keeps me
in conversation for a few minutes.

FIGURE 5.4 TANDY’S FINAL ART BEFORE DISCHARGE

Conclusion
There are many DBT-informed art therapy interventions to match any
given client’s needs and level of functioning. Within the case studies I
presented directives designed to allow individuals to practice their skills
in a safe environment while they consider the possibility of a life worth
living. The DBT-informed art therapist must possess an understanding
of suicidal thinking, accurately perceive the individual’s capacity for
taking risks, and be knowledgeable of DBT skills training and art
therapy techniques.
Mary required time, patience, and consistent validation through
a gentle approach. The directives I implemented in her therapy were
simple and meant to only do two things: promote discussion about
how the DBT skills might help her to tolerate exposing her repressed
emotional pain, and to express those feelings without self-destructive
 Inspiring and Sustaining Hope 87

behaviors. For Tandy, art therapy facilitated the complex task of

illustrating the client’s observations of her profound ambivalence
concerning positive change and recovery. Further, some of the resulting
drawings confronted Tandy with challenging dialectics.
Both individuals practiced new behavioral strategies in the art
therapy studio while their strengths as survivors were validated.
Developing a sense of competence through mastering art materials
allowed them to work on challenging ineffective thought patterns and
accept the present as it is: imperfect. Practicing mindfulness and self-
soothing skills in the studio promotes greater willingness for adaptive
risk-taking, as well.
Neither Mary nor Tandy could articulate emotions when they first
came to the DBT program. Creativity allowed them to express their
internal experiences symbolically. By examining their drawings’ content,
both women could better understand the negative consequences of
impulsive, mood-dependent behaviors. DBT-informed art therapy
enhanced ability to use skills for tolerating their pain, fear, amotivation,
and dysfunctional response patterns at their own pace. This led to a
belief that staying alive would result in desirable change—thus, they
could at last reject suicide as a solution. It is also important to note that
both Mary and Tandy identified when they were ready to discharge
from the DBT program. We agreed that they possessed the skills needed
to make better decisions regarding whatever life offered.
While I have focused specifically on DBT skills acquisition, the two
case studies also demonstrated more effective symptom management
and the beginning of personality development, which are the other two
components of effective treatment for suicidal behavior described by
Rudd et al. (2001). DBT-informed art therapy enhances one’s ability
to integrate and utilize the DBT skills outside of treatment. It offers
the visualization of choices, avenues for accepting and tolerating the
dialectics of life, and greater understanding of the unpredictable
impulsive urges for suicide. The case study subjects exhibited decreased
acting on such urges, and, consequentially, fewer hospitalizations along
with enhanced quality of life.
This chapter opened with the statement that “no single intervention
has proved sufficient” in solving the problem of suicide (The New
York Times 2018, p.A17). For individuals who struggle with chronic
suicidal ideation, ample time and resources are necessary to achieve
enduring cognitive and behavioral change. Mary and Tandy’s case
88 DBT-INFORMED ART THERAPY IN PRACTICE

studies demonstrate how combined DBT-informed day treatment

programming and art therapy might offer a valuable means of reducing
suicidal behaviors while allowing participants to develop their own
vision of hope. Next steps should include efforts to obtain empirical
support for the value of such interventions.

References
Center for Disease Control and Prevention (CDC) (2018) Table 9. Death Rates for Suicide by
Sex, Race, Hispanic Origin, and Age: United States, Selected Years 1950–2017. Accessed
on 1/4/20 at https://www.cdc.gov/nchs/hus/contents2018.htm#Table_009.
Chapman, A.L. (2006) ‘Dialectical behavior therapy: Current indications and unique
elements.’ Psychiatry (Edgmont) 3, 9, 62–68. Accessed on 5/31/19 at https://www.ncbi.
nlm.nih.gov/pmc/articles/PMC2963469/#__ffn_sectitle.
Chapman, A.L., Turner, B.J., and Dixon-Gordon, K.L. (2011) ‘To integrate or not integrate
dialectical behavior therapy with other therapy approaches?’ Clinical Social Work Journal
39, 2, 170–179.
Clark, S.M. (2017) DBT-Informed Art Therapy: Mindfulness, Cognitive Behavior Therapy, and
the Creative Process. London: Jessica Kingsley Publishers.
Healthcare News (2018) A Different Kind of Health Crisis—Suicide Rates Continue to Rise;
The Question is Why. Amherst, MA: HCN. Accessed on 2/2/19 at https://healthcarenews.
com/a-different-kind-of-health-crisis-suicide-rates-continue-to-rise-the-question-is-
why.
Linehan, M.M. (1993) Cognitive-Behavioral Treatment of Borderline Personality Disorder.
New York, NY: Guilford Press.
Linehan, M.M. (2015a) DBT Skills Training Manual (2nd ed.). New York, NY: Guilford Press.
(Original work published in 1993.)
Linehan, M.M. (2015b) DBT Skills Training Manual (2nd ed.). Handouts and Worksheets.
New York, NY: Guilford Press. (Original work published in 1993.)
Linehan, M.M. (2020) Building a Life Worth Living: A Memoir. New York, NY: Penguin
Random House.
National Institute of Mental Health (2017) Suicide. Bethesda, MD: NIMH. Accessed on
15/3/18 at https://www.nimh.nih.gov/health/statistics/suicide.shtml#part_154968.
New York Times, The (2018) ‘Defying prevention efforts, suicide rates are climbing across
the nation.’ June 7, p.A17. Accessed on 3/17/19 at https://www.nytimes.com/2018/06/07/
health/suicide-rates-kate-spade.html.
Rudd, M.D., Joiner, T., and Rajab, M.H. (2001) Treating Suicidal Behavior: An Effective, Time-
Limited Approach. New York, NY: Guilford Press.
Shea, S.C. (2002) The Practical Art of Suicide Assessment. Hoboken, NJ: Wiley.
Southwick, S.M., Ozbay, F., Charney, D.S., and McEwen, B.S. (2008) ‘Adaptation to Stress
and Psychobiological Mechanisms of Resilience.’ In B.J. Lukey and V. Tepe (eds)
Biobehavioral Resilience to Stress. Boca Raton, FL: Taylor & Francis.
US Department of Health & Human Services (UDHHS) (2012) National Strategy for Suicide
Prevention: Appendix C, Brief History of Suicide Prevention in the United States. A Report
of the US Surgeon General and of the National Action Alliance for Suicide Prevention.
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NBK109917.
von Daler, K. and Schwanbeck, L. (2014) ‘Creative Mindfulness: Dialectical Behavioral
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Therapies: Theory and Practice. London: Jessica Kingsley Publishers.
 Chapter 6

DBT in Action
Art Therapy and DBT Skills Training
in Treating Eating Disorders
SUSAN M. CLARK

Introduction
This chapter presents the rationale for providing art therapy in
conjunction with the skills training curriculum of dialectical behavior
therapy (DBT), an evidence-based treatment for emotion regulation
problems that are often issues for patients struggling with binge
eating disorder (BED) and bulimia nervosa (BN) (Safer, Telch, and
Chen 2009). It describes challenges with teaching DBT skills via the
manualized format and posits how specific art activities might enhance
comprehension and generalization. One group intervention, “DBT in
Action,” was a successful addition to several partial-hospitalization
programs at a private eating disorder (ED) treatment center. I, the
author, suggest how clinicians can practice DBT-informed art therapy
and call for research testing the efficacy of this approach.

Art therapy and EDs

Many ED programs offer art therapy in adjunct to standard treatment
protocols owing to its observed effectiveness in helping patients
tolerate and express intense emotions while ameliorating defense
responses frequently triggered by verbal interventions (Dokter 1994;
Hinz 2006; Levens 2002). Literature concerning art therapy and EDs
is typically psychodynamic (Makin 2002) and describes the reparation
of unconscious conflicts through working with artistic images. Patients
often seem more receptive to their artworks’ insights, perhaps because

89
90 DBT-INFORMED ART THERAPY IN PRACTICE

“the art is something that the individual has created and is thus an
extension of self ” (Blake 2006, p.28). Art making allows patients to
symbolically convey what they cannot explain with words by acting as
“shortcuts” for expressing difficult content (Hinz 2006, p.12). Images
may represent multiple (even contradictory) realities, such as being in
treatment and feeling ambivalent about ED recovery. Because each art
object portrays its maker’s internal experience at a given moment in
time, patients accumulate valuable pictorial records of their therapeutic
progress.
While quantitative research is scarce, mindfulness-based art therapy
(MBAT), the subject of two randomized controlled studies, appears
to improve the mental health of breast cancer patients (Monti et al.
2006, 2012). In both experiments patients reported significant post-
intervention reductions in stress/anxiety. The latter utilized functional
magnetic resonance imaging (fMRI), which revealed blood flow
changes in the left insula, amygdala, and hippocampus—the brain’s
emotional centers. Impaired insula functioning may play a role in
the development and maintenance of anorexia nervosa (AN) (Lask
2011; Nunn et al. 2008). Art therapy has also garnered recognition as a
promising posttraumatic stress disorder (PTSD) treatment (Chapman
et al. 2001; Collie et al. 2006). People with EDs frequently report trauma
histories and/or have co-occurring PTSD (Brewerton 2007).

DBT and EDs

DBT was developed for women who exhibited suicidal and nonsuicidal
self-injurious behaviors (Linehan 1993) and commonly met diagnostic
criteria for borderline personality disorder (BPD) (American Psychiatric
Association 2013). DBT synthesizes change strategies from cognitive
behavior therapy (CBT) with acceptance concepts from both Eastern
and Western contemplative spiritual traditions. Comprehensive DBT
features individual psychotherapy, group skills training, and telephone
coaching to assist with performing effective behaviors outside the
clinical milieu. Practitioners attend peer consultation meetings for
professional support and as a means of ensuring treatment fidelity
(Dimeff and Koerner 2007).
According to DBT’s biosocial theory, pervasive dysregulation results
from repeated transactions between biologically based emotional
vulnerabilities and invalidating social environments (through which
 DBT in Action 91

children learn that their private experiences, i.e., what they believe or
feel to be true, are incorrect or unreasonable). Over time, individuals
develop behavioral strategies such as cutting, purging, and substance
abuse, which, although maladaptive, reduce the intensity of a negative
affective state by avoiding its full experience. Paradoxically, emotion
regulation, DBT’s overarching goal, is facilitated through mindfulness,
an increased and/or enhanced awareness of one’s experiences of oneself
and one’s surroundings (Linehan 2015a).
Mindfulness-based interventions have proliferated in medical
and mental health care during the past two decades (McCown, Reibel,
and Micozzi 2011). Jon Kabat-Zinn, developer of the respected mind­
fulness-based stress reduction (MBSR) program, defines mindfulness
as intentionally attending to the present moment, rather than “reacting
automatically and unconsciously to the outside world and to our own
inner experiences” (Kabat-Zinn 1990, p.11). DBT teaches mindfulness
through sets of interlocking skills. Important concepts include
emotion mind, a state in which individuals are controlled by emotional
dysregulation/reactivity, and reasonable mind, where they can access
logic and critical thinking (Linehan 2015a). DBT assumes that patients
spend most waking hours in emotion mind, resulting in significant
distress and behavioral dysfunction. The desired state, wise mind, is
an “intuitive blend of emotion and reason that radically accepts and
responds to the moment just as it is” (Koerner 2012, p.20).
DBT actively targets problematic behaviors; however, this is
balanced with accepting patients as they currently function. Unique to
DBT are dialectical strategies based on an assumption that any position
(thesis) contains its opposite (antithesis) (Linehan 1993). For example,
a suicidal person can simultaneously want to live and die; similarly,
someone with AN might genuinely desire recovery and be loath to
relinquish their ED. DBT synthesizes opposite stances by accepting
patients and pushing for change: “In a dialectical approach the therapist
agrees that the client’s life is unbearable and that the client needs a
way out, and offers another route, using therapy to build a life that is
generally worth living” (Koerner 2012, p.16).
DBT effectively treats several challenging clinical populations and
issues, especially those involving emotional dyscontrol: substance
abuse/dependence, complex PTSD, suicidal/self-injuring adolescents,
high-conflict couples and families, developmental disabilities, and
certain EDs. Adaptations of the standard outpatient model include
92 DBT-INFORMED ART THERAPY IN PRACTICE

DBT for inpatient psychiatric units, residential forensic settings, and

assertive community treatment (ACT) teams (Dimeff and Koerner
2007). DBT consists of five treatment stages (Linehan 1993):
• Pretreatment reduces the likelihood of premature termination.
Orientation/commitment is ongoing because recurrent dysre­
gulation negatively impacts patients’ ability and/or willingness
to engage with therapy tasks.
• Stage 1 treats patients with the most severe symptomology.
Life-threatening (target 1) behaviors are prioritized according
to lethality. Therapy-interfering/target 2 behaviors include
those that negatively impact the therapy relationship and/or
DBT’s effectiveness. Patients commonly experience multiple
simultaneous quality-of-life-interfering/target 3 issues (e.g.,
co-occurring psychiatric conditions; substance abuse; non-
life-threatening ED behaviors; chaotic/abusive interpersonal
relationships). The objective is to replace targeted behaviors with
adaptive responses. Patients commit to a year of stage 1 DBT.
• Stages 2–4 are briefly discussed later in this chapter.
Eating-disordered behaviors can be maladaptive attempts to regulate
intense emotional states (McCabe, La Via, and Marcus 2004). While
CBT and interpersonal psychotherapy (IPT) are the most empirically
founded treatments for primary EDs (Fairburn 2008; Garner and
Garfinkle 1997), these approaches are ineffective with at least 50 percent
of individuals, particularly those with AN and/or co-occurring mental
illnesses and personality disorders (Wisniewski, Safer, and Chen 2007).
Research suggests that standard or modified/abbreviated DBT is most
helpful for less complicated clinical situations, such as the binge eating
and/or purging associated with BN and BED; this could relate to the
behavioral impulsivity that DBT targets and improves (Blake 2006; Safer
et al. 2009). According to preliminary findings, patients with severe EDs
and comorbidities may require intensive interventions, including full-
model DBT in addition to standard outpatient ED treatment (Federici,
Wisniewski, and Ben-Porath 2012).
One exciting new development is radically open DBT (RO-DBT)
(Lynch 2018a) for problems of emotional overcontrol (OC). Unlike
disorders of severe emotional under-control/dysregulation that
respond so well to standard DBT, OC disorders are characterized by
 DBT in Action 93

extreme perfectionism, aversion to novelty and risk, reduced affective

expression, difficulty recognizing the emotional cues of others, and
social aloofness. Examples include anorexia nervosa, restricting type
(AN-R), obsessive-compulsive personality disorder, and refractory
major depression (Lynch et al. 2013).
Lynch hypothesizes that OC individuals possess an inherent threat-
sensitivity that, when it occurs with family/environmental experiences
“emphasizing mistakes as intolerable and self-control as imperative”
(Lynch et al. 2013, p.3), may eventually result in chronic activation of
the sympathetic nervous system. Rather than focusing on cognitive
restructuring and affect regulation strategies, RO-DBT directly treats
neurophysiological arousal mechanisms so that patients become at
ease and are thus able to participate in more spontaneous and genuine
social interactions. RO-DBT interventions activate the ventral–vagal-
mediated parasympathetic nervous system (the social-safety system)
(Lynch et al. 2013) by having individuals deliberately change their body
postures and facial expressions. Once patients feel safe, they can better
tolerate interventions directly targeting OC symptoms.
One article described an RO-DBT-informed treatment program
for AN-R at an inpatient ED hospital unit located in southwest
England (Lynch et al. 2013). It contains several ancillary interventions
including art therapy groups designed to provide exposure to novelty
and opportunities for practicing letting go of perfectionism. Other
expressive modalities come into play during the “Themed Applications
Skills Week,” which occurs every two months when the unit’s normal
schedule is suspended so that staff and patients may “join together to
practice radical openness skills, share community meals, and practice
playful spontaneity (e.g., Taiko Drumming, Film Making, Fancy Dress,
Pantomime)” (p.6).
RO-DBT’s skills curriculum (Lynch 2018b) includes some
standard DBT concepts and skills as well as many unique ones. During
participation in an intensive training (Lynch 2015), I discovered that
many of the challenges I experienced providing art therapy to patients
with AN-R were described and explained in the model. This chapter
introduces an intervention that explores radical openness, RO-DBT’s
core skill, through combined loose and controlled artistic media.
Because they directly address the excessive inhibitory control so
characteristic of AN-R, RO-DBT-specific art therapy interventions
might become valuable to the application of art therapy for EDs.
94 DBT-INFORMED ART THERAPY IN PRACTICE

DBT skills training

Skills remedy emotion regulation deficits. Standard DBT skills
instruction follows a group-based psychoeducational format (Linehan
2015a, 2015b). Three of the four modules—interpersonal effectiveness,
distress tolerance, and emotion regulation—appear in consecutive
multi-week cycles. Two mindfulness lessons separate them, resulting
in 24 weekly sessions. Patients are exposed to each module twice during
their stage 1 treatment year.
DBT skills teach either acceptance (mindfulness/distress tolerance)
or change (emotion regulation/interpersonal effectiveness). Acceptance
skills are appropriate when current stressors or emotions cannot be
significantly reduced/eliminated. Change skills help to achieve goals
such as solving problems, decreasing susceptibility to emotion mind,
and building and/or maintaining relationships.
My experience has been that many patients dislike DBT’s handout
and worksheet-based curriculum. Although skills training employs
metaphor, storytelling, and brief experiential mindfulness activities,
patients frequently complain of confusion or boredom to even the
more experienced and dynamic group leaders. While the revised
manual (Linehan 2015a, 2015b) includes expanded teaching notes,
the model remains highly didactic and therefore may not be as helpful
to those with nontraditional learning styles. Participant feedback
concerning a DBT partial-hospitalization program for EDs included
these suggestions: make groups more interesting and include additional
opportunities for mindfulness practice (Federici and Wisniewski 2013).

DBT-informed art therapy

DBT-informed art therapy involves the strategic use of creative visual
exercises to teach stage 1 DBT concepts and skills. Although no
formal evidence-based protocol yet exists, several art therapists have
written about their interventions. Most published material hails from
English-speaking countries other than the United States (Huckvale and
Learmonth 2009; Rothwell and Hutchinson 2011; Shiell 2008). However,
one journal article (Lebowitz and Reber 2011) describes a DBT-
informed expressive arts curriculum at McLean Hospital’s renowned
inpatient adolescent unit (Belmont, Massachusetts). Another explores
psychodynamically oriented art therapy coordinated with skills training
 DBT in Action 95

in a Baltimore, Maryland residential psychiatric treatment facility for

adults (Heckwolf, Bergland, and Mouratidis 2014).
DBT-informed art therapy engages the mindfulness participating skill
(Linehan 2015b). Some clinicians believe that making art slows down
learning while activating and exposing patients to positive emotions. The
novelty of engaging in creative activities may facilitate mindful attention,
as well. This phenomenon could be related to bilateral integration, in
which the left and right brain hemispheres are trained to communicate
more effectively, resulting in improved emotion regulation and stress
management (Hass-Cohen and Carr 2008; Siegel 2012). Group members
often describe coming away with a deeper understanding of the skills;
furthermore, resulting art products can be helpful reminders of important
work long after therapy sessions have concluded.
A unique challenge of teaching DBT skills to acute ED patients
involves the cognitive consequences of malnutrition. It is not unusual
for individuals, once the refeeding process is complete or well underway,
to have forgotten many details of their early weeks in treatment. I have
encountered patients who, when asked to recall the name of a certain
skill and idea, were not able to do so; however, they remembered the
corresponding experiential exercise and also accurately described its
general learning objective(s).

Models of DBT-informed art therapy

Stage 1 DBT skills training incorporates art therapy in several possible
ways. Note that each of the following models might include individual-
or group-based interventions.
• Combined: One standard DBT skills session containing a related
art activity.
• Sequential: Two weekly sessions. The first teaches the skill(s) in
the usual didactic format. A subsequent session features a related
art activity.
• Art-based/parallel process: These DBT-themed sessions
do not follow a set modular progression, although patients
may simultaneously receive comprehensive DBT or attend a
skills group. Examples from an inpatient adolescent program
(Lebowitz and Reber 2011):
96 DBT-INFORMED ART THERAPY IN PRACTICE

– Visual journaling groups with skills-based prompts.

– Goal-setting groups using expressive arts to help patients
structure their time and balance priorities.
– Self-esteem workshops with projects completed over extended
time periods (themes include values, identity, building a life
worth living).
• Interdisciplinary: Skills training and art therapy services existing
within a highly coordinated and collaborative team milieu
(e.g., a residential treatment program) (Heckwolf et al. 2014)
and incorporating a few or several modalities and theoretical
frameworks.
• Free-standing: Experiential sessions that utilize DBT language
and assist participants in enhancing their grasp of previously
learned skills. Clinicians might design interventions for stage 1
DBT graduates (Dyer 2008) on topics such as advanced mind­
fulness and emotional expression techniques.

Characteristics of the DBT-informed art

therapist/art therapy process
Over the course of my career, I have identified several characteristics/
qualities that I believe are vital to the integrity of DBT-informed
art therapists and the therapy process. Below are some of the most
important (Clark 2017):
• Knowledgeable.
Clinicians should achieve basic competency in both art
therapy and DBT. Solid understanding of their theoretical
underpinnings, objectives, and protocols is essential, as is general
skill with their applications to EDs.
• Radically nonjudgmental.
It is important to consistently emphasize the nonjudgmental
nature of DBT-informed art therapy. Individuals struggling
with EDs tend to exhibit perfectionism (Cassin and von Ranson
2005) and approach art therapy with significant performance
anxiety. Many denigrate their abilities yet are quick to offer
complimentary critiques of peers’ artistic products: “That’s so
pretty,” “You are such a good artist,” etc. The therapist can gently
 DBT in Action 97

note such comments, then invite rephrasing in an observe-and-

describe manner. This may involve simply owning the judgment
(e.g., “I like it” or “I think the combination of blue and yellow is
striking here”), therefore accentuating the differences between
fact and opinion. If patients tolerate that level of intervention,
therapists might then introduce emotional responding: “If you
didn’t know anything about the image and who made it, what
might you guess the artist may have been feeling? Why?”
It is equally important to validate patients’ fears around not
being competent at something and encourage them to risk joining
the process, anyway. Such a gamble holds great potential for new
learning, perhaps even reparative experiences. Many associate
drawing and painting with emotional wounds originating from
their elementary school classrooms:
Art is often an area where people have experienced shaming,
humiliation, and invalidation. Fear makes us stupid, and
trauma is completely paralyzing. Ways through and beyond
this paralysis and terror can only be achieved by gentle but
strategic and challenging interventions. When overwhelmed…
to be able to think even one thought or notice one real thing
is the beginning of breaking up the cycle. (Huckvale and
Learmonth 2009, p.61)
Art therapists offer predictably nonjudgmental environments
where patients can experiment with nonverbal self-expression:
“Persons with eating disorders need to understand that there
are no expectations of beauty… They need to be free to create
whatever best embodies their feelings and thoughts at the time”
(Hinz 2006, p.18). Coping with the less-than-perfect requires
patience and practice. One woman’s enthusiasm for art eventually
became greater than her worry about making a mess. “The latex
gloves came off because it was easier and more precise to blend
chalk pastels with a bare finger. Engaging with the materials led
the way” (Huckvale and Learmonth 2009, p.55). This is cognitive
restructuring in action. Lebowitz and Reber (2011) described
how, when orienting new residents to the art therapy group, one
young woman stated that it was a place where she challenged her
need for perfection.
98 DBT-INFORMED ART THERAPY IN PRACTICE

• Validating.
Clinicians provide validation by conveying that an individual’s
point of view and behavior “make sense and are understandable
within her current life context or situation… The therapist
takes the patient’s responses seriously and does not discount or
trivialize them” (Linehan 1993, p.223). Assuming that behavior
is adaptive to the context in which it occurs, the therapist actively
looks for, identifies, and describes reasonable aspect(s) of the
patient’s response to events. Validation supports DBT’s change
strategies and teaches patients to validate themselves over time
(Koerner 2012).
Model validation by appreciating all creative products as
examples of genuine self-expression. Every image possesses value
unrelated to appearance or the level of technical skill required
for its creation, simply because it exists and reflects the unique
characteristics of its maker, who, through the therapy process,
gradually discovers that they, too, are essentially valid. This is
the kernel of truth, the metaphorical golden nugget lying behind
the dross of ineffective behaviors and cognitive distortions
(or, perhaps, unpleasant color combinations and skewed
perspective). The goal is to encourage patients to discover their
“personal expressive style” (McNiff 1981, p.38). The art therapist,
who by the nature of the work communicates greater interest
in the person and their creative process than in the ED itself,
conveys an acceptance that might ultimately translate into self-
acceptance (Hinz 2006).
Group art therapy facilitates exploration of personal issues
within a nonthreatening environment. Patients validate each
other’s realities by exchanging visual and verbal feedback.
Experiential groups, by acknowledging and accommodating
the needs of those with nontraditional cognitive styles, assist
kinesthetic and tactile learners to absorb didactic concepts.
Furthermore, “the ability to frame clinical material in a personal
and creative way offers an opportunity for self-validation as well
as the development of identity through the creation of personal
imagery” (Lebowitz and Reber 2011, p.339).
• Dialectical.
Art therapists design opportunities for patients to practice
 DBT in Action 99

dialectical thinking, through which “contradictory truths do not

necessarily cancel each other out or dominate each other, but
stand side by side, inviting participation and experimentation”
(Miller, Rathus, and Linehan 2007, p.39). I enjoy introducing
patients to “raw” (Rhodes 2004, p.7) or “outsider” (Rexter 2005,
p.11) works by self-taught artists, many of whom have mental
illnesses or other disabilities (Maizels 1996). Patients are usually
quite impressed, if not inspired, by their emotional power
and artistic integrity, despite lack of technical sophistication.
Similarly, when patients struggle with materials and harshly judge
themselves for failing to create “perfect” products, therapists can
reframe this as a learning experience (Makin 2002). As Lebowitz
and Reber (2011) explain:
We also modeled and talked residents through experiences
of “mistakes” using them as opportunities to practice self-
validation and to recognize that each time we attempt something
new and do not reach our original concept of success, we have
either opened ourselves to a new definition of success or at least
we have uncovered new information about what does not work,
therefore bringing us closer to what does work. (p.342)
In the treatment of Elaine (Huckvale and Learmonth 2009),
a chronically suicidal and self-harming woman, the clinician
designed a practical approach in which she could explore
her strong interest in art, and eventually make significant
therapeutic progress, through structured exploration of media
and techniques. The clinician was careful not to push a change
agenda, as this can be invalidating and sometimes results in
producing more—or worse—symptoms/behaviors (Linehan
1993). Elaine viewed the sessions as a chance to “have a rest
from her problems, not…where she would confront, work on, or
change them. It was an attempt to create a space uncontaminated
by previous failed attempts to change” (Huckvale and Learmonth
2009, p.55). Art therapy as constructive diversion is occasionally
“the only effective way to develop the therapeutic relationship
enough to stay out of the destructive emotional whirlpools
long enough for change to become possible” (Huckvale and
Learmonth 2009, p.56).
100 DBT-INFORMED ART THERAPY IN PRACTICE

Here, the art therapist was…also being directly “behaviorist”

(the art therapist would ask, “I wonder how it would be if you
try doing the same thing but in charcoal?” Or, “painting seems to
be going really well; how about trying to paint a new ‘subject’?”).
Making art is a physical “doing,” an action in the here-and-now.
The art therapist was working with Elaine to make different
behaviors, and thus feelings, possible within a very particular
container. Crucial to the container, of course, was the emphasis
on building the right kind of therapeutic relationship to make
the risk feel possible. Acceptance was embraced in the session
structure and the relationship. The possibility was explored
through the art materials. A dialectic between them was opened
up for reflection. (p.56)
Rothwell and Hutchinson (2011) describe the parallel-process
partnership of an art therapist and a clinical psychologist in
helping Elizabeth, who had survived extensive childhood sexual
abuse. The therapists viewed their eventual collaboration as akin
to a parental couple—one acting as “the thinking father (DBT)”
(p.19) who taught skills for change, the other “the emotional
containing mother (Art Therapy)” (p.20) who provided
acceptance, validation, and a safe environment where Elizabeth
could symbolically express her intense feelings and destructive
impulses. This allowed Elizabeth to simultaneously experience
the present, learn and practice skills, and begin working through
traumatic memories.
• Safe.
The art therapist of popular imagination possesses an almost
mystical ability to perceive symptoms, conflicts, and secrets in
patient artwork. Individuals diagnosed with EDs seem to believe
and fear this myth, and therefore may require repeated assurances
that their images will not be psychoanalyzed. Stage 1 DBT
participants typically experience interpretation as excruciatingly
intrusive/controlling. By not assuming to know any ultimate
meaning, the art therapist creates an environment conducive to
self-awareness, such as when a patient in the process of talking
about a drawing suddenly realized that “his words didn’t match
his picture” (Rabin 2003, p.24).
 DBT in Action 101

Throughout their parallel-process art therapy/DBT work

with Elizabeth, Rothwell and Hutchinson (2011) composed
two validating environments, both of which encouraged her
“to experience her emotional world without pathologizing
her or seeking to directly investigate the root causes” of her
issues (p.24). In many cases, it is better to work on containing
feelings instead of attempting to understand and transform
them (Dokter 1994; Levens 2002), an empathetic “building up
rather than uncovering” (Shiell 2008, p.61). I have noticed that
structured art directives reduce the likelihood of regression
and acting-out behaviors. However, DBT-informed art therapy
provides opportunities for spontaneity, as well, and this synthesis
is essential for managing ED patients’ coexisting terror of losing
control and need for cognitive flexibility: “The challenge is to
present the individual with tasks that require focus but also
permit freedom within the art task… This provides a balance:
freedom within form; I call it a safe haven” (Rabin 2003,
pp.27–28).
Over the course of approximately 4 years, I designed and implemented
weekly 60-minute sequential art therapy groups in my facility’s CBT-
and DBT-adherent adult and adolescent partial-hospitalization
programs. These “DBT in Action” groups were generally well-received;
however, as might be expected, they were significantly less popular
with patients suffering from AN-R (especially those with comorbid
personality disorders) whose profound perfectionism and rigidity
persist within even the most nonjudgmental experiential group
environments. Clinicians should practice accepting these patients’
limitations by allowing them to participate as much or as little as they
are able, while balancing an expectation that they attend to the process
(i.e., remain alert) and offer appropriate verbal feedback to peers.

STAGES OF DBT-INFORMED ART THERAPY

Stage 1 DBT-informed art therapy
The number and variety of effective DBT-informed art therapy activities
is limited only by a clinician’s creativity, skill, and enthusiasm. Most
naturally facilitate mindfulness practice, effective emotional expression,
102 DBT-INFORMED ART THERAPY IN PRACTICE

and mastery. One can also design projects to help teach and reinforce
specific skills. What follows is an abbreviated selection of experientials
that I devised for my clinical practice.

Mindfulness
Therapists can transform practically any visual art exercise into a
mindfulness lesson. The following are two ways of experiencing and
practicing mindfulness.

UPSIDE-DOWN DRAWING (ADAPTED FROM EDWARDS 2012, PP.17–26)

Collect various coloring pages from books and the internet—ones
sufficiently complex to hold the interest of adolescents and adults, but
not so detailed that they would be extremely difficult or time-consuming
to copy by hand. Briefly demonstrate how to start by placing unlined
paper beside an upside-down coloring page of the same or similar size
and beginning to copy the image (no erasing). Encourage participants
to refrain from verbally labeling features along the way (e.g., “that’s an
upside-down ear”), but rather observe the lines and their relationships
to one another. Once they complete and view drawings right side up,
they are often pleasantly surprised by their technical accuracy. Patients
may then color/embellish images to create original works of art.

STATES OF MIND SYMBOLS

Participants make mandalas (circle drawings) representing their
experiences of the three states of mind. Advise against resorting to
written words and/or common symbols (hearts, smiley faces); rather,
encourage artists to convey the essence of each through color, shape,
and form. Another option is to replace, or elaborate upon, the wise
mind mandala by painting a papier-mâché mask form to depict what
one’s wise mind might look like if personified. Lebowitz and Reber
(2011) describe an experiential where patients identify one or more
women they view as particularly wise-minded and come up with some
colors and images to represent her/them: “We invite the residents
to think of women they admire and the qualities that inspire their
admiration, and challenge them to think about how they might embody
these qualities themselves” (p.340). Patients write for about 10 minutes,
and then make visual representations of their “inner wise woman” using
drawing media and magazine images.
 DBT in Action 103

Interpersonal effectiveness
In this module, patients learn how to pursue personal objectives
by saying “no” and/or asking for what they want while preserving
important relationships and maintaining self-respect (Linehan 2015b).
The activities consist primarily of role play exercises for practicing
assertive communication. However, I designed a brief drawing sequence
to enhance participants’ understanding of presented skill sets (one of
which appears below).

INTERPERSONAL-STYLE SKETCHES
After brainstorming definitions and examples of passive, aggressive,
passive-aggressive, and assertive/interpersonally effective behaviors,
participants create representations of the first three by portraying each
person as a stick figure, symbol, or abstract representation. Urge group
members to show, not tell (i.e., suggest behaviors through images rather
than written words). Patients then share their pictures, guessing and
describing behaviors. This usually prompts discussion around how it
feels to be on both the giving and receiving ends, as well as possible
motivating factors (e.g., aggression/anger may be secondary to fear).
The next step is to similarly portray a current important relationship.
Patients then create larger drawings illustrating what those relationships
might be like if they, at least, behaved in more interpersonally
effective ways.

Emotion regulation
Emotion regulation skills help patients identify and understand the
purpose of emotions, reduce vulnerability to emotion mind, and
decrease the frequency of unwanted emotions and emotional suffering
(Linehan 2015a, 2015b). The following activity facilitates this by
exposing patients to their feelings in a safe, contained manner.

DRAWING YOUR EMOTIONAL HURRICANE, ROLLERCOASTER, OR WAVE

Mehl (1997) asked patients to draw their dysregulated emotions
as hurricanes. I provide comparable prompts; for example: Draw or
paint a feeling in landscape form or as a real or imaginary nonhuman
creature (and then respond to some written questions concerning
the creature’s personality, natural habitat, what it would say to the viewer
if it could speak, and so on). These allow for sufficient objectivity to
observe, describe, and better understand emotional experiences. In
104 DBT-INFORMED ART THERAPY IN PRACTICE

the rollercoaster assignment, the emotional crisis cycle becomes the

twisting and turning rail upon which the patient-as-coaster-car travels.
Participants label their thoughts, feelings, and behaviors leading up to
a crisis, the crisis itself, and what happens on the way down (as the
crisis abates and eventually concludes). The result is, essentially, an
illustrated behavior chain analysis (BCA). BCAs are painstaking, step-
by-step/cause-and-effect descriptions of events leading up to, during,
and following maladaptive behaviors (Linehan 1993).
In Figure 6.1, the person symbolizes her anxiety’s life cycle as a
wave that begins, increases in intensity, reaches maximum power, and
gradually declines. She included a numeric scale to identify the level
of distress, as well as a skills breakdown point where her emotion is
so extreme that she can no longer problem-solve and/or use complex
coping strategies. Notice how she listed appropriate behavioral
responses for all phases of the emotional experience. The wave drawing
activity can also teach urge surfing, which involves riding out a strong
desire to engage in ED behavior(s) (Safer et al. 2009).

Figure 6.1 Drawing of an emotional wave

 DBT in Action 105

Distress tolerance
Many distress tolerance activities are specific to skills retrieval and
generalization. For example, since patients are apt to forget potentially
helpful skills during periods of intense emotional arousal, they make/
decorate portable booklets in which they list various crisis survival and
reality acceptance strategies (Linehan 2015a, 2015b). They also might
assemble kits for distraction and self-soothing (e.g., puzzle books,
silly putty or clay, aromatherapy products) and have each for specific
situation(s) or environment(s) (e.g., automobile, purse, office, locker).
One adolescent patient used his pet rock and habitat (Clark 2017) to
help him get through difficult therapeutic meals in a day treatment
program; he would place it on the table beside his eating utensils.

PERSONAL ZEN GARDENS

The therapist introduces the Zen garden, explains its role in mindful
contemplation, and demonstrates how patients will construct their own
using inexpensive photo frames, foam board, and sand (Figure 6.2).
Twigs, seashells, stones, smooth pieces of colored glass, acorn caps,
small wooden craft sticks, and toothpicks are available for decoration
and to build rakes and other “gardening” tools. Patients seem to obtain
great enjoyment from creating unique Zen gardens. Several have
reported keeping them in their bedrooms or other convenient locations
and rearranging the contents and/or sand designs (as a way to focus
their thoughts and self-soothe).

Figure 6.2 A Zen garden

106 DBT-INFORMED ART THERAPY IN PRACTICE

Radical openness (RO)

RO is the key skill in RO-DBT. Lynch defines it as a willingness to
consider new (and perhaps personally disconfirming) information
and feedback, as well as an ability to respond flexibly to the current
moment. RO is often extremely challenging, since it involves “actively
seeking out those areas of one’s life that one wants to avoid, or may find
uncomfortable, in order to learn” (Lynch 2015). Patients may practice
by acting opposite to the typical OC desire to rigidly control the creative
process and art product.

SMUGGLING WATERCOLOR
Smuggling is a therapeutic strategy of gently suggesting the possibility
of a reality different from what the individual believes to be absolute
truth. Lynch (2015) calls this “getting new information under the
barbed-wire” of a patient’s defenses. Individuals with AN-R and other
OC conditions usually despise watercolor due to the medium’s loose,
unpredictable nature. However, art therapists can smuggle the potential
value of letting go of some control by mentioning that the final product
will likely be more desirable if, during the first part of the activity, one
allows the watercolor to do what it wants on the dampened paper. It
is also helpful to assure them that, during the second part, they will
receive opportunities to take back some control. Instruct patients
to experiment with applying a variety of watercolor pigments onto
dampened paper, allowing them to freely bleed and intermingle over
the entire surface. After the piece has dried, either naturally or with a
hairdryer, patients can add to it as desired with high-control media (e.g.,
markers, pens, watercolor pencils, and/or oil pastels). The paper may
also be cropped or cut into other shapes. I have observed that those who
allowed themselves to participate as directed were often thrilled with
aesthetically pleasing results. And, perhaps most importantly, afterward
they seemed somewhat less convinced that controlling everything is
always an effective habit (at least when engaging in art).

Stage 2 DBT-informed art therapy

Stage 2 assists those who have achieved stability to address PTSD-
related issues, including intrusive symptoms (e.g., flashbacks,
nightmares), situational avoidance, and self-invalidation. Patients who
enjoy and benefit from stage 1 DBT-informed art therapy might choose
 DBT in Action 107

to continue as they enter stage 2. PTSD treatment pioneer Bessel van

der Kolk (1996) advocates the creative therapies in treating traumatized
individuals who have lost the ability to verbally communicate their
internal experiences:
Prone to action, and deficient in words, these patients can often express
their internal states more articulately in physical movements or in
pictures than in words. Utilizing drawings and psychodrama may help
them develop a language that is essential for effective communication and
for the symbolic transformation that can occur in psychotherapy. (p.195)
Another option is a graduate group designed to assist individuals
with reinforcing and generalizing previously learned DBT skills (Dyer
2008). Interventions focus on practicing mindfulness through image
making and other creative activities with the intention of more deeply
integrating skills acquired during stage 1.

Stage 3 DBT-informed art therapy

Because stage 3’s goal is to build a life worth living—one of ordinary
happiness and unhappiness (Linehan 1993)—and patients are now
presumably skilled enough to manage any resulting emotional
dysregulation, body image work might be indicated here. Rabin (2003)
and Hunter (2012) describe compelling art therapy interventions for
body image problems. There is also a plethora of qualitative literature
concerning art therapy for other quality-of-life-interfering conditions
(e.g., depression, chemical dependence, debilitating physical illness)
(Malchiodi 2003); theoretical frameworks include psychodynamic,
humanistic, and cognitive behavioral (Rubin 2001).

Stage 4 DBT-informed art therapy

Stage 4 addresses the incompleteness some patients experience
after problems in living are resolved. Individuals seeking a sense of
connectedness to a greater whole might explore spiritual traditions or
contemplative practices. Renowned psychiatrist James F. Masterson
(1990) made a case for the arts in resolving personality disorders
and went so far as to say that creativity is the birthright of all fully
functioning human beings. Masterson believed that individuals with
a healthy sense of self possess the “potential for leading a creative
108 DBT-INFORMED ART THERAPY IN PRACTICE

life and dealing with problems and challenges in new ways” (p.208).
Those who deeply value artistic endeavors might pursue stage 4 with
a transpersonal and/or explicitly spiritual art therapy practice (Allen
2005; Farrelly-Hansen 2009; Horovitz 2002).

Conclusion
What might the future hold for this approach? Other creative arts thera­
pists are beginning to work in a DBT-informed manner: some music
therapists integrate their techniques with skills training (Plener et al.
2009; Spiegel, Makary, and Bonavitacola 2020), and a drama therapist has
written about her experiential method of teaching skills to women with
EDs (Rubin 2008). Additionally, recent neurobiological research suggests
benefits from applying multi-sensory interventions to learning (Shams
and Seitz 2008) and the treatment of complex PTSD (Hass-Cohen and
Carr 2008); to this end, certain art therapists have explored multi-modal
processes combining visual art, music, movement, drama, and creative
writing (von Daler and Schwanbeck 2014).
Perhaps DBT skills training featuring expressive arts interventions
will one day become an evidence-based treatment. Unfortunately,
many art therapists lack the necessary background and/or interest in
quantitative methodologies, which may warrant collaboration with
colleagues versed in conducting research. Such joint efforts could
help build the body of research and foster the use of DBT-informed
art therapy. Lebowitz and Reber (2011) suggest starting with following
patients as they enter a combined DBT/art therapy model through
at least six months post-discharge. The results of such a qualitative
project might then facilitate small randomized studies comparing
DBT-informed art therapy with “treatment-as-usual”: skills instruction
through the standard didactic model.

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 Chapter 7

DBT-Informed Ceramic-Based Art

Therapy Groups for Adolescents
Educating the Community About the Impacts of Sexual
Abuse Through Public Exhibition and Social Activism
SHELLEY KAVANAGH

Introduction
My first exposure to dialectical behavior therapy (DBT) was close to
20 years ago, not long after I had begun my career as an art therapist.
It took place during a camping trip with my children and some family
friends. We were all seated around the campfire when, suddenly, a
pager went off. The pager in question belonged to Dr. Shelley McMain,
a friend who had recently started working with Marsha Linehan,
clinical psychologist and the developer of DBT. I watched as Shelley
rummaged for her pager, then called someone back on what would
now be considered a prehistoric cell phone. While Shelley attended to
the emergency I was struck by the calm and direct manner she used
with her distressed client (who needed help managing high urges to
engage in self-injury). I soon learned how this form of therapeutic
communication, phone coaching, provides support outside of traditional
office hours—particularly for individuals struggling with borderline
personality disorder (BPD) (Linehan 1993).
DBT evolved from Linehan’s efforts to create a treatment that
directly targeted suicidality. Initially, her interventions were so focused
on changing problematic cognitions and behaviors that many recipients
felt misunderstood, invalidated, and criticized (and, consequently,
often dropped out of treatment). As the research developed, however,
Linehan added techniques intended to convey validation and help
clients accept themselves, their thoughts, and intense emotions. DBT

112
 DBT-Informed Ceramic-Based Art Therapy Groups for Adolescents 113

eventually came to rest on a foundation of dialectical philosophy (Marx

and Engels 1970), whereby therapists strive to continually balance/
synthesize acceptance and change-oriented stances (Linehan 2020).
DBT relies heavily on the use of validation and metaphor (Koerner
2012). Further, it combines standard cognitive behavior therapy (CBT)
with mindfulness concepts and skills largely derived from Buddhist
meditation practices (Linehan 1993).
During the years that followed I built a career as a DBT-informed
art therapist and, in 2009, began formal DBT training that included
a two-year practicum at the Centre for Addiction and Mental Health
(CAMH). My educational activities eventually led to the development
of a ceramic-based art therapy group for child and adolescent sexual
abuse survivors. Now in its 17th year, the program invites participants
to gather and sculpt their experiences of trauma and healing into
clay. This form of expression has helped many of my clients to reduce
often longstanding self-harming behaviors. In addition, they receive
opportunities to share their stories with the public through exhibits at
The Gardiner Museum of Ceramic Arts. Children and youth between
6 and 19 years old are supported by the expertise of a distinguished
ceramic artist (Lynn Fisher) and a credentialed art therapist (me), as
well as a supportive group of co-facilitators that changes from year to
year for education and training purposes.
This chapter highlights how clay-based DBT-informed art therapy
groups integrate safety, self-regulation skills, resilience enhancement,
and body-based mindful awareness practices. An essential component
is social activism, which plays a key role in helping young artists to
identify themselves as “thrivers” (Dinsmore 1991, p.46). Thriving is the
recovery stage in which a trauma survivor has healed to the point where
she enjoys general life satisfaction and is forward-focused. Thanks to
collaborations between Radius Child and Youth Services (formerly the
Sexual Abuse Family Education Treatment/“SAFE-T” program) and
The Gardiner Museum, projects spanning almost two decades have
raised awareness about mental health issues. To help adolescents who
self-injure cope with the trauma of sexual abuse, this program bridges
what begins as a private and individual recovery process to a collective,
political one. Communal exhibits support these young people in finding
their creative voices, challenging histories that previously oppressed/
silenced them, authoring alternative stories of hope, and experiencing
themselves as artists who actively contribute to social change.
114 DBT-INFORMED ART THERAPY IN PRACTICE

The foundation
My desire to provide young people with the skills necessary to reduce
or eliminate impulsive and self-harming behaviors emerged when I
was little more than an adolescent myself. I first volunteered, at age 18,
to teach art in an open custody facility for youth convicted of criminal
offenses. Open custody facilities are small, highly supervised residences
generally located within the community. The individuals I encountered
struggled with significant emotion regulation problems; as a result, they
often behaved impetuously and came into conflict with house staff
(authority figures the youth sometimes viewed as akin to their abuse
perpetrators). According to the Crisis and Trauma Resource Institute,
most youth who break the law are trauma survivors (Oudshoorn 2016).
Research consistently shows that as many as 90 percent of offenders
between the ages of 12 and 17 years old have experienced some sort of
childhood trauma (Abram et al. 2004; Oudshoorn 2020).
Creating art relaxed the young residents; as a result, they were more
willing to talk about personal experiences. During moments of calm
self-reflection they often commented about how art helped connect
them to the present. They could step away from their usual patterns of
ruminating about the past and/or worrying about future unknowns.
Only years later would I fully understand that the art making activities
cultivated mindfulness, the core skill in DBT (Linehan 2015a, 2015b).
This would profoundly shape my life and work.
In my early 20s I became a counselor for Street Outreach Services
(SOS), a Toronto agency serving adolescents who had been trafficked
into prostitution. Self-harm was common among the clients. Many
also used various substances in their efforts to avoid the unbearable
emotional pain of childhood physical and sexual abuse. During this
same time period I was also employed with an Etobicoke senior high
school (in Toronto’s west end) for teens with similar risky behaviors
and unique learning styles. Like their counterparts at SOS, most of my
students disclosed significant trauma histories. While participating in
the expressive arts program they shared stories about witnessing and
being subjected to violence or abuse. They, too, typically engaged in
self-harm to numb the intensity of their internal chaos.
Another commonality between the youth at SOS and the Etobicoke
students was a drive to channel emotional suffering through visual self-
expression. They did this by drawing or spray-painting on public walls
and bathroom stalls (as well as anything else they viewed as a potential
 DBT-Informed Ceramic-Based Art Therapy Groups for Adolescents 115

canvas). I also noticed that, just as the youth in the open custody facility
developed a greater capacity to attend to the present moment through
art therapy, many of the students with learning disabilities seemed to
become better able to focus and process new material. I believe that
that was a direct result of the arts-based trauma therapy they received.

ALICE’S STORY
This was particularly true for one 16-year-old girl receiving therapy for
intrafamilial sexual abuse at the SAFE-T program. A prominent adolescent
psychologist had diagnosed Alice with cognitive delays, and she was not
expected to ever function independently. Alice attended my ceramic-based
art therapy group as part of her treatment plan. This group, co-facilitated
at that time by my brilliant colleague Karen Holladay, comprised ten young
women between the ages of 13 and 18.
For Alice, creating, and then verbally processing, her sculptures
provided the structure and safety she needed to eventually talk about being
drugged and then molested, which she described as feeling “like falling
down the rabbit hole” in Lewis Carroll’s famous novel Alice in Wonderland
(2001). Alice had previously talked about experiencing the world around
her as if “in a fog”—that is, nothing ever seemed real, tangible, or hopeful.
However, once she had established herself as part of the art therapy group’s
community, Alice felt comfortable enough to begin disclosing further details
of her abuse history within individual psychotherapy sessions. Over time
she also grew more aware, focused, and capable of attending to the present
moment rather than continuously feeling “stuck in the past” as before. After
18 months of therapy, Alice went on to study at a community college. She
even published a poem about her trauma recovery.

Working through trauma with one’s hands

Given the medium’s unique properties, sculpting with natural clay may
be well suited for trauma-informed art therapy:
Clay work is a body-based psychotherapy that can be used in healing
grief, depressed mood, anger, and fear (Sherwood 2004). As a form of
clay work, Clay Art Therapy (CAT) combines nonverbal and verbal
elements in the psychotherapeutic processes. The processes of clay work
integrates the experience and of multi-sensory modalities (tactile, visual,
116 DBT-INFORMED ART THERAPY IN PRACTICE

proprioception (Elbrecht 2013), auditory), and kinesthetic activities in

interacting with clay that range from gentle touch…to intense input
of physical energy (e.g., pounding, rolling, molding clay slump). The
processes of creating personally meaningful clay products require
intense participation of perceptual skills, affective expression, creating
symbolically meaningful clay works, cognitive functions (e.g., memory,
decision making, organizational skills), and creative ability. These various
processes can help raise the ability to properly understand emotion
and better control of emotional expression. Through these processes,
distorted thoughts and emotions can also be progressively restored and
organized into a holistic piece (Carr 2008). Verbal expression of emotions
will eventually become easier in psychotherapeutic process that can
potentially benefit improvement of alexithymia (Nan and Ho 2014). (Nan
and Ho 2017, p.238)

According to author and trauma specialist Noah Hass-Cohen (Hass-

Cohen and Carr 2008), making art together in a group environment
fosters healthy interactions, connectedness, and a sense of belonging
that transcends language. Further, I suspect that our particular
art therapy group, featuring as it does a profoundly sensory-based
modality, supports growth in the brain areas where previously only
trauma resided. Clay is indeed a unique medium. A recent randomized
controlled trial (RTC) study showed that a clay/sculpture intervention
was more effective in reducing depression and improving general
mental health (and a sense of well-being) than was a nondirective two-
dimensional visual art intervention (Nan and Ho 2017). Similarities
exist between the sculpting process and interpersonal relationships, as
well. There is a constant flow of conversation; when the artist pushes the
clay, the clay pushes back. This heavily tactile material responds, reacts,
and often must be wrestled with, in the same manner that relationships
require if they are to fully develop.
Clay begins as a shapeless piece of earth. However, the art therapy
group participants transform it into astonishing symbolic repre­
sentations. Clay provides a conduit for emotional expression. It leaves
an imprint; feelings move through one’s hands and into its substance,
and the unseen becomes visible. This process allows exposure to inner
traumas and wounds, documented in a manner that can facilitate
healing. Like the course of therapy itself, the firing process (which
entirely changes the material substance of the clay) has inherent
 DBT-Informed Ceramic-Based Art Therapy Groups for Adolescents 117

vulnerabilities. For example, a sculpture may be shattered. Yet the artist,

with the group’s support and encouragement, can find ways to make the
piece whole again.

Clay sculpture as a specifically DBT-informed practice

All projects emphasize dialectics, acceptance, validation, and
compassion. DBT recognizes that, for healing to occur, full acceptance
of current realities must balance every quest for change. Representing
one’s trauma history with clay in a manner that includes past struggles,
current coping patterns, and future hopes offers an effective method of
addressing all four of the DBT skills modules (core mindfulness, distress
tolerance, emotional regulation, and interpersonal effectiveness).
Additionally, ceramics making fosters self-validation and other
achievable treatment goals including personal mastery and developing
a more flexible, adaptive sense of self.

Distress tolerance skills—ACCEPTS

Incorporated within the intention of the ceramic therapy groups is the
DBT distress tolerance ACCEPTS skill (Linehan 2015a, 2015b). This
is a group of distraction strategies; its purpose is to cope effectively
with difficult feelings and situations by tolerating what one cannot
immediately change. ACCEPTS helps us navigate crisis-level emotional
states, such as when the mind is flooded with negative thoughts and/or
when the body feels extremely activated.
ACCEPTS comprises distracting with Activities, Contributing,
Comparisons, opposite Emotion(s), Pushing away, other Thoughts,
and other Sensations (Linehan 2015b, p.166). In terms of the group’s
therapeutic sculpture/clay work, ACCEPTS plays out as follows:
A—Activity: Creating with art materials is an excellent distracting
activity!
C—Contributing: When strong emotions take over, it can seem as
though our problems and worries are all-encompassing. During such
moments it is important to step outside of ourselves. Being part of a
group that displays artwork for the purposes of teaching the public
about the impacts of abuse/trauma—with a focus on contributing to a
collaborative ceramic piece—is a way of paying it forward: the sculpture
is left behind as a gift to new clients coming into the art therapy group.
118 DBT-INFORMED ART THERAPY IN PRACTICE

C—Comparisons: If we observe ourselves getting caught up in our

issues and emotions, we may take a step back and express gratitude for
what we do have. In addition, group members can compare how they
are currently functioning with when the abuse was first disclosed (and/
or during an earlier point in their trauma recovery process).
E—(opposite) Emotions: We may use opposite-to-emotion action as
a tool to bring balance and return to a neutral ground. This technique
invites us to engage in behaviors that are directly opposite to the intense
emotion’s action urge. For example, if feeling sad, then participate in the
group art project (instead of isolating and/or doing nothing).
P—Pushing away: It may be necessary to take a break from a distressing
situation by leaving it mentally for a while. Within the ceramic
studio one might engage in a conversation with a peer. Over time,
we demonstrate to ourselves that we can distract from the thoughts/
feelings that do not serve a positive purpose in the moment (while still
validating their existence).
T—(other) Thoughts: This can be done in a ceramics group by looking
at artwork in the gallery, practicing a mindfulness technique, or using
the provided journal for drawing or writing poetry.
S—(other) Sensations: Physical sensations can give great relief when
we are overcome with intense emotions. Clay possesses an interesting
texture and odor that some find soothing. In addition, pounding,
slapping, and roughly kneading it is a good way to channel strong,
agitated physical energy.

Distress tolerance skills—radical acceptance

Radical acceptance, an important distress tolerance skill (Linehan 2015a,
2015b), encourages us to fully explore the notion of self-acceptance.
Marsha Linehan claims that “acceptance may lead to sadness, but
deep calmness usually follows” (2015a, p.342). In other words, radical
acceptance eventually results in a sense of freedom and peace. Clients’
personal narratives, reformed into ceramic sculptures, provide
opportunities to represent metaphorically their inner experiences.
Metaphors are powerful because they convey abstract thoughts or
feelings. They also help to facilitate a dialectical stance of accepting
our present circumstances while simultaneously moving us toward
necessary growth. When clients work with clay while holding an
 DBT-Informed Ceramic-Based Art Therapy Groups for Adolescents 119

openness and curiosity as to what form it will take, they are essentially
practicing acceptance. They own their hurtful past experiences, allow
for the present moment to be what it is, and imagine potential future
healing landscapes. More precisely, this activity facilitates emotional
pain tolerance to ensure the possibility of positive change.
The clay-firing process embodies the dialectic of establishing control
as necessary while also letting go. In a shared kiln one must trust that
the other pieces were hollowed carefully. If not scored well, they can
easily break. Firing tests the artist’s willingness to relinquish ultimate
control over the product; this is another powerful analogy for radical
acceptance. Because accepting reality requires fully acknowledging life
on life’s own terms, it also follows that one must learn how to let go.
Transforming raw clay into a ceramic piece explores this idea on
multiple levels. The client, in choosing what emotional material to
process, personalizes the experience from the very beginning. Sculpting
calls for delicate and careful control. This offers a potentially meditative
and grounding experience that invites her to be present in her body.
Finally, as mentioned earlier, there is a great degree of uncertainty
involved with firing clay, which necessitates the client’s ability to accept
the end result of her piece, just as it is, after the transformation of the
firing process is complete.

The role of mindfulness

One method for building and supporting group participants’ coping
skills is a brief mindfulness activity at the beginning and close of each
art therapy session. These exercises, intended for both personal practice
and the group’s benefit, can take many forms (mindfulness might involve
working with clay or could be a guided visualization). Mindfulness is at
the core of DBT. This foundational tool helps participants practice being
in the present moment, bringing awareness to judgmental thoughts
with the aim of reducing judgments of self and others, and letting go of
any attachment to how things “should” be. Mindfulness supports group
members to progress with their art making, and to transition out of the
ceramic studio when the session comes to a close.
A mentorship and profound friendship with Toronto-based art
therapist and Rinzai Zen practitioner Suzanne Thomson has deepened
my understanding of self-compassion centered mindfulness, which has
recently become integral to the work I share with clients. What grew
most apparent to me over time is that those individuals who engaged in
120 DBT-INFORMED ART THERAPY IN PRACTICE

cutting reduced their frequency of self-injury as they learned to tolerate

emotional discomfort during the art therapy group. I also believe that
connecting with other participants was key. As relationships among
group members grow, self-harm behaviors usually decline. The
experience of being part of a community, and a corresponding decrease
in isolation, seems to help clients commit to a life worth living. The
building of the group is equivalent to the development of hope.
One of the artists, age 13, describes their artwork (Figure 7.1):
My sculpture represents my journey. It began in a rough way; someone
who I thought was my friend ended up not being the case—they broke
my trust. Now I am on a great path. Before (prior to the start of the
group) I wasn’t myself; I was down. Since the group, I feel like I am not
alone, there are people there for me. Working with art has helped with
this. Just know there is always hope and people there for you.

Figure 7.1 “My sculpture represents my journey… Just know

that there is always hope and people there for you.”

Art therapy, community building, and social activism

The partnership between The Gardiner Museum and the SAFE-T
program began in 2004. Its goal was to provide young sexual abuse
survivors with opportunities to create their personal trauma narratives
in clay. The trauma narrative is a cognitive behavior therapy (CBT)
 DBT-Informed Ceramic-Based Art Therapy Groups for Adolescents 121

technique used to help individuals who have suffered from abuse

express and make sense of those events. The trauma narrative also serves
as a form of exposure to painful memories (Deblinger et al. 2011). The
client shares the story of her traumatic experience(s) through verbal,
written, and/or artistic means.
Additional goals of creating a trauma narrative are to incorporate
unspoken aspects of the person’s past into their life story, explore
difficult emotions, and recreate this story through the construction of
a new meaning. Group participants share with the intention of releasing
unresolved pain to make room for new, healthy experiences. Clay is
a parti­cularly safe and effective material for trauma work. It allows the
participant/artist to maintain distance and gain mastery at the same
time. Creating distance from one’s trauma, a trait inherent to working
with clay via its long-form creation period, allows the artist time to
process unforeseen emotional responses that may arise during group.
Further, given the long-form creation period, artists may work through
their traumas and build resilience.
As evidenced by Alice’s story, ceramic-based art therapy groups
provide opportunities for children and adolescents to interact with
peers with similar backgrounds. When a young artist meets others who
have also endured sexual abuse, her realization that she is not alone
reduces the typical sense of isolation. Ceramic art projects are designed
to combine the wisdom of reflection, the beauty of compassion, and
the science of creativity into a unique source of support for trauma
survivors. The group process itself allows participants to come together
and empower one another, as well as develop a sense of agency in their
individual lives.
Every year features a metaphor-focused project such as “Bridge to
Resiliency.” Another, entitled “Our Piece of the Sky,” was a response to
Half the Sky: Turning Oppression into Opportunity for Women Worldwide
(Kristof and WuDunn 2008). This book portrays courageous women
who experienced adversity and took great risks to contribute to their
communities. We shared these stories with the 2012 ceramic group
participants in the hope that they would identify with them.
A continuous theme throughout every annual project is acknow­
ledging and building community. Our 2014 project was inspired by
Maya Angelou’s wise words: “There is no greater agony than bearing an
untold story inside you” (Angelou 2009, p.114). This quote supported
the idea that group members create their trauma narratives for their
122 DBT-INFORMED ART THERAPY IN PRACTICE

own recovery while also using art to inform the public about the impact
of sexual abuse.
At the close of every project, group members come forward to share
their personal experiences and artwork in a public exhibition at The
Gardiner Museum. By this time they are usually not just determined to
break the silence of sexual abuse; they also feel confident in their role
as agents of change. This self-assurance starts with developing personal
creativity and results in championing the values of social justice and
community engagement.
A group I worked with in 2013 coined the term “One Together”
in honor of children who lived halfway around the world and had
similar trauma backgrounds. That year’s theme was an artistic response
to the 160 Girls Project, a legal initiative led by attorneys and social
workers from Kenya and Toronto. The 160 Girls Project compelled the
enforcement of existing Kenyan laws prohibiting sexual assault, where
previously rape was systemically perpetuated and went unprosecuted.
The all-female ceramic group felt a kinship with these girls on another
continent and wanted to lend their support through raising awareness
in a public exhibit at The Gardiner Museum: a clay sculpture consisting
of over 160 hands and figures wrapped around the United Nations
Convention on the Rights of the Child. One year later, Toronto’s first
Child and Youth Advocacy Centre opened its doors (and provided
referrals to the ceramic group). The legal crusade in Kenya continued
to receive ongoing exposure, as well.
In 2015 a ceramic project entitled “Forging New Paths” took shape.
The SAFE-T program had transitioned into a community-based agency,
Radius Child and Family Services. Radius joined with The Gardiner
Museum to continue to break the silence that often shrouds sexual
exploitation. Participants sculpted their symbolic footsteps and placed
them on a clay “journey” to represent how traveling with others makes
the passage more accessible and less burdensome. These trailblazers were
inspired by a quote found on Pinterest (attributed to Tom Hiddleston):
“You keep putting one foot in front of the other, and then one day you
look back and you’ve climbed a mountain” (Aniban 2017) (Figure 7.2).
As one client identified within her artist statement:
My first piece was inspired by another group member: a mountain with
large obstacles and supports to help me overcome. Large rocks blocking
a clear/positive path represent these tough times. A bridge shows the
 DBT-Informed Ceramic-Based Art Therapy Groups for Adolescents 123

supports over a waterfall and substance use as a way of coping. I’m

shown at the top, celebrating overcoming such difficult times.
My second piece is a book showing negative sides of my life that I use
to help cope. It shows strategies that I’ve used to get me through tough
times and how I’ve stopped self-harming. Although it’s still a thought,
it’s never acted on.

Figure 7.2 Collaborative ceramic piece inspired by Tom Hiddleston’s

words: “You keep putting one foot in front of the other, and
then one day you look back and you’ve climbed a mountain.”

Another group member shared: “Following repression came expression,

as I’d always been paranoid about what I did and didn’t say. Art got me
out of that habit.”
In 2018 a collective ceramic piece entitled “Our Sheros” was
an homage to all the powerful women who have helped keep the
conversation of sexual abuse in the forefront of many minds and hearts.
The artists defined a shero as “a female hero, a female that displays
strong heroic traits under tremendous pressure and is triumphant over
her circumstances.” Sheros are girls and women who act courageously,
especially in times of adversity and uncertainty; sheros have been
through extraordinary experiences and have proven to be sheroic. They
exemplify what is possible and inspire people of all ages. The #MeToo
and Time’s Up movements, which both emerged during the timeframe
of this project, were extremely validating for many of the group
participants. #MeToo, founded in 2006 by Tarana Burke, has helped
survivors of sexual violence—particularly Black women/girls and
124 DBT-INFORMED ART THERAPY IN PRACTICE

other young women of color from disadvantaged communities—find

pathways to healing (Garcia 2017). Time’s Up (founded by Hollywood
celebrities) shares a similar vision for women’s empowerment with
#MeToo (Langone 2018): it asserts that everyone deserves to be free
of harassment, sexual assault, and discrimination. The “Our Sheros”
sculpture was also reminiscent of the words of Maya Angelou (1993):
“History, despite its wrenching pain, / Cannot be unlived, but if faced /
With courage, need not be lived again.”
The most recent ceramic project involved some interesting
synchronicity. While the group participants met and worked weekly
in The Gardiner Museum’s basement studio (called the building’s
foundation), Ai Weiwei, one of the world’s most influential living artists
and social activists, displayed his show “Unbroken”—a perspective on
human rights violations and social justice—on the top floor. While the
artworks upstairs reflected boundary-breaking (Davidson 2019),
the work being created below expressed freedom from the oppression
of sexual abuse.
The large mindfulness bowl shown in Figure 7.3 was created by me
as a witness response to the courage, commitment, and creativity each
group participant embodies as they reveal their personal experiences
of recovery from sexual abuse. In a desire to honor the sharing of pain
and healing that occurs in the clay studio, I offer a quote by Thích Nhất
Hạnh (2001): “Love is not just the intention to love, but the capacity to
reduce suffering, and offer peace.”
The bowl embraces the Metta meditation that nourishes loving-
kindness as a restorative process (Thích Nhất Hạnh 2020):
May I Be Happy
May I Be Well
May I Be Safe
May I Be Peaceful and at Ease
May You Be Happy
May You Be Well
May You Be Safe
May You Be Peaceful and at Ease
May We All Be Happy
May We All Be Well
May We All Be Safe
 DBT-Informed Ceramic-Based Art Therapy Groups for Adolescents 125

May We All Be Peaceful and at Ease

May the experience of community, belonging and interconnectedness
always overflow.

Figure 7.3 Mindfulness bowl created by the author in

response to the group members’ process and artwork

Conclusion
I have, over nearly two decades of providing clay-based art therapy
groups, striven to maintain a validating and nonjudgmental clinical
environment congruent with DBT’s principles. DBT helps individuals
to build on their strengths, develop self-confidence, and build mastery.
And, like DBT, working with clay encourages clients to identify and
appropriately challenge maladaptive beliefs, assumptions, and habitual
behaviors that have historically made their lives more difficult. The
experience of attending group art therapy sessions, sculpting a narrative
indicative of both trauma and healing, and then putting the resulting art
work on public display for others to witness and take inspiration from,
have all contributed to trauma survivors’ capacities for moving forward.
My recollection of how Shelley McMain made herself so available to
her client during that now long-ago evening left a permanent impact
on my own willingness to embrace individuals who have typically not
received much validation. I have been honored by the trust of so many
126 DBT-INFORMED ART THERAPY IN PRACTICE

courageous young people, and am grateful for my children, friends, and

colleagues that support me as deeply and fully as they do.

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poets.org/poem/pulse-morning.
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yet-4dd0fc5b5cbc.
Carr, R. (2008) ‘Sensory Processes and Responses.’ In N. Hass-Cohen and R. Carr (eds) Art
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Elbrecht, C. and Antcliff, L.R. (2014) ‘Being touched through touch. Trauma treatment
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Journal of Art Therapy 19, 1, 19–30.
Garcia, S.E. (2017) ‘The woman who created #MeToo long before hashtags.’ The New York
Times. October 20. Accessed on 10/7/20 at https://www.nytimes.com/2017/10/20/us/
me-too-movement-tarana-burke.html.
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Marx, K. and Engels, F. (1970) Selected Works (Volume 3). New York, NY: Progress Publishers.
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anxiety through art: Theoretical ground and clinical issues.’ Annals of Depression and
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Nan, J.K.M. and Ho, R.T.H. (2017) ‘Effects of clay art therapy on adults outpatients with
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Manitoba: Crisis and Trauma Resource Institute (CTRI). Accessed on 5/31/20 at https://
ca.ctrinstitute.com/blog/youth-in-conflict.
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 Chapter 8

From Hatch to Handshake

Combined Art Therapy and DBT Skills Training in a
High-Security Learning Disability Treatment Unit
EMMA ALLEN AND ANTHONY WEBSTER

Introduction
Tactile stimulation (touch, in particular) is a highly personal and
profound method of nonverbal communication as well as an important
component in the development and maintenance of physiological,
psychological, and emotional regulation throughout the human
lifespan. Consensual touch facilitates a calming sense of empathy, safety,
and reassurance (Hill 1995); it is perhaps also a powerful mechanism
for repairing preverbal or nonverbal developmental disturbances (Zur
and Nordmarken 2011).
Touch is one of the fundamental human experiences: to know loving
or unwanted touch, the traumatic rupture of boundaries and their
repair. Touch is the basis for secure attachment, linked to earliest body
memories, to the ability to handle the world, to sexuality and injury.
(Elbrecht and Antcliff 2014, p.19)
Within the helping professions, however, touch is a sensitive and
complex topic (Hetherington 1998; Hunter and Struve 1998). The
counseling, social work, and psychotherapy fields generally regard
physical contact between patients and clinicians as a boundary
violation with strong potential for harm (Karbelnig 2000). However,
prior to the Covid-19 pandemic, handshakes (now a serious health
concern) were relatively commonplace and, at times, unavoidable (Zur
and Nordmarken 2011). In high-security forensic psychiatric treatment
units, touch is only appropriate and/or acceptable during restraint (i.e.,

128
 From Hatch to Handshake 129

restricting movement), pat-down searches (inspecting clothing on the

body for concealed items), and routine nursing duties (e.g., delivering
medication, completing physical examinations, and so on). Whenever
risk levels escalate, forensic unit staff attempt to contain or reduce the
patient’s potential violence to self/others through seclusion, a method of
therapeutic isolation and confinement that prevents, limits, or subdues
free movement (Bleijlevens et al. 2016; Department of Health 2014).
At the National High Secure Learning Disability (NHSLD) men’s
service,1 a 54-bed unit where this case study is based, patients live
in specialized low-stimulation suites (containing a bedroom and
bathroom) with observation windows. Communal areas are carefully
monitored via 24-hour closed-circuit television (CCTV) surveillance.
Individuals in seclusion receive their nursing and therapeutic care/
support exclusively through a hatch window until immediate risk
subsides.
Such safety measures, although necessary, preclude any potential
benefits from close connections with others. There is strong evidence
that people experience significantly limited social contact as
dehumanizing (Alty and Mason 2013; Wadeson and Carpenter 1976).
Additionally, some patients report that risk management techniques
make them feel “institutionalised, deskilled, bored, frustrated, and
treated as an object to be managed” (Tomlin 2020, p.2). Restraint may
also provoke hostility, depression, and suicidal ideation (Franke et al.
2019).
A high proportion of patients in the NHSLD men’s service unit
have histories of significant childhood neglect as well as physical and/
or sexual abuse. Posttraumatic stress disorder symptoms can engender
strong fears of touch and close bodily proximity where touch may
internally represent aspects of the original trauma; this may precipitate
acute emotional dysregulation—even acts of violence (Allen 2018;
American Psychiatric Association 2013). Hence, handshakes, such as
those occurring at the start or end of many therapeutic relationships,
are discouraged with sequestered forensic patients. Allen writes about
how these individuals “pose high risks to others, in particular by
grabbing staff at the seclusion hatch” (p.142).2
The present chapter is a continuation of “The Boy Who Cried
Wolf ” (Allen 2018), which described a collaborative/cross-disciplinary
dialectical behavioral therapy (DBT) skills training and art therapy
intervention in the NHSLD men’s service unit. Its subject was “Daniel,”
130 DBT-INFORMED ART THERAPY IN PRACTICE

a male in his mid-20s. Daniel presented with a “complex history of anti-

social criminal behavior and co-morbidity of bipolar disorder, borderline
personality disorder and intellectual developmental disorder (IDD)…
[and] trauma relate[d] to…suffering long and extensive family
violence and abuse” (Allen 2018, p.140). He was frequently secluded
due to recurring threats and/or attacks against female staff. The initial
treatment phase took place at a hatch window and slowly progressed
to lower-security ward-based sessions.
This chapter reviews the therapeutic process portrayed in “The Boy
Who Cried Wolf ” and then explores the subsequent, more intensive
interventions that followed. Co-author Emma Allen previously
suggested that seclusion may have provided a “safe retreat” for Daniel
where he could maladaptively “‘segregate’ his emotions” and thus avoid
challenging situations (Allen 2018, p.144). However, the unique triadic
therapy relationship (art therapist/patient/DBT therapist) created “an
alternative sense of containment to that offered by seclusion” (p.150)
so that Daniel could tolerate his eventual transition from long-term
isolation into general ward life.
We portray the evolution of Daniel’s ability to regulate intense
emotions as well as authentically engage with us, the authors, through
the use of art and DBT skills training. We also posit that by outlining
his own hands, as well as ours, Daniel developed healthier attachments
(within which he neither feared being left nor maintained urges to grab
and hold on). In the context of his artwork, Daniel was at last seen and
heard; by the end of therapy, he had finally let go of the compulsive need
to physically offend and could appropriately shake hands with us. The
chapter describes the journey leading from the hatch window to this
handshake. We conclude with recommendations for future practice and
suggest a combined DBT and art therapy approach that is suited to a
forensic learning disability (LD) setting given its physical restrictions.

DBT and its adaptations

DBT is a specialized, multi-modal cognitive behavior therapy (CBT) for
extreme affect regulation problems (Linehan 1993). This popular and
empirically founded intervention was developed to treat chronically
suicidal individuals who frequently met the diagnostic criteria for
borderline personality disorder (BPD) (Dimeff and Koerner 2007;
Rathus and Miller 2002; Rizvi and Linehan 2001). DBT interventions
 From Hatch to Handshake 131

and strategies aim to balance standard CBT’s emphasis on change with

accepting patients as they are in the present moment. The long-term
goal is “increasing clients’ capabilities in experiencing and managing
emotions, interpersonal relationships, and crises” (Swales and Dunkley
2020, p.18).
DBT has been adapted for other diagnoses and clinical situations,
including forensic environments (McCann et al. 2007) such as prisons
and institutions for young offenders (Shelton et al. 2009, 2011). DBT
demonstrates effectiveness with low patient engagement (Linehan et al.
1991; Verheul et al. 2003), anger, and aggression (Frazier and Vela
2014). While its impact upon recidivism requires further investigation
(Tomlinson 2018), research does support DBT’s capacity to reduce risk-
related behaviors in those with LDs (Lew et al. 2006). Brown, Brown,
and Dibiasio (2013) state that DBT’s core principles and strategies (e.g.,
validation, positive reinforcement, the dialectic of acceptance versus
change) can address entrenched “patterns of escalating emotions, which
are underlying factors associated with challenging behaviors” in IDD
patients (pp.284–285).

DBT-informed skills training:

The I Can Feel Good (ICFG) program
A significant component of comprehensive DBT is psychoeducational
and contains four didactic modules: core mindfulness, distress
tolerance, emotion regulation, and interpersonal effectiveness skills
(Linehan 2015a, 2015b). Although the skills curriculum is only one
piece of DBT’s standard evidence-based model, recent studies indicate
that it can be a valuable sole and/or primary intervention (Linehan
2015a; Linehan et al. 2015). Furthermore, modified skills systems exist
for the unique needs of LD and IDD populations (Ashworth et al.
2018; Brown 2015). For example, I Can Feel Good: DBT-Informed Skills
Training for People with Intellectual Disabilities and Problems Managing
Emotions (Ashworth et al. 2018) is “specifically designed to help those
with an intellectual disability and personality disorder to identify
emotions, thoughts, and behaviours, increase self-awareness and reduce
unwanted impulsive behaviours” (Allen 2018, p.141). The program
achieves this, in part, by reducing the number of skills, eliminating
complex language and mnemonics, and repeating modules to help
improve understanding and retention.
132 DBT-INFORMED ART THERAPY IN PRACTICE

The I Can Feel Good (ICFG) manual (Ashworth et al. 2018) places
more of an emphasis upon experiential learning than does standard
DBT, with its strong language-based approach (Linehan 2015a, 2015b).
ICFG encourages patients to become more aware and accepting of
their internal cognitive and emotional experiences through practical
tasks featuring visual methods, physical teaching tools, and creative
activities (Morrissey and Ingamells 2011). A wide range of exercises
focus on bodily sensations as well as props to aid in comprehending
abstract concepts. An example of the latter is the use of a papier-
mâché head filled with colored balls representing thoughts. Because
visual learning is essential for this patient group, DBT’s handouts and
homework materials were redesigned to include more pictures than
words (Ashworth et al. 2018).
Nontraditional teaching methods such as ICFG can help abuse
survivors, as well. Even years after the actual event(s), traumatic
experiences overstimulate the brain’s right hemisphere while shutting
down the left hemisphere (which is necessary for higher neurological
functions including verbal communication, sequencing, and execu­
tive functioning) (van der Kolk 2015). Such processes are crucial to
benefiting from psychoeducational programs like DBT. Hence, the
effects of posttraumatic stress may pose a significant impediment to
both day-to-day functioning and to the optimum acquisition and
retention of new cognitive and behavioral skills.

Art therapy
Clinical art therapy is a therapeutic discipline that incorporates visual
art-based creative methods such as drawing, painting, collage, and
sculpture into mental health treatment. Interventions can range from
simple and/or rudimentary activities (where the emphasis is on the
creative process) to ones intended to resolve psychological problems by
exploring symbolic material within the artworks themselves. The latter
approach is often called art in therapy, dynamically oriented art therapy,
or art psychotherapy (Malchiodi 2011).
Like DBT, art therapy/art psychotherapy exists in multiple treatment
milieus and is adapted for the LD and forensic populations (Bull and
O’Farrell 2012; Gussak 2012; Gussak and Cohen-Liebmann 2001). It
has also begun to garner interest as a promising brain-based trauma
treatment (King 2016). For Daniel, a nonverbal approach was ideal
 From Hatch to Handshake 133

because it was “less threatening…due to his communication deficits

and avoidance through verbalisation” (Allen 2018, p.140). Art therapy
provided an alternative means of accessing emotions in ways that were
effective with past traumatic experiences, while keeping the patient
grounded in the present.
Although our work with Daniel had deep roots in psychodynamic
processes (and was art psychotherapy to a large degree), for the
purposes of this chapter we center on its more cognitive behavioral
and humanistic elements. That said, certain schema therapy-informed
principles (Rafaeli, Bernstein, and Young 2011), as well as ideas from
attachment theory (Solomon and Siegel 2003), appear when relevant.
For example, while the DBT skills were invaluable for Daniel’s treatment
and recovery, we maintain that “[o]verall…it was our joint therapeutic
relationship, and our offering of a secure and trusting attachment that
helped re-engage Daniel into therapy and out of the seclusion suite”
(Allen 2018, p.150).

Combined DBT skills training and art therapy interventions

The merging of DBT skills training and therapeutic art activities is a
relatively new treatment method and is not currently supported by
quantitative research. DBT-informed art therapy approaches may
assist with the delivery, retention, and generalization of the behavioral
skills (Clark 2017). The incorporation of art therapy activities into
DBT skills training involves hands-on experiential directives (finger
painting, for example, provides a preverbal expressive language access­
ible to all learning capabilities). According to Heckwolf, Bergland, and
Mouratidis (2014), coordinating them “both in case conceptualization
and in therapy sessions can reinforce skills gained within each approach
alone and link parts of therapy for the patient, creating a more coherent
treatment experience” (p.330). Integrating creative art interventions
into the four didactic DBT skills training modules is thought to have
greater impact upon recovery and well-being for those specifically
identified as suited to both therapies, and can initiate significant
changes in therapeutic relationships and psychological presentations
(Huckvale and Learmonth 2009).
Another possible benefit of combining these particular inter­
ventions relates to DBT’s focus on present-day issues as well as current,
active behavior, whereas traditional art psychotherapy concerns itself
134 DBT-INFORMED ART THERAPY IN PRACTICE

more with the past and “unconscious and pre conscious material yet
to surface” (Rothwell and Hutchinson 2011, p.25). Perhaps these
differing approaches allow one therapy to “balance out the other”
(p.25). However, both work from the premise that suppression of
emotions leads to suffering (Gross and Levenson 1997; Linehan
2015a; Roemer and Borkovec 1994). Thus combined approaches
tend to highlight full emotional experiencing and expression (Clark
2017). An example is Huckvale and Learmonth’s (2009) integration
of DBT’s theoretical and practical features (such as synthesizing
acceptance and change, the development of wise mind, and so on) with
pragmatic image making processes to create a cohesive psychosocial
education model.
Clinicians may devise DBT and art therapy sessions to equip patients
with new strategies for identifying dysfunctional thoughts/emotions,
as well as managing them more effectively, through techniques like
problem-solving and changing existing behavioral responses (Clark
2017; Johnson and Thomson 2016). Our approach for increased distress
tolerance and emotion regulation capacities revolves around fostering a
“here-and-now awareness” (Haeyen, Kleijberg, and Hinz 2018, p.166):
the recognition and acceptance of one’s own and others’ self-expression
in order to improve one’s mental health, resilience, and flexibility. Our
triadic (2:1) combined art therapy/DBT-informed approach described
below involves building a sense of agency, exploring the relationships
with self and others, and alleviating fears of abandonment. Our rationale
considered the importance of touch for emotional, physiological, and
interpersonal development (Harlow 1958). The work with Daniel,
centered as it was on relationships and collaboration, seemed to
naturally result in images of our hands.

Forensic art therapy and DBT with LDs

and IDDs: Combined interventions
Art therapy and DBT have been applied to the delivery of LD offender
treatment programs/interventions in several settings (Huckvale
and Learmonth 2009; Rothwell and Henagulph 2017; Rothwell and
Hutchinson 2011). For example, the combined modalities in LD
forensic services appeared to increase one’s patient’s emotional literacy
and ability to “bear the pain” of her traumatic past and current
psychiatric symptoms (Rothwell and Hutchinson 2011, p.24). Research
 From Hatch to Handshake 135

has shown that art therapy may assist those with an LD to improve
communication, mentalization, and self-reflection—thereby reducing
levels of aggression (Hackett 2012). In our work with Daniel, we
designed art therapy directives3 that provided visual metaphors of the
DBT-informed psychoeducational concepts (which made them more
accessible to him). Clinicians may also modify existing directives to
meet the needs, characteristics, and abilities of individuals in forensic
settings (Gussak 2012).

DANIEL
Daniel, stage one
Daniel’s mother died when he was an infant; shortly thereafter his father
began to abuse him both physically and sexually (which continued into
adolescence) (Allen 2018). Daniel received treatment within several
hospital settings starting in his late teens. However, following an
escalation of antisocial and criminal behavior, he was admitted to the
NHSLD unit for risk of harm to self and others, and to treat his existing
comorbid diagnoses.
Emma, the art therapist, and an assistant psychologist (Richard
Short) began to work with Daniel during a period when he “fluctuated
from being nursed in seclusion and LTS following assaults and threats to
kill female staff ” (Allen 2018, p.139). He was isolated after a psychiatric
decompensation with psychosis and homicidal ideation, including a
physical attack on his female DBT therapist, that took place in the high
secure unit. Daniel also exhibited a propensity for “fantasy and ex­
aggeration” (p.140); he had made numerous false claims of abuse and
neglect against staff. Richard became his new DBT therapist.
Usually hostile toward females, Daniel “placed [Emma] and art
therapy on a pedestal” (p.140). That changed when she disclosed her
need to take a planned sick leave for a few months: “Although this was
not an ending, Daniel found the prospect of me ‘abandoning’ him
difficult to tolerate, and he became angry and fearful. He pushed me
away, and I fell off the pedestal” (p.140). Concerned about his escalating
agitation and intimidating manner while in Emma’s presence, the
multidisciplinary team decided to suspend therapy for an extended
period. Unfortunately, the long-term seclusion and lack of contact
took a substantial toll on Daniel’s mental state, which had “severely
deteriorated” (p.141).
136 DBT-INFORMED ART THERAPY IN PRACTICE

After Emma’s return, the team recommended that Daniel resume

treatment: His Recovery Care Plan “had indicated that he should continue
with DBT for emotional regulation and improved problem-solving skills
[…] and art therapy for the better understanding of feelings and improved
behaviours” (p.141). Sessions occurred on a 2:1 basis (two clinicians to a
single patient) to decrease the risk of violence. Providing both art therapy
and DBT skills training during the same session “prevented Daniel
‘splitting’ therapists off and making serious allegations” (p.141). In the
beginning, the interventions consisted of introducing basic cognitive
and behavioral techniques (e.g., mindful breathing and/or visualization
exercises, focusing on positive self-talk, squeezing a paper cup in lieu of
a stress ball4) and DBT-informed concepts:
During this pre-therapy work, we integrated ICFG Mindfulness Practice
Worksheets, repeating exercises that differentiated between a Hot, Cool
and Wise Mind to enable learning and reduction of risk, building upon
coping skills and self-reflection through “in-the-moment” coaching.
This took place through both the seclusion and quiet room hatches.
(p.142)
When the time came to introduce art supplies, the clinicians provided
Daniel with pastels, “passing his chosen colour through the hatch one
at a time… Offering materials felt like providing him food: a form
of nourishment and care that was harder for him to reject or attack”
(p.146). Daniel learned how to use different colors to describe his
emotions (e.g., “suicidal red,” p.147), as well as symbolize their related
physical sensations and felt locations in his body. Sessions continued
to be structured first around mindfulness worksheets (from the ICFG
manual), and then image making.
Turn-taking felt similar to the parenting process, giving the other
parent a break or a “breather.” […] At times, I felt distressed as if
unable to comfort an infant. It felt exhausting to endure his tests: we
had to prove that we were not the “abandoning mother” and “abusive
father.” It seemed that the DBT exercises brought a paternal structure,
with its focus on behaviour, whilst art therapy offered a more maternal
focus upon emotional expression and containment (Rothwell and
Hutchinson 2011). (Allen 2018, pp.144–145)
By the time that Richard announced his imminent departure from
the ward in order to start doctoral training, Daniel was well enough
 From Hatch to Handshake 137

to endure some exploration of his feelings concerning endings, grief,

and underlying fears of abandonment—that is, being left alone “to die”
(p.148). He eventually came to trust that he was not being rejected and
agreed to continue joint therapy with another DBT therapist (co-author
Anthony Webster).
Our three-way relationship had offered a unique opportunity to support
Daniel with unresolved bereavement and loss: a prominent theme for
individuals with learning disabilities, when the patient’s existence can
be validated by knowing that another cares if they live or die. Offering
art materials not only offered hope, but allowed him to feel human
again. (pp.148–149)
The final session with Richard, carefully observed by nursing staff sitting
nearby, took place out of seclusion with both clinicians and Daniel
together in the dining room. It was a successful experience and the
patient was able to say goodbye to Richard. In addition, he indicated
willingness to continue to work on his issues using art therapy and DBT.

Daniel: At the hatch

This second phase transpired over 13 months and included a more
formal combination of art therapy and DBT. The art therapy component
was a directive, mindfulness-based approach with joint/combined
three-way image making.5 Over the course of his therapy we witnessed
a significant reduction in physical violence from Daniel, who earned
transfer to a low-dependency ward prior to being discharged to a
medium (lesser) secure unit.

Combined DBT and art therapy with Daniel

The weekly sessions took place in the ward dining room. We provided
Daniel with a therapy calendar that noted any upcoming cancelled
sessions. The purpose was to ease Daniel’s anxiety and support him
in retaining information. We also hoped to reduce the likelihood of
complaints and/or allegations.
Applying DBT and art therapy simultaneously provided emotional
regulation and reinforcement of practicing, accepting, and changing.
DBT strengthens and enhances art therapy by maintaining a structure,
while the image making of art therapy provided sensory input,
138 DBT-INFORMED ART THERAPY IN PRACTICE

mindfulness in action, and a safe container for Daniel’s manageable

emotions. DBT techniques helped focus on the positive, distracting
him from his homicidal expressions and incorporating mindfulness
provided an important common ground for us both as practitioners.
(Allen 2018, p.150)

Session structure
• Initial check-in (5 minutes): We often used visual methods for
identifying emotional states, such as Blob Trees and Men (Wilson
and Long 2017).
• DBT skills training/psychoeducation (20 minutes): We used the
ICFG manual.
• A mindfulness exercise (5 minutes): Examples include a brief
watercolor activity, guided imagery and relaxation/breathing
script, and progressive muscle relaxation.
• Joint/combined image making (10–15 minutes): These were in
response to a specific art therapy directive. For consistency and
containment, Daniel worked in a sketchbook provided by us.
• A brief guided breathing exercise (10 minutes): Daniel would
squeeze a stress ball in both hands while inhaling/exhaling to
feel more balanced.
• Concluding check-out (5 minutes): We summarized the session
content and evaluated Daniel’s emotional state prior to his re-
entering the ward.

Fears of being forgotten: Trauma at hand

Art therapy with forensic patients often uncovers painful emotional
states such as fear of abandonment, feelings of inadequacy, and grief/
loss (Collier 2016), and can also create “opportunities for mastering
trauma from neglected experiences of, and failures in, past emotional
containment and boundaries” (Allen 2020, p.36). Internal states are
more articulately expressed in pictures than through words; hence, it
is crucial to devise a symbolic language for processing and coming to
terms with trauma (van der Kolk 2015). Loss, especially difficulty with
change, is prominent in those with LDs. Given his terror of “being
 From Hatch to Handshake 139

forgotten” (Figure 8.1), Daniel required consistent reassurance that we

would both return after breaks in therapy (Kuczaj 1998; Stokes and
Sinason 1992).
People with LDs are among the most vulnerable and socially
excluded client groups and have a greater occurrence of physical and
mental health issues (Emerson et al. 2011). The trauma Daniel had
experienced during childhood drastically impaired his development of
boundaries to the point where he had little concept of safety. Daniel’s
conceptualization of separateness from the environment did not extend
much further than his own personal space. The loss of his mother and
subsequent paternal physical/sexual abuse had removed any sense of
internal security. In its stead was an intense fear of being discarded,
forgotten, and/or abused.
Whenever Daniel’s physical boundaries were encroached on, it
felt like a breach in his tenuous self-concept, which he perceived as
a life or death situation (the threat being a potential re-experiencing
of childhood abuse). He often reacted with explosive violence and
aggression. This served to reaffirm his personal space, and thus create
an accurate perception of safety, in relation to the external environment.
An example: Daniel not only had profound need for attention and
care, as well as a fear of abandonment; he was also extremely averse
to touch. The administration of medication was highly distressing for
him and he would often become more confrontational with staff at
medication time.
To repair the boundaries his father had violated early on, Daniel
needed Anthony to build trust and provide reassurance that he
would not be mistreated in the absence of Emma. Daniel’s recurring
allegations of abuse by staff, we felt, resulted from a profound need
to be heard, cared for, and affirmed. The presence of both a male
and a female therapist emulated adoptive parents. We held in mind
the schematic approach of reparenting (Kellogg and Young 2006) as
we strove (within professional boundaries) to address Daniel’s unmet
childhood emotional needs while limiting cross-over between the two
therapeutic models.6 Reparenting provided a means through which we
could attempt to restore/extend upon boundaries via listening to and
validating Daniel whenever appropriate, as well as apologizing for his
childhood experiences.
140 DBT-INFORMED ART THERAPY IN PRACTICE

Handprints
During one image making session Daniel spontaneously drew around
both of his hands, then added descriptions of his most significant
fears: “not having someone to talk to,” “being forgotten,” “not having
somebody close,” and “losing a best friend” who was moving on
(Figure 8.1). We explored how outlining his hands as part of the artistic
process helped focus mindful attention toward his own body as well as
validate and release difficult emotions; the words themselves, with our
guidance, assisted Daniel in restructuring anxiety-provoking thoughts
into affirmations (e.g., the fear of being forgotten became I will be
remembered). This image, made in the center of his sketchbook, seemed
to reach out to both therapists. Some of the pieces that followed also
included Daniel’s hands; these were reminiscent of both M.C. Escher’s
1948 lithograph “Drawing Hands” (Escher 2016) and the Cueva de las
Manos—that is, the Cave of Hands—in Argentina, with its prehistoric,
stenciled human handprints (Troncoso, Armstrong, and Nash 2018).
Hands are what make us human; they create and give us purpose, but
paradoxically, “are precisely what disobey” (Leader 2016, p.4). Daniel’s
drawings appeared to say: “Here I am.”

Figure 8.1 Fear of being forgotten

 From Hatch to Handshake 141

Drawing around another person’s hands allows for a nonthreatening

visual, tactile, and emotional connection, as well as opportunities for
exploring boundaries. Through the creation of collaborative art works
involving both Emma and Anthony, Daniel gradually appeared to grow
more comfortable with closeness. While significant physical contact
was obviously not appropriate, this symbolic and imaginal linking of
hands became an innovative replacement for touch. It also evidenced
the developed therapeutic relationship between the clinicians and this
patient. Daniel initially outlined our hands on the same page as his
own. Over time, however, he drew them closer and closer together until
the fingers slightly overlapped, as seen in Figure 8.2. This piece was
created by Daniel drawing around the therapists’ hands, and vice versa,
a process that involved very minor physical contact to which Daniel
responded appropriately (we noticed how he gently touched our hands
as he drew around them).
Image making became the medium through which Daniel could
access and communicate his thoughts and feelings. Inherent within his
IDD were significant cognitive issues (i.e., difficulties with processing,
assimilating, and relaying information). Art therapy allowed him
a nonverbal means of emotional expression and facilitated in-the-
moment practice of distress tolerance skills. The combined art therapy
and DBT helped Daniel to assert his sense of personal boundaries
without resorting to violence. By effectively managing the physiological
impact of traumatic memories (and therefore becoming more grounded
in the present), Daniel could better differentiate between past threats
and his current surroundings.
Daniel was ultimately able to maintain close proximity to us and
interact effectively, something he had never experienced with his own
parents. Daniel took the lead, which enabled him to reclaim some
control back in his life and build a sense of safety—not only with us, his
therapists, but in relation to other people, as well. Over time, pat-down
searches and other procedures no longer held the same threat. There
was a marked reduction in violence and aggression during searches as
well as administration of medication by nursing staff. Daniel shifted
from viewing himself as a perpetual victim to a survivor. His growing
confidence improved his capacity to engage with others.
Image making focused on expressing and discharging emotions
(such as Daniel’s fear of abandonment and anger). This provided a
foundation for the DBT-informed psychoeducation, which utilized
142 DBT-INFORMED ART THERAPY IN PRACTICE

both the ICFG people skills modules and distress tolerance. The latter
comprised body maps, that is, visual templates of the human body
exploring how emotions are physically experienced, the roles they play
in communication, and recognizing them in others.7
Repeatedly drawing around our hands in our work with Daniel
cemented his body awareness into the present therapy (rather than
keeping it trapped in past trauma). One half of Figure 8.2 features our
joined hands while the other half is a collaborative painting where we
all made marks on the page; this piece shows a diverse range of colors
and shapes.

Figure 8.2 Actions speak louder than words

When working with those who have personality disorders, it is

important not to overanalyze the past, but, rather, to remain focused
on the present. This helps prevent unhelpful repetitive patterns such as
self-defeating behaviors. Instead, the objective is to use image making to
externalize various states of mind and emotions (Springham et al. 2012).
Externalization allows patients to notice and witness their internal
experiences from a reasonable distance and prevent overidentification
 From Hatch to Handshake 143

with them. This is essentially mindfulness of current thoughts and

emotions (Linehan 2015a, 2015b). For example, we often suggested that
Daniel take the lead on the breathing exercises and image making and,
if his mind wandered, to simply notice that and gently return to the
current moment. Working with thoughts/feelings in this way helps one
to experience them as temporary manifestations rather than permanent
states.
After completing a series of joint/combined mindful watercolor
paintings, Daniel described one as a “happy ending” (and he asked
Emma to write this on the image) (Figure 8.3). Over the course
of 13 months, Daniel had evolved from hopeless in the face of past
traumas to optimistic and hopeful for the future. We watched his
relationships improve, along with his developing sense of self and
personal boundaries, as he progressed from long-term seclusion
and reintegrated into ward life. Imagery allowed Daniel to be seen
and heard. Our final handshake at the close of therapy increased an
internal sense of calm, empathy, and reassurance, restoring previous
disturbances (Hill 1995).

Figure 8.3 A happy ending

144 DBT-INFORMED ART THERAPY IN PRACTICE

Conclusion
This chapter described the integrated use of art therapy and DBT skills
training interventions with a young man residing in a long-term, high-
security forensic treatment unit for an LD and psychiatric conditions.
Daniel was frequently secluded due to his impaired self-regulation
capacities, which were in large part the result of extensive childhood
trauma. Although necessary given the high risk of harm to others, this
lack of physical contact and human connection had had a negative
impact on Daniel’s mental and emotional health.
The paired experiential and didactic approach provided containment,
grounding, and resolution of emotional experiences; furthermore, it
appeared to help empower Daniel through a newly acquired awareness
of agency and control, the opposite of learned helplessness (Maier
and Seligman 2016). The DBT skills themselves were one important
component. Creative self-expression was the other. DBT’s emotion
regulation skills afforded Daniel the means to develop and reinforce
healthy separateness from the external world without the need to resort
to violence.
The resulting nascent sense of safety is what allowed him to feel
confident enough to invite us into his artwork during later sessions.
Daniel’s act of drawing around his therapists’ hands enabled touch to
occur safely and appropriately within the high secure setting—making
the impossible possible and establishing true human connection.
Daniel’s personal agency seemed to increase when he returned to
drawing around his own hands, grasping and letting go of emotions
rather than becoming them.
We suggest adapting joint/combined image making to suit working
under extreme physical restrictions. Therapists should consider the
active use of the body and hands with those who have been abused or
neglected (while also minimizing the risks of exploitation). This may
help build a sense of mastery over the physiological effects of trauma
through the acquisition and application of DBT skills and creative
self-expression. We also suggest that forensic arts psychotherapists
consider the use of touch as a basis for secure attachment that is linked
to early body trauma, and “the ability to handle the world” (Elbrecht
and Antcliff 2014, p.156).
Daniel has transitioned from the NHSLD men’s service unit to a
less-secure setting. We hope that our work together will inspire other
therapists to consider a similar approach for the benefit of patients who
 From Hatch to Handshake 145

struggle with complex conditions and needs. Combined DBT-informed

skills training and art therapy interventions appear to hold promise for
helping such individuals as they move forward with their lives.

Acknowledgment
We are grateful to Daniel for consenting to share this work, for all that
he has taught us in our practice, and for assisting other clinicians to
develop theirs, as well.

Endnotes
1 The National High Secure Learning Disability (NHSLD) men’s service unit is part of
Rampton Hospital, located in Nottinghamshire, UK, which also provides national high
secure treatment for four other patient populations: mental health (male), the deaf
(male), personality disorders (male), and women with mental illnesses, personality
disorders, and/or learning disabilities. Rampton is one of three high secure hospitals in
England and Wales.
2 “This became exceedingly clear at the time of our first joint session with Daniel: Daniel
had been asking after us, and was looking forward to seeing us both. The hatch was
placed open for us by staff. Daniel greeted us through the window with a smile and
offered his hand through the gap to shake our hands. Richard went first, and I followed,
but Daniel gripped hard at my hand and wrist, not letting me go. I asked him to let go
and he suddenly apologized, saying he ‘didn’t know what came over’ him. I remember
feeling a little shaken—by how possessive this felt—and left with a feeling that I couldn’t
ever let him down. Hyper-sensitive to feeling rejected or abandoned, Daniel often tested
boundaries in dangerous ways” (Allen 2018, p.142).
3 Art therapy directives included a variety of drawing games, collaborative mandala
paintings, and mindfulness-based watercolors (i.e., watching water drop onto the
paper, noticing the merging colors). Others: Draw your emotions and/or locate their
related sensations in your body using body map templates (see endnote 7). We also
encouraged spontaneous image making in response to each DBT skills module’s themes
and concepts.
4 As “trust and integration go hand in hand” (Siegel 2010, p.86), we encouraged Daniel
to squeeze a stress ball (sometimes referred to as a hand exercise ball) in time with
his breathing. This can relieve muscle tension and address the physiological aspects of
trauma by assisting individuals with gaining conscious awareness of their physical selves
(van der Kolk 2015). Posttraumatic stress disorder (PTSD) has a profound impact on the
person’s ability to piece sensory information together into a whole, coherent experience
(McFarlane 2010). Therefore, it is likely that the stress balls (used during guided
mindfulness exercises) allowed Daniel to focus on his bodily sensations and begin to
reconnect with brain areas associated with wider self-awareness. These structures are
significantly underactive in PTSD cases (e.g., the parietal lobes, which manage physical
sensations; the insula, which links physical sensations and emotions; and the anterior
cingulate, which links emotions and thought) (van der Kolk 2015). NOTE: Throughout
our work with Daniel, we focused a great deal on physical/kinesthetic methods to help
him better manage the physiological symptoms of his trauma.
5 Joint/combined three-way image making refers to the technique we employed with Daniel
in which all three of us collaborated in the creation of a single artwork. Sometimes this
146 DBT-INFORMED ART THERAPY IN PRACTICE

involved taking turns (adding to the piece one person at a time). On other occasions we
simultaneously contributed marks, images, etc.
6 An example of this took place when Daniel misinterpreted the intent of a physical
examination that had been requested by his specialty doctor. Daniel believed that it
would be a genital exam, which, although not the case, triggered a heightened state of
agitation (he was anxious and fearful of sexual abuse). Like new parents on the scene, we
reassured Daniel of the nature of the exam. This evoked a significant shift in his level of
trust toward us both, and afterward the team noticed a marked reduction in the number
of aggressive outbursts.
7 Body maps are grounded in CBT theory (Rapee et al. 2000; Santen 2015; Zandt and
Barrett 2017). We used them with Daniel as a psychoeducational exercise. He would
draw or color his current internal emotional experience onto a blank template of an
androgynous human body. We guided him with prompts about specific emotions
(e.g., “When you’re angry, where does it sit in your body?”). We coupled this with an
exploration of language he could use to effectively describe his emotions and physical
experiences. Daniel appeared to find the body map exercises useful for separating out his
emotions, which had become enmeshed by the trauma. For instance, Daniel’s experience
of fear was often heavily entwined with anger and shame. Through this exercise he
was not only able to draw them apart from one another but also developed a wider
vocabulary for communicating each emotion to others.

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 Part 2

Multi-Modal DBT-
Informed Approaches
 Chapter 9

DBT Case Conceptualization

Featuring Art Therapy and
Poetry Interventions
YVETTE DUARTE

Introduction
This chapter presents combined dialectical behavior therapy (DBT)
and art therapy, a novel intervention that appears particularly effective
for some individuals. I, the author, provide the case conceptualization for
Muneca (pseudonym), a young adult who completed one year of
comprehensive outpatient services at Awake DBT, Inc.1 in San Jose,
California. The client’s second six months of treatment featured a
weekly skills training group that included DBT-informed art therapy
activities, as well as ongoing individual DBT sessions (the latter of
which also contained art therapy elements).
I share Muneca’s story via a modified DBT case conceptualization
format2 and follow this with some drawings and poems the client
created during their participation. The chapter also considers how
integrated DBT, art therapy, and poetry may have helped this individual
to achieve some of their treatment goals. It concludes with suggestions
for researching DBT-informed art therapy interventions and measuring
treatment outcomes.

DBT
DBT is a well-known cognitive behavior therapy for severe emotion
regulation problems (Koerner 2012; Linehan 1993; Swenson 2016). It
was designed to treat borderline personality disorder (BPD), a mental
illness marked by impulsive, risky, and/or self-destructive behaviors,

153
154 DBT-INFORMED ART THERAPY IN PRACTICE

frequent or chronic suicidal ideation (SI) and attempts, self-injury, severe

mood instability, relationship difficulties, intense fears of abandonment,
and poor treatment response (American Psychiatric Association 2013;
Dimeff and Koerner 2007). According to Marsha Linehan, PhD, DBT’s
developer, “[T]he unrelenting crises and behavioral complexity of a
borderline patient often overwhelm both the patient and the therapist”
(1993, p.165). Such intense situations and high-risk problems require
a very structured, specific, and inclusive intervention with clearly
defined, consistent priorities.
DBT is a behavioral treatment program, not so much an individual
psychotherapy approach. It is a combination of individual psy­
chotherapy sessions, group [skills] training, telephone coaching, a
therapist consultation team, and the opportunity to help change the
client’s social or family situation as well. (Linehan 2020, p.9)
Comprehensive treatment at Awake DBT involves a six-month
commitment, including one 24-week cycle of skills training. The
curriculum contains four modules: core mindfulness, distress tolerance,
interpersonal effectiveness, and emotion regulation skills (Linehan
2015a, 2015b). DBT consists of five stages: pretreatment3 and stages
1–4. After a thorough assessment of a client’s history and presenting
issues, the clinician determines the appropriate treatment stage. For
the purposes of this case study, I focus on stage 1 DBT, the typical
entry-level intervention for those with problems “so pervasive that they
significantly impair quality of life, interfere with therapy, and pose a
threat to life” (Koerner 2012, p.27).
Miller, Rathus, and Linehan (2006) state that the focus of Stage 1
DBT is on attaining “a life pattern that is reasonably functional and
stable” (p.46). To this end, the therapist and client collaboratively work
toward four primary behavioral categories. Target behaviors refer to
behaviors that are explicitly identified as needing to change. These are
addressed within the individual therapy session and “are approached
hierarchically and recursively as higher-priority behaviors reappear”
(Miller et al. 2006, p.46).
Listed in order of importance, the four DBT stage 1 targets are (1)
decreasing life-threatening behaviors, (2) decreasing therapy-interfering
behaviors (on the part of the client and/or therapist), (3) decreasing
quality-of-life-interfering behaviors, and (4) increasing behavioral
skills. Clients record any occurrence of primary “target” behaviors
 Art Therapy and Poetry Interventions 155

(Linehan 1993, p.165) on a diary card and bring this monitoring tool
with them to every individual therapy and skills training session.
Routine review of the diary card assists with keeping both client and
therapist focused on the primary targets (Miller et al. 2006).

Art therapy
The American Art Therapy Association (AATA) describes art therapy
as “an integrative mental health and human services profession that
enriches the lives of individuals, families, and communities through
active art making, creative process, applied psychological theory, and
human experience within a psychotherapeutic relationship” (2017).
Although a detailed exploration is outside the scope of this chapter,
it is important to note that, as with other mental health disciplines,
art therapy “is used to encourage personal growth, increase self-
understanding, and assist in emotional reparation” (Malchiodi 2012,
p.1). However, unlike DBT, art therapy has not obtained a strong
evidence base, as the existing research is mainly qualitative in nature.

DBT-informed art therapy

Some clinicians believe that art therapy can serve as a valuable
complement to DBT. Huckvale and Learmonth (2009) found that
DBT’s dialectical approach4 to acceptance and change (as well as the
concepts of emotion regulation and developing one’s wise mind5)
resonates with art making processes both within and outside of
formal art therapy environments. Clark (2016) defines DBT-informed
art therapy as a “strategic use of creative visual exercises to explore,
practice, and generalize stage 1 DBT concepts and skills” (p.190).
As such, it introduces novel multi-modal (e.g., visual, kinesthetic)
interventions to DBT’s primarily language-based skills training
protocol (Linehan 2015a, 2015b); these may be more engaging for
nontraditional learners. The resulting enhanced mental interest could
potentially improve skills retention because participants are more likely
to associate personal meaning with the acquired information (through
creating artistic metaphors and symbols) (Dyer 2008). Furthermore,
such heightened interest/attention may stimulate the core mindfulness
skill of participating effectively: According to Clark (2016), combined
DBT and art therapy clients “often describe coming away with a deeper
156 DBT-INFORMED ART THERAPY IN PRACTICE

understanding of the skills, and the resulting art product can be a

helpful presence and reminder of important work long after the actual
therapy session has concluded” (p.115).
Art making gives participants an alternative method for discovering
and integrating didactic materials through various creative media such
as collage, pencils, pastels, paints, and clay. I suspect that this unique
application offers a depth not attainable through standard language-
centered skills training. Megan Shiell, a DBT-informed art therapist
from Australia, points out that “clients are learning in two different
ways: one from a skills-based cognitive approach, and one from an
experiential, nonverbal style of learning” (personal communication)
(Clark 2017, p.111). Along these same lines, von Daler and Schwanbeck
(2014) write:
As efficacious as DBT is in helping clients change behaviors, regulate
emotions and create a life worth living, we wanted to integrate the
wealth of possibilities that comes from the sensory engagement,
imagination, and creativity of expressive arts—that might augment
growth and deepen engagement and transformation. (p.237)

The DBT/art therapy skills group at Awake DBT

Only one of Awake DBT’s several skills training groups includes art
therapy. Individuals who express interest in this advanced group at
the time of their intake interview must demonstrate solid familiarity
with the DBT skills (and/or have successfully completed a standard
skills training group).
I introduced the DBT/art therapy group in 2015. My intention was
to help clients better integrate DBT into their daily lives by engaging
in creative methods for exploring, expressing, and deepening their
comprehension of the DBT concepts/skills. Group members frequently
state that they feel that they are “getting” the material on a deeper level.
Many also note how they connect with peers in a more intimate, authentic
manner than seemed possible while attending the regular didactic DBT
skills training group. Additionally, clients report that they feel good about
themselves and what they accomplish through DBT/art therapy.
The two-hour-long group commences with a brief mindfulness
exercise (20 minutes) followed by a review of the previous week’s skills
practice homework (30 minutes). After a 5-minute break the session
resumes with a DBT skills lesson (25 minutes), then a related art therapy
 Art Therapy and Poetry Interventions 157

exercise (40 minutes with sharing/processing time). I end the session

with a new skills practice homework assignment.
During their intake Muneca talked about how they wanted to attend
the group and shared a belief that they learned best by creating art.
Throughout the second half of their DBT tenure, Muneca received art
therapy interventions within both DBT individual therapy and skills
group. As for the individual sessions, these were woven into target 3
(quality of life) work after we had addressed any target 1 and/or target
2 behaviors. Art therapy provided Muneca with ample opportunities
to externalize their inner experiences through the nonverbal language
of lines, colors, and textures. The resulting artworks provided concrete
evidence of Muneca’s journey toward health and wholeness.

CASE CONCEPTUALIZATION—MUNECA
Muneca’s DBT case conceptualization consists of the following: client
description/presenting problems, biosocial theory, stage 1 primary targe­
ted behaviors, and life worth living goals.

Client description/presenting problems

Muneca, a 21-year-old Mexican American nonbinary person, was referred
for comprehensive DBT as part of their discharge plan from an inpatient
treatment facility. Muneca reported psychiatric symptoms beginning at age
15 (e.g., “falling behind on homework,” “crying and being moody”). At intake
they carried the following diagnoses: major depressive disorder, generalized
anxiety disorder, and attention deficit hyperactivity disorder (ADHD).
Muneca endorsed a history of self-harming behaviors (e.g., cutting, skin
picking) but claimed that their last cutting episode occurred during high
school, when they had used a blade to “feel something” and “deal with the
emotional pain.” Muneca received inpatient psychiatric treatment on at
least six occasions for SI when they were under the age of 15, as well as
four more times as an adult. Their most recent hospitalization occurred
six months prior to entering Awake DBT. Other risk factors included the
suicides of a nephew and their best friend.
Muneca displayed significant behavioral impulsivity fueled by emotional
dysregulation. During these episodes they might overspend. They also
reported “spiraling out of control when bad things happened.” Muneca
struggled with intense anger (another common BPD symptom), which they
often expressed by punching walls. Muneca denied any extreme outbursts
158 DBT-INFORMED ART THERAPY IN PRACTICE

for several months prior to starting DBT. However, they maladaptively

controlled their anger by “shutting down”/isolating (which resulted in
bouts of sadness). Muneca often chose not to directly communicate their
needs for fear of “being a burden.”

Other symptoms/behaviors: Muneca had difficulty concentrating

and could be quite forgetful. They frequently exhibited paranoia and
occasionally dissociated around other people. They sometimes experienced
depersonalization, as well. Muneca reported smoking marijuana one to
two times a week; however, use increased when they were emotionally
dysregulated. During their time in comprehensive DBT, Muneca was
prescribed Prozac and Abilify.

Biosocial theory
DBT’s biosocial theory posits that BPD is a disorder of the emotion
regulation system and that emotion dysregulation “is due to high emotional
vulnerability plus an inability to regulate emotions” (Linehan 1993, p.43).
Linehan hypothesized the following: first, individuals prone to emotion
dysregulation possess high sensitivity to emotional stimuli; they react
quickly, and “[e]vents that might not bother many people are likely to
bother the emotionally vulnerable person” (Linehan 1993, p.44). Second,
they experience emotional intensity—responses are extreme, and such
high arousal can dysregulate cognitive processes, too. Third, emotions
are long-lasting, with a slow return to baseline. Koerner (2012) states that
difficulties managing emotions negatively impacts myriad areas of one’s
life: “Most of what we do and who we are depends on mood stability and
adequate emotion regulation” (p.5).
During their DBT assessment Muneca reported feeling “very sensi­
tive to people’s energy.” They described many examples of sudden
reactions that were out of proportion to the prompting event(s). Muneca
concurred that these intense emotions seemed to take much longer to
return to normal levels compared with other people’s responses.
According to the biosocial theory, BPD develops through repeated
transactions between this innate sensitivity and one or more invalidating
environments. Koerner (2012) elaborates that pervasive invalidation
occurs when “our valid primary emotional responses” are treated by others
as though they are “incorrect, inaccurate, inappropriate, pathological or
not to be taken seriously. Primary responses of interest are persistently
squelched or mocked; normal needs for soothing are regularly neglected
or shamed; honest motives consistently doubted and misinterpreted” (p.6).
 Art Therapy and Poetry Interventions 159

Muneca reported that their parents failed to validate their emotional

experiences. For example, their father apparently responded to their
frustration or sadness by yelling. Whenever their mother supported him (or
remained neutral), Muneca felt disregarded and invalidated. In addition to
conflicts with their parents, Muneca was bullied by other children because
they were “different,” and quick to tears or anger. Their physical appearance
was also quite unlike that of their Christian school classmates: they dyed
their hair and dressed in their own unique style. Muneca attended the
school from sixth through eleventh grade but was expelled for cutting and
threatening to kill themselves shortly after their best friend committed
suicide. Although Muneca did not then possess the resources or capacity to
manage academic challenges, they eventually graduated from high school.
Interactions between Muneca’s inherent sensitivity and invalidating and
traumatic environmental factors may have impaired their ability to regulate
emotions and moods.
Linehan’s biosocial theory holds that emotionally vulnerable children
are unlikely to naturally acquire competence with managing intense affect—
hence why DBT explicitly teaches emotion regulation skills (Koerner 2012).

Stage 1—Primary targeted behaviors

Muneca and I agreed to collaboratively address the following:

– Target 1/Life-threatening behaviors: These are the most serious

behaviors and, therefore, prioritized. Target 1 includes suicide
attempts, significant SI, and self-harming acts (especially resulting
in tissue damage).

Muneca denied current target 1 behaviors, although they had a recent

history of psychiatric hospitalizations related to SI. Muneca had once
created a plan to jump in front of a train. However, they did not make any
attempts. Muneca also reported that they had not cut themselves in several
years.

– Target 2/Therapy-interfering behaviors (TIBs): These get in the way

of effective DBT and include not completing diary cards and/or skills
group homework, as well as treatment absences. The goal is to
reduce both client and therapist TIBs and increase behaviors that
“enhance the continuation and effectiveness of therapy” (Linehan
1993, p.129). Linehan explains that individuals “who are not in
therapy or who, though nominally in therapy, do not engage in or
receive therapeutic activities, cannot benefit” (p.129).
160 DBT-INFORMED ART THERAPY IN PRACTICE

In the beginning, Muneca did not consistently complete their diary card and
homework assignments. A missing link analysis (a type of behavior analysis
for identifying treatment obstacles) indicated that ADHD made it difficult for
them to concentrate and, therefore, follow through. This TIB declined as
Muneca developed mindfulness skills (and set reminders on their phone).

– Target 3/Quality-of-life-interfering behaviors: These are behaviors/

problems that create (or are themselves) obstacles to improving
overall quality of life. Muneca’s target 3 behaviors included
difficulties with obtaining housing and with securing employment.
They also contended with some financial and academic issues.

Muneca possessed several negative self-judgments that contributed to

their overall emotional dysregulation and often precluded them from
pursuing and achieving important goals (an example of the secondary
target self-invalidation6). They also lacked appropriate follow-through
with tasks such as registering for classes at school and completing job
and housing applications. Further, intense emotions reduced Muneca’s
ability to keep relationships; they did not trust other people and tended to
ineffectively confront friends when upset.
Muneca and I collaborated during the intake to identify some initial
goals and targets. Targets are behaviors that must change (i.e., decrease,
stop, or increase) for the client to achieve their goals. Muneca’s primary
targets were to: (1) decrease punching walls or “shutting down” when
angry; and (2) increase motivation (and reduce isolation).

– First target behavior.

Muneca wished to better control anger, which often resulted in SI/psychiatric

hospital admissions. The function of their angry behavior, for example
punching walls and “shutting down”/withdrawing, was twofold: Muneca
wanted their father to stop yelling and wanted their mother to validate their
emotions. This was sometimes effective when one or both parent(s) showed
concern or provided some validation (which unintentionally reinforced the
target behavior). However, if Muneca withdrew and ruminated to the point
of feeling very depressed (and communicating that they might attempt to
kill themselves), they frequently ended up in the hospital for SI.7

– Second target behavior.

Muneca exhibited a pattern of isolating from friends, which triggered

loneliness and an ever-decreasing motivation to socialize. Withdrawal
 Art Therapy and Poetry Interventions 161

was a way to avoid, in the short term, normal but painful feelings of grief/
sorrow. For example, on the anniversary of their friend’s death, Muneca
did not leave their bedroom all day and ruminated on guilt, which, although
unpleasant, was not as painful to Muneca as the sadness. The behavior
was dysfunctional because it ultimately made Muneca more depressed
and probably in need of hospitalization (this is an example of the secondary
target inhibited grieving8).

Life worth living goals (LWLGs)

During the intake process clients also establish LWLGs, specific things they
must achieve to create the kind of life they desire. These goals are what
drive/motivate treatment (while the target behaviors get in the way of
treatment). Muneca’s LWLGs were as follows:

– LWLG 1.

Muneca wanted to become more independent from their parents and

ultimately move to Oregon with their boyfriend: “I want to be less affected
by what my parents are dealing with and be at peace with them. I want
to become my own person.” However, Muneca also wished to be on good
terms with them. Improving their relationship with both their mother and
father would strengthen Muneca’s support system (which would help them
to feel more confident in living independently).

– LWLG 2.

Muneca’s second goal was to develop more friendships so that they would
not be as lonely.

Comprehensive DBT is a complex treatment model containing

numerous and sophisticated assumptions, procedures, and strategies.
Although its skills training component is extremely important,9 skills
are not always sufficient (Koerner 2012). Other aspects of DBT that
were crucial for Muneca included contingency management, cognitive
restructuring, and exposure interventions.
Contingency management utilizes reinforcement principles to
increase desirable behaviors and decrease undesirable ones. Because the
client/therapist relationship is typically so powerful and positive, these
strategies are often “ways to manage the contingent relationships between
the patient’s behavior and the therapist’s responses so that the ultimate
outcomes are beneficial instead of iatrogenic” (Linehan 1993, p.297).
162 DBT-INFORMED ART THERAPY IN PRACTICE

Cognitive restructuring procedures assist clients to change both

the style and content of their thinking. This was essential for reducing
Muneca’s negative self-judgments so that they were more able to
regulate their emotions. This involved challenging dysfunctional
beliefs such as “my anger defines me” and replacing it with a less
extreme cognition (i.e., “anger doesn’t define me and it’s okay to be
angry sometimes”).
Mindfulness of emotions is an exposure practice. For example,
clients are “instructed to ‘experience’ exactly what is happening in the
moment, without either pushing any of it away or grabbing onto it.
They are also instructed to ‘step back from’ and observe judgmental
responses to their own behaviors” (Linehan 1993, p.354). Linehan
further states that, “[i]n its entirety, mindfulness is an instance of
exposure to naturally arising thoughts, feelings and sensations…and
may be particularly useful way to encourage exposure to somatic cues
associated with emotions” (p.354). This treatment was helpful for
Muneca in decreasing emotional/physiological arousal after conflicts
with their parents. Exposure work allowed Muneca to fully experience
the emotions so that they no longer feared and avoided them.

ART THERAPY AND POETRY: DBT IN ACTION

Art therapy and poetry: DBT in action
This section explores some of the artwork that Muneca created during
their DBT participation. These pieces specifically addressed the
previously mentioned target behaviors and LWLGs. Although Muneca
used a variety of art materials in both their individual DBT sessions
and within the art therapy/skills group, this case conceptualization
highlights the following: a 8.5 × 11 in. spiral-bound multimedia
sketchbook (referred to as “blue spiral”), alcohol ink markers, and thin
pens. Muneca preferred to draw with markers and pens, which, as more
controlled media options, allowed them to feel more comfortable and
secure in their creative expression.

Activity 1: Create a LWLG (Figure 9.1)

Purpose
Explore meaningful treatment goals applicable to the client’s personal
conceptualization of their life worth living.
 Art Therapy and Poetry Interventions 163

Materials
The blue spiral sketchbook, markers, and pens.

Procedure
During one of our individual sessions I asked Muneca to create an
image representing their LWLGs, which included improving their
relationships with their parents and becoming more independent.

Discussion
Muneca stated that the scale illustrated “wanting more balance in
[their] life” so that anger and anxiety would not continue to overwhelm
them: “The moon represents the dark night of the soul and dealing
with emotions. The sun represents when things go well and [are] lit up.
I could stay balanced whether it’s the day or night.” The title indicated
that “Hopefully, whatever journey I was on, I would reach a balance.”

Figure 9.1 “That’s all, folks!” (Create a life worth living goal)

Activity 2: STOP skills diagram (Figure 9.2)

Purpose
Deepen (enhance and reinforce) the client’s understanding of the DBT
STOP skill (Linehan 2015a, 2015b). STOP is part of the distress tolerance
module (crisis survival skills) and comprises four consecutive steps/
components: Stop moving (don’t act on impulsive behavior urges); Take
a step back and breathe; Observe what is happening both inside and
outside of oneself; and Proceed mindfully (“Think about your goals. Ask
Wise Mind: Which actions will make it better or worse?”) (2015b, p.327).
164 DBT-INFORMED ART THERAPY IN PRACTICE

Materials
The blue spiral sketchbook, markers, and pens.

Procedure
This assignment was given in a DBT/art group session. I invited
participants to make a diagram of the STOP acronym and draw their
own iconography for each of the four steps/components.

Discussion
Muneca wanted to break their pattern of becoming extremely stressed
and overwhelmed, then suicidal (which had resulted in numerous
hospitalizations). Using STOP decreased their suicidal urges when
their father yelled at them and/or did not acknowledge their feelings.
Muneca also wished to reduce what they called “shutting down” in
response to becoming emotionally upset (i.e., isolating and ruminating
about stepping in front of a train). These episodes typically resulted
in Muneca calling 911, then being hospitalized for suicidal ideation.
Using colored markers in their blue spiral sketchbook, the client made a
diagram of a figure demonstrating the STOP skill in its entirety. Muneca
reported that drawing all four steps/components in this way helped
them to better understand and integrate STOP into their expanding
repertoire of effective behaviors. Over time, they became less reactive
when they felt angry, and hence made more desirable choices.

Figure 9.2 The STOP skill

 Art Therapy and Poetry Interventions 165

Activity 3: Mindfulness of current emotion (Figure 9.3)

Purpose
Deepen (enhance and reinforce) the client’s understanding of the
mindfulness of current emotion skill by practicing it, and then further
exploring the observed affect state through creative expression.
Mindfulness of current emotion involves exposing oneself to that
emotion by attending to it fully and not pushing it away.

Materials
The blue spiral sketchbook, markers, and pens.

Procedure
During an individual session Muneca struggled with intense anger.
I directed them to practice breathing and observing their body
sensations until the emotion subsided. Afterward, the client shared that
their distress had significantly decreased. Muneca then completed this
symbolic artwork.

Discussion
The snake image came to Muneca while practicing mindfulness of their
current emotional state. Muneca explained that the snake held divine
wisdom; further, it represented transformation and infinity (expressed
by the snake eating itself). Muneca added that the fangs depicted anger.
However, this snake was controlled and would not strike unless it was in
danger. It showed a strong presence but did not need to lash out. Muneca
reported that they felt more confident after completing this exercise.

Figure 9.3 Riding the wave of anger—divine

wisdom (mindfulness of current emotion)
166 DBT-INFORMED ART THERAPY IN PRACTICE

Activity 4: Wise mind (Figure 9.4)

Purpose
Strengthen personal understanding of wise mind (the inherent wisdom
in each of us).

Materials
The blue spiral sketchbook, markers, and pens.

Procedure
This exercise was completed during an individual therapy session. The
directive was for Muneca to create an image of the wisdom they felt in
that moment after reaching their goal of finding housing.

Discussion
Layla was the final artwork that Muneca made around their second
LWLG (to develop friendships and decrease loneliness). They had
worked on processing unresolved grief in order to build healthier
relationships and to feel more connected with other people. One day
near the end of treatment, Muneca came to their individual session
excited about having just secured an apartment in Oregon. They were
looking forward to moving out of their parents’ house and becoming
more independent. Muneca identified Layla as their “wise mind
monster” (and smiled as they described this creature as “soft, furry,
and warm”). Muneca described how Layla possesses a “third eye”—also
symbolic of DBT’s “middle path” (Linehan 2015b, p.74)—with which
to see things more clearly. It is their “eye of wisdom.” Muneca believed
that they had grown a great deal and had strengthened their wise mind
over the course of the DBT treatment.

Figure 9.4 Layla the wise mind monster! (Personal

conceptualization of wise mind)
 Art Therapy and Poetry Interventions 167

Poetry
Poetry writing was another powerful means of self-expression for this
client. Muneca engaged in creative writing on their own. However, they
often shared their poems during the skills group homework review.
Muneca’s writing changed over the course of their time in the DBT
program. The poems appear to reflect a developing sense of self. For
example, in several early pieces they described themselves as wounded
and “empty.” Yet by the time they had graduated from DBT, Muneca
came across as more confident as well as capable of empathizing and
connecting with others. This following poem describes how they felt at
the beginning of their treatment journey.
Vessel
I am but an empty vessel for mental illness to do its dirty work
My body used to house a person, but the demon was always there
Lurking, hiding, waiting, rationalizing its existence away,
Until one day, a coup happened,
And the person became hostage to their own skin and shed itself
away.
So, they walked with their demon to the train tracks,
Where the sweet but violent embrace of death was
Supposed to come at 60 miles per hour
With 70 tons of weight behind it to back it up in case speed wasn’t
enough
It missed.
So even though the train missed, I still manage to hate myself
everyday
And have long since left my body rotting for the demon to feast on.
—12/1/17
Although it was composed only four months after “Vessel,” the next
poem, Muneca said, spoke to the middle phase of treatment and finally
being able to “calm down.”
Calming Down After a Panic Attack (A Love Letter to Me and
All Other Survivors)
Breathe
In
Out
In again
Out again
168 DBT-INFORMED ART THERAPY IN PRACTICE

You made it to here, the now

The you in this present moment
A present to yourself from you
A beautiful soul so deep with words
That haven’t even been invented yet
Used to describe you and your every feature
Indescribable
So, beautiful
Mind body and soul
You’re wonderful
Give yourself some credit
Because you deserve it
Anxiety is an unwanted guest
Even when you do your best
Coming when least expected
Leaving you affected
Trashing the living room of your mind
And leaving you pieces of garbage to find
Even when you try to make it feel most unwelcome…
…But you have survived this abuse
before, and you have survived it now.
You did your best
And that’s all that matters.
—12/1/17
Muneca wrote the final poem, “Prayer,” nearly two years after “Vessel.”
They describe it as “represent[ing] how far along I have come.”
Prayer
I’m living life to the fullest, choosing to be ever present in this
moment. Yeah I’m skipping rope by landmines and treading ever so
carefully by crossroads, where the steel demon ravages on rails at 60
miles per hour, taking souls where they need to travel for a small fee,
but I am free! More free than ever! For what is life, if it’s not lived
freely? Yeah I wear my heart on my cloak of shame, but have since
ripped the cloak to pieces in exchange for a peace of mind and have
kept the heart safe within me. I’m going to sing my song all through
the night ’til the Lord, goddess, whoever the hell is in charge beckons
me onwards home. And even though I am preyed upon by the
earthly powers that be and the system that is, I pray that I can save
 Art Therapy and Poetry Interventions 169

a few lives at least before my time is up. Please to whoever is reading

this, don’t give up! There is more to see than what meets the eye.
Even if you don’t believe in you, take it from me who has such faith
in you and what you are capable of. Yes, my faith is blind, but that
doesn’t make it wrong or make me wrong.
—11/15/19

Conclusion
By the end of their participation in the year-long comprehensive DBT
program, Muneca had accomplished their goals of becoming more
independent, moving to Oregon, and improving their relationship with
their parents. They were also starting to make new friends. Muneca
believed that DBT art therapy had been especially helpful because it
allowed them to work through many life challenges using creative
expression. Muneca stated that the combined modalities allowed them
to learn most effectively. Writing poetry and doing art on their own
would not have been as helpful because they needed the structure
of the group (Muneca had a hard time focusing and the group kept
them accountable and on track). They also recognized how much they
learned about themselves through engaging with others. For example,
they were able to make a lot of progress practicing communication and
validation with their peers.
While DBT is an evidence-based intervention, as of this writing
DBT-informed art therapy has not undergone any rigorous research
trials proving its effectiveness. To join the ranks of empirically founded
treatments, DBT-informed art therapy requires statistically significant
data indicating that it results in tangible reductions of BPD symptoms
and behaviors. It is possible to explore outcomes with measurement
tools such as the Borderline Symptom List (BSL) self-rating scale
(Bohus et al. 2007), as well as comparing diary cards before and after
treatment. At Awake DBT, Inc., we are currently starting to administer
pre- and post-intervention tests to our DBT/art therapy clients.

Endnotes
1 Awake DBT, Inc. is a private psychotherapy practice in San Jose, California that
specializes in comprehensive DBT. It was the first program in northern California (and
15th in the entire United States) to receive credentialing through the DBT-Linehan
Board of Certification (2014–2020). Certified programs “demonstrate having the
necessary components and organization to deliver DBT with fidelity to the model”
(www.dbt-lbc.org).
170 DBT-INFORMED ART THERAPY IN PRACTICE

2 In cognitive behavior therapy (CBT), case conceptualization refers to a detailed hypothesis

concerning the cause(s) and maintenance of a person’s psychological problems, symptoms,
and behaviors (Kuyken, Padesky, and Dudley 2009; Persons 2008). Case conceptualization
is a principle-driven approach that identifies and targets mechanisms from psychological
theories such as cognitive theory and behaviorism (e.g., classical conditioning; operant
conditioning). Specific to DBT, Manning (2018) notes that a solid case conceptualization

[…] uses the principles and the protocols of the treatment to assess client goals
and behaviours, create a treatment plan, and provide accurate interventions that
ultimately bring the clients to his/her life worth living goals. It begins with the
initial assessment and continues through pretreatment. Throughout treatment
specific behavioural targets are conceptualized using a behavioural formulation,
including functions, controlling variables, and the behavioural interventions that
treat the behaviours. The case conceptualization is organic and changes as needed.
Formal case conceptualization can be written or therapists can articulate their
conceptualization of a case as they conduct the therapy. (pp.237–258)
3 Linehan (1993) states that “[a]greement on goals of treatment and general treatment
procedures is the crucial first step before therapy even begins” (p.97). Pretreatment
prepares the prospective DBT client and DBT therapist to work together. Both must
commit to working toward the identified treatment goals. This crucial stage “focuses
solely on eliciting a commitment that is sufficiently strong, durable, and meaningful to
carry the [client] through the challenges of behavioral change” (Swenson 2016, p.204).
4 A unique aspect of DBT is its emphasis on dialectics. Linehan (2020) describes this, in
practical terms, as

[…] the dynamic balance between acceptance of oneself and one’s situation in life,
on the one hand, and embracing change toward a better life, on the other. (That is
what “dialectics” means—the balance of opposites and the coming to a synthesis)…
This balance between pursuing change strategies and pursuing acceptance strategies
is a basis DBT, and unique to DBT. This emphasis on acceptance as counterbalance
to change flows directly from the integration of Eastern (Zen) practice, as I
experienced it, and Western psychological practice. (pp.7–8)
5 The goal of DBT mindfulness practice is cultivating one’s wise mind, which Linehan
(1993) describes as a “center of calmness” (p.215) that adds intuitive knowing to the
other states (reasonable mind and emotion mind).
6 Muneca’s negative self-judgments are examples of a secondary behavioral target called
self-invalidation. Secondary targets are “rigid, ineffective behavior patterns functionally
related to stage 1 primary treatment targets” (Dimeff and Koerner 2007, p.120). Linehan
refers to these patterns as dialectical dilemmas because of their transactional nature. The
antithesis of self-invalidation is emotional vulnerability. Emotional vulnerability (and
hence the individual’s inevitable inability to regulate their emotions) results in increased
invalidation from the environment (Koerner 2012; Swenson 2016). Over time, the client
tends to adopt the characteristic of the invalidating environment and “invalidate her own
affective experiences…look to others for accurate reflections of external reality, and…
oversimplify the ease of solving life’s problems. Invalidation of affective experiences leads
to attempts to inhibit emotional experiences and expression” (Linehan 1993, p.72).
Muneca was initially quite susceptible to emotional triggers and, as a result, had
frequent psychiatric hospitalizations (inpatient stays decreased over the course of their
DBT participation). Their oversimplification of life’s difficulties led to extreme shame
and self-criticism/punishment when goals were not met. Muneca often put themselves
down by saying “I am stupid” and ruminating on their mistakes. Muneca also habitually
apologized for actions that did not warrant an apology (these behaviors also reduced
during treatment).
 Art Therapy and Poetry Interventions 171

7 This is an example of operant conditioning, which Heard and Swales (2016) define as
the process whereby animals learn to associate a behavior with specific consequences
and those consequences of the behavior then significantly control the probability of
that behavior reoccurring. Skinner (1953, 1976) used the term “operant” as he viewed
many behaviors as “operating” on the environment in ways that produced certain
consequences. A contingent relationship thus exists between the operant behavior and
its consequences. Consistent with many forms of behavior therapy, DBT therapists use
behavioral analysis to assess and describe the contingent relationships related to the
target behaviors. Therapist and clients can then apply contingency management…to
change problematic contingent relationships (p.9). Heard and Swales (2016) describe
how operant conditioning includes reinforcement and punishment: “These processes
contribute both to the development and maintenance of a client’s problematic behaviors.
Reinforcement occurs when a consequence of a behavior increases the likelihood that
the behavior will occur again” (p.9).
8 The secondary behavioral target inhibited grieving “refers to attempts to avoid or escape
emotional experiences related to sadness and loss” and is “heavily influenced by the
invalidating environment” (Swenson 2016, p.170). Muneca reported experiencing
survivor’s guilt after the suicides of both their nephew and best friend. They avoided
feeling their grief by isolating themselves and ruminating about suicide, which resulted
in several hospitalizations.
The antithesis of inhibited grieving is unrelenting crises (Linehan 1993). The
individual’s high emotional reactivity, along with chronic highly stressful life events,
triggers a strong, automatic avoidance response. Suicidal thoughts can be maladaptive
efforts to problem solve by momentarily reducing emotional distress. However, the
individual becomes “engaged in a constant effort to block awareness and extinguish
memory of negative events” (Swenson 2016, p.170). Swensen (2016) adds that inhibited
grieving may ultimately create “a level of suppression and detachment that lends itself
to extreme loneliness, despair, and suicide” (p.170). As with Muneca’s self-invalidation,
this pattern of inhibited grieving reduced over time and treatment. Muneca is now able
to fully experience their emotions.
9 Below are some examples of how DBT skills (Linehan 2015a, 2015b) helped Muneca.
Core mindfulness skills were designed by Marsha Linehan as secular and behavioral
versions of ancient meditation practices. She (2020) states that: “The second aspect
of DBT that makes it unique is the inclusion of mindfulness practice as a therapeutic
skill, a first in psychotherapy. This, too, came from my experience with Zen…” (p.8).
Mindfulness skills decreased Muneca’s low motivation and tendency to isolate. They
developed an ability to tolerate and fully experience difficult emotions like sadness
without resorting to problematic behaviors for relief. They developed a strong personal
understanding of their wise mind (Activity 4/Figure 9.4).
Emotion regulation skills enabled Muneca to work through intense emotions without
becoming overwhelmed. The skill mindfulness of current emotion (Activity 3/Figure 9.3)
strengthened their ability to experience grief over the deaths of loved ones. They also
implemented opposite action to combat low motivation and isolation, so that they could
look for a job, explore housing options, and connect with friends. Muneca subsequently
reported more frequent experiences of joy.
Distress tolerance skills assisted Muneca in managing dysregulation so that they
could interact with their parents without becoming aggressive and/or suicidal. Crisis
survival strategies such as STOP (Activity 2/Figure 9.2) helped Muneca handle
overwhelming emotions so that they could improve family relationships and avoid
additional psychiatric hospitalizations.
Interpersonal effectiveness skills taught Muneca to assert themselves much more
competently. Over time they could directly communicate their wants and needs. This
allowed Muneca to achieve their objective(s) and, more often than not, simultaneously
improve important relationships and maintain their self-respect.
172 DBT-INFORMED ART THERAPY IN PRACTICE

References
American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental
Disorders (5th ed.) (DSM-5). Washington, DC: Author.
Bohus, M., Limberger, M.F., Frank, U., Chapman, A.L. et al. (2007) ‘Psychometric properties
of the borderline symptom list (BSL).’ Psychopathology 40, 126–132.
Clark, S.M. (2016) ‘DBT in Action: Integrating Art Therapy Techniques and Dialectical
Behavior Therapy Skills Training into the Treatment of Eating Disorders.’ In A.
Heiderscheit (ed.) Creative Arts Therapies and Clients with Eating Disorders. London:
Jessica Kingsley Publishers.
Clark, S.M. (2017) DBT-Informed Art Therapy: Mindfulness, Cognitive Behavior Therapy, and
the Creative Process. London: Jessica Kingsley Publishers.
DBT-Linehan Board of Certification (2014–2020) About DBT: What is DBT? Accessed on
10/8/20 at https://dbt-lbc.org/index.php?page=101119.
Dimeff, L.A. and Koerner, K. (eds) (2007) Dialectical Behavior Therapy in Clinical Practice:
Applications Across Disorders and Settings. New York, NY: Guilford Press.
Dyer, M. (2008) Visual and Experiential DBT (presentation/workshop). Annual Conference
of the American Art Therapy Association, Cleveland, Ohio.
Heard, H.L. and Swales, M.A. (2016) Changing Behavior in DBT: Problem Solving in Action.
New York, NY: Guilford Press.
Huckvale, K. and Learmonth, M. (2009) ‘A case example of art therapy in relation to
dialectical behaviour therapy.’ International Journal of Art Therapy 14, 2, 52–63.
Koerner, K. (2012) Doing Dialectical Behavior Therapy: A Practical Guide. New York, NY:
Guilford Press.
Kuyken, W., Padesky, C.A., and Dudley, R. (2009) Collaborative Case Conceptualization:
Working Effectively with Clients in Cognitive-Behavioral Therapy. New York, NY: Guilford
Press.
Linehan, M.M. (1993) Cognitive-Behavioral Treatment of Borderline Personality Disorder.
New York, NY: Guilford Press.
Linehan, M.M. (2015a) DBT Skills Training Manual (2nd ed.). New York, NY: Guilford Press.
(Original work published in 1993.)
Linehan, M.M. (2015b) DBT Skills Training Manual (2nd ed.). Handouts and Worksheets.
New York, NY: Guilford Press. (Original work published in 1993.)
Linehan, M.M. (2020) Building a Life Worth Living: A Memoir. New York, NY: Random
House.
Malchiodi, C.A. (ed.) (2012) Handbook of Art Therapy (2nd ed.). New York, NY: Guilford
Press.
Manning, S. (2018) ‘Case Formulation in DBT: Developing a Behavioural Formulation.’ In
M.A. Swales (ed.) The Oxford Handbook of Dialectical Behaviour Therapy. Oxford, UK:
Oxford University Press.
Miller, A.L., Rathus, J.H., and Linehan, M.M. (2006) Dialectical Behavior Therapy with
Suicidal Adolescents. New York, NY: Guilford Press.
Persons, J.B. (2008) The Case Formulation Approach to Cognitive-Behavior Therapy. New
York, NY: Guilford Press.
Skinner, B.F. (1953) Science and Human Behavior. New York, NY: Macmillan.
Skinner, B.F. (1976) About Behaviorism. New York, NY: Random House.
Swenson, C.R. (2016) DBT Principles in Action: Acceptance, Change, and Dialectics. New
York, NY: Guilford Press.
von Daler, K. and Schwanbeck, L. (2014) ‘Creative Mindfulness: Dialectical Behavioral
Therapy and Expressive Arts Therapy.’ In L. Rappaport (ed.) Mindfulness and the Arts
Therapies: Theory and Practice. London: Jessica Kingsley Publishers.
 Chapter 10

Group InCircle
Development and Implementation of a Novel DBT-
Informed Creative Arts Therapy Group for Veterans with
Serious Mental Illness in a Large Hospital Setting
JEREMY STEGLITZ, SCOTT LEVSON,
MELANIE PACI, AND TRACELA M. ZAPATA

Introduction
Serious mental illness (SMI) is a significant problem in the United States
and affects nearly 13.1 million adults (National Institute of Mental Health
2019). American military Veterans are disproportionately impacted
by SMI (Trivedi et al. 2015). Dialectical behavior therapy (DBT) is a
cognitive behavioral approach that has shown significant promise in
reducing high-risk behaviors (e.g., self-harm) and improving overall
quality of life among this population (Goodman et al. 2016). However,
DBT’s primarily group-based skills training format may not be an ideal
treatment for Veterans with SMI. While group therapy is often a useful
and cost-effective method of addressing mental health problems, such
individuals (particularly those in a hospital setting) possess unique
cognitive impairments that may interfere with learning via traditional
instructional methods (Twamley et al. 2019). Veterans have reported
consistent challenges with acquiring DBT skills due to group-related
anxieties as well as the density of the curriculum’s didactic content
(Barnicot et al. 2015).
Art therapy, an “integrative mental health and human services
profession that enriches…lives…through active art-making, creative
process, [and] applied psychological theory” (American Art Therapy
Association 2017), could overcome some of the major barriers to DBT
skills acquisition among Veterans contending with SMI. Art therapy

173
174 DBT-INFORMED ART THERAPY IN PRACTICE

can reduce anxiety (Cho 2016; Tang et al. 2019); further, it may facilitate
and/or enhance the comprehension of new learning by recruiting
neuroanatomical brain structures not involved in traditional didactic
skills training models (Havsteen-Franklin and Altamirano 2015).
Active art making, more so than usual language-based instruction,
requires the integration of higher cortical cognitive processes—such as
planning, attention, and mindful problem-solving—that play significant
roles in learning (Hass-Cohen and Carr 2008). Sub-cortical centers
involved in implicit motivation (e.g., the limbic system and brainstem)
are also activated by art therapy interventions (Rubin 2016). Grounded
in affective-sensory experiences, art therapy comprises repeated
experiences that directly contribute to the formation and strengthening
of complex information associated with the consolidation of new
material (Chancellor, Duncan, and Chatterjee 2012).
This chapter describes the development and implementation of a
DBT-informed creative arts therapy group within an outpatient mental
health treatment program for Veterans. The 23-week intervention,
named Group InCircle, is an alternative to the standard DBT skills
training model that delivers educational material through a manualized
protocol featuring highly structured lesson plans, handouts, and
worksheets (Linehan 2015a, 2015b). We, the authors, adapted lessons
from Susan M. Clark (2017), and also created novel lessons during
weekly brainstorming sessions.

A challenge (and a possible solution)

The Psychosocial Rehabilitation and Recovery Center (PRRC), a
voluntary intensive outpatient program of the Washington DC Veterans
Administration Medical Center (DCVAMC), provides support
and treatment to Veterans with SMI diagnoses. The PRRC utilizes a
strengths-based approach to promoting psychosocial rehabilitation
and assisting patients in enhancing their adaptive and social skills, self-
care, employment satisfaction, crisis resolution skills, problem-solving
abilities, and overall quality of life. A major priority of the Veterans
Health Administration (VHA), one of the largest hospital systems in the
United States, is to “empower [patients] to improve their well-being”
and to provide “both patient-centered and evidence-based” services
that support “learning, discovery, and continuous improvement” (VHA
2017). With that in mind, the PRRC offers a myriad of recovery-oriented
 Group InCircle 175

treatment options geared toward helping Veterans optimize their

symptom management while engaging in meaningful self-exploration
and skills acquisition.
The PRRC utilizes an interdisciplinary team approach consisting of
clinical social workers, psychologists, recreational therapists, chaplains,
vocational rehabilitation specialists, nurse case managers, and peer
support specialists. The census varies; however, approximately 200
Veterans are enrolled in programming each month. The PRRC’s hours of
operation are 7:30 AM to 4:00 PM, Monday through Friday. Treatment
is multi-modal and patients may elect to participate in individual
psychotherapy, recovery coaching, and peer support services, as well
as a wide array of groups.
During an average week the PRRC offers nearly 50 groups. The
daily schedule, including groups, workshops, orientation sessions, and
community meetings, is posted in the facility’s hallway; each morning,
Veterans elect what they will attend that day. Groups are facilitated
by nurse case managers, psychologists, social workers, peer support
specialists, and student trainees. Topics include acceptance and
commitment therapy (ACT), spirituality, and health and wellness (to
name a few).
When Group InCircle was first developed and integrated into
the PRRC’s program, two of the four authors (who were completing
postdoctoral fellowships in severe mental illness) co-facilitated it.
Another worked as a staff psychologist at that time and provided
clinical supervision to the above-mentioned authors, while the fourth
served as the program manager. Although each clinician possessed
some familiarity with both DBT skills training and art therapy, this
was their first attempt to combine the approaches.

The genesis of Group InCircle

DBT skills is a well-liked group within the PRRC and multiple iterations
took place throughout the week. There were also some art therapy
groups (albeit less ubiquitous than DBT skills training). However, we
soon realized that, despite its popularity, many Veterans struggled with
DBT’s highly language-based concepts and acronyms. Such barriers
precluded many patients’ retention and application of the skills—and
prompted some to attend multiple DBT groups each week (rather
than explore other PRRC offerings) in the hope that repetition would
enhance their understanding.
176 DBT-INFORMED ART THERAPY IN PRACTICE

The difficulties that many Veterans experienced with conventional

DBT skills training were highlighted within one early Group InCircle
session. During the prelude to a lesson on the interpersonal effectiveness
(IE) module’s GIVE (relationship-centered) behavioral strategies,
Veterans received a handout explaining each item in the skills set. This
was intended to orient them to these ideas prior to engaging in a related
art activity. While both authors took the information for granted,
most patients expressed significant confusion and unfamiliarity with
validation, an essential component of GIVE (Linehan 2015a, 2015b).
Although the authors attempted explanations (primarily using
synonyms for the word itself), only after participating in the art therapy
activity did the patients fully understand the concept.
This anecdote illustrates the inspiration for Group InCircle. We came
to appreciate that, far too often, DBT skills were not being adequately
metabolized by our Veterans owing to a variety of barriers. Using a
creative medium to help enliven and enrich the content made it more
accessible for some. Based on previous research suggesting that art
therapy can synergistically enhance traditional skills-based therapeutic
approaches such as cognitive behavior therapy (CBT) (Cho 2016; Rubin
2016), Group InCircle’s goal, in alignment with the missions of the
VHA and PRRC, was to integrate DBT and art therapy interventions
to improve skills acquisition among PRRC Veterans.

Identifying stakeholders and seeking buy-in

An important step in Group InCircle’s development was to determine
the stakeholders—that is, any individuals, groups, or organizations
who would be impacted by project outcomes. This included the
group members themselves, group facilitators, PRRC leadership,
administrative staff, and other clinicians. In order to obtain necessary
buy-in, it was imperative to convey the rationale for Group InCircle as
well as how the new program offering might benefit each stakeholder
(Appendix 10.1, “Strategic Statement of Need”).

Needs assessment
The authors conducted a multi-level needs assessment to demonstrate
Group InCircle’s potential value for stakeholders. The initial level
involved a review of the current literature on DBT, art therapy, and SMI.
Its purpose was to identify any clinical challenges that might require
 Group InCircle 177

further attention and/or research. During the second level the authors
conducted informal interviews with the PRRC’s leadership, staff,
and clinicians. Our aim was to better understand these stakeholders’
perspectives and opinions concerning ongoing program needs.
The third and final level focused on better understanding the
Veterans’ clinical priorities. The authors developed a 10-item/5-
point Likert scale self-report survey (from 1 = Strongly Disagree to
5 = Strongly Agree) to anonymously assess patient attitudes toward
traditional didactic group therapy, as well as their perceived obstacles
to skills acquisition (Appendix 10.2, “Veterans Needs Assessment”). For
example, items on the scale included the statements “I don’t understand
the therapy skills” and “I’m interested in practicing skills in a new,
creative way.” The results (Table 10.1) were synopsized in a Strategic
Statement of Need that we presented to PRRC staff, clinicians, and
leadership to assist with buy-in.

Table 10.1 Results of Veterans Needs Assessment (n = 9)

Item Average response
(1 = Strongly Disagree,
5 = Strongly Agree)
1. I don’t have time to practice therapy skills. 2.25
2. I don’t understand the therapy skills. 2.33
3. Practicing new therapy skills is not part of 2.25
therapy.
4. It’s hard for me to focus in group to learn the 2.67
therapy skills.
5. Practice is not assigned in the groups I attend. 2.63
6. I’m interested in practicing skills in a new, 4.22
creative way.
7. Practicing therapy skills takes too much time. 2.25
8. It’s not clear to me how to practice therapy skills. 3.00
9. The therapy skills aren’t useful in my life. 2.50
10. The lessons in group are too wordy or have too 2.38
many handouts.

Responses suggested that the PRRC patients were, in general, strongly

interested in “practicing skills in a new, creative way.” Veterans seemed
178 DBT-INFORMED ART THERAPY IN PRACTICE

to deny that time management issues precluded learning new skills;

indeed, they reported having ample opportunities to practice what was
covered in group. However, it is also noteworthy that the Veterans were
neutral about whether they understood how to practice these skills,
which perhaps suggests obstacles to traditional, classroom-based ways
of teaching psychoeducational material with text-heavy handouts.

Identifying deliverables
Once investment was established among stakeholders, the authors
moved on to Group InCircle’s deliverables. In other words, we
determined the components that would comprise the final product
(e.g., participant evaluations/surveys, the therapist manual, posters
for professional presentations). These were integral parts of the
development and implementation process.

Formative and summative evaluations

After each group session the facilitators administered a two-item
qualitative survey that assessed the participants’ experiences with,
and the perceived effectiveness of, that week’s art therapy exercise. We
collected formative evaluations throughout the implementation process
to optimize, in real time, the structure and delivery of Group InCircle.
Summative evaluations were longer assessments administered at the
end of each module (mindfulness, interpersonal effectiveness, emotion
regulation, and distress tolerance). Our goal was to collect patients’ self-
reported behavioral outcomes associated with the four skills sets. These
22-item 5-point Likert scale surveys were anonymous in order to protect
the Veterans’ confidentiality (Appendix 10.3, “Summative Evaluation”).

Sustainability and dissemination

The therapist manual consisted of lesson plans outlining the agenda
and structure for every session (Appendix 10.4, “Lesson from the
Therapist Manual”). It comprises 23 weekly 50-minute lessons. The first
10 minutes are dedicated to reviewing homework; the middle 30 minutes
is devoted to the new art therapy exercise; and the final 10 minutes is
used to process the new art therapy exercise and assign homework.
The manual provides current group leaders with a solid framework
for facilitating Group InCircle. The manual is also instrumental in
supporting sustainability because it contains all the information needed
 Group InCircle 179

to train future facilitators. Other deliverables associated with project

sustainability and dissemination included informal reports in PRRC
staff meetings and the published posters and articles.
The authors regularly shared process and outcome results during
staff meetings to maintain buy-in as well as to seek feedback for
optimizing the group process. We disseminated results via poster
sessions at the DCVAMC; these also attracted Veterans who might
benefit from Group InCircle. Given the novelty of a DBT-informed
creative arts therapy intervention within such a setting, we sought out
opportunities to disseminate process articles.

Determine procedures and timeline

High- and low-level planning
There were three main strategies in facilitating the development,
implementation, and sustainability of Group InCircle.
First, the authors executed a high-level project plan to organize
deliverables into three major phases: (1) Planning, (2) Implementation
and Monitoring, and (3) Project Close. Under Planning, which lasted
from October through November of 2017, we included the following
deliverables: completion of the strategic statement of need, completion
of the needs assessment survey, completion of the summative and
formative evaluations, recruitment of group members (see recruitment
procedures, below), attending staff meetings/obtaining stakeholder
buy-in, and drafting the therapist manual. Implementation and
Monitoring spanned December 2017 through April 2018 and included
the completion of the therapist manual, launching Group InCircle in the
PRRC, the administration of summative and formative evaluations,
attending weekly meetings with the group co-leader, attending monthly
meetings with key stakeholders, ongoing patient recruitment as needed,
and the analysis of formative evaluations. Project Close took place from
May through August 2018 and included disseminating results, training
new group co-leaders, and optimizing the therapist manual.
Second, the authors employed a Gantt chart to organize the high-
level deliverables into a detailed timeline (broken down by the weeks
of each month). The Gantt chart specified when each deliverable would
be initiated and completed.
Third, the authors used a work breakdown structure (WBS) for
low-level planning. The WBS was a dynamic document that facilitated
180 DBT-INFORMED ART THERAPY IN PRACTICE

communication between the project leads and stakeholders. It consisted

of a detailed table that outlined the following: specific tasks associated
with each deliverable, a description of each task, the name of the person
leading the task(s), the anticipated duration to completion, the deadlines
to completion, the actual completion dates, and current status (e.g., In
Progress, Completed).

Patient recruitment
Recruitment of potential Group InCircle members took place during
the planning stages and continued throughout project implementation
on an as-needed basis. It comprised different modalities, including
(1) emails to PRRC staff/clinicians, (2) flyers (posted on PRRC
community boards and distributed in staff and community meetings),
(3) announcements in weekly PRRC staff meetings as well as monthly
community meetings attended by PRRC staff and patients, (4) within
one-on-one meetings with clinical case managers (who were in charge
of Veterans’ treatment plans), and (5) during hospital-based research
presentations where hospital staff and patients could inquire about the
project.

Project implementation
Information and data gathering
After each weekly group the facilitators administered brief two-item
questionnaires (i.e., the previously mentioned formative evaluations)
to attendees. These qualitative measures assessed the patients’ general
experiences in Group InCircle that day, as well as the perceived impact
of the creative arts therapy exercise on their acquisition of the new
DBT skill. In this manner, group leaders collected timely formative
feedback (i.e., self-reported level of learning and attitudes toward the
intervention) that could be used to optimize the group throughout its
implementation phase.
To quantitatively assess the learning of DBT skills, an outcome-
based 22-item 5-point Likert scale measure (from 1 = Strongly
Disagree to 5 = Strongly Agree) was administered before and after
each of the four skills modules. The authors adapted the 22-item scale
from validated measures that independently assessed skill-learning
 Group InCircle 181

related to mindfulness (e.g., “I am open to the experience of the present

moment”), emotion regulation (e.g., “When I’m upset, I believe there is
nothing I can do to make myself feel better”), interpersonal effectiveness
(e.g., “I allow friends to see who I really am”), and distress tolerance (e.g.,
“I’ll do anything to stop feeling upset”). Unfortunately, given several
methodological and organizational limitations, the quantitative data
collection was not completed.

Maintaining stakeholder engagement

PRRC staff and leadership
Group InCircle’s two facilitators met monthly with PRRC staff and
leadership to discuss implementation and qualitative outcomes. During
these meetings the co-leaders solicited feedback concerning manual
development, art therapy exercises, and clinical challenges.

Veterans
Veteran responses concerning their experiences in Group InCircle were
shared weekly to empower them throughout the group implementation
process. Depending on the group’s size, co-leaders also conducted
ongoing recruitment efforts.

Creative arts therapy exercises

As a multi-modal group therapy, Group InCircle included nonvisual art
elements to provide a range of creative learning exercises. For example,
the second lesson in the interpersonal effectiveness module was GIVE
Sculpt. Inspired by Virginia Satir’s (1978) family therapy interventions,
this exercise invited pairs of group members to each use their body
to “sculpt” a particular skill within the GIVE skillset (e.g., “I,” or “act
Interested”) (Linehan 2015a, 2015b). There would be a “giver” and a
“receiver.” The giver would be the person who sculpts their body, while
the receiver would use mindfulness skills to observe the sculpt and
then guess which skill the giver was embodying (see Appendix 10.5,
“Lesson from the Therapist Manual (GIVE Sculpt)”). Figure 10.1 shows
a patient’s personal conceptualization of two of DBT’s states of mind
(Linehan 2015a, 2015b).
182 DBT-INFORMED ART THERAPY IN PRACTICE

Figure 10.1 Client artwork: DBT states of mind

Project optimization and sustainability

Formative data analysis: Qualitative surveys and artwork
After every session the group facilitators collected and analyzed the
anonymous formative evaluations. Overall, patients reported positive
experiences with the creative arts therapy exercises (in terms of focus
and engagement with the concepts/skills taught that day). For example,
one commented: “[Collage] helped me to focus on my values and what
is important to me.” Another veteran reported that creative activities
could be “fun” and assisted her with emotion regulation skills: “It helped
me to see how I feel about stuff.”

Complete deliverables
Manual and publications
The Group InCircle therapist manual, which ultimately included
23 weekly sessions across four different clinical skills modules, was
completed after the group’s first cycle. Its main purpose was to provide
a framework for future co-leaders to implement and optimize the
 Group InCircle 183

group. The authors disseminated qualitative findings on both a formal

and informal basis within the DCVAMC. We also presented a research
poster to Veterans, staff, and hospital leadership.

Develop transition plan

The transition plan helped ensure Group InCircle’s sustainability after
its original facilitators transitioned out of the PRRC. In addition to the
therapist manual, the authors created an archival system on the hospital
share drive so that PRRC staff could access group documents and
procedures. Given that the DCVAMC is a training hospital, we were able
to recruit clinical psychology trainees who had an interest in DBT and art
therapy. We invited the new co-leaders to observe several weeks’ worth
of sessions in order to become familiar with group processes, format,
and members. They then transitioned to facilitating the group (while the
authors observed and provided feedback, real-time support). In addition,
all four clinicians met regularly before the final transition to review group
processes as well as the organization of the archival folder.

Lessons learned
To the best of the authors’ knowledge, Group InCircle was the first
combined DBT skills training and creative arts therapy intervention
ever launched at a VA hospital. While there were many successes, Group
InCircle’s first iteration also presented some important challenges.
Because the PRRC groups were open-entry, a number of patients
joined and exited Group InCircle every week. Benefits to this policy
included the ability of the Veterans to easily access groups they had an
interest in and/or felt they needed; it also provided flexibility for those
who struggled with executive functioning and, therefore, traditional
language-based types of learning.
Unfortunately, the resulting inconsistent attendance precluded our
collection of longitudinal data for tracking individual patients’ progress
over time. Second, we did not have a control group to directly compare
formative and summative outcomes. It would be beneficial to conduct a
randomized controlled trial in which Veterans are recruited and placed
into one of two separate treatment modalities (a traditional DBT skills
training group or Group InCircle) to accurately assess the added value
of a creative arts therapy component.
184 DBT-INFORMED ART THERAPY IN PRACTICE

Conclusion
Group InCircle proved to be an enjoyable and enriching group within
the PRRC of the Washington DC VAMC. Its development was inspired
by the authors’ realization that, while DBT skills training delivered
through a traditional didactic group format is highly sought-after, the
content was frequently not fully understood or retained by Veterans
struggling with SMI. Our solution, to combine psychoeducational
instruction with carefully designed creative interventions, was
appreciated by PRRC staff and patients alike for its apparent potential
for facilitating the latter’s overall comprehension and generalization of
necessary behavioral strategies. We view DBT-informed arts therapy as
a promising method of reinforcing skills training and welcome future
research investigating its efficacy.

References
American Art Therapy Association (2017) Definition of Profession. Accessed on 1/12/20 at
www.arttherapy.org/upload/2017_DefinitionofProfession.pdf.
Barnicot, K., Couldrey, L., Sandhu, S., and Priebe, S. (2015) ‘Overcoming barriers to skills
training in borderline personality disorder: A qualitative interview study.’ PLoS ONE
10, 10, e0140635.
Chancellor, B., Duncan, A., and Chatterjee, A. (2014) ‘Art therapy for Alzheimer’s disease
and other dementias.’ Journal of Alzheimer’s Disease 39, 1, 1–11.
Cho, A.S. (2016) ‘Suicide and Non-Suicidal Self-Injury: Art Therapy and Mindfulness
Techniques in a School Setting to Help Decrease Levels of Anxiety, Depression, and
Stress in Adolescents.’ Unpublished Doctoral Dissertation, The Chicago School of
Professional Psychology, Chicago, Illinois.
Clark, S.M. (2017) DBT-Informed Art Therapy: Mindfulness, Cognitive Behavior Therapy, and
the Creative Process. London: Jessica Kingsley Publishers.
Goodman, M., Banthin, D., Blair, N.J., Mascitelli, K.A. et al. (2016) ‘A randomized trial
of dialectical behavior therapy in high-risk suicidal Veterans.’ The Journal of Clinical
Psychiatry 77, 12, e1591–e1600.
Hass-Cohen, N. and Carr, R. (eds) (2008) Art Therapy and Clinical Neuroscience. London:
Jessica Kingsley Publishers.
Havsteen-Franklin, D. and Altamirano, J.C. (2015) ‘Containing the uncontainable: Responsive
art making in art therapy as a method to facilitate mentalization.’ International Journal
of Art Therapy 20, 2, 54–65.
Linehan, M.M. (2015a) DBT Skills Training Manual (2nd ed.). New York, NY: Guilford Press.
(Original work published in 1993.)
Linehan, M.M. (2015b) DBT Skills Training Manual (2nd ed.). Handouts and Worksheets.
New York, NY: Guilford Press. (Original work published in 1993.)
National Institute of Mental Health (NIMH) (2019) Mental Illness. Accessed on 2/25/21 at
https://www.nimh.nih.gov/health/statistics/mental-illness.shtml#part_154788.
Rubin, J.A. (ed.) (2016) Approaches to Art Therapy: Theory and Technique (3rd ed.). New
York, NY: Routledge. (Original work published in 1987.)
Satir, V. (1978) Peoplemaking. London: Souvenir Press.
 Group InCircle 185

Tang, Y., Fang, F., Gao, H., Shen, L., Chi, I., and Bai, Z. (2019) ‘Art therapy for anxiety,
depression, and fatigue in females with breast cancer: A systematic review.’ Journal of
Psychosocial Oncology 37, 1, 79–95.
Trivedi, R.B., Post, E.P., Sun, H., Pomerantz, A. et al. (2015) ‘Prevalence, comorbidity, and
prognosis of mental health among US Veterans.’ American Journal of Public Health 105,
12, 2564–2569.
Twamley, E.W., Thomas, K.R., Burton, C.Z., Vella, L. et al. (2019) ‘Compensatory cognitive
training for people with severe mental illnesses in supported employment: A randomized
controlled trial.’ Schizophrenia Research 203, 41–48.
Veterans Health Administration (VHA) (2017) About VHA. Accessed on 10/11/17 at https://
www.va.gov/health/aboutvha.asp.
 Appendices

Appendix 10.1: Strategic Statement of Need

GroupInCircle
A novel group psychotherapy to augment
DBT skills acquisition in PRRC Veterans

Strategic Statement of Need

A major goal of the VA is to “empower Veterans to improve their well-
being,” while the VHA’s vision is to provide “both patient-centered
and evidence-based” services that support “learning, discovery, and
continuous improvement.” Specifically, it strives to “partner with each
Veteran to create a personalized, proactive strategy to optimize health
and well-being.” The Psychosocial Rehabilitation and Recovery Center
(PRRC) of the Washington DC VA Medical Center (DCVAMC) is a
mental health clinic that serves Veterans with serious mental illness
(SMI). It is a recovery-oriented center that aims to use evidence-based
psychological treatments to help Veterans with SMI develop skills that
are needed to achieve their goals and reintegrate into the community.
Dialectical Behavior Therapy (DBT) is an evidence-based skills-
oriented approach that has shown promise in improving the well-being
and psychological health of Veterans. However, Veterans in the
PRRC have demonstrated difficulties in learning DBT skills. Recent
studies have found that two of the most common patient-reported
barriers, in general, are group-related anxiety and difficulty under­
standing the material. Furthermore, SMI has been associated with
cognitive deficits that directly impair Veterans’ capacity to retain new
skills via traditional, didactic approaches.
Art therapy has the potential to overcome some of the major barriers
to DBT skills acquisition in the PRRC. Art therapy can reduce anxiety
and enhance understanding of new skills by recruiting neuroanatomical
structures not involved in traditional didactic training. It requires the

186
 Group InCircle 187

integration of higher cortical thinking, such as planning, attention,

and mindful problem-solving, that play significant roles in the
learning process. Sub-cortical centers that are involved in implicit
motivation, such as the limbic system and brainstem, have also been
activated by art therapy interventions. Grounded in affective-sensory
experiences, art therapy comprises repeated experiences that directly
contribute to the formation and strengthening of complex information
associated with consolidation of new material.
Some evidence-based treatments, such as Cognitive Behavior
Therapy, have begun integrating art therapy into their protocols with
promising effects, suggesting that art therapy can synergistically enhance
traditional didactic skills-based therapeutic approaches. Therefore,
we propose to develop and implement a novel group psychotherapy
that integrates DBT and art therapy to enhance DBT skills acquisition
among PRRC Veterans. The specific objectives of the proposal include:

Goals
1. To improve Veterans’ learning and retention of DBT skills.
2. To increase the frequency of DBT skills practice between sessions.
3. To enhance Veterans’ self-efficacy and recovery.

Appendix 10.2: Veterans Needs Assessment

G r o u p I n C i r c l e :: DBT + Art Therapy

In January 2018, we are beginning a new psychotherapy group in the
PRRC called Group InCircle. It’s a DBT-informed art therapy group
that is open to all Veterans who are interested in learning the core
DBT skills in a new way. As with most groups, Group InCircle will
include practicing new skills between sessions. We are interested in
your experience with practicing new skills. There are no right or wrong
answers, and all of your responses will be kept confidential. Please circle
the response that feels most accurate for your current experience, using
this scale:
1. = Strongly Disagree
2. = Disagree
3. = Neutral
188 DBT-INFORMED ART THERAPY IN PRACTICE

4. = Agree
5. = Strongly Agree

Strongly Disagree Neutral Agree Strongly

Disagree Agree
1. I don’t have time to
1 2 3 4 5
practice therapy skills.
2. I don’t understand the
1 2 3 4 5
therapy skills.
3. Practicing new therapy
1 2 3 4 5
skills is not part of therapy.
4. It’s hard for me to focus
in group to learn the 1 2 3 4 5
therapy skills.
5. Practice is not assigned
1 2 3 4 5
in the groups I attend.
6. I’m interested in
practicing skills in a new, 1 2 3 4 5
creative way.
7. Practicing therapy skills
1 2 3 4 5
takes too much time.
8. It’s not clear to me how
1 2 3 4 5
to practice therapy skills.
9. The therapy skills aren’t
1 2 3 4 5
useful in my life.
10. The lessons in group
are too wordy or have too 1 2 3 4 5
many handouts.

Please share any other thoughts or reactions you might have about
practicing new therapy skills:
.............................................................
.............................................................
.............................................................
.............................................................
Thank you!
 Group InCircle 189

Appendix 10.3: Summative Evaluation

G r o u p I n C i r c l e :: Creating a Life Worth Living

Group InCircle is a DBT-informed art therapy group that is open
to all Veterans who are interested in learning the core DBT skills in
a new way. As with most groups, Group InCircle will include practicing
new skills between sessions. As a way to measure the effectiveness of
the group and to ensure we are meeting your needs, we are interested in
your current experience with DBT therapy skills as well as your overall
recovery. There are no right or wrong answers, and all of your res­
ponses will be kept confidential. Please circle the response that feels
most accurate for you right now, using this scale:
1. = Strongly Disagree
2. = Disagree
3. = Neutral
4. = Agree
5. = Strongly Agree

Strongly Disagree Neutral Agree Strongly

Disagree Agree
1. I am open to the
experience of the present 1 2 3 4 5
moment.
2. I sense my body,
whether eating, cooking, 1 2 3 4 5
cleaning, or talking.
3. I see my mistakes and
difficulties without judging 1 2 3 4 5
them.
4. I feel connected to my
experience in the here- 1 2 3 4 5
and-now.
5. I can put myself in
1 2 3 4 5
others’ shoes.
6. When I’ve been
wronged, I confront the 1 2 3 4 5
person who wronged me.
7. I allow friends to see
1 2 3 4 5
who I really am.

Cont.
190 DBT-INFORMED ART THERAPY IN PRACTICE

Strongly Disagree Neutral Agree Strongly

Disagree Agree
8. I am comfortable in
1 2 3 4 5
social situations.
9. When I’m upset, I have
difficulty focusing on other 1 2 3 4 5
things.
10. I am confused about
1 2 3 4 5
how I feel.
11. When I’m upset, I have
difficulty getting anything 1 2 3 4 5
done.
12. When I’m upset, I
believe there is nothing I
1 2 3 4 5
can do to make myself feel
better.
13. Feeling upset is
1 2 3 4 5
unbearable to me.
14. When I feel upset, all I
can think about is how bad 1 2 3 4 5
I feel.
15. Other people seem to
be able to tolerate feeling 1 2 3 4 5
upset better than I can.
16. I’ll do anything to stop
1 2 3 4 5
feeling upset.
17. I can always manage to
solve difficult problems if I 1 2 3 4 5
try hard enough.
18. It is easy for me to stick
to my aims and accomplish 1 2 3 4 5
my goals.
19. I can usually handle
1 2 3 4 5
whatever comes my way.
20. I engage in work or
activities that enrich myself 1 2 3 4 5
and the world around me.
21. I am making progress
1 2 3 4 5
towards my goals.
22. I have control over my
1 2 3 4 5
mental health problems.

Thank you!
 Group InCircle 191

Appendix 10.4: Lesson from the Therapist Manual

Agenda
9.1. Review of Action Plan
9.2. Brief review of FAST skills
9.3. FAST Collage (Part 1 of 2)
9.4. Process art therapy exercise
9.5. Action Plan

9.1. Review of Action Plan

• Practice at least one GIVE skill between now and next group
• Review successes and obstacles

9.2. Brief review of FAST skills

• FAST is a way to remember self-respect effectiveness skills
• Self-respect effectiveness means acting in a way that maintains
or increases your self-respect after an interaction with someone.
The key question here is how to ask for what you want or say no
in a way that you will still respect yourself afterward
• Distribute Interpersonal Effectiveness Handout 7 (Linehan 2015b)
if needed, depending on skill-level of members
• FAST stands for Fair, (no) Apologies, Stick to values, Truthful
– (Be) Fair: Be fair to yourself and the other person when you try
to get what you want
– (No) Apologies: Do not over-apologize. When apologies are
warranted, of course, they are appropriate. But no apologizing
for being alive, for making a request, for having an opinion, or
for disagreeing
– Stick to values: Avoid selling out your values or integrity to get
your objective or to keep a person liking you
– (Be) Truthful: Don’t lie, act helpless when you are not, or
exaggerate. A pattern of dishonesty over time can erode your
self-respect
192 DBT-INFORMED ART THERAPY IN PRACTICE

9.3. FAST Collage (Part 1 of 2)

• Skills/concepts
– General mindfulness
– FAST skills (relationship effectiveness)
• Materials
– Magazines
– Scissors (if allowed by clinic)
– Folder for the selected magazine clippings
• Procedure
– Invite group members to brainstorm their current values (i.e.,
the “S” of FAST)
– Lay out magazines on table(s)
– Ask group members to select several magazines and select
images and words that represent their values
– Also inform group members that some images and words might
inspire or help identify their current values
– Place cut-out images and words in folder for Session 10 FAST
Collage (Part 2)

9.4. Process art therapy exercise

• Invite group members to share their experience of identifying
magazines, flipping through pages, and identifying images and
words that are values-based
• Provide feedback on accuracy of FAST skills and conceptualization
of values, if needed

9.5. Action Plan

• Do at least one thing that is in line with a current value
• Notice how you feel after living in line with your value
• Notice how you feel when you do not live in line with your value
 Group InCircle 193

Keeping Respect for Yourself :: FAST

h a n d o u t (Linehan 2015b, p.130)
• (Be) Fair by being fair to yourself and to the other person.
Remember to validate your own feelings and wishes, as well as
the other person’s.
• (No) Apologies by not over-apologizing. No apologizing for
being alive or for making a request at all. No apologies for having
an opinion, for disagreeing. No looking ashamed, with eyes and
head down or body slumped. No invalidating the valid.
• Stick to values by not selling out your values or integrity for
reasons that aren’t very important. Be clear on what you believe
is the moral or valued way of thinking and acting, and “stick to
your guns.”
• (Be) Truthful by not lying. Don’t act helpless when you are not.
Don’t exaggerate or make up excuses.

Appendix 10.5: Lesson from the

Therapist Manual (GIVE Sculpt)
Agenda
8.1. Review of Action Plan
8.2. Brief review of GIVE skills
8.3. GIVE Sculpt
8.4. Process art therapy exercise
8.5. Action Plan

8.1. Review of Action Plan

• Practice at least one DEAR MAN skill between now and next
group
• Review successes and obstacles

8.2. Brief review of GIVE skills

• GIVE is a way to remember relationship effectiveness skills
194 DBT-INFORMED ART THERAPY IN PRACTICE

• Relationship effectiveness means maintaining or improving your

relationship with another person while trying to get your needs
met in the interaction
• Distribute Interpersonal Effectiveness Handout 6 if needed,
depending on skill-level of members
• GIVE stands for Gentle, Interested, Validate, and Easy manner
– (Be) Gentle: Being gentle means being kind and respectful in
your approach. People in general respond to gentleness more
than they do to harshness. Gentleness means: no attacks, no
threats, no judging, and no disrespect.
– (Act) Interested: Listen to the other person’s point of view,
reasons for saying no, or reasons for making a request of
you. Don’t interrupt or try to talk over. There are times when
you’re not actually interested in what they want to talk about.
Choosing to listen means deliberately choosing to be effective in
achieving your goal of helping them have a positive experience
with you.
– Validate: This means communicating that the other person’s
feelings, thoughts, and actions are understandable to you, given
his or her past and current situation. We can validate without
agreeing.
– (Use an) Easy manner: Try to be lighthearted if appropriate.
Use a little humor if that’s your style. Smile if appropriate. Ease
the other person along.

8.3. GIVE Sculpt

• Skills/concepts
– General mindfulness
– GIVE skills (relationship effectiveness)
– Mindfulness of others
• Materials
– None
 Group InCircle 195

• Procedure
– A sculpt is a way to use your body as a sculpture
– In general, select a specific pose to represent or communicate
something and hold that pose
– Ask two group members to volunteer
– Have one of the group members be the “giver” (i.e., the one
doing the sculpt) and the other be the “receiver”
– The “giver” silently selects a specific GIVE skill (e.g., act
Interested) and “sculpts” that skill (i.e., form his/her body and
face to suggest that s/he is acting interested)
– The “receiver” mindfully observes the “giver” and (a) tries to
guess which GIVE skill the “giver” is sculpting, and (b) pays
attention to the “receiver’s” internal experience
– There is no specific time-limit to this exercise, so use your
clinical judgment

8.4. Process art therapy exercise

• Invite group members to share their experience
– Guess which GIVE skill the “giver” was sculpting
– What was it like to be the “giver”?
– What was it like to be the “receiver”?
• Provide feedback on accuracy of GIVE skills

8.5. Action Plan

• Practice at least one GIVE skill between now and next group

Keeping the Relationship :: GIVE

h a n d o u t (Linehan 2015b, p.128)
• (Be) Gentle by being kind and respectful. No attacks: No verbal
or physical attacks. No harassment of any kind. Express anger
directly with words. No threats: If you have to describe painful
consequences for not getting what you want, describe them
196 DBT-INFORMED ART THERAPY IN PRACTICE

calmly and without exaggerating. No “manipulative” statements,

no hidden threats. Tolerate a “no.” Stay in the discussion even if
it gets painful. Exit gracefully. No judging: No moralizing. No
“If you were a good person, you would…” No “You should…” or
“You shouldn’t…” Abandon blame. No sneering: No smirking,
eye rolling, sucking teeth. No cutting off or walking away. No
saying, “That’s stupid, don’t be sad,” “I don’t care what you say.”
• (Act) Interested by listening and appearing interested in the
other person. Listen to the other person’s point of view. Face the
person; maintain eye contact; lean toward the person rather than
away. Don’t interrupt or talk over the person. Be sensitive to the
person’s wish to have the discussion at a later time. Be patient.
• Validate with words and actions, show that you understand the
other person’s feelings and thoughts about the situation. See the
world from the other person’s point of view, and then say or act
on what you see. “I realize this is hard for you, and…”, “I see that
you are busy, and…” Go to a private place when the person is
uncomfortable talking in a public place.
• (Use an) Easy manner by using a little humor. Smile. Ease the
person along. Be light-hearted. Sweet-talk. Use a “soft sell” over
a “hard sell.” Be “political.” Leave your attitude at the door.
 Chapter 11

Creative Mindfulness
DBT Skills-Oriented Intermodal Expressive Arts Therapy
for Populations with Severe Emotion Dysregulation
KARIN VON DALER

Introduction
Severe, chronic emotion dysregulation can lead to self-harm behaviors,
impaired relationships, substance abuse, and a general lowered quality
of life (Linehan 1993, 2015a). It is often the subjective experience of
intense emotional distress that brings people into therapy, regardless
of whether said dysregulation is later identified as stemming from one
or more specific diagnoses (e.g., borderline personality disorder (BPD),
major depression, bipolar disorder, eating disorders, posttraumatic stress
disorder, and so on) (Kass and Trantham 2014). Many arts therapies-
oriented clinicians find that working with these individuals via their
usual methods is challenging, and, at times, outright ineffective. Some
expressive interventions are not sufficiently directive and/or structured
to contain intense affect—and risk overwhelming clinicians and clients
alike (Huckvale and Learmonth 2009; von Daler and Schwanbeck 2014).
Even when arts therapies facilitate appropriate emotional expression,
there may not be adequate integration of new skilled behaviors for
improved regulation outside of the treatment setting. This can prompt
therapists to look to cognitive behavioral approaches for solutions;
however, these are not designed to provide clients with the experiences
of creativity and play that could give them access to previously
unknown perspectives and resources. Ultimately, the dilemma of feeling
ineffective versus abandoning the desired “organic, non-directive, and
spontaneous elements of art-making” (Huckvale and Learmonth 2009,
p.62) can leave practitioners feeling helpless or burnt out (von Daler
and Schwanbeck 2014).

197
198 DBT-INFORMED ART THERAPY IN PRACTICE

This chapter presents a method for developing healthy emotion

regulation capacities that balances sensory experiences and fun with
a cohesive, skills-based framework. Creative Mindfulness (CM) is
an embodied, multi-modal expressive arts and dialectical behavior
therapy (DBT)-informed intervention. Embodiment means centered
on the felt sensory experiences within, and outside of, the physical
body. My (the author’s) primary goal is to describe how CM might
foster lasting emotional wellness in those who contend with the chronic
suffering of emotional chaos. A secondary aim is to suggest a way of
addressing such extreme dysregulation that is both playful and effective,
thus lessening the risk of therapist burn-out and/or abandonment of
attempts to work with this challenging population.
The chapter draws on theories from the expressive arts therapies and
DBT; however, it also refers to relevant supporting tenets from clinical
neuroscience. Further, it provides concrete suggestions for facilitating
enduring change in clients’ abilities to regulate emotions through
safe, structured, and collaborative engagement with their therapists.
The reader will come to understand how core elements of DBT and
expressive arts therapy can comprise a simple and immediately
applicable model for working with severe emotional distress.

Emotion regulation and dysregulation

DBT’s developer, Marsha Linehan, states that emotion regulation is “the
ability to control or influence which emotions you have, when you have
them, and how you experience and express them” (2015a, p.323). It is
an individual’s capacity for modulating his or her emotional intensity
in order to respond with flexibility to the needs/demands of the current
environment and circumstances. According to Pavuluri, Herbener,
and Sweeney (2005), “[V]oluntary self-regulation of negative affect is
essential to a healthy psyche” (p.2). Individuals with a solid repertoire
of emotion regulation strategies can adapt to a broad range of stressful
situations. Further, they are more likely to respond in a manner that
aligns with their own needs, values, and intentions.
Emotion dysregulation, conversely, refers to a response that is
neither well-modulated nor contained, that causes significant distress,
and is not within the range of adaptive emotional responses. Pavuluri
et al. (2005) elaborate that deficits in regulating affect are “commonly
associated with major mood disorders like depression and bipolar
 Creative Mindfulness 199

disorder. Numerous behavioral and cognitive models implicate poor

negative affect regulation as a major factor contributing to vulnerability
in bipolar and unipolar disorders” (p.2).
Chronic emotion dysregulation has a variety of possible mani­
festations, such as low behavioral inhibition (which can result in
verbal threats and/or aggressive or destructive acts), mood swings,
profound yet undefined emotional pain, anxiety, and/or loss of interest
in social contact. Vulnerable individuals tend to experience marked
hypersensitivity to stimuli, more frequent intense feeling states
(compared with less sensitive people), and slower return to a baseline/
normal level of emotional experiencing (Linehan 2015a).

Causes of emotion dysregulation

DBT suggests that emotion dysregulation has bio-psycho-social origins
related to transactions between an individual’s innate sensitivity and
invalidating (sometimes outright traumatic) family, social, and/or
cultural environments (Linehan 2015a). In addition, there is growing
consensus that emotion dysregulation manifests physiologically
through the stress response as fight, flight, freeze, or fold (Levine 2010).
The brain areas most associated with affect regulation are the
prefrontal cortex and the amygdala. The hypothalamus (which controls
certain functions of the autonomic nervous system and affects the
endocrine system) and the anterior cingulate (which also plays a role
in the autonomic system and in certain higher-level functions, such
as decision making and impulse control) are involved, as well (Kass
and Trantham 2014; Pavuluri et al. 2005). Finally, although the popular
serotonin hypothesis has been criticized in recent literature, it is well
established that brain chemistry has a marked impact on emotion
dysregulation and regulation (Brogan 2016; Linehan 2015a).

Emotional dysregulation as addressed in CM

DBT’s emotion regulation skills training module is designed to help
clients understand the purpose of emotions, lower their vulnerability
to painful feeling states, and decrease suffering:
Emotions can be viewed as problematic, mysterious, and dangerous by
those who have experienced intense emotional invalidation. Teaching
200 DBT-INFORMED ART THERAPY IN PRACTICE

that emotions are natural responses to stimuli, affect our body, mind,
and behaviors, and are functional in getting us to respond to situations,
is essential. The goal of emotion regulation is not to eliminate negative
and unpleasant emotions, but to reduce suffering that arises from either
denying emotions, being too reactive or unable to regulate emotions
once they arise. (von Daler and Schwanbeck 2014, p.237)
CM identifies four significant challenges faced by those who struggle
with emotion regulation deficits, then presents a corresponding
objective or intervention(s) for each:
1. The first challenge is a basic inability to identify and name one’s
own emotions (Linehan 2015a). CM exercises feature the DBT
core mindfulness “observe” and “describe” skills (Linehan 2015b,
p.53) to help the client notice and accurately label what they are
feeling.
2. Another challenge involves difficulties with experiencing, and
appropriately containing, painful affect. CM’s multi-sensory,
structured approach may help develop or strengthen an
individual’s capacity for full emotional experiencing.
3. A third challenge is that dysregulation impairs the ability
to choose when, how (and whether) to express feelings. CM
implements multi-modal creative methods for inhibiting or
reducing emotional reactivity, as well as developing a wider
variety of adaptive behavioral options.
4. The final challenge arises from a limited capacity for intentionally
generating positive emotions. CM’s multi-sensory and embodied
format encourages the client to devise healthy methods of
prompting joy, pleasure, and connection.

Background
CM was developed by me and my colleague, Lori Schwanbeck (von Daler
and Schwanbeck 2014). In 2004 Lori and I were both student interns
at a low-fee psychotherapy training clinic in San Francisco. There, we
learned to run DBT skills groups for women diagnosed with BPD and
other psychiatric disorders. All of the group members contended with
extreme emotion regulation problems that often resulted in serious
 Creative Mindfulness 201

(and, occasionally, life-threatening) self-harm impulses. For several

years after we became licensed clinicians, Lori and I also co-facilitated
a weekly group for women with eating disorders.
I was fascinated by DBT’s effectiveness, yet (as an expressive arts
therapist) also felt somewhat frustrated with the skills training protocol’s
limited opportunities for play and embodiment. However, Lori and
I had, independently of each other, made the following important
observation: whenever we used the more experiential exercises
suggested in the manual (e.g., guided mindfulness meditations, role
plays for interpersonal effectiveness) (Linehan 2015a), the participants
became more engaged. They exhibited improved skills retention,
as well.
Our first attempts at integrating DBT skills with expressive arts
therapy interventions quickly showed the potential of this combination.
Skills group sessions immediately became more dynamic. Further,
many clients reported that these new immersive activities allowed them
to directly experience the skills’ effects, in the here-and-now (rather
than just talking about them).
The CM protocol initially consisted of the 20 exercises we used when
teaching the most popular DBT skills in our groups. Lori and I also
shared the curriculum with other practitioners who were interested in
using this intervention with their own clients. Nine more exercises were
added for our chapter in Mindfulness and the Arts Therapies: Theory and
Practice (von Daler and Schwanbeck 2014).
CM can be used in group settings as well as individual therapy. This
chapter presents modified versions of most of the exercises from the
2014 chapter. I have also added seven new activities designed to support
the development of healthy emotion regulation.

Perspectives from clinical neuroscience

CM is inspired by neuroscientific research from the past two decades.
Several theories are at the core of our intervention as it relates to
emotion regulation. The emphasis on mindful presence is based on
growing evidence that such approaches can strengthen emotion
regulation by supporting regulatory functions in the central nervous
system (Kass and Trantham 2014; van der Kolk 2014). In addition,
CM aims to engage the whole brain in a combined bottom-up and
top-down approach (Siegel 2007): Mindfulness alone can be seen as
202 DBT-INFORMED ART THERAPY IN PRACTICE

a primarily top-down approach, meaning that it aims to affect higher

functions of the brain, such as cognition and awareness, and activates
the frontal lobes through self-reflection, insight, and witnessing (Kass
and Trantham 2014).
However, persistent emotion dysregulation is a full-body experience
that may originate from early, preverbal traumas. Memories of such
events are often not consciously recalled (implicit). They imprint as
disorganized sensory impressions—for example, fragmented sounds,
odors, visual images, and somatic sensations. In such cases, a bottom-up
approach, meaning an intervention that directly engages the body and
senses, is necessary (van der Kolk 2014). CM’s combined strategy aims
to access the deeper sensory imprints while tapping into the regulatory
benefits of mindful attention.
CM is based on an assumption of neuroplasticity: that the brain is
malleable, and all neural events, such as actions, thoughts, sensations,
memories, and emotions, directly impact its structure and function.
Every experience shapes one’s brain and, consequently, one’s behavior
and way of being (Doidge 2007). When a person engages in healthy,
skillful responses to emotional distress, with sufficient repetition her
brain will gradually rewire itself and retain this new learning (thus
replacing the original maladaptive behaviors). These interventions
allow adaptive emotional experiences to be integrated in the nervous
system. They also provide the necessary elements for novel behavioral
responses to become as accessible as the original, less adaptive ones
(Hanson and Mendius 2009).
Trauma research suggests that multi-sensory memories are more
accessible than abstract/cognitive ones, as they offer deeper reminders of
the imprint (van der Kolk 2014). Hence, Lori Schwanbeck and I (2014)
hypothesized that an event will have a more enduring impression on
the brain whenever multiple sensory centers (e.g., the somato-sensory,
visual, and olfactory cortices) are engaged as the new experience/
learning takes place. Such sensory and experience-based impressions
may create broader, better anchored neural networks (Chatterjee and
Hannan 2016).
According to psychologist Stephen Porges’ polyvagal theory (2009),
the vagus nerve comprises two distinct branches, which trigger their
own unique relaxation response via the parasympathetic nervous
system. The dorsal/back branch elicits primitive, pervasive shut-down
states (freeze and fold/collapse). The ventral/front branch, in contrast,
 Creative Mindfulness 203

is more highly developed and supports emotional well-being. Ventral–

vagal responses are activated by play and positive social interactions,
as well as singing, visual imagery, dramatization, and other types of
embodied self-expression (Kass and Trantham 2014; Porges 2009).
Finally, neuroscientific research on psychotherapy outcomes
notes the importance of right brain to right brain hemispheric
communication: the unconscious, wordless interactions that
occur within healthy contact between parent and child (and can
be employed within therapeutic encounters to optimize emotion
regulation) (Schore 2005). For example, a clinician might intuit their
client’s unexpressed emotional state and communicate it back to her
in a more regulated, tolerable manner. This type of contact cannot be
accomplished through verbal dialogue alone; rather, it must arise from
an attunement to facial expression, voice tone, and bodily movement
(Schore 2005), elements of communication that are actively fostered in
the expressive arts approach.

The clinical model of CM

Factors to consider
CM adapts to particular clinical need(s) according to the following
factors:
• Taste and aptitude for art modality (e.g., dance, painting, drama,
music, poetry, and so on). For example, if a client loves to
draw but is uncomfortable with movement, simply emphasize
drawing as the primary option when planning and suggesting
interventions.
• Severity of dysregulation. CM teaches mindfulness through
focused attention on the art making process (rather than on
the internal sensory experiences or the emotions themselves)
to reduce the risk of flooding the nervous system. According to
some trauma-informed theories, an ability to attend to the
external environment is a prerequisite for full embodiment,
a phenomenon of complete emotional/physical attunement
(Levine 1997; Rothschild 2000). Such externally oriented
activities lay the sensory groundwork for fully experiencing
internal states in the form of emotions and bodily sensations.
This first stage will take as long as the client requires.
204 DBT-INFORMED ART THERAPY IN PRACTICE

• Treatment stage. In the early phases of therapy, CM employs

highly structured activities and exercises. As the process moves
forward, however, more improvisational and self-directed work
ensues.

Stages of the CM intervention

CM sessions generally transition through three stages of learning
and change. Each draws from both DBT concepts and expressive arts
therapy tenets.

Distancing (distraction)/decentering
The initial step in building more regulated emotional responses to
stress and pain involves intentionally separating from habitual patterns
of negative thoughts/behaviors. In DBT, distraction skills turn one’s
attention away from a distressing experience. This mindful refocusing
helps break rumination cycles that might otherwise result in cascades
of emotional reactivity.
Distancing is similar to decentering in the expressive arts therapies
(Knill, Levine, and Levine 2005). Decentering invites focus away from
emotions related to the presenting issue and toward playful creation
(which sometimes leads to new possibilities in the here-and-now of
the creative process): “…[D]ecentering activities can open the door to
unexpected surprises and often emerge with spontaneity or intuition.
They point in the direction of an alternative world experience through
a distancing effect” (Knill et al. 2005, p.64).
We first offer validation and nonjudgmental witnessing of the
problem represented in the client’s artwork, then encourage exploration
of its other aspects. For example, the client may draw an image of her
depression, which the therapist acknowledges. However, the therapist
then comments on and/or inquires about aspects (lines, colors, and
so on) that the client had not mentioned. This stage broadens the
individual’s imagination to consider previously unconscious or
unknown possibilities—thus making room for new skills and ways of
acting.

Creating a new experience/range of play

The client’s attention is now focused on more regulated, adaptive
emotional experiences, with an emphasis on sensory immersion
 Creative Mindfulness 205

and creating something. In DBT, building a new positive experience

works to deliberately increase and solidify positive emotions. In the
expressive arts therapies, the strategy of expanding the “range of
play” (Knill et al. 2005, p.64) offers a wider aesthetic repertoire and
sparks the imagination, thereby increasing access to resources such as
flexibility, creativity, new perspectives, and ways of responding (von
Daler and Schwanbeck 2014). To continue with the previous example,
the therapist might advise the client to familiarize herself with those
heretofore unexplored lines and colors via the creation of a second art
piece (such as a clay figure).

Application of the new skill in the client’s

life/rehearsal and performance
To fully anchor and integrate a new response (and to make it as
compelling and effective as older, less adaptive ones), the client must
repeatedly apply and practice it. DBT refers to this as generalization,
where the behavior is accessible in many situations and circumstances
(Linehan 2015a). The resulting artwork is a tangible manifestation of the
learning that occurred during a particular therapy session. Performing,
touching, hearing, or viewing the art piece outside of session reminds
its creator of associated feelings and cognitions, and can act as a sort
of talisman or reminder of the healing experience (Rothaus 2014). For
example, I had a client choose a beautiful gray rock to take home and
hold during a difficult phone conversation she planned on having.
This stone was part of a sculpture that she had made during session
that represented a state of calm and balance that arose from observing
and describing. The client returned the following week and reported
that, even though the phone conversation had been difficult, her rock
had “kept [her] on track so [she] did not spin out” into emotional
dyscontrol. It reminded her of the skills she had connected to during
the previous session.

Examples of CM exercises
Although the following selected activities are categorized within DBT’s
four skills training modules, each supports emotion regulation in
a general sense. They are appropriate for both group and individual
sessions. Depending on need, such exercises can range from 15 minutes
in length to most of the therapy hour.
206 DBT-INFORMED ART THERAPY IN PRACTICE

Core mindfulness skills

Mindfulness creates a framework for the emotion regulation module’s
more direct work with affect. These foundational skills help clients
access their ability to observe and describe current emotions and
remain present while avoiding the judgments and ruminations that
often trigger episodes of dysregulation (Linehan 2015a, 2015b).
“Wise mind” is central to mindfulness and DBT. This concept refers
to the meeting/synthesis of our rational and emotional faculties. Wise
mind balances pure emotion with logical thought; further, it includes a
sense of intuition that expands beyond both.
• Sculpture/drama: Ask the client to imagine what her wise mind
might look like if it were physically present. What kind of body
posture would it have? How would it move? How would it sound
when it talked? Invite her to shape its form with clay and feel
it with her hands. Then suggest a role play exploring how wise
mind might respond in an emotionally charged situation.
Observing is the awareness of one’s moment-by-moment internal and
external emotional experience.
• Movement: Bring awareness to the sensation of an emotion in
the body as the client gives it expression by moving about the
room. Ask her to watch for any changes in her emotional state.
• Visual art: Observe the client’s (or fellow group members’)
emotion-based image—slowly, one color and shape at a time.
Describing entails putting words to one’s emotional experience, using
sensory and factual language.
• Painting/sculpture: The client makes art describing an
observation from a previous exercise. This could be a sensation
in one’s belly, a shape in a painted image, a specific movement.
Emphasize naming the emotions experienced in the exercise and
repeating back the client’s words.
A nonjudgmental stance involves open receptivity. One refrains from
evaluating anything as good or bad.
• Visual art: Ask the client to close her eyes and paint with
her fingers. Next, with eyes open, she will practice speaking
 Creative Mindfulness 207

nonjudgmentally about the piece. Outline the client’s figure

on a large piece of paper. She then draws or paints symbolic
representations of where in her body she experiences various
emotional sensations.
One-mindfully means doing one thing at a time with full awareness.
• Sculpture: Ask the client to explore a lump of clay with as many
senses as possible, practicing immersing herself in the here-and-
now of the experience.
• Music: Play various pieces of music. Invite the client to stay fully
present (and return to listening whenever the music prompts an
emotion, or if her mind wanders).
Effectively is responding to the reality of a given moment, keeping in
mind one’s long-term goals rather than what one may judge to be right
or fair.
• Visual art: Create a group (or dyad) painting. Begin with one
person and pass the painting around, instructing each client to
add to the piece. If/when strong emotions arise, guide participants
to return to the idea of present-moment effectiveness.
• Sculpture: Divide art materials (paper, glue, clay, fabric, popsicle
sticks, etc.) unevenly among group participants (i.e., one person
gets most of the fabric, and so on). Everyone builds a tower (or
another shape) using only the materials they received.

Emotion regulation skills

These skills aim to reduce emotional vulnerability, identify and modulate
negative emotions, and deliberately create positive ones (Linehan
2015a, 2015b). Clients develop emotional balance by exploring a more
spacious, self-compassionate relationship with their affective states.
Accumulating positive emotions involves an intentional pursuit of
enjoyable activities and experiences to this end.
• Multiple art forms: Co-create a weekly ritual of engaging in
the creative processes the client most enjoys. Ask the client to
journal about the impact on her mood (being sure to name each
positive emotion that arises, employing the mindfulness observe
and describe skills).
208 DBT-INFORMED ART THERAPY IN PRACTICE

• Receptive music therapy: The client listens to pieces of music

deliberately chosen for the desired emotional valence.
Building mastery involves doing things that make one feel competent.
• Multiple art forms: Ask the client to choose a form of self-
expression she feels good at and engage with it both inside
and outside of therapy sessions. Help the client to notice how
practicing something that she has mastered can positively impact
her mood.
Coping ahead is planning for how to effectively handle emotionally
challenging future situations.
• Drama: Brainstorm and role play acting skillfully and practicing
good self-care in difficult circumstances.
• Visual art/writing: Ask the client to write and/or illustrate how
she would like the situation to occur in a story format, setting
the new scene with as much detail as possible.
Opposite-to-emotion action is a skill for decreasing the presence or
intensity of an emotion by engaging in a manner that is opposite to its
action urge.
• Movement: Instruct the client to find and hold a body position
that represents a difficult emotion they are experiencing. Then
shift into a position that represents a positive emotion—the
opposite of the negative emotion. Invite the client to use observe
and describe to notice the differences in mood and energy
between each body position.
• Visual art: Ask the client to paint an image of a difficult negative
emotion. Notice what colors and shapes best express the emotion
and allow plenty of time until there is nothing more to express.
Then ask her to deliberately choose colors and shapes that
represent the opposite emotions and paint with those. Notice any
judgments and/or shifts in mood and feeling state. At the end,
observe and describe both images nonjudgmentally and notice
what feelings, states, and action urges are evoked from each image.
• Writing: Compose a story that includes all the current feelings
and action urges. Use observe and describe to give as much detail
as possible. Then imagine the opposite feeling state and write
 Creative Mindfulness 209

multiple new endings with solutions and behaviors that spring

from this state.

Distress tolerance skills

Distress tolerance skills help create emotional balance because they
prevent the downward behavioral and emotional spiraling that often
accompanies, and in turn exacerbates, emotional dysregulation. These
strategies can also assist clients with improving their current emotional
state (Linehan 2015a, 2015b).
Distracting is shifting attention away from distressing emotions in
order to prevent emotional flooding.
• Movement: Move (alone or together) energetically to music
that invites dancing and shifting awareness away from negative
emotions and toward pleasurable bodily sensations.
Self-soothing with the five senses involves intentionally engaging in acts
of comfort, nurturance, and kindness toward oneself.
• Movement: Invite the client to move gently and rhythmically
(perhaps with slow rocking, gentle patting, or by giving their
own body a hug).
• Drama: Invite the client to imagine and then role play what a
warm, caring friend might say if they were here. The therapist
can then portray that friend, repeating what the client had said
in a similar tone of voice, as the client plays herself. Encourage
the client to focus on how she feels when hearing those words.
Improving the moment is a set of skills for getting through an emotionally
difficult time by deliberately making it better.
• Visual arts: Ask the client to practice working with what is available
in the moment. Complete a quick imperfect drawing, and then ask
what else the image “needs” in terms of colors or shapes.
• Guided imagery with all senses: Lead clients through imagining
personally pleasing colors, images, shapes, body sensations, and
sounds.
Pros and cons lists involve assessing both the desirable and undesirable
consequences of a potential emotion-fueled action (the intent is to curb
impulsive, reactive behaviors).
210 DBT-INFORMED ART THERAPY IN PRACTICE

• Movement/sculpture: Invite the client to reflect on the

consequences and effects of making several specific life choices,
such as taking a new job or not, initiating a new relationship,
and so on, by experiencing each choice within the body. Make
“islands” around the room with colored scarves to represent
different choices. Step onto the first island; then observe and
describe how it is to have taken the choice this represents. Then
step onto another and notice the difference between them. After
the client has visited all the islands of choices, ask her to step
aside and reflect on what she noticed.
Radical acceptance means accepting one’s emotions and circumstances
as they are, regardless of whether one likes them or agrees with them.
• Visual arts: Have clients draw or paint an experience including
their related emotions and exactly how it is for them, but without
any added value judgments—such as how bad it is, how things
should be instead, and so on—and allow themselves to become
immersed in reality and express that in colors and shapes.

Interpersonal effectiveness skills

Interpersonal relationships are deeply connected and intertwined with
emotion regulation. Attunement and secure attachment are at the root
of affect regulation, and affect regulation is often impaired by poor
attachment. Our ability to self-regulate is founded within our first
relationship(s) (Schore 2003). Healthy adult relationships are essential
because of their potential to engender good emotional regulation,
and because less adaptive ones are common triggers for dysregulation.
Interpersonal effectiveness skills increase the likelihood of achieving
one’s goals by asking for what one wants or setting appropriate
boundaries (saying no) while maintaining self-respect and the integrity
of important relationships. These skills also support emotion regulation
because they counter the reactive emotional expressions that often
result from dysregulation—and can trigger or worsen relationship
problems.
The DEAR MAN skills are steps to effectively communicate and
address a problem with another person.
• Drama: Have clients role play in dyads to practice communicating
ineffectively—and then effectively—in an imagined and
 Creative Mindfulness 211

somewhat challenging interaction (in which they might normally

become emotionally dysregulated and have difficulty expressing
and asserting themselves). They will experiment with finding the
appropriate tones of voice, body postures, and facial expressions
as they go through the steps of Describing the facts, Expressing
how they feel, Asking for what they want, Reinforcing the benefits
to the other person, staying Mindful, Appearing confident, and,
finally, Negotiating a good solution for both parties (Linehan
2015b, pp.125–126). Ask them to track how each feels in their
body. Additionally, you can have a third group member help by
directing the scene and providing feedback.
GIVE skills are helpful when keeping the relationship is a higher priority
than getting what one wants.
• Drama: Ask clients to role play making a request. Invite them
to play with finding the right voice and body stance for them,
practicing how to express emotions as they appear Gentle,
Interested, Validating, and Easy in their manner (regardless of
the emotional pressure they may feel inside) (Linehan 2015b,
p.128). Encourage clients to be cognizant of how their inner
states change as they practice.
FAST is a skills set that aims to support healthy self-respect.
• Drama: Clients role play in dyads, holding to their positions
when challenged and not reacting or collapsing for emotional
reasons. For example, person A wants a favor from person B;
however, person B does not want to give it them. Person B’s job
is to insist on saying “no” to the request regardless of what person
A says. Coach clients to hold a somatic awareness of their center,
observing boundaries as they go through the four letters/steps:
(be) Fair, non-Apologetic, Stick to their values, and be Truthful
(Linehan 2015b, p.130).

CASE STUDY: LINA

Lina is a 51-year-old Danish woman. She has seen me in my Copenhagen
clinic every few weeks for the past year. She suffers from debilitating mood
swings, alternating between fits of rage and crushing sadness. Her emotion
regulation problems had previously led to self-harm behaviors and suicidal
212 DBT-INFORMED ART THERAPY IN PRACTICE

thoughts. Lina experienced a tumultuous and chaotic childhood with

parents who loved her, but were “unable to really connect [with me] and
[were] basically just stuck in their heads.”
Lina recently went through a divorce. She is understandably sad and
angry given that her former husband had suddenly left her for a new
relationship. Lina is highly gifted, creative, and intelligent; however, she
has struggled to find a career that suits her. She never completed any
formal education past her high school diploma.
Lina’s moods and strong emotions make it difficult for her to stick with
plans. We agree that she has improved a lot since beginning therapy, and
I always notice that she is very engaged when learning how to find more
emotional balance. She finds it liberating to focus on concrete behavioral
skills after years of participating in analytical and depth-oriented
psychotherapy. Today Lina is very upset about a recent email interaction
with her former husband, and she is visibly distraught as she walks in. She
quickly recounts the story as she takes off her winter coat with fast, jerking
movements. She begins to cry as soon as she sits down.
Lina’s emotions seem to intensify as she leans over and pounds
her legs with her fists. I want to validate and support her, perhaps
communicate that I can see and understand her distress. I am not sure
that she can hear this, however, and so I wait until she comes to a natural
pause. I then gently ask if she can observe and describe what she is
feeling. Lina grows more upset in response to this perhaps overly skills-
focused query. “I don’t know, I really don’t, except I just don’t want to feel
this way any longer…” Noticing that my invitation for Lina to be mindful
of her internal state seemed to exacerbate her dysregulation, I decide to
simply be empathically present with her in the moment. I again validate
her emotional response.
Lina eventually stops crying and looks up at me. I then ask, “Would
you be willing to draw how this feels to you?” Lina says “Sure,” and begins
to make large, rapid marks (in black, purple, and blue) across the paper.
Next, she writes the word “help” in Danish, as well as the letters A-A-A-A-
A-A-H. I gently support Lina in continuing to express her current experience
by “Let[ting] it all just come out onto the paper.” Her movements slow
somewhat after a few minutes. Although verbalizing her emotional state
is at first too difficult given the intensity of her dysregulation, Lina is able
to draw.
As time goes by Lina add a few words, and, finally, can speak with me
about her artwork. Lina seems a bit calmer and is now very involved in
 Creative Mindfulness 213

her process. I ask whether she can identify a body posture that fits the
feeling state in her drawing. She confirms this with a “yes,” then slumps
into her chair, grabs her hair at the roots with both fists, and shakes her
head vigorously from side to side. I remark that that looks very painful, to
which she replies “Well, yeah…it is.”
I go on: “I know what I am about to say may be challenging right now,
but could you show me what you sense might be the opposite emotion to
this, I mean, what that opposite feeling might look like in a body posture?”
Lina nods and starts to move around, searching for the right one. At last
she sits up, arches her back a little, lifts both arms into the air, and looks
up at me. She then breathes out in a big sigh, lowers her arms, and settles
into a more neutral stance. “What was the feeling you showed me there?”
I ask. Lina hesitates, then says “Relief, maybe? Calm?” I then invite her to
mindfully move back and forth between the two poses a few times, and
really notice how that feels.
I do this to help Lina appreciate that it is possible to shift in and out of
emotional states, and that accessing the emotion opposite to the one we
feel stuck in can sometimes pull us out of it. As Lina starts moving again,
I remind her to observe and describe her experience in the moment and
to notice nonjudgmentally if/when the body movements seem to affect
her mood. Lina and I talk some more about her process. She is now rather
calm and focused; her eye contact has improved, as well. I ask her to
brainstorm with me how she can deliberately repeat the exercises from
today to shift out of any overwhelming moods that might come up during
the week—if, for example, she receives another email from her ex. Further,
I ask about how she might create some positive emotions by recalling
today’s experience. We talk about what DBT skills and pleasant feelings
were at play during the exercise and consider activities that might remind
her of them. She decides to anchor her learning from today with another
drawing. Lina quickly sketches what appears to be a bouquet of several
red, pink, and orange flowers. She then draws a carrot-like figure that she
calls “the chief.” This figure often comes up as a kind of representation
for her wise mind. I ask Lina if she can tell me more about “the chief” and
what it stands for here, and she says: “That’s the wise and strong part of
me that I showed you before in the movement when I sat up.” She adds,
“It’s a feeling that I want to hold onto…even if he writes me again. I can
look at the drawing and remind myself before I write back…but I do need
to keep reminding myself.”
214 DBT-INFORMED ART THERAPY IN PRACTICE

Discussion of case study

In this case study we met Lina, who has a long history of struggling
with emotion regulation and yet is very open to learning new, adaptive
behaviors. DBT skills she and I work with in the session are opposite
to emotion action, observe and describe, one-mindfully, nonjudgmental
stance, and accumulating positive emotions. By exploring them through
drawing and movement, Lina can feel and experience each skill in a
profound way. We have discovered during our work together that this
creative and embodied approach allows her faster and more enduring
access to the skills, and to her own inner resources, than do the
traditional cognitive, verbal modalities.

Conclusion
Emotion dysregulation is at the core of many of the most painful states of
suffering and psychiatric diagnoses. Art therapy-oriented clinicians are
often uncertain about how to work effectively with highly emotionally
reactive individuals. The DBT-informed CM approach teaches emotion
regulation skills in a playful, engaging manner while reducing the risk
of overwhelming sensitive nervous systems.
This intervention also works to support integration of new
emotional learning by anchoring and repeating the experience through
the senses. CM is readily adaptable to the needs of various client issues
and treament environments. Further, it serves as a foundation for less
structured expressive arts interventions, which clients may explore
during later therapy stages.
Over the course of several years of implementing and teaching this
approach, we have been encouraged by observations that our clients
achieve lasting improvements in their emotion regulation capacities.
However, empirical qualitative research is needed to assess more solidly
CM’s efficacy and usefulness.

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Doidge, N. (2007) The Brain that Changes Itself: Stories of Personal Triumph from the Frontiers
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Hanson, R. and Mendius, R. (2009) Buddha’s Brain: The Practical Neuroscience of Happiness,
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Levine, P.A. (2010) In an Unspoken Voice: How the Body Releases Trauma and Restores
Goodness. Berkeley, CA: North Atlantic Books.
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New York, NY: Guilford Press.
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(Original work published in 1993.)
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New York, NY: Guilford Press. (Original work published in 1993.)
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neuroscience perspective.’ Neuropsychiatric Disease and Treatment 1, 1, 9–15.
Porges, S.W. (2009) ‘The polyvagal theory: New insights into adaptive reactions of the
autonomic nervous system.’ Cleveland Clinic Journal of Medicine 76, 2, 86–90.
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Arts Therapies: Theory and Practice. London: Jessica Kingsley Publishers.
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 Chapter 12

Toward a Distress Tolerance-

Informed Expressive Arts
Therapy Protocol with Vulnerable
Populations Experiencing
Multiple, Persistent Barriers
CHLOE SEKOURI

Introduction
The expressive arts offer rich opportunities for valuable therapeutic
experiences. By attending to insights afforded by dialectical behavior
therapy (DBT)—and DBT’s distress tolerance skills module, in
particular (Linehan 1993, 2015a, 2015b)—expressive arts-based
clinicians are uniquely positioned to teach, model, and support the
use of creative activities in managing overwhelming emotions and de­
veloping healthy self-care practices. This is especially critical for indi­
viduals experiencing multiple, persistent problems and barriers in their
psychosocial functioning.
This chapter presents one method for incorporating a DBT-informed
artmaking practice into one’s clinical work. It describes my, the author’s,
protocol for a combined visual art/poetry/psychoeducational technique
via the case example of Cathy (pseudonym), a 28-year-old sex trade
worker contending with chronic homelessness/housing insecurity,
substance abuse, and mental illness. This chapter concludes with
suggestions for effectively delivering such an intervention to similarly
vulnerable clients.

216
 TOWARD A DISTRESS TOLERANCE-INFORMED PROTOCOL 217

Who am I and what am I doing?

While this chapter describes a cognitive behavioral model, DBT, I am
influenced by several therapeutic traditions. For example, the school
I attended, the Vancouver Art Therapy Institute (VATI), was, at the
time I studied there, a traditional psychodynamic training program
that emphasized object relations and depth psychotherapies. Exposure
to other approaches brought me to the work of art therapist and clinical
psychologist Mala Gitlin Betensky. I practice her phenomenological
inquiry method (1995) in almost every expressive arts therapy session
I conduct. My work is also grounded in insights from Gestalt therapy
(Perls 1969a, 1969b), solution-focused brief therapy (Berg 1989;
de Shazer and Dolan 2012), motivational interviewing (Miller and
Rollnick 2012), and anti-oppressive social work practice (Dominelli
and Campling 2002). My only formal clinical training is in expressive
arts therapy. Regarding foundational social work and counseling skills,
I am self-educated (or, rather, I have been taught by my clients through
trial and error).

People come and people go

Many of my clinical experiences took place in a drop-in center in
Vancouver’s infamous Downtown Eastside (DTES). Such environments
present therapists with challenges around choosing an appropriate
framework for their goals as helpers (Bloom 2001; Cameron 2007;
Campbell 2012). As the name indicates, it is the nature of drop-in
services for people to come and go. The interaction you are having in
any moment with any client may be the only interaction you will ever
share, so it is worth considering a single-session treatment approach
(Slive and Bobele 2011).
I was mindful to round off each exchange so that, if I did not work
with the person again, there was no blatant unfinished business. Some
individuals engaged with me one time only, never to return; others tried
art making but did not continue with it despite being frequent drop-in
center users. Some wanted to regularly spend time in conversation with
me, but consistently declined art. Committed art therapy clients were
rare. Hence, I frequently employed the solution-focused brief therapy
(SFBT) model. Rather than maintaining a focus on the problems that
bring clients to therapy, SFBT encourages us to remain future-oriented,
218 DBT-INFORMED ART THERAPY IN PRACTICE

goal-directed, and working on solutions. In the SFBT framework every

therapy participant is a visitor, a complainant, or a customer (Berg 1989).
On one end of the engagement/commitment spectrum, there are
visitors and complainants. Visitors typically come at another person’s
request. They are willing to attend therapy, but usually only to please
the other individual. A visitor is not personally invested in change
(Berg 1989). Complainants desire to talk about their difficulties,
air frustrations, and/or analyze or criticize other persons involved.
However, a complainant typically lacks the ability to see how their own
behavior may contribute to their problem(s) (Berg 1989).
On the other end are the customers who are ready to problem-
solve. Therefore, they go beyond mere compliance; they are active
participants and collaborators (Berg 1989). Customers appreciate that
they might have contributed to the issue(s) at hand and know that they
must author any solutions. This echoes DBT’s assumption (Linehan
1993) that individuals in treatment “may not have caused all of their
own problems, but they have to solve them anyway” (p.107). The
customer will consider novel ideas and is open to different methods
for approaching the problem (Berg 1989).
Whether visitors, complainants, or customers, individuals seeking
services at the drop-in center rather consistently expressed profound
skepticism toward the idea of psychotherapeutic change. As one put
it, “The power of positive thinking has never un-raped anybody.” She
certainly had a point.
Even if my clients had been willing, both the drop-in context
itself and the difficult life conditions they experienced outside the
center suggested that psychodynamic-oriented modalities would be
inappropriate. People require a certain baseline level of stability and
safety for such deep interventions to be productive, ethical, and pointful
(Bloom 2011; Cameron 2007; Campbell 2012; Watson 2007). This
realization has dripped from the helping professions and infused the
overculture—such that I recently saw a t-shirt printed with the slogan
“Stop looking at the past; that’s not where you are headed.” But if it isn’t
necessarily helpful to dig into the past, what can we do instead?

DBT
Developed during the 1980s by psychologist Marsha Linehan, DBT is
a behavior therapy designed to treat borderline personality disorder
 TOWARD A DISTRESS TOLERANCE-INFORMED PROTOCOL 219

(BPD) (Linehan 1993). It has since been applied to a wide range of other
mental health concerns (Gross 2015; Newhill and Mulvey 2002). The
model is particularly efficacious for problems that include emotion and
mood dysregulation elements such as substance abuse/dependence,
unresolved trauma, and attachment issues (Feigenbaum 2007; Hayes
et al. 2004; Welch, Rizvi, and Dimidjian 2006).
DBT’s psychoeducational skills training curriculum, just one
component of this comprehensive evidence-based intervention, consists
of four interlocking modules: mindfulness, interpersonal effectiveness,
emotion regulation, and distress tolerance skills (Linehan 2015a,
2015b). Each module circles back to, and informs, the others. While
it makes sense to speak of them as separate entities, in the context of
teaching customers one may find that all four skills sets are present
(and needed) in any given moment. This is analogous to some organic
biological processes. For example, the seeds of future apples are present
in apple blossoms, within the juicy just-ripe fruit, as well as in every
decomposing core.
While the principal uses we have for the blossoms, whole fruit, and
core are different and varied, apple seeds are, by necessity, present in all
states. And so it is with DBT: seeds of mindfulness are present within
the distress tolerance skills. Similarly, emotional regulation must be
present for a customer to improve their interpersonal effectiveness
capabilities. Thus it is with some trepidation that I attempt to discuss
the distress tolerance skills in isolation from the other modules.

Distress tolerance skills

Many people believe that the point of seeking out helping services is
to change or eliminate undesirable circumstances. Troubled marriage?
Divorce or try couples counseling. Abusive boss? Quit or speak with HR
for mediation. Low self-esteem? Engage in personal work that builds
confidence as well as a realistic sense of one’s self. Another assumption is
simply that some problems have no real-world solutions. Many drop-in
center participants, at some point during our interactions, have voiced
serious doubt that psychotherapeutic treatment “actually works.”
On one hand, they are correct: psychotherapy cannot reanimate
the dead, eliminate all trauma sequelae, or return the sufferer to a
state of pristine wholeness (should such a thing exist). On the other, I
believe they are mistaken: the point and the power of DBT lies within
220 DBT-INFORMED ART THERAPY IN PRACTICE

its acknowledgment that some issues and situations are inherently

unfixable—and that we must accept their existence in order to avoid
unnecessary suffering (Linehan 1993, 2015a, 2015b). When we
discard fantasies of closure, what remains is our human capacity to
live, as best we can, despite the unavoidable pain involved. DBT aims
to help customers accept, construct meaning for, and endure distress
without relying on coping behaviors that place them at additional
risk for injury. In other words, the essence of the distress tolerance
module is learning to bear pain skillfully, using methods that do no
further harm.
The vehicle for this is mindfulness. In a nutshell, DBT’s mindfulness
skills center on the ability to accept, without judgment, oneself as
well as the current situation. Note that accepting reality is not the
same as approval. For example, acknowledgment of inequality is
not tantamount to desiring or condoning it. The distress tolerance
module leverages the customer’s use of mindfulness to survive crisis
and upset while refraining from making things worse (no matter how
unintentionally).

Who is the expressive arts therapy participant?

CATHY
Cathy was a 28-year-old woman of mixed indigenous Canadian and white
settler ancestry. We worked together intermittently at the drop-in center for
a period of six months in 2007. I should mention that not all of our clinical
encounters involved art therapy or DBT. However, those interactions are
not relevant here and therefore were not included.
Cathy grew up in Alberta with her six younger siblings. Their mother
struggled with substance abuse problems that resulted in significant child
welfare involvement. When not in foster care placements, Cathy and her
sisters and brothers resided with a variety of extended family members.
Cathy ran away from her last foster home at age 16 and eventually made her
way to Vancouver. Like many young people who come to the city alone and
lacking a support network, she found community, fellowship, danger,
and explo­itation within the infamous Downtown Eastside (DTES). By the
time she was 17 years old, Cathy was supporting herself through sex work.
If it were possible for me, writing today, to ask Cathy to describe herself,
I suspect that she would include several other facts. For example, she
 TOWARD A DISTRESS TOLERANCE-INFORMED PROTOCOL 221

might tell you how much she loved to read. I believe that Cathy would also
talk about her volunteer work in the public library, for a local women’s
center, and with a community garden initiative. Employees of mental
health and social service systems are subtly, and sometimes not-so-subtly,
conditioned to see client narratives that support certain paradigms. One
cannot include case study information without implying that the subject is
a case. I am in a quandary because I know I must tell you something about
Cathy, but I also appreciate that I will inevitably fail to do her justice. I have
tried to resolve this (at least partially) by disrupting the narrative before
you with reflexivity as well as with an acknowledgment of my limitations
and personal biases.

Procedural overview: A DBT-informed

art therapy intervention
In the expressive arts therapies, the creative process (as well as any
resulting artistic products) functions as a safe container for over­
whelming feelings. It is therefore unsurprising that some practitioners
resonate with DBT’s distress tolerance component. Creating art helps
us bear pain skillfully.
After completing a DBT-informed art therapy activity I supported
Cathy’s use of worksheets and journaling, taking care to point out any
connections between her experiences/insights and the following crisis
survival strategies (Linehan 2015a, 2015b):
• mindful distraction activities
• self-soothing practices
• improving the moment skills
• examining pros and cons (i.e., the likely desirable/undesirable
consequences of both using DBT skills and of resorting to
maladaptive behaviors).
These strategies were, by necessity, combined with instruction in
mindfulness and how to turn one’s attention toward accepting reality.

Objective
To develop and/or improve an individual’s distress tolerance skills using
directive, experiential art-based methods.
222 DBT-INFORMED ART THERAPY IN PRACTICE

Duration
There is no ideal format for this protocol given that the nature of my
drop-in center work was fluid, situational, and highly individualized. In
this instance, Cathy and I met one-to-one for 120 minutes (which was
inclusive of some participant-initiated cigarette breaks).

Art materials and equipment

I keep on hand the following basic items: paper of various sizes and
colors, bound notebooks of lined paper (used as participant journals),
canvases, pre-cut collage images, acrylic paints, fluid paint medium,
molding paste, chalk pastels, conté pencils, assorted plastic/rubber
toys and other found items, spray adhesive, glitter glue, scissors,
paintbrushes, spatulas, a small kitchen torch, and a hairdryer (for quick-
drying paint, glue, and so on). If space and budget allow, I include
additional materials.
NOTE: My experience has been that agencies serving vulnerable
populations with multiple barriers typically lack the budget and
infrastructure for sculpting work. Potentially one of the wettest
visual mediums, clay might not be a good fit for customers in need of
significant emotional containment. I believe that such individuals tend
to become easily overwhelmed when using clay.

The session—Understanding DBT’s states of mind

The purpose of this session is to familiarize the participant with the
art making space and supplies, as well as offer basic information about
three unique states of mind as understood in DBT: emotion mind,
reasonable mind, and wise mind (Linehan 2015b, p.50).
When emotion mind predominates, our behavior is controlled
by our affective state (Linehan 1993, 2015a, 2015b). It is difficult (or
impossible) to think in a logical manner. Emotion mind’s dialectical
opposite, reasonable mind, is intellectual, rational, and excels at
identifying cause–effect relationships. In reasonable mind we can plan
how to navigate difficult situations. We possess the capacity to respond
based on evidence and facts (Linehan 1993, 2015a, 2015b).
The third state, wise mind, integrates/synthesizes emotions with
rational thought. It also adds a dimension of intuitive knowing. Wise
mind is greater than the sum of its parts; here we see more clearly and
can grasp the bigger picture (Linehan 1993, 2015a, 2015b). Further,
 TOWARD A DISTRESS TOLERANCE-INFORMED PROTOCOL 223

wise mind ensures that the needs of both emotion and reasonable
minds are met: it validates intellectual processes and allows for the
soothing/regulation of intense emotions.

WISE MIND

Emotion mind Rational mind

Figure 12.1 Therapist’s diagram: DBT states of mind

Protocol
Below are the sequential steps for implementing the intervention:
1. First I introduce the participant to available supplies via pre-art
play. This consisted of the participant experimenting with the
materials to gain familiarity with them.
2. Next I draw the DBT states of mind diagram (Figure 12.1) on
paper while noting verbally that “Wise mind is our sweet spot,
the place where we are balanced and make our best choices.”
3. I then invite the participant to collage her/his personal concep­
tualization of each state of mind.
4. I hold the space while the participant makes art. Holding the
space involves being with someone without judgment, putting
one’s own needs and opinions aside, and allowing the client to
just be (Gafner 2013).
5. I witness the participant’s finished artwork and attend to any
commentary.
6. I invite the participant to journal about this experience (if
desired).
224 DBT-INFORMED ART THERAPY IN PRACTICE

Discussion (Cathy’s process)

After warming up with some pre-art play using the collage materials on
hand, Cathy created her own DBT states of mind diagram (Figure 12.2).

Figure 12.2 Participant image: “My Minds”

(collage, conté, chalk pastel)

When sharing the states of mind diagram from Figure 12.1 with
Cathy, I sketched it onto the back of a used envelope with a ballpoint
pen. Experience has taught me that many individuals who are new to
art therapy flounder when presented with nondirective art making
prompts. Further, those lacking a formal visual art background often
express feeling anxious and/or intimidated (usually resulting from
perfectionism and negative judgments), which has a chilling effect
on their ability to relax into a creative process. By using materials of
perceived low value (e.g., dollar store pen, scrap paper fished from the
recycling bin), I communicated to Cathy that she should not worry
about her piece needing to be perfect, special, or precious.
We had had sufficient verbal interactions prior to this first art
making session for me to know that Cathy would not take risks without
a sense of reciprocity. My intuition told me that, by providing a simple
handmade visual example, she would more readily accept my invitation
to make art. A selection from our discussion about her piece follows:
CS: Can you tell me the story of how you made this?
C: Okay, so in the emotions section, the first thing I put down was the
words “Tempest Rim” because when I saw it in with all the collage
 TOWARD A DISTRESS TOLERANCE-INFORMED PROTOCOL 225

stuff, it made me think of that Shakespeare play The Tempest, you

know that one with the storm and the creepy magician?
CS: Uh huh.
C: So, when I saw that, I thought about the storm. That’s kinda how
my emotions feel, like a wild storm at sea, right? Then I looked for
a water picture and I found a perfect one—it’s all stormy—so I put
that one down, too. (pause) The next thing I put down was the green
and blue swoop thing. I like both those colors. I’m not sure why I
picked it. I just like green and blue together.
CS: Right.
C: It’s funny, though, because looking at it now, it looks like an ocean
wave to me.
CS: Yes, it looks like that to me, too.
C: Freaky how that works, hey?
(both laugh)
C: So, then the next thing I put down was the girl in her underwear…
CS: Any thoughts on that?
C: Well, I liked it just because I liked her old-time underwear. (laughs)
(pause) As I look at it, it’s a sorta ridiculous picture. I’m like, “Bitch,
why you afraid of a toy alligator?” (laughs) (pause) Seriously, though,
I think that it’s about manipulation. She’s playin’ at being afraid, but
she’s not really afraid. She’s all like, “Oh, I’m so cute and sexy and
scared. You gotta help me.”
CS: You make anything of that?
C: (sighs) (pause) Well, that’s life, right?
CS: Like, all of life, or life in the game?
C: (laughs) Well, I meant it as life in the game. That’s how you are with a
date, right? Keep him happy, play along, make your money, get out.
But just now, when you asked me that, maybe it is all of life—like
most of us playing somebody sometime for something.
CS: Huh. (pause) Anything else?
C: Yeah. (pause) I saw that little house and wanted it on there. After
I stuck it on, I drew in the flames because some emotions are like
being on fire, right?
CS: Yes.
C: Fire and water at the same time somehow. Then when I found that
scrap of paper with the doodle on it, it looked too perfect, I wanted
to wreck it, just cross it out, get rid of it.
CS: Uh huh.
226 DBT-INFORMED ART THERAPY IN PRACTICE

C: So, I used that skinny chalk to scribble on it. Take that, you damn
doodle!
(both laugh)
C: And then the last thing was the hand with the candy bowl. (pause)
CS: Okay, what’s happening there?
C: Well, I like how her nail polish matches the jellybean colors.
CS: Anything else?
C: (sighs) It makes me think about when I was a teenager, I had bulimia,
right, I told you that, didn’t I?
CS: Yes.
C: So if I got stressed out, which was all the time, I’d eat my feelings…
and I was starting to get fat.
CS: Uh huh.
C: And I didn’t wanna be fat, and I had seen about bulimia on TV—on
Maury or some shit. And I thought “Okay, let’s give that a try.”
CS: Right.
C: I don’t do that anymore, though.
CS: Oh?
C: (laughs) Crack keeps me nice and skinny now.
At this point in the session Cathy excused herself to go outside to smoke
a cigarette. We resumed our work after she returned.
CS: Do you want to say more about your collage, or do you want to do
something else?
C: Let’s talk about the collage.
CS: Sounds good.
C: So, the overlap in the circles…
CS: Wise mind.
C: Yeah, the wise mind. The first thing I put down was the bowl with
the floating candles. I liked how the candle looks like a flower. The
picture is very simple. I liked that.
CS: I wonder why you were drawn to it.
C: (pause) I think it makes me feel peaceful, relaxed. Is that part of
wisdom?
CS: What do you think?
C: (pause) Yes. (pause) Then I saw that picture of the present, and I
started to think that wisdom is a kind of gift, right?
CS: Yes.
 TOWARD A DISTRESS TOLERANCE-INFORMED PROTOCOL 227

C: And maybe the point of wise mind is it’s the gift you give yourself
when you balance emotional and mental things.
CS: Mmmmm.
C: It’s like a seesaw, maybe, like on a playground. One end goes up, the
other goes down, then the other way. But sometimes it balances out
and everything is…level.
CS: Right. (pause) You’ve said the word balance a couple of times and I
notice one of the images is a dandelion seed labeled “balance.” How
important is balance?
C: How do you mean?
CS: Like, in wise mind, is balance always a part of it, or just sometimes?
C: Always.
CS: Okay, good, that’s good to know. Anything about the seed labeled
“laughter”?
C: Can’t get through a day without it, right? I mean, if you don’t laugh,
I’d say you are pretty much fucked! (laughs)
CS: True that.
(both laugh)
CS: Anything about the fact you colored the overlap in?
C: I just wanted to show that the circles overlap. I wish I hadn’t used
the chalk. I don’t like how it feels on my hands. If I do another one,
I think I’d fill it in with felts…are there felts?
CS: I can get some.
C: I’d have to use white paper then, so the felts would show up.
CS: I can get some that show up on black, like some metallic ones or
gel felts or something.
C: Metallic ones would be cool! (pause)
CS: Anything to say about the rational mind part of your collage?
C: There’s not much there.
CS: How so?
C: Well, there’s a cute smart girl in her glasses. That’d be me if I wore
glasses. (laughs)
CS: Anything else?
C: Not really, just a great big ol’ brain. (long pause)
CS: I have a guess about your collage. Want to hear it?
C: Sure!
CS: My guess is you feel confident about your mind, being smart, so
there isn’t a ton to say.
C: My brain speaks for itself, huh?
228 DBT-INFORMED ART THERAPY IN PRACTICE

(both laugh)
CS: Meanwhile, the emotion part, it can cause some trouble. Maybe get
you unbalanced, so you put more in that circle…
C: Yeah, ’cause I’m trying to figure it out. I’m like, “What is all this
feeling shit?”
CS: Right.
C: So why do you think I filled up the wise mind part?
CS: Why do you think you did that?
C: (pause) I’m wishing and hoping for that stuff. Sometimes it seems so
close, and sometimes not.
CS: Right.
As our session continued, Cathy and I transitioned from the art-based
process to a didactic/psychoeducational lesson involving DBT skills and
journaling. The materials were based on contents from The Dialectical
Behavior Therapy Skills Workbook (McKay, Wood, and Brantley 2007)—
specifically, the checklists “Radical Acceptance Coping Statements”
(p.11), “Distract Yourself from Self-Destructive Behaviors” (p.13), and
“Self-Soothing Using Your Sense of Vision” (pp.24–25), as well as the
“Create Your Distraction Plan” worksheet (pp.22–23).
Under other circumstances I might have used the “Big List of
Pleasurable Activities” checklist (pp.15–16) as well, but opted not to
here because it reflects an economic lifestyle that was outside of Cathy’s
grasp at the time of this session. I was concerned that the list could
be upsetting to her (i.e., owing to a possible perceived implication
that feeling better is only for people who have the money to afford it).
Instead I gifted Cathy with a blank journal and pen, and together we
brainstormed her personal list of pleasurable activities.
As Cathy and I discussed the worksheets and she wrote down her
answers, I facilitated making connections between skills she already
possessed and the distress tolerance modules. For example, Cathy’s self-
reflection tied directly into an ability to weigh the pros and cons. In
addition, I assisted her in appreciating that making art can function as
a distraction from dysphoric states, be used to self-soothe, and improve
the moment with an infusion of beauty and creativity.
Within a few sessions of receiving a journal Cathy started to
compose poetry and bring her poems to our therapy sessions. When
I inquired about how she felt before, during, and after writing poetry,
Cathy replied:
 TOWARD A DISTRESS TOLERANCE-INFORMED PROTOCOL 229

It lets the pressure off. When I feel the emotions building up inside
me, I can write down a line or two. I usually feel bad when I start and
feel really bad while I’m doing it. It’s kind of my wallow time. After the
poem comes out, I feel better, lighter, more in control. It’s like the poem
has absorbed all my negative emotions.
Poetry therapy is a form of expressive arts therapy and involves the use
of poems, narratives, and other spoken or written media to promote
healing and well-being (Mazza 2017). While I had not initially offered
creative writing suggestions or directives to Cathy, I started to do so
after she introduced some of her poems into our sessions. Poetry proved
a rich vehicle for Cathy to safely explore her emotions and responses to
people and life events. For example, Cathy wrote an untitled piece about
her involvement with the sex trade:
Open mouths with teeth
Everyone wants a bite
of my juicy ass
fuck that
I’ll either be a cannibal or a suicide
While discussing this poem Cathy identified themes that she had
not previously given voice to. Interestingly, Cathy never made visual
art directly associated with any poems, nor did she write poetry that
connected to her visual art. When I mentioned this during one of our
sessions, Cathy replied:
Yes, I notice that, too. I mean, the poems and the art are connected
because they are made by the same person, by me, but it’s like some
things are better dealt with in words, and some in pictures. They are
connected because it’s all happening in one life, my life, but it’s like I
want to keep things in separate compartments.

Other ideas for combining DBT skills and art making

Self-soothing through vision is an obvious match for visual art
making. However, other sensory elements lend themselves to a distress
tolerance-informed art therapy session, such as:
• Playing or listening to music (sound).
• Dance, self-massage, or yoga activities (touch) to supplement the
230 DBT-INFORMED ART THERAPY IN PRACTICE

haptics already embedded in the making of music (e.g., the feel

of the ukulele strings, the texture of the drum skin) and visual art
(e.g., sensations available when we interact repetitively with paint
while finger painting, sculpting with clay, and so on).
Even simple acts such as offering healthy snacks (e.g., herbal teas, fruit)
provide clients with specific examples for integrating these skills into
daily life.
Art making of any medium can be incorporated into a willing
individual’s distraction plan or used to improve the moment. If desired,
clinicians may develop didactic psychoeducation lessons connecting
the principles of distress tolerance to what has just taken place in the
therapeutic encounter. My experiences suggest that it is best first to
provide the creative intervention, then process the client’s response(s) (as
well as the artistic product)—and, finally, introduce psychoeducation.
It will likely always be the case that some individuals resist didactics
and worksheets. This is their right. Roll with the resistance and meet
them wherever they are.

Conclusion
This chapter introduced a novel method for using expressive arts
techniques to teach select DBT skills to customers of an urban drop-in
center. These individuals often experience multiple, persistent barriers
to their optimum functioning and tend to harbor skepticism around the
potential value of mental health treatment services. Cathy was one such
person, a vulnerable young woman who contended with significant
psychiatric issues, homelessness, and substance abuse; further, she was
employed in the sex trade.
Cathy’s engagement with an expressive arts therapy process, along
with the resulting creative products (visual art and poetry), facilitated
a point of access for valuable conversations concerning her thoughts,
feelings, and behaviors, as well as the pros and cons of various choices
and options. These discussions connected easily with DBT’s distress
tolerance skills module; as a result, Cathy could explore her personal
experiences of such important concepts as wise mind, crisis survival,
and reality acceptance. She ultimately acquired self-regulation skills
that had previously been much less accessible to her owing to the
standard didactic handout and worksheet-based format.
 TOWARD A DISTRESS TOLERANCE-INFORMED PROTOCOL 231

The presented protocol is certainly not appropriate in all treatment

milieus. However, my hope is that it will provide readers with helpful
insights around potential applications for combined DBT skills training
and creative arts interventions. Cathy’s reported feedback suggests that
the process of making art, then stepping back to objectively observe and
describe her work with a trained expressive therapist, improved this
woman’s emotion regulation capacity as well as an overall enhanced
effectiveness in activating her wise mind. Clinicians may find the
inspiration to develop this intervention further and test its validity
through formal research projects within their places of employment.

References
Berg, I.K. (1989) ‘Of visitors, complainants, and customers: Is there really such a thing as
“resistance”?’ Family Therapy Networker 13, 1, 21.
Betensky, M.G. (1995) What Do You See? Phenomenology of Therapeutic Art Expression.
London: Jessica Kingsley Publishers.
Bloom, B.L. (2001) ‘Focused single-session psychotherapy: A review of the clinical and
research literature.’ Brief Treatment and Crisis Intervention 1, 1, 75–86.
Cameron, C.L. (2007) ‘Single session and walk-in psychotherapy: A descriptive account of
the literature.’ Counseling and Psychotherapy Research 7, 4, 245–249.
Campbell, A. (2012) ‘Single-session approaches to therapy.’ The Australian and New Zealand
Journal of Family Therapy 33, 1, 15–26.
de Shazer, S. and Dolan, Y. (2012) More than Miracles: The State of the Art of Solution-Focused
Brief Therapy. London: Routledge.
Dominelli, L. and Campling, J. (2002) Anti-Oppressive Social Work Theory and Practice. New
York, NY: Palgrave Macmillan.
Feigenbaum, J. (2007) ‘Dialectical behavior therapy: An increasing evidence base.’ Journal
of Mental Health 16, 1, 51–68.
Gafner, G. (2013) Therapy with Tough Clients: Exploring the Use of Indirect and Unconscious
Techniques. Bancyfelin, UK: Crown House Publishing Limited.
Gross, J.J. (ed.) (2015) Handbook of Emotion Regulation (2nd ed.). New York, NY: Guilford
Press. (Original work published in 2009.)
Hayes, S.C., Masuda, A., Bissett, J.L., and Guerrero, L.F. (2004) ‘DBT, FAP, and ACT: How
empirically oriented are the new behavior therapy technologies?’ Behavior Therapy 35,
1, 35–54.
Linehan, M.M. (1993) Cognitive-Behavioral Treatment of Borderline Personality Disorder.
New York, NY: Guilford Press.
Linehan, M.M. (2015a) DBT Skills Training Manual (2nd ed.). New York, NY: Guilford Press.
(Original work published in 1993.)
Linehan, M.M. (2015b) DBT Skills Training Manual (2nd ed.). Handouts and Worksheets.
New York, NY: Guilford Press. (Original work published in 1993.)
Mazza, N. (2017) Poetry Therapy: Theory and Practice. New York, NY: Routledge.
McKay, M., Wood, J.C., and Brantley, J. (2007) The Dialectical Behavior Therapy Skills
Workbook: Practical Exercises for Learning Mindfulness, Interpersonal Effectiveness,
Emotion Regulation, and Distress Tolerance. Oakland, CA: New Harbinger.
Miller, W.R. and Rollnick, S. (2012) Motivational Interviewing: Helping People Change (3rd
ed.). New York, NY: Guilford Press. (Original work published in 2002.)
232 DBT-INFORMED ART THERAPY IN PRACTICE

Newhill, C.E. and Mulvey, E.P. (2002) ‘Emotional dysregulation: The key to a treatment
approach for violent mentally ill individuals.’ Clinical Social Work Journal 30, 2, 157–171.
Perls, F.S. (1969a) Gestalt Therapy Verbatim. Moab, UT: Real People Press.
Perls, F.S. (1969b) In and Out the Garbage Pail. Lafayette, CA: Real People Press.
Slive, A. and Bobele, M. (eds) (2011) When One Hour is All You Have: Effective Therapy for
Walk-In Clients. Phoenix, AZ: Zeig, Tucker, and Theisen, Inc. Publishers.
Watson, R.A. (2007) ‘Ready or not, here I come: Surrender, recognition, and mutuality in
psychotherapy.’ Journal of Psychology and Theology 35, 1, 65–73.
Welch, S.S., Rizvi, S., and Dimidjian, S. (2006) ‘Mindfulness in Dialectical Behavior Therapy
(DBT) for Borderline Personality Disorder.’ In R.A. Baer (ed.) Mindfulness-Based
Treatment Approaches: Clinician’s Guide to Evidence Base and Applications. Cambridge,
MA: Academic Press.
 Chapter 13

Queering DBT
Critical DBT-Informed Art Therapy with
the LGBTQIA+ Community
MARY WEIR

“I mainly get support from within a personal relationship at the

moment,” I say.
And has your boyfriend been helpful? my therapist politely inquires.
I pause. You see, I went to get a sexual health check the other day:
Have you had unprotected sex recently?
“No, but my partner has.”
Oh dear, is this the first time that they have been unfaithful?
“They weren’t unfaithful; we are ethically non-monogamous. This is a
routine check-up.”
And did he wear a condom?
“They don’t have the right genitals for a condom.”
Err…ah, okay, and so did she sleep with a man or a woman?
My femme1-identified partner, like me, was assigned female at birth but
does not identify with binary2 pronouns. Although I feel guilty, I let this
slide for the sake of simplicity.
“Man.”
And did he wear a condom?
“Well, he is trans,3 so he doesn’t currently use condoms specifically.”
I’m sorry, did they or didn’t they have penetrative sex?
“They did have penetrative sex but there was no need for a condom.
This is a routine check-u—”
I don’t understand…are you saying…

233
234 DBT-INFORMED ART THERAPY IN PRACTICE

She seems flustered, and so distracted by trying to work out my love life
that she starts to insert the speculum without warning me first. I freeze,
inhale sharply, and put my hands over my face.
Are you okay?
“Nope,” I force out.
She removes the speculum and I remain frozen in place.
“I have had sexual trauma…” I eventually stammer.
Without acknowledging her failure to prepare me for the penetration
(or my momentarily unraveling) she moves on with clinical matter-of-
factness:
Do you usually have problems with sexual health checks?
“Just the failure to ask for my consent,” I growl internally (but remain
silent).
I certainly hope you are getting help! Maybe you could see a counselor.
“I’m usually okay as long as there is lots of clarity and preparation.”
I’m sad that, in my highly dysregulated state, and fearing her defen­
siveness, I can only deliver this somewhat passive feedback. I leave,
shaken and emotionally drained.
No: I am angry, as well. And I feel dissociated for a long time afterward.
.............................................................
My therapist is still looking at me.
Is he supportive? they repeat.
I silently run through possible replies, considering the potential
outcomes of each:
1. “He” assumes heteronormativity.4
2. The use of “he” is based on my feminine performativity.5
3. Both assumptions place me within a binary that is a result of
gender policing.6
4. They also make similar assumptions of my significant others.
Ugh. It all feels too difficult, having so recently experienced my queer7
identity and trauma history intersect. After a prolonged pause, I reply:
“They are supportive” (“they” is another indirect correction that
 Queering DBT 235

surreptitiously covers multiple partners and nonbinary genders). It goes

unnoticed by my therapist, who continues to use masculine pronouns.
Eventually I discontinue our sessions, claiming to be “in a much better
place.” This is a lie. The idea of educating a mental health provider on
identity politics simply feels like a waste of expensive therapy time.

***
Introduction
A self-authored identity
When I was younger, I saw my queer experience through the lens of
the surrounding society: flawed, problematic, and dangerous. Openness
felt impossible within a conservative religious family. At 16 years
old I spent nearly six months in a day program for adolescents with
suicidal ideation and self-harming behaviors. I now imagine that I was
considered a difficult client—in and out of emergency departments and
never really connecting with my therapists.
Today I use dialectical behavior therapy (DBT)-informed arts
therapy within my own counseling practice, as well as in partnership
with programs serving youth, LGBTQIA+8 individuals, and sex trade
workers. While engaging with DBT-based principles and interventions,
therapy participants9 and I intentionally deconstruct preconceptions
that tie our identities to problem-saturated discourses. Psychology
has historically viewed divergence from Western cultural norms as
maladaptive. It has (and sometimes still does) elevated the expertise
of the therapist, who is often privileged by wealth, education, and
professional status, over that of the person living out their differences
within deeply inequitable cultural milieus. An object of the therapeutic
gaze for much of my own youth, I am sensitive to how some providers
problematize their clients’ behavior in unhelpful ways. I seek to cultivate
a vastly different environment for the individuals with whom I work.
DBT’s developer, Marsha Linehan (1993), describes how its
“dialectical perspective on the nature of reality and human behavior”
stresses interrelatedness and wholeness based on the assumption
that “identity itself is relational” (p.31). She acknowledges that this
perspective conflicts with current cultural/sociological mores around
independence as normative behavior: “[A]lthough there is a ‘de­
pendent personality disorder’…there is no ‘independent personality
236 DBT-INFORMED ART THERAPY IN PRACTICE

disorder’” (p.55). Linehan suggests that entrenched sexist attitudes—in

particular, parental devaluation and/or rejection of female children
who do not possess typical feminine characteristics, interests, and
abilities—might result in the type of corrosive invalidation thought to
contribute to the etiology of borderline personality disorder (BPD).
Sadly, the world outside of the home is typically little different given
overlying cultural values. Hence “[it] is difficult to imagine how such a
child could not grow up believing that there must be something wrong
with her” (p.56).
Therapists should be cognizant of how we might, through our
foundational beliefs and/or treatment models, perpetuate participants’
experience of inherent wrongness. While aspects of DBT’s origins
and philosophies contain a “holistic view…compatible with both
feminist and contextual views of psychopathology” (p.31), I posit
that we must offer much more if we are to become fully inclusive of
LGBTQIA+ experience. Considering how “stress stemming from social
stigma, discrimination, and the coming out process” may account for
significant symptomization (Pelton-Sweet and Sherry 2008, p.170),
this is a serious ethical concern. I view the extrication of psychological
methods from their histories, power structures, and theories as part
of the mindfulness practices advised for DBT-informed practitioners.
Linehan describes “compassionate flexibility (i.e., the ability to take
in relevant information about the client and modify one’s position
accordingly, including the ability to admit to and repair one’s inevitable
mistakes)” (Dimeff and Linehan 2001, p.11) as an essential skill. In
treating LGBTQIA+ participants, compassionate flexibility must
entertain the active queering of DBT.

Queering
Queering, a verb that rainbow (LGBTQIA+) people often use when
engaging in critical practices, involves observing the broader culture
through an anti-cis10-heteronormative lens. Queering dismantles
cultural ideals through which heterosexual/binary/genital-based
concepts of gender drive what experiences and behaviors are validated
(Sedgwick 2012) and reconstructs them in more inclusive ways.
Throughout history, diversity of sexual and gender expression has
been conflated with criminality, pathology, and deviance (Woods
2018). However, “[q]ueer…does not seek to ‘rationalise’ difference. It
is not interested in simply adding differences to normative structures,
 Queering DBT 237

but rather in seeking to disrupt the very idea of normalcy through

legitimising differences on their own terms” (Zappa 2016, p.4). As a
critical theory it “is suspicious of the very categories of better, useful,
appropriate, productive, and valuable as these are understood in the
present order” (Horkheimer 1972, pp.206–207).
This chapter considers the oppression of LGBTQIA+ com­
munities within Western psychological models, including their
overrepresentation as high-risk mental health clients with inequitable
contemporary diagnosis (BPD, in particular). I seek to disentangle
DBT from its socially normative frameworks through critical analysis.
Further, I intend to be radically explicit regarding my researcher
privileges and transparent regarding my own subjectivity/biases. Given
that clinical observation has often been covertly, sometimes overtly, the
domain of the Western heteronormative man, my engagement with
academia is activism. I unashamedly acknowledge my rainbow and
feminist viewpoints, as well as the fact that I employ unconventional
means for understanding experiences occurring beyond the domain
of traditional academic understanding. This approach addresses how
[M]any people of trans*11 and queer identities are often not “out”
to their service providers and thus we should begin with the simple
recognition that providing room for people to tell their own stories
facilitates client connection and understanding, both of which are vital
for competent mental health care. (Schroeder 2014, p.36)
Recognizing the importance of greater visibility for rainbow people,
without co-opting another’s experience for my privileged academic
purposes, is a delicate balance. Autoethnography (an ethnographic
account of the author’s own life experiences), a/r/tography (a living
inquiry including art making, creative writing, and other activities
not traditionally associated with academic research), and fictionalized
therapeutic accounts offer “ways to create useful arts therapy session
descriptions in contexts where it is unethical to reference recognisable
clients” (Green 2015, p.33). Self-revelation is necessary for rainbow
therapists/researchers to establish mutual understanding and trust
with participants who suffer from queerphobia and discrimination.
Therefore, this chapter describes some of my experiences as both
therapy participant and provider. It offers a first-person narrative
weaving together creativity, activism, and the academic.
238 DBT-INFORMED ART THERAPY IN PRACTICE

Background
My home of Aotearoa, New Zealand has engaged in some recent
reflection on the mental health crisis, particularly around how support
systems marginalize people of color, women+,12 and the rainbow
community. A report from Victoria University (Fraser 2019) revealed
that “the number of people who said their mental health professional
required education about sex, sexuality, and gender diversity has
increased” (p.12). Although clinicians are less likely to try to force clients
to fit their preconceptions (Fraser 2019), psychological discrimination
persists.13 Identity and diversity politics evolve so rapidly that therapists
educated several years ago may struggle to respond skillfully to the
language and behaviors of today’s LGBTQIA+ population. People
under age 40 are four times more likely than those over 40 to present
fluid, indefinable, gender-nonconforming identities (Schroeder 2014).
This challenges Western psychology’s highly categorical models and
might result in overrepresentation of self-concept pathology among
gender/sexually fluid and/or nonbinary individuals.

Figure 13.1 Posters by Gender Minorities Aotearoa

(supporting gender diversity in Aotearoa)
 Queering DBT 239

Even therapists who strive to transform structural inequity may

unintentionally commit discrimination and/or microaggressions14
toward those who traverse social terrain beyond their own cultural
maps. This is particularly true when clinicians possess a primarily binary,
cis-heteronormative, and/or monogamous experience. Furthermore,
LGBTQIA+ experiences are often entangled with other markers of
inequity such as race, socioeconomic status, and neurodiversity.15
Indeed, gender and sexuality are singular facets of a potentially
infinite intersectional multiplicity. I am queer and a survivor of youth
homelessness and psychiatric institutionalization, but I am also white,
self-employed, cis-privileged (at first glance), and use an academic
voice. While I cannot speak for all rainbow people, I hope that my work
facilitates the self-advocacy and self-determination of those who seek it.

Therapy is a queer situation

We have been sitting here for a while. I feel an expectancy to the silence;
however, I just breathe and sink into my center. Suddenly the young
man blurts out: “I’m pansexual16!” I nod encouragingly. “I didn’t feel
like I could talk properly about sexuality stuff with my last therapist,
but these help” (he indicates the Pride flag sticking out of a potted plant
in the corner and the little rainbow-themed heart on the bookshelf).
Although Fraser’s research (2019) identifies “visual signs of support” as
some of the most helpful therapist actions (p.14), I marvel at how often
participants remark on them with appreciation.
He is a university student who sought me out after a string of failed
relationships with “traditional psychologists,” hoping that “something
different,” like art therapy, might help. My frustration bristles as I
recall the language in his treatment reports. The summary concluded
that “therapist/patient rapport was not established,” and I wonder if
professional mythologies about difficult clients (Jones 2012; Lawn and
McMahon 2015) influenced the therapist to surmise that he “display[ed]
sub-threshold BPD symptomology (DBT models advised).”
While I do not believe in “difficult” participants, I do appreciate
difficult life circumstances. I also contend that covert structural
oppressions can oblige individuals to adapt in creative, unconventional
ways. Hence, I determine to cultivate unknowingness and deeply listen
to each person’s narrative (feeling as I do that therapeutic success is
mostly determined by a full acceptance of what is).
240 DBT-INFORMED ART THERAPY IN PRACTICE

Who decides what defines BPD?

Comprehensive DBT is a team-based model developed by clinical
psychologist Marsha Linehan (Linehan 1993, 2015a, 2015b) to support
individuals at high risk of self-harm and/or suicide. It is a popular
treatment for BPD, a diagnostic label not lacking in controversy:
BPD became both a female and despised diagnosis. This shift in meaning
occurred largely in the 1970s and 1980s, decades in which radical
feminists fought to legitimate women’s anger and sexual expression, at
the same time asserting a right to protection from physical or sexual
abuse and launching a sustained critique of psychiatry for its role in
women’s subjugation. (Cahn 2014, p.3)
Both anger and active sexuality are more acceptable for men (Gavey
and Senn 2014), and BPD has undoubtedly contributed to stigmatizing
their expression in women+ (Berger 2014): “As long as men hold
positions of power it is their beliefs that count, and they tend to see
women’s aggression—because it remains inexplicable in male terms—
as comic, hysterical, or insane” (Campbell 1993, p.2). Some argue that
the increasing number of men diagnosed with BPD reflects an ironing
out of clinical gender bias (Weiderman and Sansone 2009). Perhaps,
however, gender policing has merely extended to include men and the
rainbow community. Weiderman and Sansone (2009) describe how
“when psychologists perceived a male client as gay, they were more
likely to diagnose the client as having BPD” (p.280).
Furthermore, there appears to be an illogical conflation of
heteronormative divergence with pathology: “The combination of
impulsivity and a relatively unstable sense of personal identity may
also help explain the elevated rates of homosexual behavior among
individuals with BPD” (Weiderman and Sansone 2009, p.280). A cis-
heteronormative environment is one in which rainbow identities are
undermined, invalidated, demanded to change, and aggressed (and/
or microaggressed) against. Invalidating environments, through which
chronic emotional dysregulation is likely to develop (Linehan 1993),
can be socio-systemic; as previously mentioned, they do not exist only
on a personal or familial level. Heteronormative (diagnostic) bias likely
contributes to apparent “higher rates of non-heterosexual identity,
behavior, or attraction in BPD populations” (Reuter et al. 2015, p.3).
I urge clinicians and researchers to consider what differentiates BPD
from complex posttraumatic stress disorder (C-PTSD), for “sexually
 Queering DBT 241

violent behavior is not as clearly demarcated from ‘normal’ sexuality

as one may like to think” (Gavey and Senn 2014, p.340). A critical
lens “helps us to see the ways in which sexual choices are constrained
and regulated, and it also forces us to recognize that sometimes these
dynamics are actually forms of sexual violence” (Gavey and Senn 2014,
p.340). Cultural oppressions/microaggressions against marginalized
genders and sexualities are complex, ongoing traumatic experiences
that fall upon a spectrum of institutionalized and systemic abuse.
I also believe that any drive toward behavioral change born out of
unexamined biases is coercive. I endured a lot of really harmful sex
under the belief that I had an avoidance of physical intimacy (as posited
by therapists and trauma indexes, and perhaps “caused” by sexual
trauma, ambivalent attachment, or perversity, according to popular
reading). I had the impression that I was the problem in a relationship
where I felt unsafe; however, with the help of a really awesome queer
community, I eventually discovered that I didn’t have a fear of intimacy
at all, only specific prerequisites—such as trust, deep emotional
connection, and a direct welcoming of my diverse and fluid sexuality,
which shifts quite happily between very and not so expressive. In other
words, I realized that I also belonged to the A+ part of LGBTQIA+: I
am a Gray Ace or demisexual.17

DBT and the rainbow: Radical acceptance, radical openness

DBT and DBT-informed treatments involve classic behaviorist
interventions such as contingency management (e.g., positive and
negative reinforcement, punishment) (Linehan 1993). A usual goal is
for “new capabilities [to] generalize to the natural environment” (Dimeff
and Linehan 2001, p.10). But how does one address the likelihood
that such natural environments contain invisible cis-heteronormative
assumptions? Thus, I became curious about mindfulness, acceptance,
and change—and how therapists could more wisely engage with each.

Mindfulness (and heart-mind-fullness)

Intersectional work demands that I expand my conceptualization of
mindfulness. Am I aware of the ways in which my foundational beliefs
inform what changes I expect from participants? And, in practicing
mindfulness, am I not just cognizant of their personal emotions, but
also of the systemic factors influencing them (within the therapeutic
242 DBT-INFORMED ART THERAPY IN PRACTICE

space as well as the world at large)? While DBT’s mindfulness module

is largely a secular skillset, it is important to acknowledge the Eastern
mystical traditions from which Western mindfulness has taken much
of its contemporary form. However, translations of citta, Pali/Sanskrit
for something akin to heart-mind (O’Brien 2020), tend to leave out the
heart. I propose the term heart-mind-fullness: my fusion of a therapeutic
manifold awareness with compassionate longing for collective freedom
from suffering. This encourages a heart-full systemic view (because
self-liberation cannot be achieved apart from the liberation of all)
(O’Brien 2020).

Acceptance
Acceptance involves receptivity to, and a nonjudgmental stance toward,
what is. In working with people of diverse genders and sexualities,
acceptance may seem an obvious necessity for socially conscious
interventions. Yet I see acceptance as an underachievement. Rather,
I ask myself: “Can I own that existing power dynamics, foundational
beliefs and historical influences inform my own position and affect my
ability to be really accepting?” In relationships where I have felt safest,
there was a welcoming element to the other person’s behavior that went
beyond mere acceptance. They acknowledged their own fallibilities and
blind spots and conveyed a willingness to be changed by our encounters.
This brings to mind radical openness, the core skill of another type of
DBT—RO(radically open)-DBT.18
[R]adical openness means developing a passion for going opposite to
where you are. It is more than mindful awareness. It means actively
seeking those areas of our lives that we want to avoid or may find
uncomfortable, in order to learn. It involves purposeful self-enquiry
and a willingness to be wrong, with an intention to change if we need
to change. It is humility in action. (Lynch 2018, p.187)
Radical openness challenges therapists to explore novel perspectives
and ways of being (especially ones quite different from what they are
usually drawn to, or even approve of). Compared with standard DBT’s
radical acceptance skill (Linehan 2015a, 2015b), radical openness is
perhaps even more radical:
Radical acceptance means letting go of the fight with reality, and turning
intolerable suffering into tolerable pain, whereas radical openness
 Queering DBT 243

challenges our perceptions of reality. Radical openness posits that we

are unable to see things as they are but instead see things as we are. Thus
RO encourages the cultivation of self-enquiry and healthy self-doubt in
order to…learn from what the world may have to offer. (Lynch 2018,
p.190)

Figure 13.2 An image by art therapy participant Indi—

mindfulness of inner experience (DBT mindfulness of
thoughts and emotions; Linehan 2015a, 2015b). It depicts
a diverse self-concept with multiple gender expressions
(some of which they described as “disconnected” due to
traumatic experiences, stigma, and discrimination)

Change
DBT necessitates that clinicians carefully “balance [the] use of
acceptance and change strategies within each treatment interaction…
to inhibit judgmental attitudes and practice radical acceptance of the
client in each moment while keeping an eye on the ultimate goal of
the treatment” (Dimeff and Linehan 2001, p.11). Traditional cognitive
behavior therapy (CBT)’s emphasis on change and outcomes is not
effective for individuals with severe emotion regulation difficulties,
and DBT developed to remedy that deficit (Linehan 1993). DBT
acknowledges the importance of strong validation and acceptance of
current functioning (Linehan 2020); however, I believe that DBT and
DBT-informed approaches can still overemphasize change for some
individuals. While I happily support behavior modification in those
intrinsically motivated to pursue it, I feel called to shift my expectation
that participants change according to my limited worldview. I believe
244 DBT-INFORMED ART THERAPY IN PRACTICE

that, with absolute validation and acceptance, the right kinds of

transformation will naturally emerge.
When working with rainbow (and, in fact, all) participants of
DBT-informed art therapy, my own self-reflection, and possible self-
correction, always precedes the behavioral component. I prioritize my
own unknowing and curiosity to reduce the likelihood that my clinical
training will inadvertently hijack their self-determination. Often the
needed change “is not to reduce symptoms or increase emotional
regulation skills, but to assist clients in generating narratives that
feel truer and more meaningful to them than the problem-saturated
account” (Berger 2014, p.4). This requires a deep consciousness of
my own blind spots and constant adjustment of treatment models in
response to the nuance of an individual’s experience.
International research shows that sexual/gender diverse people
contend with negative mental health issues resulting from the chronic
stress of stigma, discrimination, and violence (Fraser 2019). Gender
Minorities Aotearoa (2017) notes that “[a]ttempted suicide amongst
trans populations sits at 40%. If healthcare providers refuse assistance,
this increases to 61%”—for, in being refused affirmative care, their
risk of “harassment, assault, sexual violence, or worse” is increased
and/or prolonged. Additionally, “Gay and lesbian adolescents report
attempted suicide at rates approximately twice that of their heterosexual
counterparts” (Pelton-Sweet and Sherry 2008, p.170). Given DBT’s
emphasis on “decreasing life-threatening, suicidal behaviors” (Dimeff
and Linehan 2001, p.11), it is likely used with rainbow people the
world over. While community members may participate in DBT
owing to high rates of suicidal ideation and self-harm, and also because
“diagnostic bias may lead to an overestimation of the prevalence of
BPD in gay samples” (Ibáñez et al. 2015, p.7), I argue that behavioral
targets are not the primary picture for LGBTQIA+. We need support
in challenging systems and languages that continue to position us as
aberrant others. Because my sexuality and gender remained deeply
entangled with cultural beliefs about “normality,” I spent years feeling
mad and bad. The pathologization of hyper- and hypo-sexuality, and
the othering experienced through multiple psychological diagnoses,
only compounded this. Internalized queerphobia continues to affect
me whenever I am confronted by people who cannot accept my unique
ways of being.
 Queering DBT 245

Fluidity in practice
DBT-informed models alongside different ways of being
LGBTQIA+ individuals may, or may not, bring rainbow issues into
therapy. Responsive clinical support involves preparing for the
acknowledgment and processing of systemic marginalization, yet not
demanding this if participants focus on other challenges. That said,
I have observed how many do come with internalized invalidating
narratives that deeply affect their self-worth.19 The models I draw from
include internal family systems (IFS) (Shwartz and Sweezy 2020), Gestalt
(Perls, Hefferline, and Goodman 1994), trauma embodiment (van der
Kolk 2014), transpersonal (Rowan 2005), and feminist narrative (Berger
2014)-informed art therapies. As with queering DBT, such methods rarely
end up looking or sounding precisely like their standard counterparts;
I find myself altering frameworks, techniques, and languages to be less
prescriptive and better welcoming of diversity/inclusiveness.

***
“I want to die,” they say.
This is not the first time I have heard this. I’ve tracked their risk
factors for a while: a history of self-harm, no planning involved in past
suicidal ideation, but an ongoing dialogue with despair. The participant
enjoys a support network of chosen family members (who are aware of
these thought patterns).
I gently weave reassessment into the conversation, to which they
respond: “I wouldn’t act on it, no; I am just feeling so helpless…”
I have noticed that when people feel disempowered, they can be
particularly sensitive to input, so I ask for consent before proceeding.
Me: I have a perspective which I find useful. Would you be interested
in hearing it?
Participant: Yeah, I’m open to that.
Me: Even if an absolute ending isn’t really on the cards right now, I
imagine that this statement is still coming from somewhere. And, in
my life, it has often been a feeling or a part of my experience that I
want to end. It’s reasonable to want difficult experiences to go away.
I notice feeling quite curious about the part of you that might be
directing the “I want to die” thoughts.
246 DBT-INFORMED ART THERAPY IN PRACTICE

We’ve touched on dialogue territory before, so they sit for a moment,

eyes half-closed. I watch as tension in their shoulders builds—and then
suddenly drops—with a sigh.
Participant: It’s this bit that is always switched on, you know, like it’s got
to be defending me, explaining that I’m real, that I deserve to exist in
the world. That it’s not bad or disgusting to be different or whatever.
This part is just really fucking exhausted, because it never gets to
rest. It feels like the only time it will get to rest is when it’s dead.
I pause and breathe that in. We look each other in the eye for a long
moment.
Me: It seems to me like this part of your inner community exists in
its own right. It has been doing a huge job defending you and it
doesn’t sound like it had much of a choice, or a voice, in that. I get
the sense that, if it felt welcome to speak, it might have a lot more
to say than simply “I want to die.” Would you be open to extending
an invitation to it?
Participant: How?
Me: Well, imagine we’re in a drama improvisation. You would be
playing the part of Defender, and we could speak to them and ask
them about their experience. Interested?
Participant: I could give it a try.
Me: Okay, Defender-Being: I’m really curious about your story. What’s
been going on for you?
The participant’s eyes shift a little to the left, then drop to the mug of
chamomile tea sitting on the art table.
Participant: I’m so tired; it’s taken me this long to feel safe enough
to come out, and all that has meant is I have to work twice as hard to
defend my identity, and sometimes the people around me won’t even
recognize that identity at all, so I feel like I’m bad news and invisible
at the same time.
Me: That does sound exhausting! I can see why you really wish you
could rest. I wonder if there is something you need or want which
could make this burden easier to bear?
Participant: I need support, but it’s scary to ask for it. I want to know
I’m not alone in this and that I’m not crazy. It makes me feel crazy
 Queering DBT 247

when people tell me that I’m making up my identity, or that I’m just
doing this for attention.
Me: It’s really reasonable to want support—that’s a lot to be defending
such big stuff on your own. It seems to me that identities are
perfectly adapted creatures in highly specialized environments, like
olm salamanders or flying lemurs—no one else can decide how they
should look because we don’t know the unique ways and needs of
their particular ecology. I don’t think you’re crazy at all. I think that
the rigid categories of what has become “normal” aren’t working
anymore, and it’s people like you who are creating more flexible
ways of being in this world. Flying lemurs don’t fly because they’re
seeking attention, flying lemurs fly because they are flying lemurs!
The uniquely adapted creature sitting in front of me bursts into laughter.
We giggle a little more together before I ask: “What is the Defender
noticing now?”
Participant: I’m feeling a little bit less crazy, but I kind of feel this
big energy inside too, like maybe angry, or just wanting to go
“arggghh”—like, let out some frustration.
Me: It sounds like you know what you need best. What if we stand up
and make some space for that?
Together, we move away from the chairs; the participant begins to
hesitantly shake out their hands and arms (while making some little
“grrrrrrrrrrr” sounds under breath). Standing opposite them, I gently
mirror—and then amplify—both sound and movement, welcoming
fuller expression. Together we build a crescendo; throwing our
arms between poses of head-clutching frustration and air-beating
challenges, we reach an animalistic roar that feels satisfying and true
to the unavoidability of the situation. This quickly turns into sighs of
satisfaction and relaxation, which naturally closes with a huge breath
in and out.
“Where are we now?” I wonder.
“The Defender sort of feels like they have a bit more energy,” comes
the reply, “like, I don’t know, but maybe the fight could be worth it
eventually?”
“I really hope so too, and it’s folks like you who are creating change,”
I say, and smile.
248 DBT-INFORMED ART THERAPY IN PRACTICE

***
This dialogue illustrates one example of IFS-informed creative arts
therapy (using sound/movement to express inner experiences)
combined with a DBT-informed approach toward invalidation and
discrimination. Validation involves conveying to participants “that their
responses make sense and are understandable within their current life
context and situation.” Further, the therapist “actively accept[s]…and
communicate[s] this acceptance. Clients’ responses are taken seriously
and…not discounted or trivialized” (Linehan 2015a, p.88). The
participant heard me validate their situation, then directly witnessed it
through my mirroring and amplification of their movements/sounds.
The long-term goal was to support their existing resources for self-
validation.
Through autoethnographic Master’s research (Weir 2018), I
explored how reframing pathology in a strengths-based manner might
assist psychotherapy participants to recover from “narratives that have
been imposed upon them, exploring collaboratively how power and
oppression have shaped their views of themselves” (Berger 2014, pp.6–
7). There is nothing wrong with being labeled “maladjusted” in an unjust
system; rather, this is creative maladjustment (King 1967), a potential
catalyst for change. While fictionalized to respect confidentiality and
ownership of personal material, the above dialogue illustrates how this
plays out in my therapy practice.

Conclusion
Queer differs from what is normal, and
rainbow normalizes difference
The reclamation of queer by rainbow community elders has helped shift
sexual and gender divergence from a source of shame into one of pride.
Similarly, the term rainbow evokes inclusion as a part of normal human
experience. In authentically representing my experience as a sexuality-
and gender-fluid human whose identity continues to metamorphose
throughout life, I find that I need the wisdom of both. Queering
confronts cis-heteronormative defaults within the psychology/art
therapy domain and presents something a bit unusual: like anything out
of the ordinary, it is sometimes asked (perhaps covertly) to get back into
 Queering DBT 249

the box, to clean up and be more status quo. Rainbow wisdom, pushing
back in a light, cheeky way, says “I am what I am and there is nothing
odd or unusual about it, in fact it’s normal to be different!”
I envision a world that holds personal narratives and creative
ways of knowing as valuable as academic research—complementing
(i.e., making more complete) our understanding of what it means to
be human. Through a queer lens, well-being is not expressed through
resolved differences. Rainbow is a spectrum that finds strength in
variety. This is crucial when working with DBT-informed practices
that emphasize finding synthesis within paradox and achieving a
stable sense of self. As de Bono (2017) states: “Argument is the very
essence of dialectic” (p.38), which at times “locks us into dangerous
and unproductive polarities” (p.420). I prefer to explore the unresolved,
where “dichotomy is softened by ‘possibility,’ overlap and fuzzy edges.
Alternative views can lie alongside each other—in parallel” (de Bono
2017, p.35).

Figure 13.3 Indi’s tree image. Part of a “self-narrative” series

that illustrates strengthened resources in objective and
self-respect effectiveness (DBT interpersonal effectiveness
skills; Linehan 2015a, 2015b). They imagined a world
where their rainbow identity, as well as their “broken”
parts, and various other selves, were all welcome

DBT itself emerged from polarized cultural structures. For example,

Western psychological paradigms assumed to be “relatively consistent
across cultures” (American Psychiatric Association 2013, p.773) are
250 DBT-INFORMED ART THERAPY IN PRACTICE

presented as oppositional to indigenous or folk health practices, which

have been tragically colonized and/or deemed unscientific. Therapist-
as-expert stands in contrast to patient in need of specialized care. It
is only by doing our own self-reflective and paradigm-deconstructing
work that we can hope to hold the kind of radically open spaces that will
allow participants’ diverse gifts to fully develop and express themselves.
We might also discover that, as we welcome these practices into the art
therapy space, aspects of our own psyches that have felt unaccepted or
unloved also may experience a sense of belonging.
I invite readers to engage with deep self-reflection, become more
open to alternative perspectives, and explore the self-determined
research of diverse communities. There are numerous resources for
making therapy/counseling services more affirming and inclusive
(accessed through a Google search or by contacting local rainbow
organizations that advocate for equitable health care). Through a queer
lens we may dismantle pathologizing discourses around our fluid/
boundaryless, uncategorizable selves and celebrate them, instead, as
valid ways of being. Sometimes it is the therapist who requires the most
psychoeducation; hence we, as therapists, are responsible for doing
the necessary inner work that can, over time, contribute to collective
equality and well-being.

Endnotes
1 Femme is a multivalent term that may have emerged from lesbian culture to describe
one’s relationship to cultural notions of femininity (as in butch and femme women).
Femme can also convey feminine-oriented nonconformity/fluidity. It performs as
a noun (“their gender is femme”), adjective (“he’s quite a femme guy”), and—my
personal favorite—verb (“I’m gonna femme tonight”). I use femme to reclaim what our
culture considers “less than” compared with masculinity. One’s behavior need not read
consistently (or even occasionally) as “feminine” in order for one to be, or do, femme.
Restricting femme to those who display stereotypical femininity is a form of gender
policing.
2 Gender binary/binarism: Classification of gender into two distinct, opposite categories
of masculine/man and feminine/woman. Nonbinary identities (Richards, Bouman, and
Barker 2017) fall outside of this, such that individuals may identify as transgender,
or having no gender, or having more than one gender (experienced as fluidity
and/or changes in gender over time). Nonbinary individuals possess a variety of sexual
orientations as well as gender expressions. Genderfluid refers to an identity in flux or
moving between genders.
3 Trans is popularly used for transgender, and sometimes nonbinary identity, or gender
identity that differs from the one assigned at birth. Like femme, trans is multivariant;
one person’s experience can be quite different from another’s (see trans*, endnote 11).
 Queering DBT 251

4 Heteronormativity is the worldview of heterosexuality as normal or preferred sexual

orientation (Warner 1991). Heteronormativity relates to attitudes and behaviors that
are consistent with traditional Western gender roles.
5 Gender performativity, first proposed by feminist philosopher Judith Butler (1990),
posits that identities such as man or woman are collections of learned cultural behaviors
rather than innate, biological aspects of self. My performance of behaviors culturally
ascribed to femininity led the therapist to assume I identified as a woman. This was
entangled with presumed heterosexuality, causing them also to surmise my partner was
male.
6 Gender policing describes both individual and cultural enforcement of mandates that
(1) one should ascribe to the dominant cultural paradigm of identifying as either a man
or a woman, and/or (2) one’s gender should be fixed rather than fluid, and/or (3) one’s
behaviors should match this gender according to dominant cultural ideals.
7 Queer reflects divergence from normative models of gender, sexuality, and romantic
orientation. Originally a pejorative label for nonheterosexual people and/or behavior
(O’Brien 2009), by the 2000s queer had increasingly come to describe a spectrum of
diverse gender and sexual identities (although not without controversy and criticism).
8 LGBTQIA+ stands for lesbian, gay, bisexual, trans, queer, intersex, and asexual, plus any
other identity/orientation/experience diverging from gender-binary heteronormativity.
9 Participant: I prefer this to more common terms that seem to convey power hierarchies
and active/passive dualities (e.g., doctor–patient; treatment provider–treatment
consumer). While client has become a welcome alternative to the pathological-oriented
tradition of patient, I still find it dry and unrepresentative of the rich reciprocity that
often exists in therapeutic relationships. Hence, I use participant because it feels more
reflective of the active role and personal resourcefulness of the individuals with whom
I work.
10 Cis (cisgender): Individuals whose gender identity is the same as the sex assigned them
at birth.
11 Trans* is a variant of trans (see endnote 3). The asterisk borrows from computer-
mediated language to “metaphorically…capture all the identities—from drag queen to
genderqueer—that fall outside traditional gender norms” (Ryan 2014).
12 Women+ is sometimes used for inclusion of nonbinary, gender-nonconforming, and
transgendered individuals within feminist practice that emphasizes women.
13 Research regarding the rainbow community notes “variability of gender expression
over time for all identities” (Schroeder 2014, p.36). However, this is not directive of
mainstream practice. In Aotearoa, most individuals seeking mental health services
during gender transition have “felt pressure to conform to a dominant narrative during
their assessment, e.g. having a binary identity, knowing they were trans from an early
age, or feeling ‘trapped in the wrong body.’ This suggests that though [there are] many
individual professionals providing good support to their clients, professionals must
still ask outdated questions because of systemic demands” (Fraser 2019, p.15). If such
assumptions persist in relation to gender, they may also be notable for sexuality and all
manner of minority experiences.
14 Microaggressions: Brief and commonplace verbal, behavioral, and/or environmental
communications that intentionally or unintentionally communicate derogatory,
insensitive, or hostile messages toward a minority, marginalized, and/or stigmatized
group. However insignificant such subtle invalidating expressions may seem from the
perspective of the culturally privileged, microaggressions have serious and ongoing
negative impacts on those who experience them frequently throughout life.
15 Neurodiversity refers to a variety of cognitive, emotional, learning, attention, and other
differences in human brain and mental functioning. This nonpathological term was
coined by Australian psychologist Judy Singer (2017).
252 DBT-INFORMED ART THERAPY IN PRACTICE

16 Pansexual: Romantic and/or sexual attraction that is not limited by the other person’s
gender, genitalia, and sexual orientation.
17 Gray Ace includes sexualities falling on a nonpathological spectrum of asexuality
(experiencing sexuality from none of the time to some of the time, and under varying
conditions). Demisexual refers to individuals for whom sexual attraction is contingent
upon an initial nonsexual connection (although the required type and depth of
connection varies).
18 RO-DBT is a transdiagnostic intervention for psychiatric disorders characterized by
excessive self-control (e.g., refractory depression, anorexia nervosa, avoidant personality
disorder, obsessive-compulsive personality disorder) (Lynch 2018). RO-DBT branched
off from standard DBT during the early 2000s.
19 A profound, recurrent issue is the incongruence between personal desires to accept in-
betweenness and social expectations of conformity to binary concepts. I am constantly
told, in a thousand subtle (and not-so-subtle) ways, that I must be straight or gay, single
or monogamous, man or woman, well or unwell—while each polarity is deemed either
“good” or “bad.”

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 Chapter 14

Integrating DBT-Informed
Psychoeducation with
Visual Journaling
Practical Considerations
PENELOPE JAMES

Introduction
This chapter offers practical guidance to mental health clinicians who
wish to build the efficacy of traditional psychoeducation methods
through the art therapy technique of visual journaling. Psychoeducation
is a therapeutic intervention that provides cognitive and behavioral
skills instruction for managing mental illness symptoms; further, it
assists individuals in taking personal responsibility for their recovery
(Bhattacharjee et al. 2011). I, the author, observed that a responsive
visual art/reflective writing-based process appeared to assist in
building my day treatment program clients’ understanding of, and
personal connection with, the concepts and skills they learned in a
psychoeducational group. This, in turn, may have enhanced these
individuals’ capacity to implement the skills in their daily lives.
Fundamental aspects of integrating visual journaling with
psychoeducation are outlined, in detail, to demonstrate their apparent
value in encouraging participation and enriching the therapeutic
experience. This description is not intended to provide primary core
art therapy training for the therapist or art therapist. Rather, I offer
lessons learned from a decade of work combining art therapy with
psychoeducation in a clinical mental health setting (specifically,
a mood management group that is part of a psychiatric hospital’s
outpatient day treatment program). The information is structured as

255
256 DBT-INFORMED ART THERAPY IN PRACTICE

a step-by-step guide for facilitating visual journaling with optimum

potential therapeutic outcomes. Please note that these ideas may
require modification for different client populations as well as for one’s
own workplace. Hence, I offer them in the spirit of “take what you need
and leave the rest.”

The mood management group

It has been a privilege to work with this committed group and witness
its members’ self-defining recovery over the past five years. Clients are
referred to the outpatient adult day program by their psychiatrists. The
mood management group, which runs from 9:30 AM to 3:00 PM every
Friday, welcomes individuals who enter following a hospital discharge,
as well as some who have not previously been hospitalized for mental
health issues.
This weekly open group contains many long-term members,
some of whom have attended for years (while others, after a period of
participation, feel ready and able to leave). Their ages range from 18 to
70 years. Typical diagnoses include major depression, anxiety disorders,
schizophrenia, bipolar disorder, and borderline personality disorder
(BPD). Comorbid diagnoses can include gambling addiction, substance
dependence, and eating disorders.

Group goals
Participants are united by the common experiences of living in the
community with mental illness, as well as a motivation to make positive
behavioral changes. The mood management group’s primary goal is to
teach clients psychoeducational skills so that they may pursue more
functional lives. A secondary goal is to assist clients in recognizing
when their symptoms become overwhelming, and acknowledging if
they require additional interventions (e.g., a hospital admission, change
in medication(s), and/or individual therapy). The ability and willingness
to self-assess and reach out for appropriate help are considered evidence
of an individual’s developing emotional health and resilience.
The mood management program draws from a variety of approaches,
including dialectical behavior therapy (DBT) (Linehan 1993). DBT
offers psychoeducational skills to address ineffective cognitive,
emotional, and behavioral patterns with the aim of increasing positive
Integrating DBT-Informed Psychoeducation with Visual Journaling 257

outcomes in clients’ daily lives. The four DBT skills training modules
are core mindfulness, distress tolerance, interpersonal effectiveness,
and emotion regulation (Linehan 2015a, 2015b).
The day program schedule, which remains the same from week to
week, is written on the group room whiteboard along with the featured
psychoeducational skill. This ensures that participants know the general
theme and direction of the group. I often ask if there is anything speci­
fic that they would like to work on that day. Whenever possible, I
facilitate the psychoeducation in response to clients’ requests.
It is useful to provide breaks. These allow opportunities for clients to
engage in informal social interactions during which “group cohesion,
independent of the leaders, is…fostered” (Linehan 1993, p.20).
Further, breaks help the group to shift cleanly between check-in, the
psychoeducation lesson, and the creative visual journaling portion. I
find that the optimal time for the first break (morning tea) is after the
check-in session and before the psychoeducation session. The second
(lunch) is scheduled between psychoeducation and visual journaling.
The full sequence and duration of program events is as follows: check-in
(1 hour), meditation (5–10 minutes), morning tea break (30 minutes),
psychoeducation (75 minutes), lunch (45 minutes), visual journaling
(110 minutes), and group close (10 minutes).

Group positioning
During the check-in and psychoeducation sessions, participants sit
together in a semi-circle. This arrangement facilitates their equal and
clear viewing of the whiteboard, the facilitator, and each other. It also
allows me to easily see and engage with all group members, which is
necessary for my proper functioning as therapist: I can address a single
member, while, at the same time, assess and respond to the needs of
the entire group (Moon 2016). Because the semi-circle helps members
to be heard and witnessed by one another, it also encourages group
identification, empathy, and bonding.

Group structure
The clinical portions of the mood management group consist of five
distinct phases: part 1—check-in (1 hour), part 2—meditation (5–
10 minutes), part 3—psychoeducation (75 minutes), part 4—visual
journaling (110 minutes), part 5—group ending (10 minutes).
258 DBT-INFORMED ART THERAPY IN PRACTICE

PHASES OF THE GROUP

Part 1: Check-in
The day commences with a one-hour check-in session during which
clients have an opportunity to speak. I see this as critical for a success­
ful therapeutic outcome, given that it prepares members for the
psychoeducational learning to follow. If a client is sitting on some
troubling or exciting news, it may be hard for them to focus on didactic
materials. Each person is allotted approximately eight minutes (but
this timeframe varies according to the number of attendees and their
individual needs). I invite participation with the prompt: “Would you
like to share how things are going for you?”
Check-ins typically focus on the difficulties and/or progress
that clients have experienced during the previous week. This might
include reports on the relative effectiveness of psychoeducational
skills practiced outside of therapy. I observe each client’s presentation
while listening to the content of what they share. When appropriate,
I provide validation. I also take note of how their experiences could
be applied to the psychoeducational material I will teach that day (or
to past lessons).
For example, a client shared that he struggled to get out of bed in
the morning due to a depressed mood and overwhelming negative
thoughts, including a belief that it was too hard to face the world. The
client acknowledged that he felt much worse whenever he followed
those thoughts and stayed in bed. I reminded him of opposite action,
which the group had recently explored. Opposite action is an emotion
regulation (ER) skill. The ER module includes a range of strategies that
reduce suffering by changing, or lowering the intensity of, unwanted
emotions (Linehan 2015a, 2015b). If, after “checking the facts” (Linehan
2015b, p.228), the individual determines that a behavioral urge (in this
case, to give up and remain in bed) would likely perpetuate or increase
a difficult emotion (i.e., depression), he might choose to go against this
self-destructive pattern by engaging in the direct opposite behavior (i.e.,
getting up and facing the day).
Over time, opposite action could reduce this client’s suffering
and help him to stay connected with his long-term goal of building
a functional life. However, the strategy must be implemented
wholeheartedly—that is, “all the way”—in order to successfully oppose
the mind’s often compelling negative messages (Linehan 2015b, p.231).
In this instance, the client identified that the appropriate all the way
Integrating DBT-Informed Psychoeducation with Visual Journaling 259

steps were to get out of bed, have a shower, and eat breakfast. Opposite
action is also an example of behavioral activation, an evidence-based
treatment for depression, which can release clients from engaging in
self-defeating behaviors such as isolating and rumination (Linehan
2015a).

Part 2: Meditation
A brief meditation exercise is the next step toward readying the group
for psychoeducation. Mindfulness meditation assists in setting aside the
check-in content so that participants may shift to a calmer and more
present-centered stance. Mindfulness is the underlying component
for all DBT skills acquisition (Linehan 2015a). Kabat-Zinn (2009)
describes it as a process of accepting ourselves in the present. He notes
that, in order to improve our health and well-being, “we have to start
from where we actually are today, in this moment, not from where we
would like to be” (p.280).
Linehan defines mindfulness as “the intentional process of
observing, describing and participating in reality nonjudgmentally, in
the moment, and with effectiveness” (2015a, p.151). This is not only the
primary instruction for sitting meditation, but also in experiencing
one’s day-to-day life. When increased self-awareness is combined with
psychoeducational skills, clients often become less reactive as well as
more cognizant of their ability to respond effectively (as opposed to
remaining stuck in compulsive problematic behaviors).
Depending on the amount of time available, I facilitate a guided
meditation practice either at the end of check-in or at the beginning of
the psychoeducation session. Group meditation can include practices
such as a body scan, which involves gaining present-centered awareness
of one’s body, breath, and mind (Dreeben, Mamberg, and Salmon
2013; Linehan 2015a). Another practice, “Stopping the War Within”
(Kornfield 1993, p.30) encourages observing rising physical sensations,
thoughts, and emotions through an intention of kind attention
(kind attention is designed to foster compassionate, nonjudgmental
acceptance toward oneself).
At the close of the practice I invite clients to share feedback. This
assists the therapist with planning future group meditations. It can also
help clients validate and reinforce any of their positive experiences
(which could foster the eventual development of a personal practice).
260 DBT-INFORMED ART THERAPY IN PRACTICE

At-home mindfulness activities are encouraged as they can facilitate

significant positive behavioral change (Linehan 2015a).

Part 3: Psychoeducation
Individuals with serious psychiatric illnesses often contend with a
debilitating sense of isolation. Participation in psychoeducational
programs may alleviate this through highlighting the universality
of clients’ struggles. As group members share their respective lived
experiences, empathy and compassion for self and others naturally
develops. However, the trust and comfort that results from validating
one another’s symptoms and issues can at times inadvertently reinforce
personal identification with mental health problems (Cruwys and
Gunaseelan 2016).
The challenge, then, is to balance nonjudgmentalness and accep­
tance with recognizing the destructive consequences of symptom-
driven behaviors. Linehan (2015a) describes DBT’s dialectical
philosophy, which asserts that two opposing things can be simulta­
neously true—in this case, “the need for clients to accept themselves
as they are in the moment and the need for them to change”
(p.5). Psychoeducation encourages embracing the dialectic of
nonjudgmentally acknowledging a mental health diagnosis while, at
the same time, working toward effectively managing it. This, in turn,
can assist clients in developing a sense of personal responsibility for
building a life worth living (Linehan 2015a) through positive behavioral
change.

The task of the therapist

During the psychoeducation session the therapist provides a safe place
for clients to actively participate. I encourage lively but judgment-free
discussion and the sharing of personal reflections. My role as the group
leader also involves writing relevant pointers on the whiteboard (Figure
14.1), as well as offering feedback and respectful prompting around
specific psychoeducation skills and strategies.
My objective in teaching psychoeducation is to give clients a solid
understanding of its relevance to their psychiatric issues as well as how
to apply it practically in their lives. I have observed that clients are
keen to learn a potentially helpful intervention when they are experiencing
difficult, and often accelerating, symptomology. Merely possessing this
Integrating DBT-Informed Psychoeducation with Visual Journaling 261

knowledge can ease distress by counteracting helplessness. This is an

example of the DBT emotion regulation skill building mastery, which
shifts a client’s focus from hopeless beliefs toward a sense of competence
(Linehan 2015a).

Figure 14.1 An example of psychoeducation

notes on the whiteboard

Notes
To encourage active notetaking, each participant receives a clipboard,
some blank paper, and a ballpoint pen. This hands-on engagement,
together with interactive discussion, helps clients gain a clearer
understanding of the ideas presented and builds group cohesion
(Clanton Harpine 2015). The resulting notes provide a handy reference
for reading at home in between sessions.

Part 4: Visual journaling

During the lunch break I set up portable tables for visual journaling.
The session begins with reflective writing, followed by art making.
Prior to commencing the activities, I encourage clients to write the
date and featured psychoeducational skill on their paper to serve as a
reminder of past assignments. The psychoeducation notes remain on
the whiteboard so that clients can refer to them during their creative
explorations.
262 DBT-INFORMED ART THERAPY IN PRACTICE

Provision of art media

I offer a moderate range of options. Too much choice can be over­
whelming and thus inhibit engagement (Waller 1993), especially when
participants are not familiar with art materials. Yet a certain degree
of variety “creates a context for people to find their way to a medium
that reflects their particular state of mind” (Ward 1999, p.112). It is
important to purchase products of a good usable standard because it
signifies respect for the clients and their work. Further, the creative
process is much less likely to be hindered by frustrations associated
with inferior materials.

Figure 14.2 Visual art journal

Visual art journal

Some of my clients keep a dedicated art journal in a bound sketch
book so that their work is organized and easily accessible. The journal
contains psychoeducation notes as well as clients’ reflective writing and
art making from the visual journaling sessions—a valuable reference
when struggling with symptoms or difficult emotions between groups
(Figure 14.2). Clients can also continue their visual journaling practice
at home as a self-care activity.
• Reflective writing.
Integrating DBT-Informed Psychoeducation with Visual Journaling 263

The visual journaling session commences with personal reflections

regarding the psychoeducational skill. Clients have 20–30 minutes for
this activity.
You are now invited to write for about fifteen to twenty minutes about
your responses to the skills learning. You can write as little or as much
as you like within the time frame. I encourage you to use “I” statements.
The more personal your writing, the more meaningful it can be for you.
You might like to write about your blocks to using the skill. You can
write about how you think your life might be improved with using the
skill. You can write about whatever came up for you during the skills
learning.

The role of the therapist

The therapist is a silent witness throughout the visual journaling
activities. I am the group’s safe container, holding and tolerating
whatever arises for participants during their creative explorations. For
example, I notice one client pause thoughtfully before she puts pastel
to paper. Another client is engrossed and tearful as she writes (I can
integrate such observations into the feedback I later provide, with the
goal of facilitating deeper exploration). The therapist encourages clients
to expound their creativity. As Ward (1999) notes, “It is the relationship
with both the therapist and the art process itself that brings about
change in art therapy” (p.104).

Therapeutic efficacy of group silence

Silence is a powerful intervention during the visual journaling
activities in that it can “help clients to collect and organize their
thoughts and to better connect with themselves” (Regev, Chasday, and
Snir 2016, p.73). This was highlighted for me during a lesson on the
interpersonal effectiveness DEAR MAN skills (Linehan 2015a, 2015b).
One participant spoke of feeling devastated by his inability to discuss
relationship issues with his partner. He then, in quiet contemplation,
wrote about his hope for respectful and effective communication
(Figure 14.3). This authentic connection with the skill would likely not
have happened without the implementation of group silence.
264 DBT-INFORMED ART THERAPY IN PRACTICE

Effective communication
Communicating a desired result, while maintaining values and self-
respect. While you may not get the result you are after, you will
have gotten your message across authentically—my truth matters
and it’s what matters to me. Get clarity and provide clarity by
separating the situation, what it means to me, that it matters to me,
and how it affects the other, staying true to myself by being mindful,
(appearing) confident, and negotiable.

It matters to me and that’s why it matters.

Figure 14.3 EFFECTIVE COMMUNICATION

I request silence with the prompt: “During your creative process try not
to talk as silence gives you the opportunity for self-exploration and the
opportunity to notice your thoughts and feelings. This is your time to
give attention to your needs.”

Voluntary participation
I always invite (rather than require) group members to participate in
the visual journaling activities. A balanced approach acknowledges
apprehension while gently pulling for engagement (Clark 2017). Clients
tend to encourage one another to join in. When someone is particularly
reluctant to do so, however, I allow her to simply observe. This is with
the understanding that she does not distract other group members.
Interestingly, an observer often will eventually pick up a pastel, brush,
or pen and either make marks, draw, or write something.

The therapist models participation

Facilitators can join in the visual journaling as a means of modeling
the creative activities. Briefly sharing one’s reflective writing and/or the
meaning of one’s artwork within the context of the psychoeducational
lesson can be helpful for group members. However, while this should be
an authentic practice, it is important that the therapist’s participation is
done for the benefit of the group rather than as a personal therapeutic
experience.
• Sharing of reflective writing.
Integrating DBT-Informed Psychoeducation with Visual Journaling 265

To communicate that the writing segment is nearing a close, I give

a prompt five minutes before its end. I then wait until everyone has
finished and put their pens down before inviting them to share. It is
vital that no one continues to write while others are reading. Group
processing is a time to be present for one another. Listening to
fellow participants’ stories is always done through an accepting and
nonjudgmental lens.
I orient clients to this approach as follows: “You now have an
opportunity to share your reflective writing. I encourage those of you
who are listening to sit back and listen with an open heart and mind.
We can learn from hearing each other’s stories.”

Responding through an appreciative lens

I invite feedback by simply asking, “Would anyone like to respond?”
Respect and appreciation are central. Every story is validated and
gratefully received. There is no critique of writing style, grammar, or
content. Frequently, after someone shares, there is not much that I
or the other clients need to add; the writing speaks for itself. However,
sometimes I encourage the person to elaborate on their reflections as a
way of helping them to process a deeply personal issue.

The value of digression from the psychoeducation focus

Occasionally an individual does not choose to engage with the featured
skill. Instead, they write or create a visual image about their current
emotional state, a personal difficulty, or another source of distress.
In such instances I will affirm and validate the resulting creative
expressions because I view whatever emerges as valuable. It is better to
release an urgent internal experience than repress it in order to adhere
faithfully to the directive.
• Art making.
The art making session immediately follows the reflective writing and
reading/sharing segments and runs for around 30–45 minutes. The
prompt is as follows:
You are now invited to create an art response to the skills learning. You
can create an image exploring the benefits of using the skill, or an image
exploring your blocks that stop you from using the skill. You can create
a dual image; on one section of your art paper you can represent your
266 DBT-INFORMED ART THERAPY IN PRACTICE

life without the skill, on another section of your art paper your life with
the skill. You can create an image of whatever arose for you around the
skills learning (Figure 14.4).

Figure 14.4 Dual image (client exploring mindfulness of thoughts)

Directives as options for client art making

Clients may, either individually or collectively, request ideas for
creative responses. Therefore, in preparing for the program day, I not
only read up on the planned psychoeducational skill, but also spend
time formulating prospective activities for their art making. In order
to ensure clients’ agency around their creative work, I always frame a
directive as an option and not as an order (McNeilly 2006).

Individual directives
Directives that are personalized can provide clients with a secure
framework within which to explore their internal experiences. A
young woman who joined the group following a discharge from
hospital shared, “I don’t like non-directive art therapy. I get lost in
my emotions. It’s like I’ve got nothing to hold onto.” I responded by
asking, “Does the directive help you to contain your feelings?” “Yes,”
the client replied. “When I’m given directives, I feel safer.” This was
helpful information, and I offered optional art directives each week. I
also gave her mandalas to color whenever she completed her artwork
before other group members had finished (the structural forms within
the mandala patterns provided additional containment and safety). In
time, this client was able to come up with her own ideas for her art.
Integrating DBT-Informed Psychoeducation with Visual Journaling 267

Group directives
An example of the entire group requesting direction for their artwork
took place during a cognitive behavior therapy (CBT) skills session,
the topic of which was the four communication styles (e.g., passive,
aggressive, passive-aggressive, and assertive). CBT’s objective is to build
positive life-enhancing experiences by restructuring distorted thought
patterns into more accurate ones (Hogan 2016). Clients identify their
interpersonal strengths and deficits by exploring the communication
styles. This forms a foundation on which to build assertiveness skills
through psychoeducational models like DBT (DEAR MAN skills as
previously discussed). In response to the group’s desire for further
direction, I drew simple stick figures on the whiteboard, each portraying
a different style. I then added adjoining dialogue bubbles, and together
as a group we worked out what caption might fit each bubble. The
clients used this as a guide to engage in their artwork and create their
own figures and captions.

Alleviating fear of art making

Many adult clients have not made art since childhood and can be
fearful of the prospect. Fortunately, there are ways to help assuage such
anxiety. It is essential to reassure them that the focus is on the creative
experience rather than an end-product. This can help these clients to
feel less pressure:
It is the process, not the final product, that is important in art therapy.
This is an opportunity for self-expression. Whatever you create is
appreciated. You don’t have to make a pretty picture. You can do an
illustrative image, or you can create an image using marks, shapes, and
colors. And you can put words in the image.

Words in the image

Often clients with minimal art experience will have ideas that are too
difficult to draw. Words can thus be literally included as part of the
image. In fact, single words and/or phrases may become an integral
aspect of an art piece as well as a natural component of the image within
visual journaling (Ganim and Fox 1999).

Collage
Certain art activities help to make for a less daunting experience. Collage
is a good starting point as it does not require one to draw anything.
268 DBT-INFORMED ART THERAPY IN PRACTICE

Invite clients to look through magazines and choose images and words
representing their responses to the psychoeducation. They then can cut
out, position, and paste these onto the paper to create a cohesive piece.

Mandalas
Coloring is another activity that can provide a sense of safety and
structure for the apprehensive art therapy participant. Provide a black-
and-white mandala design (patterns within a circle) and offer the option
of coloring it in a manner that somehow conveys their response to the
psychoeducation. Participants may choose from a variety of art media
such as watercolors, acrylic paints, oil pastels, colored markers, or pencils.
They might also make their own mandala by outlining a circle on blank
paper, into which they can then create their own unique patterns.

The therapist as witness to art making

As previously discussed, the facilitator models silent, mindful attention
throughout the art making period. The therapist’s act of witnessing
the group’s creative process encourages clients to attend to their own
experiences more mindfully (Grosz 2013). I find it compelling to watch
the myriad paths that therapeutic creativity can follow: the gradual
forming of an image as each mark appears on the blank paper; color
combinations evolving, stroke by stroke; the juxtaposing of contrasting
textures as each layer of art media is applied; the scraping back to
unearth an underlying symbol; and the improvised use of whatever is at
hand (such as running a pen through paint to gain an expressive effect
or dabbing the artwork with a paper towel as a final finishing touch).
Importantly, giving clients feedback on what you observed of their art
making process can lead to significant insights.
• Sharing of artwork.
I provide a five-minute notification that the art making period is coming
to an end. When the time is up, I clean the whiteboard so that the
artwork can be seen without distraction. Viewing begins once everyone
has finished. All participants give their full attention to this process.
Each client is individually invited to share their piece and describe its
meaning. I display artwork in a central position on the whiteboard,
using magnets, so that they are easily viewed by everyone.
I introduce this segment with the prompt: “You are now invited
to share and, without interruption, speak about the meaning of your
artwork.”
Integrating DBT-Informed Psychoeducation with Visual Journaling 269

Options for processing artwork

Verbal processing is encouraged; however, there are times when a
client may not want to show their work to the group. They may also
not wish to talk about it or have others respond. These desires should be
respected. In such instances one can offer various alternative options for
participation. For example, they might opt to have their artwork viewed
by the group in silence. I also mention that, while they may not want
to talk about their artwork, it can be enlightening to receive feedback.
Sometimes others’ responses to an image can trigger helpful ideas and
insights (and this may eventually get the artist talking).

Viewing images with a psychoeducation focus

I encourage participants to frame their expositions in relation to skills
training. Through the many different perspectives that clients bring,
the group can build a diverse and comprehensive understanding of a
given skill. Discussing their image may yield fascinating and insightful
explorations around the psychoeducational lesson that would not
have happened without this creative element. “You had to be there” is
what comes to mind as these dynamic, adventurous, in-the-moment
happenings energize, validate, and motivate the clients in their journey
of healing through skills-based learning.
I prompt clients to reflect on their artwork as follows: “How does
your image relate to the skills learning? What feelings and thoughts
about the skill came up for you while creating your artwork?”

Client as expert
I am constantly impressed by how naturally clients, many of whom
have not drawn or painted since early childhood, will speak about their
artwork’s symbolic content. Because art is an expression of the self,
the client’s own voice is paramount. The meaning that she attributes is
accepted and explored. When facilitating sharing of ideas in response
to an art piece, the therapist is careful to maintain these respectful
guidelines.

The therapist is not an “expert”

The group facilitator neither makes assumptions nor offers diagnostic
interpretations of images. Still, it can be helpful to share some of one’s
observations around an individual’s art making process and/or any
distinctive aspects of their artwork. This might include simple feedback
270 DBT-INFORMED ART THERAPY IN PRACTICE

such as “You seemed to be soothed by the flow of the water color paints”;
“You looked like you were releasing strong feelings as you vigorously
applied the oil pastels”; “I notice the deep colors and rough texture of
the left side in contrast to the light colors and smoothness of the right
side of your artwork.”

The therapist maintains a light touch

This stance was instilled in me following a session on anxiety
management. I interpreted an image of a large lounge chair beside a
window with flowers around the frame as a pleasant scene. The artist
then disclosed the emotional pain she experienced when alone at home,
immobilized with anxiety: she sat at this window and felt cut off from
the world. How much further from the truth could I have been?! This
confirmed the necessity of waiting for each participant to speak her
truth rather than immediately applying one’s assumptions. As McNeilly
(2006, p.36) so aptly advises, “It is important to know when to shut up.”

Peers respond respectfully

I offer the other group members an opportunity to participate with the
prompt: “Would anyone like to respond to the image?”
Group feedback is given with respect for the client, their artwork,
and their interpretations (i.e., never as a critique). With these guidelines
in place, peers can add significant richness, depth, and insight with
their meaningful remarks.

Confidentiality and the safekeeping of visual journaling

According to Ward (1999), “How and where images are kept and who
can see them or touch them need to be carefully considered” (p.113). I
encourage clients to keep their reflective writing and artwork in a safe,
accessible place. I also caution them to be mindful about with whom
they share these personal and sensitive materials outside of group. On
the one hand, family members and friends can be ignorantly dismissive
or even ridicule such creative expressions. On the other, sharing with a
trusted and validating person can deepen both parties’ understanding
of the changes that the client is working toward. In addition, the client
may greatly benefit from exploring the artwork and reflective writing,
along with the insights that arose during the group process, with their
individual therapist.
Occasionally someone will discharge from the program and leave
Integrating DBT-Informed Psychoeducation with Visual Journaling 271

their work behind. In such cases I advise keeping them in a locked

cupboard (assuming this is practical and realistic for one’s workplace).
Your national art therapy association provides guidelines around the
brief and long-term storage of clients’ creative materials.

Photographing visual journaling

Owing to their deeply personal and confidential nature, I do not
generally support the reproduction of client artwork and reflective
writing. The mood management group adheres to the guideline “What
you hear and see here: When you leave here, let it stay here.” This
ensures the safest possible container for therapeutic processes. If there
is a necessity for photographing visual journaling responses, one must
obtain written permission from the client artist. Again, please refer to
your national art therapy association’s directives on such matters.
It is important to note that requests for clients to reproduce
their visual journaling should be made thoughtfully. Casual and/or
spontaneous requests tend to evoke permission given out of perceived
pressure from the therapist or fellow participants. Allow the individual
ample time to think through and process their authentic needs (rather
than quickly acquiescing).

Part 5: Group ending

At the end of the day I briefly check in with each person about how
they are feeling and whether they wish to mention anything that had
particularly resonated with them. I also encourage clients, in their own
time, to write about what it was like to share their creative responses as
well as any insights that arose through the processing and exploration.
At this point I ask the group if there are any specific issues that they
would like to work on during future psychoeducation sessions.
Finally, I express my sincere gratitude for everyone’s courage and
willingness to participate in this therapeutic experience. Clients often tell
me how tired they feel at the end of the day, and it is no wonder: they have
listened, discussed, taken notes, reflected through writing, symbolized
through art making, shared, identified, interpreted, and explored. The
individual inspires the group as the group inspires the individual. As one
client remarked, “The visual journaling helps me to connect with the skill
on a personal level. It helps me to think about how to apply the skill in my
life and how to communicate that learning to the group.”
272 DBT-INFORMED ART THERAPY IN PRACTICE

Conclusion
The chapter illustrated how a combined psychoeducation and art therapy
intervention may enhance the skills acquisition of adult participants in
a DBT-informed mood management group. Psychoeducation builds
clients’ awareness of their dysfunctional thought and behavior patterns;
furthermore, it teaches them to respond in more adaptive ways. The
approach acknowledges the client as central to their own recovery—
indeed, as the primary source of re-education and wellness.
However, traditional didactic models may inadvertently foster
a passive acquisition of knowledge. The active nature of reflective
journaling and making art empowers individuals to take a more
assertive, engaged role in their skills development. Rather than
merely being fed information, they step forward (as the therapist
simultaneously steps back somewhat) and make personal, emotional
connections with the materials. In so doing, they become the expert in
their journey of recovery.

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Clanton Harpine, E. (2015) Group-Centered Prevention in Mental Health: Theory, Training,
and Practice. New York, NY: Springer International.
Clark, S.M. (2017) DBT-Informed Art Therapy: Mindfulness, Cognitive Behavior Therapy, and
the Creative Process. London: Jessica Kingsley Publishers.
Cruwys, T. and Gunaseelan, S. (2016) ‘“Depression is who I am”: Mental illness identity,
stigma and wellbeing.’ Journal of Affective Disorders 189, 36–42.
Dreeben, S.J., Mamberg, M., and Salmon, P. (2013) ‘The MBSR body scan in clinical practice.’
Mindfulness 4, 4, 394–401. doi:10.1007/s12671-013-0212-z
Ganim, B. and Fox, S. (1999) Visual Journaling: Going Deeper than Words. Wheaton, IL:
Quest Books.
Grosz, S. (2013) The Examined Life: How We Lose and Find Ourselves. London: Vintage.
Hogan, S. (2016) Art Therapy Theories: A Critical Introduction. New York, NY: Routledge.
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(Original work published in 1993.)
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Moon, B. (2016) Art Based Group Therapy: Theory and Practice (2nd ed.). Springfield, IL:
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 Author Biographies

Emma Allen, Health and Care Professions Council (HCPC)-registered

art psychotherapist, is the professional lead for arts therapies at Rampton
Hospital, one of three high secure hospitals in the UK, Nottinghamshire
Healthcare NHS Foundation Trust. Emma has worked at Rampton
since 2009 as an art psychotherapist, and she is the founder of Forensic
Sandplay Therapy (FSPT). Emma also works for Northamptonshire
Healthcare NHS Foundation Trust (within the National Offender
Personality Disorder Pathway and prison service) assessing and treating
young men at risk of developing personality disorders and who struggle
with interpersonal relationships related to their trauma histories. During
2017–2019, Emma was a treatment manager for the Aurora Project, the
first project in the UK for the prevention of sexual offending. Emma
provides clinical supervision. She is also a lecturer for forensic psychology
courses at Nottingham Trent University. Emma has authored several
book chapters and journal papers.

Susan M. Clark, LPCC-S, ATR-BC, is a registered/board-certified

art therapist as well as a licensed professional clinical counselor
(supervisor’s designation). She has worked in the mental health field
for over 20 years with a variety of adult and juvenile client populations,
including individuals contending with serious and chronic mental
illnesses, substance abuse/dependence, and eating disorders. Susan
is the author of DBT-Informed Art Therapy: Mindfulness, Cognitive
Behavior Therapy, and the Creative Process (JKP 2017). She currently
works in private practice at WiseMind Counseling in Kent, Ohio.

Jane DeSouza, ATR-BC, LCAT, received a BFA from the University

of Kansas (Painting, Drawing and Theater Design) and an MPS from
Pratt Institute (Art Therapy and Creativity Development). She worked
at Saint Vincent’s Hospital-Westchester in Harrison, NY from 1980 to
2020. During her career Jane held several important positions, including

274
 Author biographies 275

program director of Personalized Recovery Oriented Services (PROS),

a comprehensive recovery-oriented program for adults with severe and
persistent mental illness. Jane also provided dialectical behavior therapy
(DBT) skills training and clinical supervision in an outpatient mental
health clinic. Jane received the 1999 Outstanding Clinician Award from
the Westchester Art Therapy Association (WATA). Jane has worked on
various committees for the American Art Therapy Association (AATA),
including six years as the annual conference chair. Now that Jane is
retired, besides staying involved in AATA, she is enjoying community
theater, painting, reading, watching sports, and getting together with
friends and family.

Yvette Duarte is the owner of Awake DBT, Inc. in San Jose, California.
She is a DBT-Linehan Board of Certification Certified Clinician™, a
licensed marriage and family therapist (LMFT), and a registered
art therapist (ATR). Yvette graduated from Notre Dame de Namur
University with an MA in Marriage and Family Therapy/Art Therapy.
For over 20 years Yvette has practiced psychotherapy with adults,
children, and families in community-based settings such as domestic
violence shelters, supported housing, outpatient mental health services,
and homeless shelters. She has also provided trainings on DBT and art
therapy at several agencies in the Bay Area.

Penelope James is a clinical registrant of PACFA (the Psychotherapy and

Counselling Federation of Australia) and a full professional member
and registered supervisor with ANZACATA (the Australia, New
Zealand, and Asian Creative Arts Therapy Association). She works in
a variety of settings, including private practice, community health, and
clinical mental health centers. She specializes in the art therapy process
of visual journaling, which integrates art therapy with psychoeducation.
Penelope has presented at art therapy and counseling symposiums and
conferences and for the Western Sydney University Master of Art Therapy
clinical training program. Penelope received the Mental Health Matters
Consumer Involvement and Engagement Award in recognition of her
coordination of the STiGMA Exhibition. This celebratory event engaged
community members living with mental illness to explore their recovery
journeys through expressive art making. More recently she coordinated
the L&L Riverwood Creative Community “We All Are One” sculpture
for the Rookwood Cemetery Exhibition.
276 DBT-INFORMED ART THERAPY IN PRACTICE

Shelley Kavanagh, RP, RCAT, is a registered psychotherapist and

registered art therapist with over 25 years of experience working with
young people challenged by emotional and behavioral dysregulation.
She consults to numerous community-based agencies and is a faculty
member of the Toronto Art Therapy Institute. For the past several
years, Shelley has worked in a supervised practice with DBT expert Dr.
Shelley McMain, as well as with Dr. Shari Geller (who has been a great
teacher in therapeutic presence through her advancement in the field
of emotion focused therapy). Shelley’s personal mindfulness practice
is greatly enhanced by her adult children, Justine and Ryan, who often
model the DBT concept of “wise mind.” Lastly, a lifelong friendship
with art therapist Suzanne Thomson has helped strengthen, sustain,
and reinforce Shelley’s trauma-informed practices with clay.

Heidi Larew, LPCC-S, LICDC-CS, ATCS, has worked as an art

therapist for 23 years. She specializes in clinical supervision and is
experienced in spiritual care, mental health counseling, and chemical
dependency counseling. Her professional philosophy emphasizes being
present with clients, supervisees, and colleagues in ways that may foster
in them a sense of peace and hope. She enjoys the use of creativity,
storytelling, and metaphor. Heidi treasures engaging with others and
enjoys bringing laughter and kindness to the healing process.

Scott Levson, PsyD, is a staff psychologist in the Polytrauma Clinic

of the Washington DC VA Medical Center, where he provides
individual, couples, and group psychotherapy to veterans who have
experienced traumatic physical and emotional injuries. He is involved
in the supervision and training of psychology students at the extern,
predoctoral, and postdoctoral levels, and serves as a member of the
DC VA’s training committee and DBT treatment team. Dr. Levson
graduated from Chestnut Hill College in Philadelphia and gained
exposure to relational psychoanalysis at the Haverford College CAPS
clinic. He completed a predoctoral internship at the Hudson Valley
VA in Montrose, NY, as well as a postdoctoral fellowship specializing
in severe mental illness at the Washington DC VA. He also enjoys
teaching and has held adjunct faculty appointments at Chestnut Hill
College. Dr. Levson is certified in cognitive behavior therapy (CBT)
for insomnia and cognitive processing therapy (CPT) for posttraumatic
stress disorder (PTSD).
 Author biographies 277

Melanie Paci, PsyD, is a clinical psychologist who has provided

clinical services and training in the Department of Veterans Affairs
for 12 years. Her areas of specialization are recovery-oriented group
therapy, suicide prevention, and telemental health. Dr. Paci has also
been involved in program development/evaluation initiatives focusing
on suicide prevention and integrating creative processes in the delivery
of psychotherapy. She is trained and certified in several evidence-based
therapies including CPT for PTSD, DBT, acceptance and commitment
therapy, CBT for psychosis, and integrative behavioral couples therapy.

Chloe Sekouri worked in the social services as a counselor, art therapist,

and social worker in Vancouver, British Columbia, Canada. She was
based in women’s treatment programs, front-line drop-in centers, and
First Nations organizations. She worked in a youth detention facility
and as part of the North American Opiate Medication Initiative
(NAOMI) clinical trial. She completed her Master’s-level diploma in
art therapy at Vancouver Art Therapy Institute in 2004. Ms. Sekouri
has transitioned out of the helping professions, but continues to make
art as a way to explore her inner and outer worlds.

Megan Shiell, AThR, is a DBT specialist, registered art psychotherapist,

and a level 4 counselor in Australia. Megan received comprehensive
DBT training in 2008 and subsequently developed a two-day inten­
sive DBT workshop which she facilitates around Australia (to date,
she has trained approximately 2000 clinicians). Her experience in
structuring DBT teams has been extensive, as well. Megan is passionate
about assisting clinicians and clients in the use of DBT skills with an
added component of art making/creative imagery. In 2018, Megan
developed the online “ME” (Managing Emotions) ten-session DBT-
informed skills training for clinician professional development, as well
as a similar program for clients. Megan has assisted many clinicians in
developing DBT-informed skills training programs both for groups and
individual therapy. Megan’s goal is to make DBT skills accessible to as
many people as possible.

Jeremy Steglitz, PhD, MPH, is a photographer and licensed clini­

cal psychologist in Washington DC and Virginia. He is currently a
staff psychotherapist, lecturer, and supervisor at the Therapy Group
of DC. Dr. Steglitz has published numerous articles and book chapters
278 DBT-INFORMED ART THERAPY IN PRACTICE

on evidence-based practice. One of his more recent interests is the

integration of structured interventions (e.g., CBT, DBT) with depth-
oriented psychotherapies (e.g., psychodynamic psychotherapy, creative
arts therapies). Dr. Steglitz has been involved in program development
evaluation initiatives at the Washington DC VA Medical Center and
Mount Sinai St. Luke’s Hospital in New York City that have focused
on combining creative arts therapies with CBT or DBT to optimize
therapeutic impact.

Karin von Daler, MFT, REAT, is a psychologist, expressive arts therapist,

family therapist, and artist. She maintains a private psychotherapy,
teaching, and supervision practice in Copenhagen. Trained at the
California Institute of Integral Studies, Karin has taught expressive arts
therapy around the world and is the co-creator of creative mindfulness.
She recently developed the course series “The Art of Self-Healing,” as
well as “The Heal Keys,” a popular online course. Karin paints, dances,
and plays the harp.

Anthony Webster, MSc, has worked at Rampton Hospital,

Nottinghamshire Healthcare NHS Foundation Trust, since 2011.
For the past three years he has served as an assistant psychologist
across the National Men’s High Secure Learning Disability Service and
the Men’s Mental Health Service. Throughout that time he received
training in, and has supported the delivery of, both DBT and radically
open dialectical behavior therapy (RO-DBT). Prior to this, he worked
as a nursing assistant on the Personality Disorder Service for five years.
Anthony trained at Lincoln University for both his undergraduate
degree in Psychology, and MSc in Forensic Psychology. He is currently
working toward becoming a qualified psychologist.

Mary Weir, MA, is an Irish-Australian living in Aotearoa, New Zealand.

After studying visual arts, anthropology, gender theory, yoga, and
adult education (and performing and teaching circus arts for almost a
decade), they now provide art therapy for diverse folk in both private
practice and through the New Zealand Prostitutes Collective. Mary feels
that the most satisfying thing in life is to be fully oneself and hopes for
a future world where love and acceptance of diversity is the norm. They
also write about gender, sexuality, mental well-being, and the human
journey. Mary writes from home on the Kāpati coast, and wishes to
 Author biographies 279

acknowledge local iwi, and the Māori people of Aotearoa, as rightful

custodians of this land. Mary offers gratitude and acknowledgment
to their loved ones and community, who take the time to read and
support their work, because it takes a village to raise consciousness
about diversity and inclusion.

Tracela M. Zapata, PhD, is a clinical psychologist and a Booz Allen

Hamilton Associate with experience providing subject matter expertise
for healthcare initiatives within the Department of Defense (DoD). Dr.
Zapata has worked as a clinical psychologist for over 20 years, nine
of which were in the Department of Veteran’s Affairs. She has been
responsible for program development/program evaluation initiatives
in the Department of Veteran’s Affairs for six years (with a specific
focus on access to care, evaluating program effectiveness/efficiency,
and patient satisfaction). She has also provided program translation
on emerging psychological health issues. Her research experience
spans a period of ten years to include Internal Review Board (IRB)
membership, research protocol management, monitoring, adherence,
and tracking in accordance with human subject requirements and
standards. She also has experience creating reports for accrediting
bodies, funding agencies, and presenting project results/key findings
to local and national conferences.
 Subject Index

A Life Worth Living 34, 161, 162–3, 189–90 impulsivity versus choice 28
abandonment, fear of 135, 137, 138–9 invalidation experiences 24, 42,
acceptance 90–1, 158–9, 170, 236
balanced with change 41, 53, isolation versus choice of solitude 28
61–2, 84–5, 91, 94 manipulative versus resourceful 27
going beyond 242–3 numb versus content 29
radical 42, 69, 118–9, 210, 241, 242–3 ruminating versus problem-solving 28–9
ACCEPTS skill 117–8 symptoms 23
anxious versus eager 27 boundaries of self 139
art therapy box of hope activity 33
connections with dialectical
behavior therapy 29–30
calendar for therapy 137
as constructive diversion 99
case conceptualization 170
and evidence-based practice model 42–5
case studies
higher cortical cognitive
Awake DBT (Muneca) 157–69
processes in 174, 187
ceramic-based art (Alice) 115
job title evolution in 44
Creative Mindfulness (Lina) 211–4
overview of 132–3, 155
DBT-informed art therapy (Miranda) 62–4
assertiveness see interpersonal
distress tolerance skills (Cathy) 220–9
effectiveness skills
suicidal behavior (Mary) 78–82
assumptions, disrupting 52
suicidal behavior (Tandy) 82–6
atoms 30
ceramic-based art therapy
attachment 210
background 113–5
attention-seeking
as body-based psychotherapy 115–7
art therapy allows 52–3
case study (Alice) 115
versus connection-seeking 27
Clay Art Therapy (CAT) 115–6
autoethnography 237, 248
clay-firing process 119
avoidance versus intentional diversion 27–8
community building in 121–5
Awake DBT 154, 156–69, 169
contraindications for 222
mindfulness bowl 124
behavior chain analysis (BCA) 61, 104 mindfulness role in 119–20
biosocial theory 24, 90–1, 158–9 randomized controlled trial on 116
black-or-white thinking 40–1, 49 as specifically DBT-informed
body image work 107 practice 117–20
body maps 142, 146 trauma narratives in 120–1
borderline personality disorder (BPD) change
anxious versus eager 27 balanced with acceptance 41,
attention-seeking versus 53, 61–2, 84–5, 91, 94
connection-seeking 27 limited worldviews and 243–4
avoidance versus intentional check-ins 258–9
diversion 27–8 choice versus impulsivity 28
common descriptors of 26–9 clay work see ceramic-based art therapy
DBT as gold standard for 58 cognitive restructuring procedures 162
diagnostic criteria 38 collage 63, 192, 224, 267–8
gender bias in diagnosis 240–1 communication skills 70, 264

280
 Subject Index 281

community building 121–5 disrupting assumptions 52

complex posttraumatic stress distress tolerance skills
disorder (C-PTSD) 240–1 ACCEPTS skill 117–8
compliance 218 activities overview 105
Comprehensive DBT 39 case studies 171, 220–9
connection-seeking versus “Dear Emptiness” letter 32
attention-seeking 27 distracting 209
contemplative practices 107–8 improving the moment 209
content versus numb 29 in ME program 69
contingency management 161 overview 49–50, 219–20
control (and watercolor painting) 106 personal Zen garden 105
coping ahead 208 pros and cons lists 209–10
core mindfulness skills 171, 206–7 “pushing away” strategy 62–3
creative engagement 51–3 radical acceptance 42, 69, 118–9,
Creative Mindfulness 210, 241, 242–3
background of 200–1 self-soothing 209, 229–30
case study (Lina) 211–4 STOP skill 85, 163–4
clinical model of 203–4 diversion
core mindfulness skills 206–7 art therapy as constructive 99
and emotion dysregulation 199–200 versus avoidance 27–8
neuroscientific research and 201–3 drop-in center context 217–8
overview 198
practicing repeatedly 205
eager versus anxious 27
stages of 204–5
Eastern traditions 242
crisis survival toolbox 76, 81
eating disorders
art therapy and 89–90
darkness and light mindfulness 32–3 body image work 107
DBT-informed art therapy cognitive consequences of 95
characteristics of 96 control in 106
models of 95–6 DBT and 90–3
overview 50–1, 94–5, 155–6 evidence-based practices for 92
in private practice 61–2 intensive interventions for 92
DBT-informed workshop 65 perfectionist traits in 96–7
“Dear Emptiness” letter 32 radically open DBT (RO-DBT) 92–3
DEAR MAN skills 210–1 emotion dysregulation
decentering 204 causes of 199
dialectical behavior therapy (DBT) Creative Mindfulness and 199–200
as an evidence-based practice 38–40 definition 198–9
Comprehensive DBT 39 difficulties in working with 197
connections with art therapy 29–30 emotion mind 45, 91, 222–3
core concepts 40–2 emotion regulation skills
focus on present moment 133–4, 142–3 accumulating positive emotions 208–9
gold standard for BPD 58 case studies 83, 158, 171
lack of knowledge of 65 coping ahead 208
overview 25 mastery building 18, 208, 261
pretreatment stage 92, 135–7 opposite-to-emotion action
range of clinical populations treated 91–2 208–9, 213, 258–9
support for clinicians in 39 overview 48–9, 198
see also skills training rollercoaster drawing activity 103–4
dialectical dilemmas 41, 79 emotional overcontrol (OC) disorders 92–3
dialectical thinking 41, 98–100 emptiness
dialectics 26, 40–1, 79, 91, 170 compensatory behaviors 23
diary cards (DCs) 61, 155 in context of BPD 22–4
directives creative interventions for 31–4
group 267 definition 23
individual 266 other perspectives of 25–6, 30–1
282 DBT-INFORMED ART THERAPY IN PRACTICE

emptiness cont. handprints 140–2

pause as 31 hands, working with 115–7, 133
poem 22–3 handshakes 129, 143, 145
engagement (creative) 51–3 “happy ending” painting 143
engagement/commitment spectrum 218 heart-mind-fullness 241–2
Escher, M.C. 33, 140 heteronormativity 251
evidence-based practices (EBPs) Hiddleston, Tom (quote) 123
art therapy and 42–5 high-security unit see forensic art therapy
definition 38 homework 51
dialectical behavior therapy as 38–40 hope 53
for eating disorders 92 hurricane drawing activity 103–4
fears of conformity and 44
overview 37–8
I Can Feel Good (ICFG) program 131–2, 136
experiential learning 132, 156
IFS-informed creative arts therapy 248
expert, client as 269–70
improving the moment 209
exposure practice 162
impulsivity versus choice 28
externalization of emotions 142–3
inhibited grieving 171
interconnectedness artwork activity 33–4
FAST skills 191–2, 211 internships/training 57, 59
fear interpersonal effectiveness skills
of abandonment 135, 137, 138–9 case study 171
of art making 267 DEAR MAN skills 210–1
femme (definition) 250 FAST skills 191–2, 211
firing process (clay) 119 GIVE skills 181–2, 193–6, 211
forensic art therapy overview 48
formal therapy stage 137–43 sketches activity 103
handprints 140–2 introversion 28
“happy ending” painting 143 invalidation experiences 24, 42,
overview 134–5 90–1, 158–9, 170, 236
pretreatment stage 135–7 irreverence 52
session structure 138 isolation versus choice of solitude 28

Gardiner Museum of Ceramic Arts 113, 122 journaling see visual journaling
gender binary (definition) 250
gender performativity 251
language/terminology 11
gender pronouns 11
learning disability
generalization 50–1, 205
hands-on experience and 133
GIVE skills 181–2, 193–6, 211
I Can Feel Good (ICFG) program 131–2, 136
Gray Ace (definition) 252
mental health issues 139
group activities 48
LGBTQIA+ people
see also mood management group
academic activism 237
Group InCircle
femme (definition) 250
arts therapy exercises 181–2
gender binary (definition) 250
background of 175–6
Gray Ace (definition) 252
dissemination 178–9
invalidation and 236
evaluations of 178, 180–1, 182, 189–90
pansexual (definition) 252
identifying deliverables 178–9
queering 236–7
patient recruitment 180
rainbow wisdom 249
planning for 179–80
suicidal behaviors (prevalence) 244
and PRRC staff 181
therapist ignorance around 233–5, 238–9
Strategic Statement of Need 186–7
therapist privilege and 235
sustainability 178–9, 182
trans (definition) 250, 251
therapist manual 182–3, 191–5
visual signs of support for 239
see also veterans
life-threatening behaviors 159
guided imagery exercises 49
loving-kindness meditation 124–5
 Subject Index 283

mandalas 268 observer-self 65

manipulative versus resourceful 27 “One Together” 122
mastery building 18, 208, 261 one-mindfulness 207
materials, quality of 224, 262 open custody facilities 114
ME program Opening the Space technique 32
art in 68–70 openness
development of 66–7 radical 241, 242–3
wise mind in 67–8 radically open DBT (RO-DBT)
meditation 259–60 92–3, 106, 242–3
metaphor 121 operant conditioning 171
individual manifestation of 16–8 opposite-to-emotion action 208–9, 213, 258–9
metaphors 118 outcome-based reimbursement 37
#MeToo movement 123–4
mindfulness
pansexual (definition) 252
anxiety ratings after 47
parasympathetic nervous system 93
case study (Mary) 81
perfectionism 96–7
case study (Tandy) 84–5
phone coaching 112
core mindfulness skills 171, 206–7
poetry writing 167–9, 228–9
of darkness and light 32–3
pointillism 33
in DBT 41
polyvagal theory 202–3
definition of 91
positive space 31
expanding conceptualization of 241–2
practicing (repeated) 18, 51
individual manifestation of 15–6
present moment (focus on) 133–4, 142–3
in ME program 69
pretreatment stage 92, 135–7, 170
road trip (recovery process) 46
problem-solving versus ruminating 28–9
role in ceramic-based art therapy 119–20
pronouns (gender) 11
self-compassion centered 119–20
pros and cons lists 209–10
skills training 45–7, 81, 84–5
Psychosocial Rehabilitation and Recovery
states of mind symbols 102
Center (PRRC) 174–5, 181
top down approach of 202
PTSD 106–7
upside-down drawing 102
“pushing away” strategy 62–3
see also Creative Mindfulness
mindfulness bowl 124
mindfulness of emotions 162, 165 quality-of-life-interfering behaviors 160
mindfulness-based art therapy (MBAT) 90 quarks 30–1
missing link analysis 160 queer (meaning) 251
“mistakes” 99 queering 236–7
“Model for Describing Emotions” handout 80
mood management group
radical acceptance 42, 69, 118–9,
check-in 258–9
210, 241, 242–3
end of session 271
radical openness 241, 242–3
goals of 256–7
radically open DBT (RO-DBT)
meditation 259–60
92–3, 106, 242–3
overview 256
Radius Child and Youth Services 113, 122
session structure 257
rainbow wisdom 249
task of therapist 260–1
rational mind 222–3
see also visual journaling
reasonable mind 45, 91
music (rests/pauses in) 31, 32
recidivism 131
reflective writing 263
negative space 31 reparenting 139
neuroplasticity 202 resourceful versus manipulative 27
nonjudgment 96–7, 206–7, 213 restraint 129
numb versus content 29 right brain to right brain communication 203
rollercoaster drawing activity 103
ruminating versus problem-solving 28–9
284 DBT-INFORMED ART THERAPY IN PRACTICE

safe container 61, 100–1 therapeutic relationship 61, 100

seclusion (high-security treatment therapy calendar 137
unit) 129, 130 therapy-interfering behaviors (TIBs) 159–60
secrets hidden in artwork (myth of) 100 thriving 113
self-acceptance 118 Time’s Up movement 124
self-compassion centered mindfulness 119–20 touch
self-injury 84, 114, 120, 157 handprints as replacement for 141
self-invalidation 160, 170 handshakes 129
self-respect effectiveness skills 191–2 in high-security treatment unit 128–9
self-soothing 209, 229–30 power of 128
self-taught artists 99 PTSD and 129
Seurat, Georges 33 training/internships 57, 59
sheros 123 trans (definition) 250, 251
silence 263–4 trauma link to offending behavior 114
skillful means 8, 46 trauma narrative 120–1
skills training triadic therapy 135–7
as an evidence-based practice 40
combining with art therapy
unknowingness (cultivating) 239, 244
interventions 133–4
upside-down drawing 102
generalization of the skills 50–1, 205
urge surfing 104
overview 94
see also communication skills;
distress tolerance skills; emotion validation 42, 98, 248
regulation skills; interpersonal value-based payment 37
effectiveness skills; mindfulness values mountain 34
smuggling watercolor 106 veterans
social activism 113, 120–5 needs assessment 176–8, 186, 187–8
solitude, choice of 28 Psychosocial Rehabilitation and
solution-focused brief therapy Recovery Center (PRRC) 174–5
(SFBT) model 217–8 see also Group InCircle
space (empty) 31 visual journaling
spiritual traditions 107–8 art journal 262–3
states of mind symbols 102 client as expert 269–70
STOP skill 85, 163–4 collage 267–8
“Stopping the War Within” 259–60 digression in 265
stress balls 145 feedback during 265
subatomic particles 30 mandalas 268
subjective emptiness artwork 31–2 modeling the activity 264–5
suicidal behavior photographs of 271
case study (Mary) 78–82 role of therapist 263
case study (Tandy) 82–6 safekeeping of 270–1
crisis survival toolbox 76, 81 silence during 263–4
DBT and 77 therapist as witness 268
high-risk groups 74 verbal processing of 269
parasuicidal ideation 75 voluntary participation 264
prevalence of 74 words in the image 267
as public health concern 74 see also mood management group
risk assessment 75–6 visual learning 132
risk factors 74
suicidal ideation 245–7
walking the middle path 84
suicidal thinking 75–6
wise mind 19, 45–6, 67–8, 91, 166, 222–3
symbolic language 138

Zen garden 105

target behaviors 154–5, 159–61
tessellations 33
 Author Index

Abbing, A. 29 Brunero, S. 51
Abram, K.M. 114 Bull, S. 132
Allen, E. 129, 130, 131, 133, 135, 136, 138, 145 Butler, J. 251
Allen, P.B. 108 Butterworth, J. 31
Altamirano, J.C. 174
Alty, A. 129
Cahn, S.K. 240
American Art Therapy Association 173
Cameron, C.L. 217, 218
American Psychiatric Association 22,
Campbell, A. 217, 218, 240
23, 38, 45, 90, 129, 154, 249
Campling, J. 217
Angelou, M. 121, 124
Carpenter, W.T. 129
Aniban, D. 122
Carr, R. 95, 108, 116, 174
Antcliff, L.R. 128, 144
Carroll, L. 115
Armstrong, F. 140
Cassin, S.E. 96
Ashworth, S. 131, 132
Center for Disease Control (CDC) 74
Chancellor, B. 174
Barker, M.J. 250 Chapman, A.L. 38, 39, 77, 79, 90
Barnicot, K. 173 Chapman, L. 90
Barth, K.S. 58 Chasday, H. 263
Barton, T. 31 Chatterjee, A. 174
Bauer, M.G. 43 Chatterjee, H.J. 202
Bell, R.C. 39 Chen, E. 89, 92
Ben-Porath, D.D. 92 Cho, A.S. 174, 176
Berg, I.K. 217, 218 Clanton Harpine, E. 261
Berger, B. 240, 244, 245, 248 Clark, S.M. 7, 30, 41, 45, 52, 73, 77, 96,
Bergland, M.C. 95, 133 105, 133, 134, 155, 156, 174, 264
Bernstein, D.P. 133 Cohen-Liebmann, M. 132
Betensky, M.G. 217 Collie, K. 90
Bhattacharjee, D. 255 Collier, J. 138
Blake, D.M. 90, 92 Courbasson, C. 58
Bleijlevens, M.H.C. 129 Cresswell, J.D. 39
Bloom, B.L. 217, 218 Cruwys, T. 260
Bobele, M. 217
Bohus, M. 58, 169
Davidson, S. 124
Boldero, J.M. 39
de Bono, E. 249
Bonavitacola, L. 108
de Shazer, S. 217
Borkovec, T.D. 134
Dean, M. 43
Bouman, W.P. 250
Deblinger, E. 121
Brantley, J. 228
Department of Health 129
Brewerton, T.D. 90
DeSouza, J. 40, 52
Brogan, K. 199
Dibiasio, P. 131
Brown, J.F. 131
Dimeff, L.A. 58, 90, 92, 130, 154,
Brown, K.W. 39
170, 236, 241, 243, 244
Brown, M.Z. 131

285
286 DBT-INFORMED ART THERAPY IN PRACTICE

Dimidjian, S. 219 Harlow, H.F. 134

Dinsmore, C. 113 Hass-Cohen, N. 95, 108, 116, 174
Dixon, L. 58 Havsteen-Franklin, D. 174
Dixon-Gordon, K.L. 79 Hayes, S.C. 219
Doidge, N. 202 Healthcare News 74
Dokter, D. 89, 101 Heard, H.L. 171
Dolan, Y. 217 Heckwolf, J.I. 95, 96, 133
Dominelli, L. 217 Hefferline, R. 245
Drake, R.E. 37 Henagulph, L. 134
Dreeben, S.J. 259 Herbener, E.S. 198
Düchting, H. 33 Hetherington, A. 128
Dudley, R. 170 Hill, S.W. 128, 143
Duncan, A. 174 Hinz, L.D. 89, 90, 97, 98, 134
Dunkley, C. 131 Hirvikoski, T. 58
Dyer, M. 96, 107, 155 Ho, R.T.H. 116
Hogan, S. 267
Horkheimer, M. 237
Edwards, B. 31
Horovitz, E.G. 108
Elbrecht, C. 116, 128, 144
Huckvale, K. 51, 59, 61, 94, 97,
Emerson, E. 139
99, 133, 134, 155, 197
Engels, F. 113
Hunter, M. 128
Escher, M.C. 140
Hunter, M.R. 107
Hutchinson, L. 94, 100, 101, 134, 136
Fairburn, C.G. 92
Farrelly-Hansen, M. 108
Ibáñez, A.F. 244
Federici, A. 92, 94
Ingamells, B. 132
Feigenbaum, J. 219
Fox, S. 267
Franke, I. 129 Jeffrey, J. 58
Fraser, G. 238, 239, 244, 251 Jo, G. 58
Frazier, S.N. 131 Johnson, P. 134
Joiner, T. 75
Jones, K. 239
Gafner, G. 223
Ganim, B. 267
Garcia, S.E. 124 Kabat-Zinn, J. 39, 91, 259
Garfinkle, P.E. 92 Karbelnig, A. 128
Garner, D.M. 92 Kass, J.D. 197, 199, 201, 202, 203
Gavey, N. 240, 241 Katz, M.R. 58
Gender Minorities Aotearoa 244 Kellogg, S.H. 139
Gilroy, A. 43 Kilbourne, A.M. 37
Goodman, M. 173 King, J.L. 132
Goodman, P. 245 King Jr, M.L. 248
Green, D. 237 Kleijberg, M. 134
Grenyer, B.F.S. 66 Klonsky, E.D. 23
Gross, J.J. 134, 219 Knill, P.J. 204, 205
Grosz, S. 268 Koerner, K. 10, 90, 91, 92, 98, 113, 130,
Gunaseelan, S. 260 153, 154, 158, 159, 161, 170
Gunderson, J.G. 23 Kornfield, J. 259
Gussak, D. 132, 135 Kreger, R. 23
Kristof, N.D. 121
Kuczaj, E. 139
Hackett, S.S. 135
Kuyken, W. 170
Haeyen, S. 134
Hannan, L. 202
Hanson, R. 202 La Via, M.C. 92
Harley, R. 58 Lamont, S. 51
 Author Index 287

Langone, A. 124 Mendius, R. 202

Lask, B. 90 Micozzi, M.S. 91
Lawn, S. 239 Miller, A.L. 65, 99, 130, 154, 155
Leader, D. 140 Miller, W.R. 217
Learmonth, M. 51, 59, 61, 94, 97, Monti, D.A. 90
99, 133, 134, 155, 197 Moon, B. 257
Lebowitz, E. 94, 95, 97, 98, 99, 102, 108 Morrissey, C. 132
Levens, M. 89 Morrow, J. 29
Levenson, R.W. 134 Mouratidis, M. 95, 133
Levine, E.G. 204 Mulvey, E.P. 71, 219
Levine, P.A. 199, 203
Levine, S.K. 204
Nan, J.K.M. 116
Lew, M. 131
Nash, G. 140
Lieberman, M.D. 32
National Institute of Mental
Linehan, M.M. 7, 8, 10, 23, 24, 25, 26, 27,
Health (NIMH) 74, 173
30, 33, 34, 38, 39, 40, 41, 42, 45, 46,
New York Times, The 87
49, 51, 52, 58, 61, 63, 65, 67, 73, 77,
Newhill, C.E. 219
79, 80, 84, 85, 90, 91, 92, 94, 95, 98,
Nishikawa, Y. 58
99, 103, 104, 105, 107, 112, 113, 114,
Nolen-Hoeksema, S. 29
117, 118, 130, 131, 132, 134, 143, 153,
Nordmarken, N. 128
154, 155, 158, 159, 161, 162, 163,
Nunn, K. 90
166, 170, 171, 174, 176, 181, 191, 193,
195, 197, 198, 199, 200, 201, 205, 206,
207, 209, 211, 216, 219, 220, 221, 222, O’Brien, B. 242
235, 236, 240, 241, 242, 243, 244, 248, O’Brien, J. 251
256, 257, 258, 259, 260, 261, 263 O’Farrell, K. 132
Links, P.S. 23 Oudshoorn, J. 114
Locher, J.L. 33
Long, I. 138
Padesky, C.A. 170
Lynch, T.R. 92, 93, 106, 242, 243, 252
Panos, P.T. 39
Paris, J. 39, 58
McCabe, E.B. 92 Parker, A.G. 38
McCann, R.A. 131 Pavuluri, M.N. 198, 199
McCown, D. 91 Pelton-Sweet, L.M. 236
McKay, M. 228 Perls, F.S. 217, 245
McMahon, J. 239 Persons, J.B. 170
McNeill, J. 33 Plener, P.P. 108
McNeilly, G. 266, 270 Porges, S.W. 202, 203
McNiff, S. 98
Maier, S.F. 144
Rabin, M. 100, 101, 107
Maizels, J. 99
Rafaeli, E. 133
Makary, S. 108
Rajab, M.H. 75
Makin, S.R. 89, 99
Rappaport, L. 10, 65
Malchiodi, C.A. 107, 132, 155
Rathus, J.H. 65, 99, 130, 154
Mamberg, M. 259
Reber, C. 94, 95, 97, 98, 99, 102, 108
Manning, S. 170
Regev, D. 263
Marcus, M.D. 92
Reibel, D. 91
Marx, K. 113
Reuter, T. 240
Mason, P.T. 23
Rexter, L. 99
Mason, T. 129
Rhodes, C. 99
Masterson, J.F. 107
Richardi, T.M. 58
Matthews, T. 24
Richards, C. 250
May, J.M. 58
Rizvi, S. 130, 219
Mazza, N. 229
Roemer, L. 134
Mehl, J. 103
Rollnick, S. 217
288 DBT-INFORMED ART THERAPY IN PRACTICE

Rothaus, M.E. 205 Tang, Y. 174

Rothschild, B. 203 Tappan, T. 29
Rothwell, K. 94, 100, 101, 134, 136 Telch, C.F. 89
Rowan, J. 245 Thích, N.H. 124
Rubin, J.A. 107, 174, 176 Thomson, M.J. 134
Rubin, S. 108 Tomlin, J. 129
Rudd, M.D. 75, 76, 77, 87 Tomlinson, M.F. 131
Ryan, H. 39, 251 Trantham, S.M. 197, 199, 201, 202, 203
Ryan, R.M. 39 Trivedi, R.B. 173
Troncoso, A. 140
Turner, B.J. 79
Sackett, D.L. 38, 43, 45
Twamley, E.W. 173
Safer, D.L. 58, 89, 92, 104
Salmon, P. 259
Sansone, R.A. 240 US Department of Health & Human
Satir, V. 181 Services (UDHHS) 74
Schore, A.N. 203, 210
Schroeder, I.F. 237, 238, 251
van der Kolk, B.A. 107, 132, 138, 145, 201,
Schwanbeck, L. 10, 67, 77, 108, 156,
202
197, 200, 201, 202, 205
Van Dijk, S. 58
Sedgwick, E.K. 236
van Lith, T. 51
Seitz, A.R. 108
Vela, J. 131
Seligman, M.E.P. 144
Verheul, R. 131
Senn, C.Y. 240, 241
Veterans Health Administration (VHA) 174
Shams, L. 108
von Daler, K. 67, 77, 108, 156,
Shea, S.C. 75
197, 200, 201, 202, 205
Shelton, D. 131
von Ranson, K.M. 96
Sherry, A. 236, 244
Sherwood, P. 115
Shiell, M. 60, 62, 65, 94, 101 Wadeson, H. 129
Shwartz, R. 245 Waller, D. 262
Siegel, D.J. 95, 133, 145, 201 Ward, C. 262, 263, 270
Sinason, V. 139 Warner, M. 251
Singer, J. 251 Watson, R.A. 218
Skinner, B.F. 171 Weiderman, M.W. 240
Slive, A. 217 Weir, M. 248
Sneed, J.R. 58 Welch, S.S. 219
Snir, S. 263 Widiger, T.A. 23
Solomon, M.F. 133 Williams, L. 29
Southwick, S.M. 84 Wilson, P. 138
Spiegel, D. 108 Wisniewski, L. 92, 94
Springham, N. 142 Wood, J.C. 228
Stephens, P. 33 Woods, J.B. 236
Stoffers, J.M. 38 WuDunn, S. 121
Stokes, J. 139
Struve, J. 128
Young, J. 133, 139
Substance Abuse and Mental Health
Services Administration 51
Sutton, D. 51 Zappa, A. 237
Swales, M.A. 131, 171 Zur, O. 128
Sweeney, J.A. 198
Sweezy, M. 245
Swenson, C.R. 10, 153, 170, 171