Accepted Manuscript

Title: A Four-Drawing Art Therapy Trauma and Resiliency

Protocol Study

Authors: Noah Hass-Cohen, Rebecca Bokoch, Joanna Clyde

Findlay, Alyssa Banford Witting

PII: S0197-4556(17)30149-1
DOI: https://doi.org/10.1016/j.aip.2018.02.003
Reference: AIP 1505

To appear in: The Arts in Psychotherapy

Received date: 19-7-2017

Revised date: 24-1-2018
Accepted date: 9-2-2018

Please cite this article as: Hass-Cohen, Noah., Bokoch, Rebecca.,

Findlay, Joanna Clyde., & Witting, Alyssa Banford., A Four-Drawing Art
Therapy Trauma and Resiliency Protocol Study.The Arts in Psychotherapy
https://doi.org/10.1016/j.aip.2018.02.003

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 A Four-Drawing Art Therapy Trauma and Resiliency Protocol Study

A Four-Drawing Art Therapy Trauma and Resiliency Protocol Study

Hass-Cohen, Noah, Psy.D., Corresponding Author

Associate Professor
Couples Family Therapy Masters and Doctoral Programs
California School of Professional Psychology
1000 S Fremont Ave, Unit 5
Alhambra CA 91803

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Nhass-cohen@alliant.edu
noahhasscohen@gmail.com
(323) 717-6546

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Bokoch, Rebecca, Psy.D.,
Adjunct Faculty

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Alliant International University
1000 S Fremont Ave, Unit 5, Alhambra CA 91803
Anchor Children and Family Counseling

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280 S Los Robles Ave, Unit B, Pasadena, CA 91101
Tel: (323) 301-3984
Email: rbokoch@alliant.edu; rebecca@rebeccabokoch.com N
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Clyde Findlay, Joanna M.A., ATR
San Rafael, CA Psychotherapist
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Wellspring Psychotherapy Center

30 N. San Pedro Rd.
Suite 290
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San Rafael, CA 94903

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Banford Witting, Alyssa, Ph.D.

Associate Professor
Alliant International University
California School of Professional Psychology
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10455 Pomerado Road, DH-206E

San Diego, CA, 92131
T. 858.635.4889, F. 858.635.4585
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abanford@alliant.edu; banford@gmail.com
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+
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 A Four-Drawing Art Therapy Resiliency Protocol Study

The results of an art therapy experimental study of the four-drawing trauma and resiliency protocol showed:

 a decrease in overall effects of the traumatic event, negative affect, pain endorsement and possibly pain

intensity.

 an increase in the number of endorsed resources.

 the drawings had a positive impact on participants’ understanding and meaning-making of the traumatic

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event.

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Abstract

Resiliency, as fostered by creativity, imagination, and the arts therapies, is a critical factor in managing the

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impact of adversity. This pilot study investigated the potential effectiveness of a four-drawing art therapy
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trauma and resiliency protocol for coping with adverse life events. The protocol is designed according to
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memory reconsolidation research and based in art therapy relational neuroscience (ATR-N) principles and
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trauma models. The hypotheses were that participation in the four-drawing protocol would result in: decreases
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in overall effect of the traumatic event (hypothesis one), decreases in negative affect endorsement and rating as
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expressed by sadness, grief, depression and anxiety (hypothesis two and three), reductions in pain endorsement

and rating (hypothesis four and five), increases in resiliency-based resources (hypothesis six), positively rated
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impact on participants’ understanding of the problem and resources (hypothesis seven), increases in

posttraumatic growth cognitions (hypothesis eight), and increases in relational security (hypothesis nine). The
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positive effects of the four-drawing protocol components, including the drawings, questionnaires, and inquiry
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were examined. Main findings included significant decreases in the rating of the effect of the traumatic event

(hypothesis one), self-reported endorsement and ratings of negative affect (hypothesis two and three), trends in

pain reduction ratings (hypothesis five), significant increases in endorsed resiliency resources (hypothesis six),

and positive ratings of the impact of the drawing activity (hypothesis seven), but no significant changes in

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endorsement of pain (hypothesis four), posttraumatic growth cognitions (hypothesis eight), or relational security

(hypothesis nine). Additional results revealed that decreased endorsement and ratings of negative affect

continued to be maintained at follow-up, and that the inquiry had a self-reported positive impact on participants’

understanding and meaning-making of the traumatic event. It is possible that memory reconsolidation processes

may account for the positive changes.

Introduction

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Trauma has been associated with a spectrum of behavioral, emotional, cognitive, and intra- and

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interpersonal impacts, including: chronic negative affect, social isolation, and relational problems, which

sometimes qualify for a post-traumatic stress disorder (PTSD) diagnosis (American Psychiatric Association,

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2013). Trauma types include: relational versus non-relational trauma, and single incident versus chronic-

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complex trauma. The impact of trauma was shown to depend on perceived degree of threat to self and others,

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resiliency, and environmental factors (Agaibi & Wilson, 2005), including: relational insecurity and loneliness
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(Meredith, Ownsworth, & Strong, 2008), negative self-views (Sutherland & Bryant, 2005), and chronic pain
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(Liedl, O'Donnell, Creamer, Silove, McFarlane, & Knaevelsrud, 2010).

A current traumatology focus is resilience, which has been defined as the ability to cognitively anticipate
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and cope in the face of stress, threats, and challenges (Agaibi & Wilson, 2005). Critical individual abilities were
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identified, including: mastery of resources (Gil & Weinberg, 2015), capacity for positive emotions (Kok &

Fredrickson, 2013), an internal locus of control (Agaibi & Wilson, 2005), and availability of social support and
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interpersonal security (Meredith et al., 2008). Personality traits were found to contribute to the cognitive and
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emotional flexibility needed to disclose, explain, and process trauma in therapy and return to baseline levels of

life satisfaction (Peterson, Park, & Seligman, 2004). Optimism, flexibility, insight, self-confidence, aptitude for
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meaning-making, self-care, and identification as a survivor rather than a victim, were some examples (Maddi,

2006). Other characteristics that contributed to resiliency include the capacity for creativity (Gallagher &

Lopez, 2007), imagination (Kalmanowitz & Ho, 2016; Lahad & Leykin, 2013), and the appreciation of beauty

(Peterson et al., 2004). Strength-based treatment approaches that have also been suggested as contributors to

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resiliency include: short term group psychotherapy and single sessions, which are based on findings that that

most therapeutic change occurred in the first couple of sessions (Başoglu, Salcioglu, & Livanou, 2007; Slive &

Bobele, 2012; Talmon, 1993).

Art Therapy, Trauma, and Resiliency Research

Art therapy practices stimulate integrated and creative cognitive-emotional responses to trauma. Such

practices supported safe, positive emotional experiences, mastery, coping, and social-communication

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(AlAjarma, 2010; Collie, Backos, Malchiodi, & Spiegel, 2006; Johnson, Lahad, & Gray, 2010; Kalmanowitz,

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2016; Worrall & Jerry, 2007). Moreover, art therapy was acceptable for a diversity of populations impacted by

trauma, such as: refugees (Baker, 2006; Drozˇdek, Bolwerk, Tol, & Kleber, 2012), incarcerated women (Hongo,

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Katz, & Valenti, 2015), older African American women (Moxley, Washington, & Feen-Calligan, 2012), and the

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military (Nanda, Gaydos, Hathorn, & Watkins, 2010). Research with active military service members has also

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demonstrated the potential of expressive arts for integrated medical arts approaches to the treatment of
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traumatic brain injury (Jones, Walker, Masino Drass, & Kaimal, 2017; Walker, Kaimal, Koffman, & DeGraba,
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2016), whereas Carr (2008) has used a third hand approach in a palliative care case study.

Randomized clinical trials have included a diversity of art therapy methods (Baker, Metcalf, Varker, &
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O’Donnell, 2017; Schouten, de Niet, Knipscheer, Kleber, & Hutshcemaekers, 2015). For example, Erickson
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(2008) provided six weekly art therapy group sessions for incarcerated women, and Curry and Kasser (2005)

evaluated the effectiveness of mandala drawing with undergraduate students. Henderson, Rosen, and Mascaro
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(2007) also used mandala drawings three times with undergraduate students who had experienced a diversity of
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trauma symptoms. More recently, Zimmermann et al. (2015) used painting, crafts, and relaxation for three

weeks with German soldiers, and Wang et al. (2015) studied an eight-week creative writing and drawing for
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motor vehicle accident survivors to prevent post-traumatic stress disorder.

Integrated art therapy and psychotherapy research demonstrated significant decreases in trauma

symptom severity (Schouten et al., 2015). Examples include Volker (1999), who provided female sexual assault

survivors with a combined CBT and art therapy, and Stok (2007), who combined art and trauma-focused verbal

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therapy for three sessions. Lahad, Farhi, Leykin, and Kaplansky (2010) compared re-imagining traumatic

memory using selected cards as part of art making, to EMDR treatment; whereas, Campbell, Decker, Kruk, and

Deaver (2016) compared an eight-week art therapy group with Cognitive Processing Therapy for veterans.

Art Therapy, Pain, and Trauma

Trauma and pain experiences have been described as correlated and bi-directional (Camic, 1999;

Siqveland, Ruud, & Hauff, 2017). Art therapy provided a fitting treatment, as the prevalence of strong

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distressing imagery was very high for people with pain (Philips, 2011). Meaning-making, a common art therapy

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practice, seemed to provide the only connection between painful bodily imagery, sensations, and emotional-

psychological functioning (Trauger-Querry & Haghighi, 1999). Art therapy cancer research found statistically

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significant reductions in pain, fatigue, breathlessness, insomnia, lack of appetite, and anxiety (Nainis et al.,

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2006). Qualitative pain research also showed support for an integrated art-based cognitive approach

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(Czamanski-Cohen, Sarid, Huss, Ifergane, Niego, & Cwikel, 2014). Moreover, it is likely that art-making
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offered increased insight, pleasure, self-management of pain, sense of control, and quality of life (Ennis,
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Kirshbaum, & Waheed, 2017; Hass-Cohen & Clyde Findlay, 2009; Puetz, Morley, & Herring, 2013).

Models and Protocols

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Research called for art therapy models and protocols that sequenced interventions according to stages
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(Gerge & Pedersen, 2017). One such influential art therapy protocol is the Instinctual Trauma Response (ITR)

neuroscientific model, which was developed for diverse types of severe trauma. It emphasized drawing a
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graphic narrative and then having the therapist re-present the story back to the survivor (Gantt & Tinnin, 2009).
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For combat-related PTSD, Collie et al. (2006) recommended a three-stage art therapy model, which

involved: (a) reducing arousal and increasing social bonding, (b) processing memories, and (c) attaining insight.
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For the same population, Naff (2014), suggested: (a) containment and security, (b) narration and exposure

allowance, (c) integration, and (d) maintenance. Meekums (1999), proposed an internal-trauma processing

model, consisting of: (a) striving, (b) incubation, (c) new perspective, and, (d) reevaluation, whereas Rankin &

Taucher (2003) called for a six-task oriented approach: safety planning, self-management, telling the trauma

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story, grieving losses, self-concept and worldview revision, and self-relational-development. The Expressive

Therapies Continuum, a neuroscience approach, was used to treat trauma and highlights levels of processing

(Hinz, 2009). Lastly, Lahad (1993) suggested the BASIC PH model for survivors of the ongoing threat of war,

which emphasized the importance of specific categories of coping resources, and consisted of: beliefs, affect,

social, imagination, cognitions and physical care.

Therapeutic Change Agents

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Memory reconsolidation (MR) was described as a likely therapeutic change agent for art therapy trauma

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treatment (Hass-Cohen, 2016; Hass-Cohen & Clyde Findlay, 2018). For example, an ATR-N study evaluated

how a drawing protocol, which involved changing art-based presentations, and positively affected the arousal of

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a 9-11 survivor (Hass-Cohen, Clyde Findlay, Carr, & Vanderlan, 2014). Hardt, Einarsson, and Nader (2010)

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described MR as occurring each time a memory is revisited; during MR, proteins destabilize and then

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resynthesize in the memory and fear centers of the brain, forming an updated memory within a four-to-six-hour
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window of opportunity (Nader, Schafe & LeDoux, 2000). Schwabe, Nader, and Pruessner (2014) reported that
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for MR to occur, a brief reminder is required, which protects from hyperarousal and the triggering of extinction.

MR is likely a safer change process than extinction, as survivors experience exposure as frightening. Unless it is
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integrated with MR, extinction is also vulnerable to spontaneous recovery, as the conditioned or unconditioned
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stimuli may be unexpectedly activated (Monfils, Cowansage, Klann, & LeDoux, 2009; Phelps, Delgado,

Nearing, & LeDoux, 2004; Schiller, Raio, & Phelps, 2012).

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Creativity has been described as a protective catalyst for memory reconsolidation, as it transforms the
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past negative experience into something new, providing a sense of control, and distance from the event (Hass-

Cohen, 2015). For example, art-making promoted a novel sense of purposefulness, mastery, planning, and
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resourcefulness, which germinated the discovery of resiliency (Worrall & Jerry, 2007). Hass-Cohen and Clyde

Findlay (2018) emphasized that the artwork may aid the art therapist in finding personal clues that strengthen

reciprocity between the client’s different resiliency abilities. ATR-N approaches have suggested that safely

accessing non-verbal memories (Hass-Cohen & Clyde Findlay, 2018), making implicit memories explicit (Gantt

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& Tinnin, 2009), and positive effects of sensory and bi-lateral stimulation (Talwar, 2007; Tripp, 2007), likely

contributed to MR.

The ATR-N Secure Remembrance Model and the Four-Drawing Protocol

Hass-Cohen and Clyde Findlay (2015) described the ATR-N secure remembrance components as:

safety, relationships, remembrance, reconnection, and resiliency (SR-5). SR-5 does not have fixed stages, as

establishing safety and building relationships are ongoing tasks in trauma recovery (Hass-Cohen, 2016). SR-5

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follows the Tri Phasic model (Herman, 1995), which has been adapted by the International Society for Trauma

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Stress Studies. Similar to ITR (Gantt & Tinnin, 2009), and in accordance with ATR-N principles and MR

theory, SR-5 accentuates the activation of resources and integrative self-functions, as described by Avrahami

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(2006) and by Gerge and Pedersen (2017). The four-drawing protocol emerged from this framework. Clinical

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studies have demonstrated the four-drawing protocol’s potential to alleviate pain and trauma (Achterberg,

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Dossey, & Kolkmeier, 1994; Bridgham & Hass-Cohen, 2008; Clyde Findlay, 2008; Hass-Cohen & Clyde
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Findlay, 2009; 2018).
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The four-drawing protocol was piloted for a diverse range of aversive life experiences, with no

documented diagnosis of PTSD. It was designed as a single individual session of 90 to 120 minutes. Retention
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and premature dropout were identified as common concerns for trauma treatment, as well as delayed diagnosis
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(Doran, Pietrzak, Hoff, & Harpaz-Rotem, 2017; Schottenbauer, Glass, Arnkoff, Tendick, & Hafter Gray, 2008).

Thus, the four-drawing protocol was designed to address these gaps, as most models reviewed above provided
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service for homogenous populations and utilized short-term groups that ranged from full day workshops to 10-
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week treatments for diagnosed clients. The trauma pictorial narrative is promoted by four directives: (1) “Draw

a picture of the problem,” (2) “Draw a picture of yourself,” (3) “Draw the internal and external resources that
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helped you with the problem,” and (4) “Draw yourself, as you see yourself now.”

Methods

Sample Demographics

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 Participants were recruited from graduate students in a couple and family therapy program, in accordance

with the University IRB approval. Students were offered extra credit for participation in a research study.

Students who were not interested in participation were offered an alternative extra credit assignment. There

were no other incentives offered. Participants were matched with interviewers from another university campus

with whom they had no relationship. The majority identified as female (n = 27/31; 87%) and others as male.

The mean age was about 30 years old (M = 29.68, SD = 8.32), with an equal number of White and

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Hispanic/Latino participants (n = 13/31; 42%, for each), and Black/African American and Asian/Pacific

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Islander respondents (n = 2/31; 7%). The majority reported satisfactory health ratings (n = 29/31; 94%), being

spiritual (n = 24/31; 77.4%), and a third reported being religious (n = 11/31; 35.5%). Average age at the time of

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the trauma was 25 years (M = 24.94, SD = 10.06), and the traumatic event occurred, on average, about four

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years ago (M = 4.29, SD = 3.89), (Table 1).

Table 1 N
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Univariate Statistics for Sample Demographics (N=31)
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Measures

Measures included the Relationship Rating Scale (RR), Negative Affect and Pain Endorsement and
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Rating Questionnaire (NAPER), Pre-and Post-Trauma Effect (TE) items, Posttraumatic Growth Cognitions
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Inventory (PTCI) (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999), and Resource Endorsement Checklist (REC).

The RR (adapted from Bartholomew & Horowitz, 1991) required ratings of six perceived relational security
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items with two items for each type of attachment style, including: secure, insecure-avoidant, and insecure-
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dismissive relational styles. Except for the PTCI, all rating measures were on a scale of one to seven (1 “not at

all” and 7 “very much so”). The NAPER self-report items required endorsement and then rating of sadness,
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grief, depression, anxiety, and persisting pain. The Pre/Post-TE items asked participants to rate the effect of the

traumatic event on their lives in the last year. The PTCI, a standardized measure, rated self-reliance, initiative,

growth, acceptance (Foa, Ehlers, Clark, Tolin, & Orsillo, 1999). The REC required endorsement of resources

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from six areas: beliefs, emotions and feelings, social and cultural, imagination and interests, thinking and

cognitions, and self-care (adapted from Lahad & Leykin, 2013), (Figure 1).

Figure 1. Resource Endorsement Check List

Hypotheses

The first hypothesis postulated that as a result of participating in the four-drawing protocol, ratings of

overall effect of the trauma on participants’ lives, as measured by TE, would decrease from time of study entry

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(Time 1) to follow-up (Time 3). As a result of participating in the four-drawing protocol, the second and third

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hypotheses anticipated that endorsements and ratings of negative affect, as measured by the NAPER, would

decrease from Time 1 to 3. Similarly, the fourth and fifth hypotheses anticipated a decrease in pain endorsement

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and ratings from Time 1 to Time 2a, 2b, and 3 (NAPER). The sixth hypothesis projected that participation in the

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four-drawing protocol would contribute to an increase from Time 1 to 2b in endorsement of personal resources

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(REC). The seventh hypothesis specifically postulated that a significant number of participants would report
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positive impacts of the drawing activity on their understanding of the problem and their resources (Time 2b,
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post-drawing inquiry), as a result in their participation in the four-drawing protocol. Similarly, the eighth and

ninth hypotheses estimated an increase from Time 1 to 2b in posttraumatic growth cognition (PTCI) and
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relational security (RR), (Table 2).

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Table 2

Hypotheses
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Procedures
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At study entry (Time 1), participants completed pre-measures: RR, REC, and NAPER. They also chose

a traumatic life event that had happened at least one year and not more than five years ago, and rated: a) the Pre-
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TE, b) how they felt at the time of their reported trauma, and c) how they perceived their coping (Figure 2).

Figure 2. Protocol Sequence and Measures

Participation took 90 to 120 minutes and included: pre-protocol measures (Time 1), the four-drawing

activity, inquiry after the third drawing, inquiry after completing all four drawings, an endorsement and rating

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of pain at post four-drawing completion (Time 2a), post-protocol measures (Time 2b and 2c), and follow-up

measures (Time 3). As a precaution, interviewers checked in with participants for any pain experiences after

completing all four drawings, to ensure that participants were not in pain due to the motor activities associated

with drawing. Post-protocol measures included the RR, REC, NAPER, and PTCI. One week after completing

the protocol, participants were reminded of the interview and reflected on their experience by listening to a

recording of the inquiry (Time 2c). The study concluded with follow-up measures, which occurred five to six

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weeks after entry to the study (Time 1), or two weeks after the reminder reflection at Time 2c (Figure 2).

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Four-Drawing Protocol

Drawing intervention. For all four drawings, participants chose from a selection of colorful and white

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paper, and pastels or markers. After each drawing, they wrote a title and short story about the drawing. The first

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four-drawing protocol directive asked the participants to represent the problem, thus assisting in identifying

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aspects of the traumatic event that needed processing. The second directive asked for a self-portrait; thus,
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eliciting the representation of the participant’s mental self-image in the context of the adverse event. Then, an
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optional break, including a guided relaxation breathing exercise of three to five minutes, was offered. The third

directive called for a depiction of internal and external resources that had helped with the problem (Hass-Cohen
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& Clyde Findlay, 2009). The trauma memory, which was processed in the context of the resources included
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prompts: “Which resources are external? Which ones are internal? Which one of out of all the internal and

external resources is the most important to you?” To thicken the resource story, participants were then asked to
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prioritize and discuss each resource, as well as identify the order in which they drew the resources. The fourth
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and final directive, another self-portrait, was drawn after exploring the resources with the participant (Bridgham

& Hass-Cohen, 2008) and emphasizes the present tense by stating: “draw yourself as you see yourself now,”
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(Figure 3).

Figure 3. Four-Drawing Protocol Example

Post-drawing inquiry. After participants completed the drawing, they completed a brief questionnaire

about pain (Time 2a). Then, participants examined their four drawings, shared titles and narratives, and

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compared the two self-drawings (drawings 2 and 4). Then, they were asked if the protocol sequence was

meaningful and what about the sequence was meaningful to them. They also rated the following statements:

“Has your understanding of the problem changed?” (scale of 1-7), “If so what type of change was it?” (positive,

neutral, or negative), and “What contributed to this change?” After completing the drawing activity and the

related inquiry, participants completed post-measures (Time 2b), (Figure 2).

Reflection. Participants listened to a recording of their four-drawing protocol inquiry and transcribed

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their responses to the questions above (Time 2c).

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Follow-up. Participants responded to and rated the following: 1) “This event negatively affects my life

now” (scale of 1-7), 2) “The (a) art activity, (b) discussion, and (c) questionnaires positively affected my access

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to my resources” (scale of 1-7), 3) “Which of the above (a-c) was most impactful for you?”, 4) “In the time

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since participating in the protocol did you notice any changes about your experience of the art-based activity?”,

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and 5) “In the two weeks since the art activity, have you noticed any changes about your experience of the
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event?” Participants also completed follow-up questionnaires (Time 3).
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Data Analysis

Non-parametric Wilcoxon’s signed rank tests compared means for event rating, pain, and negative affect
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(Time 1 to 3), and for posttraumatic growth cognitions, attachment, affect, pain, and resources (Time 1 to 2b).
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Paired samples t-tests compared affect subscales: sadness, depression, grief, and anxiety (Time 1 to 3).

Cochran’s Q tests compared the frequency of endorsement of pain and affect from all time measurements. Pain
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data was measured and analyzed for all four times. Pain results were interpreted with caution, as at Time 1
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participants were asked if they were experiencing or had “ever” experienced persisting pain; therefore, a

separate analysis without Time 1 data on pain was also conducted for Time 2a, 2b, and 3, where participants
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were asked if they were experiencing any pain “now.” Results from the qualitative interpretation of the

drawings will be reported in a separate publication.

Results

Participants

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 Participants presented with a profile of resiliency, consisting of a strong trauma impact of pain and

negative emotions, combined with a high level of perceived coping. There were more large traumas than small

traumas in this sample (n = 21/31; 67%, versus, 6/31; 19%). Large traumas were identified as involving death,

near death, or a severe threat to self or a close other, and examples included: sudden unexpected death, sexual

assault, and life-threatening illness (n = 4/31; 12%). Examples of small trauma experiences included: divorce,

surgery, and family relationship issues. Most of the diverse types of traumas occurred during young adulthood

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(n = 28/31; 90%), and were single incident traumas (n = 19/31; 61%). A third were identified as chronic

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traumas (n = 12/31; 28%), out of which, a small percentage were childhood traumas (n = 3/31; 10%).

A large majority of the participants rated their feelings of intense helplessness, fear, or horror at the time

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of the event as very high (n = 19/31; 74%; ratings 6-7, with 7 being the highest rating possible), about a third of

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the participants rated their feelings as somewhat high (n = 10/31; 32%; ratings 3-5), and about a fifth of the

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participants rated their feelings as low (n = 6/31; 19%; ratings 1-2). Two thirds of the participants rated that they
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had coped with the event very well, (n =21/31; 68%; ratings 5-7), about a third of the participants felt they had
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somewhat coped with the event (n = 10/31; 32%, rating 3-5), and a minority reported not coping with the event

(n = 2/31; 1%; ratings 1-2). More than half of the participants rated the trauma effect on their life as somewhat
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high (n = 17/31; 55%; ratings 3-5), more than a third rated the trauma effect as very high (n = 12/31; 39%;
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ratings 6-7), and a minority rated the trauma effect as very low or not at all (n = 2/31; 6%; ratings 1-2). A

majority also endorsed experiencing overall negative affect (n = 28/31; 90%), including an almost equal
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endorsement of sadness (n = 31/31; 100%), grief (n = 25/31; 81%), depression (n = 27/31; 87%), and anxiety (n
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= 29/31; 94%). No significant correlations were found between the rating of the effect of the traumatic event or

the level of coping and the type of trauma.

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Most participants reported persisting pain at time of entry into the study (n =19/31, 61%), and frequent

pain experiences (n = 12/19; 63%), every hour (n = 2/19; 11%), every day (n = 5/19; 26%), or every week (n =

5/19; 26%). About half of the participants reported that they had been experiencing pain for more than a year (n

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= 10/19; 53%); whereas, the rest of the participants reported experiencing pain for one to 11 months (n = 8/19;

42%), (Table 3).

Table 3

Trauma Related Sample Characteristics (N=31)

Trauma Effect (Hypothesis One)

Participants’ rating of the negative effects of the trauma experience on their life, showed a statistically

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significant decrease (Z = -2.45, p = .014, p < .016) from Time 1 (M = 4.74, SD = 1.51) to Time 3 (M = 4.03, SD

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= 1.66), (Table 4).

Table 4

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Means and Wilcoxon Signed-Rank Comparisons for Study Variables

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Negative Affect (Hypothesis Two and Three)

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Affect endorsement. The number of participants endorsing negative affect from Time 1 to 2b to 3
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decreased significantly (Q = 18.78, df = 2, p = .000, p < .001). The number of participants endorsing negative
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affect at Time 1 to 2b significantly decreased (Q = 8, df = 1, p = .005, p < .001). The number of participants

endorsing negative affect at Time 1 was also significantly lower at Time 3 (Q = 15, df = 1, p = .000, p < .001).
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There was no significant decrease or increase in participants’ endorsement of negative affect from Time 2b to 3,
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(Q = 3.77, df = 1, p = .052, p < .001), suggesting that gains were maintained (Table 5).

Table 5
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Cochran’s Q-Test Endorsement Comparisons for Negative Affect and Pain

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Affect rating. Ratings of negative affect significantly decreased (Z= -3.13, p = .002, p <. 016), from

Time 1 (M = 5.26, SD = 1.12) to Time 3 (M = 2.62, SD = 1.08), (hypothesis three), (Table 4). Ratings of
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negative affect also significantly decreased (Z = -3.87, p = .000, p < .01), from Time 1 (M = 5.27, SD = 1.12) to

Time 2b (M = 2.67, SD = .94). There was no significant difference found for negative affect ratings (Z = -.358,

p = .72, p < .025) from Time 2b (M = 2.67, SD = .94) to Time 3 (M = 2.61, SD = 1.08). However, when

comparing negative affect subscales, there was a statistically significant and similar decrease from Time 1 to 3

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for all subscales, including: sadness (t (6) = 4.75, p = .003), grief (t (4) = 5.01, p = .007), depression (t (4) =

3.54, p = .024), and anxiety (t (7) = 7.00, p = .000), (Figure 4).

Figure 4. Negative Affect: Averages of Raw Data

Note. Endorsements: Time 1: Sadness (n = 31), Grief (n = 25), Depression (n = 27), Anxiety (n = 29), Time 2b:
Sadness (n = 14), Grief (n = 14), Depression (n = 5), Anxiety (n = 14), Time 3: Sadness (n = 24), Grief (n = 25),
Depression (n = 26), Anxiety (n = 22). Ratings: Time 1: Sadness (M = 5.51, SD = 1.46), Grief (M = 5.44, SD =
1.50), Depression (M = 4.78, SD = 1.72), Anxiety (M = 5.34, SD = 1.42), Time 2b: Sadness (M = 2.50, SD =
1.16), Grief (M = 2.29, SD = .91), Depression (M = 3.00, SD = 1.41), Anxiety (M = 3.00, SD = 1.47), Time 3:
Sadness (M = 2.00, SD = 1.00), Grief (M = 2.17, SD = .98), Depression (M = 2.60, SD = 1.52), Anxiety (M =

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3.56, SD = 1.01)

Pain (Hypothesis Four and Five)

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Pain endorsement. There was no significance for pain endorsement from Time 2a to 2b to 3, (Q = 4.2,

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df = 2, p = .122, p < .001), Time 2a to 2b (Q = 2.67, df = 1, p = .102, p < .001), Time 2a to 3 (Q = 3.571, df = 1,

p = .059, p < .001), or Time 2b to 3 (Q = .143, df = 1, p = .705, p < .001), (hypothesis four), (Table 5).

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Most of the participants that endorsed pain at Time 1 reported experiencing chronic and frequent pain (n
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= 19/31, 61%); therefore, for discussion purposes, further analysis assessed for significance in the difference in
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the number of participants endorsing pain between Time 1 and Times 2a, 2b and 3 (hypothesis four). Results
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showed a significant decrease in the endorsement of pain across all times (Q = 28.41, df = 3, p = .000, p < .001)
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(Table 5), (Figure 3). Pain endorsement also significantly decreased from Time 1 to 2a (Q = 17, df = 1, p = .000,
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p < .001), and from Time 1 to 2b, (Q = 11.267, df = 1, p = .001, p < .001). There was no significant change

between Time 2a and 2b (Q = 2.67, df = 1, p = .102, specified p < .001). While there was a large reduction in
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the raw number of participants that endorsed pain from Time 1 to 3 (n = 7/31 vs. n = 19/31), this frequency was

not significant (Q = 9, df = 1, p = .003, p < .001), (Table 5), (Figure 5).

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Figure 5. Pain Endorsement & Rating

Note. Time 1 (n = 19), Time 2a (n = 2) Time 2b (n = 6), Time 3 (n = 7).
Pain ratings: Time 1 (M = 4.58), Time 2a (M = 2) Time 2b (M = 2.83), Time 3 (M = 3.14).
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Pain rating. Analysis of ratings for participants who endorsed pain at Time 1 (n = 19) and continued to

endorse pain at Time 3 (n = 5/19) did not significantly decrease (Z = -2.04, p = .041. p < .016) from Time 1 (M

= 4.58, SD = 1.78) to Time 3 (M = 3.14, SD = 1.57), (hypothesis five). For participants that continued to

endorse pain (n = 6/19) from Time 1 (M = 4.58, SD = 1.77) to Time 2b (M = 2.83, SD = 1.60), ratings showed
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no significant difference (Z = -1.89, p = .059, p < .01). Finally, for Time 2b (n = 6/19) to Time 3 (n = 7/19)

there was not a statistically significant decrease in pain rating for those that continued to endorse pain (n = 6, Z

= -1.00, p = .317, p < .01), (Table 4), (Figure 3).

Relationship between affect and pain. There were no significant correlations between affect and pain

ratings or endorsements (Figure 6).

Figure 6. Negative Affect and Pain.

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Note. Time 1 (N = 31), Time 2b (n = 23), Time 3 (n =16).
Pain Endorsement: Time 1 (n = 19), Time 2a (n = 2) Time 2b (n = 6), Time 3 (n = 7). Negative Affect Ratings:
Time 1 (M = 5.26), Time 2b (M = 2.67), Time 3 (M = 2.62). Pain ratings: Time 1 (M = 4.58), Time 2a (M = 2)

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Time 2b (M = 2.83), Time 3 (M = 3.14). For purposes of illustration Time 1 endorsement was included.

Resources (Hypothesis Six)

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Participation in the protocol significantly increased the frequency of endorsed resources (Z = -4.06, p =

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.000, p < .01), from Time 1 (M = 39.81, SD = 8.11) to Time 2b (M = 46.87, SD = 7.24), (Table 5). The types of

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resources endorsed pre- or post-intervention did not significantly differ.
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Responses to Drawing (Hypothesis Seven)
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On average, participants rated that the drawing activity specifically, greatly changed their understanding

of the trauma, their resources, and the self (M = 4.71), (scale of 1-7). The average direction of change for the
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participants’ change in understanding of the trauma, resources, and self was positive (M = 1.31), (scale of 1
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being positive, 2 being neutral, and 3 being negative), (Figure 7).

Figure 7. Responses to Drawing

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Note. Increased understanding of problem (DR1, M = 4.06), Self 1 (DR2, M = 5.10), Resources (DR3, M =
4.52), Self 2 (DR4, M = 5.16)
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Participants agreed that the full protocol, including the drawing activity, questionnaires, and inquiry,

positively affected their access to their own resources (M = 5.3), (scale of 1-7). A majority rated the drawing
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activity as the most positive contributor to their ability to access resources (67%), a quarter of the participants

rated discussion as the most positive contributor (25%), and a small number rated the questionnaires as the most

positive contributor (8%), (Figure 8).

Figure 8. Protocol Components

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Posttraumatic Growth Cognitions (Hypothesis Eight)

There was no significant difference in posttraumatic growth cognitions ratings (Z = -.382, p = .702, p <

.01) from Time 1 (M = 3.263, SD = .798) to Time 2b (M = 3.333, SD = .968), (Table 4).

Relational Security (Hypothesis Nine)

There was no significant difference in attachment security ratings (Z = -.730, p = .465, p < .01) from

Time 1 (M = 5.069, SD = 1.125) to Time 2b (M = 5.195, SD = 1.007), (Table 4).

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Summary

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There were significant decreases in the trauma effect rating and negative affect endorsements and ratings

from time of entry to follow-up at five weeks later. Decreases in negative affect occurred immediately

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following the drawing activity and were maintained at follow-up, possibly accounting for the trauma effect

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rating change. Comparisons of pain measurement should be interpreted with caution due to the small sample

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and methodological issues. At time of entry, 19 participants endorsed pain, whereas, at follow-up, only six
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participants endorsed pain. The trend was changes in pain endorsement and ratings after the drawing activity
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and after the full protocol completion, which were maintained at follow-up. It also seems that as pain

experiences decreased, so did negative affect. No significant differences in the posttraumatic growth cognitions
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or relational security were noted. Interestingly, there is some evidence to indicate that high levels of resilience,
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such as those associated with a graduate student population, could be associated with low PTCI scores (Levine,

Laufer, Stein, Hamama-Raz, & Solomon, 2009). The number of endorsed resources from time of entry to after
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the drawing activity increased significantly. When compared to the questionnaires and inquiry, the drawing
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activity was rated as the most positive contributor to change.

Discussion
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The protocol’s fours drawing sequencing which included the revisiting of resource lists, the

contemplation of two self-portraits, and, the inquiry were designed to meet MR critical conditions: The

reactivating of old memories and engagement in novel and positive emotive experiences (Lane, Ryan, Nadel, &

Greenberg, 2015); Hardt et al., 2010). For the first drawing there was no assumption that the distressing event

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was the problem and thus, it functioned to redefine the problem while minimizing exposure to the trauma. The

second directive invited a view of selfhood in the context of the problem reminder. The trauma reminder and its

impact on the person’s reaction and selfhood formed the foundation for MR to occur. The updating of memory

was stimulated by the third resource-focused drawing and inquiry. Thus, the adversely impacted

autobiographical narrative was sequentially updated with resiliency factors. The fourth drawing and subsequent

comparison of the two self-portraits provided an opportunity for self-observation and for re-scripting the trauma

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narrative, while at the same time emphasized an updated view of the self. The implicit and explicit request was

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to actively integrate what had been learned in order to activate a novel reanimation of the person’s past, present,

and future (Hass-Cohen & Clyde Findlay, 2009). Throughout the protocol, implicit art-making played a critical

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role, as MR implicit and explicit memories were equally activated (Hass-Cohen & Clyde Findlay, 2017). It is

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possible that this is the reason that participants’ implicit pain experiences were modified. During the protocol,

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the emotive, cognitive, and somatic externalization of problems were likely mediated by aesthetic distancing
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(Lahad et al., 2010), and contextualization and mismatching of information (Hass-Cohen, 2016). Distancing
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provided an opportunity to reflect rather than ruminate, promoted contextualization, and set the stage for new

information to be accepted. Contextualization provided coherent temporal dimensions to fragmented

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autobiographical narratives; whereas, mismatched information provided compelling evidence that contradicted
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negative biases and beliefs. Such prediction errors triggered an interaction between the old and new memory

(Pedreira, Pérez-Cuesta, & Maldonado, 2004), which were thought to promote flexible interactions between
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physical, emotional, and cognitive perceptions (Sarid & Huss, 2010).

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Visual memory processing has been strongly correlated with overall cognitive ability (Luck & Vogel,

2014). Furthermore, it is likely that the visual memory processing involved in the planning and making of
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artwork contributed to attention and motivation, despite possible emotional distress. Since memory storage has

been described as modality-dependent (Fougnie & Marois, 2011), visual processing most likely increased the

capacity for change. Similarly, the sequencing of the art-making likely bypassed the propensity of explicit-

verbal negative biases to interfere with MR updates. Hypothetically, engaging with the arts during MR

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mitigated the influences of previous, proactive knowledge or retroactive interference, which may have

accounted for results at follow-up (Hass-Cohen, 2016). Finally, our participants presented with a high trauma

effect and high perceived coping profile, perhaps suggesting the importance of these two factors for a

traumatized population and a role for the four-drawing protocol with potentially resilient individuals.

Limitations

A main study limitation was the initial pain measurement, as it was not clear if participants endorsed

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pain in general or only at time of study entry. However, results showed that less than half of those that initially

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endorsed pain, endorsed pain experiences post-protocol participation and at follow-up. While an argument

could be made that graduate students prior knowledge positively skewed the results, we suggest that the non-

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verbal art-making expression, which is implicit and less subject to cognitive functioning, robustly mediated this

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bias. We anticipate that a future qualitative analysis of the drawings will provide additional information on

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which type of resources and resiliency traits the participants deemed most important and how the art-making
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specifically had a meaningful impact. Another main limitation was that the participants were almost all female;
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thus, the results should not be generalized to other genders. In summary, the current study piloted a single

session, strength-based, arts, trauma, and resiliency protocol, and suggested its potential efficacy for alleviating
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psychological and physical pain reactions to adversity. It was uniquely designed to provide an opportunity for
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redrawing and re-narrating selfhood in the context of recalled, perceived, and imagined resources rather than

trauma. Future four-drawing protocol research efforts will be focused on randomized controlled clinical studies.
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A

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 Fig 1
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 Fig 2
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 Fig 3
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 Fig 5
Fig 4
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 Fig 7
Fig 6
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Fig 8
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Table 1

Univariate Statistics for Sample Demographics (N=31)

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N % M SD Median
Gender 31 - 1.87 .34 2
Female 27 87 - - -
Male 4 13 - - -
Age 31 - 29.68 8.32 26
Race 31 - 1.97 1.28 1
White 13 42 - - -
Hispanic/Latino 13 42 - - -
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 African American/Black 2 7 - - -
Asian/Pacific Islander 2 7 - - -
Other 1 3 - - -
Age when the event occurred 31 - 24.94 10.06 22
Years since the event occurred 31 - 4.29 3.89 3
Physical health rating 31 - 3.90 .87 4
1= Poor 2 7 - - -
2= Unsatisfactory 2 7 - - -
3= Satisfactory 7 23 - - -
4= Good 14 45 - - -

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5= Very Good 8 26 - - -
Spirituality 31 - .77 .43 1
Yes 24 77 - - -
No 7 23 - - -

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Religion 31 - .35 .49 0
No 20 65 - - -

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Yes 11 36 - - -

Table 2

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Hypotheses
Participation in the four-drawing protocol would result in:N
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1. decreases in overall effect of the traumatic event
2. decreases in negative affect endorsement (sadness, grief, depression, anxiety)
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3. decreases in negative affect rating (sadness, grief, depression, anxiety)

4. reductions in pain endorsement
5. reductions in pain rating
6. increases in resiliency-based resources
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7. positive impact of the participants’ understanding of the problem and resources

8. increases in posttraumatic growth cognitions
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9. increases in relational security

Table 3
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Trauma Related Sample Characteristics (N=31)

N % M SD Median
Horror 31 - 5.55 1.57 7
CC

1= not at all 1 3 - - -
2 1 3 - - -
3 0 0 - - -
4= somewhat 6 19 - - -
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5 4 13 - - -
6 8 26 - - -
7= very much so 11 36 - - -
Coping 31 - 5.26 1.15 4
1= not at all 0 0 - - -
2 0 0 - - -
3 1 3 - - -

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 4= somewhat 9 29 - - -
5 7 23 - - -
6 9 29 - - -
7= very much so 5 16 - - -
Trauma effect 31 - 4.74 1.51 6
1= not at all 1 3 - - -
2 1 3 - - -
3 6 19 - - -
4= somewhat 3 10 - - -
5 8 26 - - -

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6 10 32 - - -
7= very much so 2 7 - - -
Negative affect 31 - 5.27 1.12 5.33
Sadness 31 100 - - -

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Grief 25 81 - - -
Depression 27 87 - - -

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Anxiety 29 94 - - -
Pain 31 - 4.58 1.77 5
Yes 19 61 - - -

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No 12 39 - - -
Frequency of Pain 19 - 3.22 1.44 3
1= one to three times a year
2= one to two times a month
3 17
2 11
-
-
-
-
N -
-
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3= every week 5 26 - - -
4= every day 5 26 - - -
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5= every hour 2 11 - - -
6= other (please describe) 1 6 - - -
Duration of Pain 19 - 4.67 1.65 6
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1= two weeks 0 0 - - -
2= one month 3 17 - - -
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3= two months 2 11 - - -
4= three months or more 3 17 - - -
5= six months or more 0 0 - - -
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6= a year or more 10 53 - - -

Table 4
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Means and Wilcoxon Signed-Rank Comparisons for Study Variables

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Time Measures N Pre Pre Post Post Z/t p- alpha

Mean SD Mean SD value level
TE: Rating of 31 4.74 1.51 4.03 1.66 -2.45* .014 .016
Time 1- trauma’s negative
Entry to effect on
Time 3- participant’s life
Follow up NAPER: Rating of 16 5.26 1.12 2.62 1.08 -3.13* .002 .016
negative affect

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 - Sadness 7 5.57 1.27 2 1 4.75 .003 .01
- Grief 5 5.60 1.52 2.20 1.10 5.01 .007 .01
- Depression 5 5.00 1.23 2.60 1.52 3.54 .024 .01
- Anxiety 8 5.50 1.20 3.75 .89 7.00 .000 .01
NAPER: Rating of 5 4.58 1.78 3.14 1.57 -2.04 .041 .016
persistent physical
pain
PTCI: Post- 31 3.26 .80 3.33 .97 -.38 .702 .01
Traumatic Growth
Cognitions
RR: Rating of 31 5.07 1.13 5.19 1.01 -.73 .465 .01

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Time 1
relationship items
Entry to
NAPER: Rating of 19 5.27 1.12 2.67 .94 -3.87* .000 .01
Time 2b
negative affect

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Protocol
NAPER: Rating of 6 4.58 1.77 2.83 1.60 -1.89 .059 .01
Completion
physical pain

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REC: Average 31 39.81 8.11 46.87 7.24 -4.06* .00 .01
endorsement
of resources
Time 2b- NAPER: Rating of 6 2.83 1.60 3.14 1.57 -1.00 .317 .025

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Intervention physical pain
to Time 3 NAPER: Rating of 7 2.67 .94 2.61 1.08 -.358 .72 .025
Follow up negative affect
Note. Significant Z’s are denoted with a *.
N
A
M

Table 5

Cochran’s Q-Test Endorsement Comparisons for Negative Affect and Pain

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Time Measures N Q df p-value alpha level

TE

Across Endorsement
Time of negative 31 18.78* 2 .000 .001
affect
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Endorsement
30 28.41* 3 .000 .001
of pain
Time 1 to Endorsement
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Time 3 of negative 31 15* 1 .000 .001

(Pre and 5 affect
week Endorsement
31 9 1 .003 .001
Conclusion) of pain
A

Time 1 to Endorsement
31 17* 1 .000 .001
Time 2a of pain
Time 1 to Endorsement
Time 2b of negative 31 8 1 .005 .001
Pre and affect
Post Endorsement
30 11.267 1 .001 .001
Protocol of pain

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 Interview
Time 2a to Endorsement
30 2.67 1 .102 .001
2b of pain
Time 2b to Endorsement
Time 3 of negative 31 3.769 1 .052 .001
Post affect
Protocol to Endorsement
30 .143 1 .705 .001
Conclusion of pain
Note. The * represents significance. A Bonferroni adjustment for familywise error determined alpha level for p-
value analysis.

PT
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