This document provides an overview of using expressive arts and cognitive behavioral therapy (CBT) to treat adolescent anxiety. It discusses key CBT concepts like the relationships between thoughts, emotions, and behaviors. Various CBT tools and techniques are presented for assessing and addressing anxiety, such as thought records, SUD scales, and exposure exercises. Case studies demonstrate integrating art-based activities into CBT treatment to engage clients and provide insight. The document emphasizes that art therapy complements CBT by accomplishing similar goals of developing healthy thinking and behaviors through creative means.

1. Expressive Arts & Cognitive Behavioral Therapy
(CBT)
Treating Adolescent Anxiety
Didactics & Case Studies
Roger Luscombe, MS, DKATI, RCC.
1

2. Resources
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Approaches to Art Therapy, Theory & Technique 2nd ed.
Judith Aron Rubin, ed.
Play Therapy, Theory & Practice, A Comparative
Presentation, O’Connor & Braaverman, ed’s.
CBT Connections, Anxiety Disorders in Children &
Adolescents: University of British Columbia
Anxiety Disorder Association of British Columbia (Anxiety
B.C.)
2

3. Anxiety B.C.
five important elements
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Anxiety is normal, everyone experiences it at times
Anxiety is not dangerous, although anxiety feels uncomfortable, it is
temporary, and will eventually decrease
Most people cannot tell when you are anxious
Anxiety is adaptive and helps us prepare for real danger or for
performing at our best, it triggers our “fight-flight-freeze” response
preparing our body to react
Anxiety becomes a problem when our body reacts in absence of
real danger
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4. Key Issues in Anxiety
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Anxiety is about fear
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Clinical Anxiety is Irrational
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Clinical Anxiety is Learned
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5. Anxiety Disorders: Overview
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Most common mental health problem
12 – 20% of children affected
Over 65,000 kids in B.C. with disorder
Impact and morbidity not widely
recognized
Girls often have more fears than boys
Number and types of fears across cultures
are fairly consistent
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6. Anxiety: Overview Continued
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Presence of one anxiety disorder increases risk
of developing additional anxiety disorder
Mom’s with any mental illness are 7 times more
likely to have a child with an anxiety disorder
Children and youth with anxiety disorders rarely
receive appropriate or effective interventions
If left untreated there is a significant increase in
risk of depression & substance abuse
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7. The Experience of Anxiety
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Body Fear
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Mental Fear
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Behavioral Indicators of Fear
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8. Components of the Anxiety
Response
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Behavioral Avoidance
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Distorted Beliefs
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Over Predictions of Fear
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Attentional Bias
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Physiological Responding
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9. Causes and Maintenance of
Anxiety Disorders
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Genetics
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Temperament
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Parenting
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Cognitive Factors
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Avoidance Behaviors
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10. Types of Anxiety Disorders
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Social anxiety disorder (separation anxiety
disorder)
Obsessive compulsive disorder
Specific phobias
Generalized anxiety disorder
Panic disorder w/o Agoraphobia
Post traumatic Stress disorder
10

11. anxiety
Regina
Lafay
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12. Anxiety, Regina Lafay
www.survivorart.com
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"One of the first pieces I did to express an emotion I had
not yet had diagnosed – a feeling that I had known since
I was a teen, yet nobody was available to explain it to me
or help me through it. I have only recently been
diagnosed with Generalized Anxiety Disorder, among
others. Words fail me, as they often do, so I choose art
to tell my stories. This image helped a group of troubled
teenage girls recognize that they are not alone. I
continue to be moved by their counselor’s letters, as she
and I still keep in touch."
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13. Cognitive Behavioral Therapy
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Psycho education
Managing body symptoms
Healthy thinking
Building tolerance
Relapse prevention
Evidence based
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14. Evolution of CBT
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Behavioral Therapy
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Social Learning Theory
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Cognitive Therapy
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Cognitive Behavioral Therapy
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Dialectical Behavioral Therapy
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Family Cognitive Behavioral Therapy
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Cognitive-Behavioral Art Therapy
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15. CBT & Art Therapy
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CBT not widely been accepted in the art therapy field
There has been the misconception that CBT focuses
only on the thinking process
In reality imagery, visual thinking and creativity are
aspects of cognition
Personal constructs are non verbal as well as verbal and
creating art can enrich personal constructs'
Emotional components, as illuminated in art therapy, are
an integral part of understanding a person’s cognitive
process
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Approaches to Art Therapy, Rubin
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16. Core CBT Components
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Cognitive restructuring
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Physical relaxation
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Exposure, coping skills
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Social skills training
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17. Principals of CBT
THOUGHTS
BEHAVIOURS
EMOTIONS
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18. Myers – Briggs Type Indicator
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Carl Jung’s
Psychological Types
Eg.
ESTJ - Extraversion,
Sensing, Thinking,
Judging
INFP - Introversion,
Intuition, Feeling,
Perceiving
Dichotomies
Extraversion
Introversion
Sensing
iNtuition
Thinking
Feeling
Judging
Perceiving
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19. Distorted Thinking
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All or nothing thinking
Over generalizing
Mental filtering
Disqualification of the positive
Jumping to conclusions
Magnification (catastrophizing or minimizing)
Emotional reasoning
“Should” statements
Labeling
Personalization
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20. Cognitive Approaches
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Identification of inner, private thoughts
Use of positive self-talk
Techniques for challenging negative selftalk
Self-reward
Expectations of good things to happen
Evaluation of own performance – partial
successes
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21. Physiological Approaches
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Awareness of body clues
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Deep breathing exercises
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Relaxation activities
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22. Behavioral Approaches
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Problem solving skills
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Coping skills
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Peer support
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Identification of pleasant events
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Exposure
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23. Exposure
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Interoceptive Exposure
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In vivo Exposure
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Deliberately bring on bodily symptoms of
anxiety, e.g. spinning, breathing
Deliberately entering feared situations e.g.
movies, malls
Naturalistic Exposure
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Deliberately engage in activities e.g. exercise
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24. Role of Family & Teachers
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Psycho education about anxiety and treatments
that work
Emphasize that well-intended intuitive responses
may actually enable anxiety problems
Consistency and firmness in follow through on
plans
If family concurrent difficulties with anxiety all
members receive treatment
Assist with homework
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25. CBT Tools
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Thought and Mood Charts
SUD’s Chart (subjective units of discomfort)
Fear Hierarchy Chart
Fear Monitoring Form
Grounding Tips
PTSD Impacts of Events Scale
Brief Screening Instrument for Panic Attacks
Relaxation Scripts
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Breathing, progressive muscle relaxation
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26. Children’s CBT Resources
Taming the Worry Dragons, Garland &
Clark, B.C. Children's Hospital
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27. CBT Resources cont.
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28. CBT Resources cont
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29. CBT Case Formulation
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Brief demographic
Problem identification
Problem history
Family and social adjustment
Main cognitive, physiological and behavioral
components of major problems
Client’s perspective
Case formulation
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30. CBT Treatment Plan
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Prioritization of treatment targets
Tracking of clients progress
Methods of treatment
Graduation from treatment
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31. Case Study David
31

32. Case Formulation for David
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Demographics:
 Adolescent, rural isolation, single parented,
marijuana friendly community
Problem Identification:
 Psychiatric Dx: Disthymic disorder with more severe
depression (double depression)
 Academic, social and family stressors
 Substance misuse
 General anxiety and social phobia
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33. Case Formulation cont.- 1
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Problem History, Family & Social
Adjustment:
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Unhappy as a baby
Ongoing depression last couple years
History of family depression w/ hospitalization
Poor relationship with bio dad
Daily use of marijuana for 5 years
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34. Case Formulation cont.- 2
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Problem Identification
Cognitive
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Physiological
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Negative self image, self punishing, fears of future
failure, downward spiraling thinking
Poor diet, lack of regular meals, lack of exercise, over
sleeping,
Behavioral
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School avoidance, social withdrawal, no employment,
heavy marijuana use (self identified)
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35. Case Formulation cont.- 3
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Client’s perspective
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Depression, low self esteem, addiction
acknowledged
Sense that his personal history affects his
current state
Goals include reducing fears, increase self
esteem, improve friendships, school
graduation, and be drug free
35

36. Case Formulation cont.- 4
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Case Formulation
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Psychiatrist had diagnosed depression and
recommended CBT treatment
CBT idea had hooked David, though reluctant
some readiness present (Prochaska stages)
Positive male therapist transference
Anxiety seen as possible core disturbance
36

37. Stages of Change
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James Prochaska & Carlo Diclemente
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Precontemplation Stage
Contemplation Stage
Determination Stage
Action Stage
Maintenance Stage
Relapse
37

38. CBT Treatment Plan for David
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Psycho education
Exploration of ABC triangle
Reframing
Social exposure
Expressive arts exploration
Stress reduction
Involve family in treatment
Relapse prevention
Ten to Twelve independent sessions
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39. Treatment Plan cont. - 1
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Tracking of client’s progress
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Home work check-ins, reading assignments
Thought & mood records
Sleeping pattern changes
Socialization changes
School attendance record
Drug and alcohol consumption
Changes in family time
Diet & exercise changes
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40. CBT Tools Used
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ABC triangle presented
Distorted thinking examined
Reading homework on depression & CBT
Thought records, challenging depressive
thoughts
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41. Expressive Arts Exploration
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Icebreaking, rapport making
Invites cognitive conversation
Provide creative outlet
Self esteem through art making / product
Insight acquisition
Co-art making positive transference
Provides visible record of change
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42. David’s Art Making & Gaming
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Clay pieces
Biofeedback Game
Sandtray World
Roofing Paper Medicine Wheel
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43. Clay - David
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44. Sandtray - David
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45. Biofeedback Stress
Management
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46. Clay - David
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47. Clay - David
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48. Roofing Paper - David
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49. Summary: David Case Study
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CBT model intrigued youth
Psycho education around thoughts,
emotions, behaviors very beneficial
Art therapy engaged and gave youth
insight & increased self esteem
Positive transference enabled personal
transformation process
49

50. TF-CBT for Aboriginal Child
Trauma Victim
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Honoring Children – Mending the Circle
Spiritual
Mental
Physical
Emotional
Relational
University of Oklahoma Health
Mending the Circle Sciences Center
50

51. 51

52. Case Study Sara
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Presenting Problem – General Anxiety &
Specific Phobia
Treatment Components
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Play Therapy Genogram
Fears Assessment Tool
SUD’s Hierarchy Chart
Fish Hook Diagram for anxiety attack
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53. Sara cont.
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Play therapy family
genogram
53

54. Fears Assessment Tool
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Self Rating Questionnaire, 8 biggest fears
Flying
 Punishment by mother
 Criticized by parents
 Giving a recital
 Snakes
 Mean dogs
 Dead people
 Spiders
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54

55. SUD’s Chart for Flying Phobia
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1
2
3
4
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7
8
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Looking at airplanes
Airplane play, sandtray, puzzles
Make airplane, clay, paper mache
Going to local airport
Going to Castelgar airport
Getting near a plane
Sitting in a plane
Short flight on plane
Long flight to Hawaii
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56. Panic Attack Fish Hook Model
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57. Summary of Cognitive Behavioral Art Therapy
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CBT illustrates how thoughts & emotions
& behaviors co -influence each other
CBT has particular treatment strategies to
create healthy thinking, emotional
awareness and positive actions
Art Therapy accomplishes these same
goals and fits well with CBT treatment
strategies
57

58. In Memory Of

Dr Peter Donald McLean,
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CBT Connections
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Passed away
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Nov 04, 2008
58