Running head: HOW DOES ART THERAPY HELP WITH DIALECTICAL 1 How Does Art Therapy with Dialectical Behavioral Therapy Help With Borderline Personality Disorder and Post Traumatic Stress Disorder

Finding more effective treatments for Borderline Personality Disorder (BPD) and Post Traumatic Stress Disorder (PTSD) is important to lessen the suffering, stigma, and heavy use on the mental health system. Art Therapy may help with Post Traumatic Stress Disorder with Borderline Personality Disorder according to current trends and neurobiological findings on how the trauma response works in the brain. Dialectical Behavioral Therapy has numerous studies siting its effectiveness for treating Borderline Personality Disorder. DBT may also be helpful for BPD with high rates of self-harm. BPD be Complex Trauma and is surrounded by controversies politically and culturally affecting new research directions for those who suffer from PTSD and Borderline Personality Disorder. HOW DOES ART THERAPY HELP WITH DIALECTICAL 3 How Does Art Therapy with Dialectical Behavioral Therapy Help With Borderline Personality Disorder and Post Traumatic Stress Disorder The Goal of this review is to research how Art Therapy can help with BPD and PTSD and how Dialectical Behavioral Therapy can help with BPD and PTSD. The researcher in this review has worked in a Dialectical Behavioral Therapy setting using Art Therapy as an adjunct therapy with Borderline Personality Disorders and other pathologies. Bias towards the applicability of Art Therapy with Trauma and Borderline Personality Disorder may be present due to the researchers own experience of the effectiveness using both therapies. Trauma research has shown how the brain may react under extreme or chronic stress. The findings now point to a biological process that the brain may go through and explain a lot of the symptoms of trauma exposures. The trend is moving away from symptomology as pathology and being replaced with an understanding of coping and survival as normal mechanisms of trauma. Borderline Personality Disorder and Post Traumatic Stress Disorder have complexities that include controversies about what BPD really is and how trauma can play a role in the etiology of the illness. What really is BPD and how does it compare to trauma? This paper will research recent findings as well as theoretical, political, and cultural research comparing and contrasting both. Art Therapy and Neuroscience of Trauma A recent trend has evolved in Art Therapy as a recommended therapeutic advancement for those suffering from trauma. There are physiological links in neuroscience that now look at trauma as both physiological and psychological (Malchiodi, 2003). Implicit and explicit memory is key in understanding the trauma response. Implicit memory is non-verbal, sensory, related to the body, and emotional. This type of memory is unconscious and relates to the body. Explicit HOW DOES ART THERAPY HELP WITH DIALECTICAL 4 memory is verbal, factual, conceptual, and related to ideas. Neuroimaging findings show that non-verbal response to imagery of Post-Traumatic Stress subjects, compared with controls, had diminished verbal consciousness and triggered intrusions of non-verbal memory (Trip, 2007; Tinnin, 2009). Many who experience trauma have difficulty when implicit memories are not linked to explicit memories. Basically the experiencing side does not communicate with the verbal side of the Limbic System. Art Therapy can quiet and calm the amygdala and promote a healthier coping response to balance the amygdala and hippocampus that cause the fight or flight response. What happens during a trauma is usually a freeze effect that is a survival mechanism in the Fight or Flight response. This animal like behavior is a protection from pain and often is described by humans as being an out of body experience or not feeling a presence in space. Animals during an overwhelming threat show extreme docility and humans similarly respond displaying automatic obedience. At this point the normal cognition is compromised and consciousness fails. The verbal mind does not count this process into memory and often automatically rationalizes it away or disowns the event or that the events ever occurred (Gantt & Tinnin, 2009). Art Therapy has the unique ability to bring the non-verbal mind front and center without obligatory censorship that the verbal mind possesses. The art captures the fleeting emotional message and the Art Therapist can work through the perception with the client. Art Therapists do not interject bias and work with the client on what is presented in the art. As the client steps back and looks at it, there is the opportunity to receive the emotional message and put words to it and gain meaningful insight (Tinnen, 1990). HOW DOES ART THERAPY HELP WITH DIALECTICAL 5 Art Therapy and Mind/Body Connection In light of new research on trauma, Art Therapy has the potential to integrate implicit (sensory) and explicit (declarative) memory that is often fragmented with clients suffering from events of trauma. Art Therapy can aid in self-regulating emotions and the bodies reactions to the trauma process (Malchiodi, 2010). Imagery derived from imagination can provide several levels of information processing. Visual expression involves complex sensory and emotional content, which originates in the parietal lobes and limbic system and then get forwarded to the prefrontal cortex where it can then be regulated (Lusebrink, 2010, p.169-170). The emotional expression of the visual art form is documented before the artist’s natural verbal censorship occurs (Tinnen, 1990). The Expressive Therapies Continuum (ETC) measures coordinating brain functions with visual art and can help therapists determine how a client is processing kinesthetic/sensory, perceptual/effective, and cognitive symbolic information. Each of these processes matches different parts of brain functions and could be useful tools in helping art therapists working with trauma (Lusebrink, 2010). A thirty-year study linking neuroscience, specific trauma, PTSD, image conversion, and language translation, was conducted and there were many similarities in images produced by women who suffered sexual abuse and assault. Many images had disembodied eyes and wedges indicating unresolved traumatic experiences. The study indicates the usefulness of art therapy to engage, organize, and correct dysfunctional cognitions associated with trauma. When victim’s engaged in Art Therapy the artistic form was translated to the linguistic form resulting in full realization of the experience connecting both the mind and the body. The art became the documentation of the emotions and body sensations and a holding place for the client to convert and interpret meaning from the traumatic experience (Spring, 2004). HOW DOES ART THERAPY HELP WITH DIALECTICAL 6 How Can Art Therapy Help Trauma More research is coming out on how Art Therapy can be an effective tool for a variety of symptoms, age groups and disorders. In a compilation review of findings, outcome studies were organized so that Art Therapy students, clinicians, and readers could access the data and assess the strength and relevancy of findings in accordance of individual needs (Slayton, Archer, & Maryhurst, 2010). The first study sighted was with girls and young women who had been sexually abused (ages 8-16). There was statistical reduction on 9 out of the 10 Trauma Symptom Children’s Checklist (TSCC) for anxiety, PTSD, and dissociation scales in children. The second study was with children and young adults (ages 8-16) who had been sexually abused. Statistical reduction in Anxiety (p < .03), Post Traumatic Stress (p <.02), and Dissociation-Overt (p <. 03) (Pifalo, 2002). The limitation of this study was the small sample size of 13. This researcher found many smaller studies with single cases. One such single case found was based on processing trauma through Art Therapy and bilateral stimulation. This type of Art Therapy is based on a modified version of Eye Movement Desensitization and Reprocessing (EMDR) where a protocol is followed in alternating tactile and auditory bilateral stimulation. The theory is that it helps both the implicit and explicit memory process trauma. It works by focusing dual attention through taps and sounds. Old memory networks are activated (implicit) while attention is focused on the present (explicit) with external visual, auditory, or tactile cues. EMDR takes the client through upsetting memories while attending to new information as it becomes accessed and gradually processed through the brain (Tally, 2007). The difference here is that instead of visualizing the event the client is re-creating the event in art. In this case study the client (Betty) came in with a history of childhood sexual molestation and currently was having problems with her male supervisor. In the first scribble drawing, Betty perceived within HOW DOES ART THERAPY HELP WITH DIALECTICAL 7 the lines a mother gazing at a child and missing that inner connection of the mother and child bond. In the second scribble drawing, she developed a butterfly in the upper corner walled off by a square. She described the butterfly as being “carefree with no hurt”. These earlier drawings were a starting point for brief Art Therapy. Betty portrayed her feelings of loss and feeling “worthless”. Betty shared negative beliefs she held about herself in childhood and recalled an early memory where she felt “powerless”. This memory would be the target memory. Bilateral stimulation was started with headphones and pulsars behind each knee. Betty drew her early memory of being un-loveable and was stopped to verbalize what she noticed after each picture and where she felt it in her body. Betty developed new associations of “unfair” and “irresponsible”. This process continues until Betty has a cognitive shift being, that her anger was not destructive and in fact, was fundamental to her healthy functioning. By using a modified version of EMDR with Art Therapy Betty was able to make new connections to alter her long held beliefs and create new cognitions. Betty was finally able to see her anger as “righteous” and “justified” (Trip, 2007). This case study is a good example of how Art Therapy can help connect the verbal to the non-verbal in mediating trauma. The limiting factor is that it is only one case. More research is needed on a larger scale to show the therapeutic benefits of Art Therapy with modified bilateral stimulation.