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International Journal of Offender Therapy and

Comparative Criminology 56(7) 1124 –1143

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417362 IJO56710.1177/0306624X11417362Breiner et al.International Journal of Offender Therapy and Comparative Criminology

1Wakulla Correctional Institution, Crawfordville, FL, USA 2Florida State University, Tallahassee, USA 3Florida Department of Corrections, Tallahassee, USA

Corresponding Author: David E. Gussak, Department of Art Education-Art Therapy Program, Florida State University, Tallahassee, FL 32306-0123, USA Email: [email protected]

Creating an Art Therapy Anger Management Protocol for Male Inmates Through a Collaborative Relationship

Mary J. Breiner1, Laura Tuomisto2, Elizabeth Bouyea2, David E. Gussak2, and Dean Aufderheide3

Abstract

A training partnership was established with the Florida Department of Corrections in 2003, and over the ensuing years, art therapy graduate student interns from Florida State University’s Graduate Art Therapy Program have been placed in local prisons at different times. Recently, the art therapy interns worked closely with the supervising psychologist in one prison to alleviate and redirect aggression by integrating cognitive- behavioral techniques with art therapy directives. The art therapy interns and the psychologist developed a curriculum using a combination of workbook exercises and art tasks to develop and increase the participants’ anger management skills, the Art Therapy Anger Management Protocol. This article provides an overview of art therapy in prison, the cognitive-behavioral approach to anger management with prison inmates, and how art therapy was used to support this approach. Examples of completed art tasks designed to correspond with the workbook curriculum are presented. Overall, this article presents the successful collaboration between the psychologist and art therapists and demonstrates how they facilitated improvement in the participants’ anger management skills through this program.

Keywords

anger management, art therapy, cognitive-behavioral, male inmates, prison

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Introduction

The Florida State University graduate art therapy department has established practicum- training partnerships with a variety of clinical settings in Tallahassee and the sur- rounding area. Graduate students are placed at these sites under the joint supervision of university faculty and on-site clinical staff. A training partnership was established with the Florida Department of Corrections (FDOC) in 2003, and over the ensuing years, art therapy graduate student interns have been placed in local prisons. In several of these prisons, a substantial percentage of the inmate population is treated for men- tal health problems, and in these facilities, art therapy interns have typically worked with inmates who were being treated for mental health problems such as depression, anxiety, and adjustment disorders.

In the fall semester of 2007, interns were placed at a fourth institution, Wakulla Correctional Institution (WACI). At this institution, only 3.5% of the population is currently being treated for mental health problems. WACI, designated a Faith- and Character-Based Institution (FCBI), offers a wide range of rehabilitative programming. Inmates apply to be placed at WACI; eligibility depends on maintaining positive behavior and continuous participation in FCBI programs. Because of such specific programming, it was necessary to develop an art therapy practicum agenda that cor- responded to WACI’s rehabilitative mission. It was decided that art therapy would be incorporated into an existing manualized cognitive-behavioral treatment (CBT) based anger management treatment program offered to inmates in the general population who have a history of anger problems or interpersonal violence.

Since establishing an art therapy internship site at designated state correctional insti- tutions, graduate art therapy student interns from the Florida State University Graduate Art Therapy Program have developed strong collaborative relationships with psychol- ogy staff at the participating facilities. Two art therapy interns and the psychologist developed a curriculum using a combination of workbook exercises and art therapy exercises to develop and increase the participants’ anger management skills.

This article, written by the two art therapy interns, the psychologist of the prison, the internship clinical supervisor from the university, and the FDOC’s Director of Mental Health Services, will provide a brief overview of art therapy in prison, the cognitive-behavioral approach to anger management with prison inmates, and how art therapy was used to support this approach. Pursuant to the overview, examples designed to correspond with the workbook curriculum and its efficacy will be pre- sented. This will be supported through an overview of the responses from the group members and illustrated through brief case vignettes of two participants. Overall, this article will present the successful collaboration between the psychologist and art thera- pists, demonstrating how they were able to facilitate improvement in the participants’ anger management skills through the integration of art therapy with the cognitive/ behavioral curriculum.

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Art/Art Therapy in Prison Background and History

Art in prison. Creative expression is a normal by-product of the austere correctional environment as evidenced by prison craft shops, intricate tattoos, and decorative envelopes and handkerchiefs bartered from talented inmates to send home as gifts (Kornfeld, 1997; Ursprung, 1997). The ability to create art enhances one’s status in prison, earns respect and friendship from others (Kornfeld, 1997), and provides a means to “rehumanize” those who may become “dehumanized” within a rigid and disciplinary environment (Fox, 1997). It also has been demonstrated that, for some inmates, creating art fosters frustration tolerance, alleviates depression, and increases problem solving and socialization skills (Gussak, 2004, 2006). Although specula- tive at present, there may be inferential evidence that creating art may enhance prerelease reentry programming for inmates by providing a “space for the prisoner overwhelmed by the clatter and disruption of prison life . . . and . . . the possibility of a more creative life for many after release” (Liebmann, 1994, Foreword).

Research on art and art therapy in prisons. Several studies have been conducted that reveal that art making is beneficial for prison inmates. In a study of inmates who par- ticipated in the California Arts-in-Corrections program, Brewster (1983) found that the participants received fewer disciplinary reports. The California Department of Correc- tions (1987) revealed 4 years later that recidivism decreased for paroled inmates who participated in the offered arts programs. Recognizing the potential benefits of art therapy in correctional settings, several art therapy programs have been subsequently established (Alexander, 2003; Tannenbaum, 2000; Williams, 2003) and a growing number of professional art therapists are availing themselves of the opportunity to develop art therapy services in the correctional setting (Gussak & Virshup, 1997; Hanes, 2005).

Gussak & Virshup, 1997 identified several advantages of art therapy with prison inmates. Specifically, the nonverbal aspects of art therapy were found to be helpful, especially with inmates who are unwilling or unable to talk about personal issues. Because of the lack of trust and dialogue between inmates, the effectiveness of art therapy is “specific to this population because, although inmates are cautious with words, they may allow themselves to be expressive using art materials” (Gussak & Cohen-Liebman, 2001, p. 128). In other cases, the art making may facilitate discussion in a traditionally guarded population and may at times be used as a catalyst for aware- ness and reflection, provided that such reflection is not misinterpreted as a perceived weakness. However, recently, empirical data are emerging that support the potential benefits of establishing art therapy programs in correctional settings.

Art in Florida prisons. Since the summer of 2003, several exploratory projects were initiated in designated correctional institutions in the Florida Panhandle to ascertain whether art therapy was effective in addressing some of the problems common with inmates. The results of these studies supported the hypothesis that art therapy may be an effective modality in helping to reduce depressive symptoms and increase problem

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solving, socialization (Gussak, 2007), and internal locus of control (Gussak, 2009) in some male inmates. Further studies suggested that art therapy may be effective in reduc- ing depressive symptoms and increasing internal locus of control in some female inmates (Gussak, 2009). These studies were conducted through the established intern- ship relationship between the Florida State University Art Therapy Program and vari- ous correctional institutions in Florida’s Panhandle. Unfortunately, there have been no other empirical studies evaluating the effectiveness of art therapy with correctional populations.

Through these internship collaborations, the art therapy interns have learned vari- ous approaches in using the art therapy with prison inmates in the anger management program at the facility. The work presented here emerged from one of these partner- ships, and what materialized is a unique art therapy focus that adapted the cognitive- behavioral anger management curriculum used in the mental health department at the facility.

Offender Treatment-Best Practice In correctional psychology, one of the main goals of treatment for offenders is to reduce recidivism. Over the past several decades, research has focused on what types of treat- ment are effective in accomplishing this goal (Landenberger & Lipsey, 2005; Lipsey, Chapman, & Landenberger, 2001; Pearson, Lipton, Cleland, & Yee, 2002; Wilson, Bouffard, & Mackenzie, 2005) and how to maximize treatment efficacy by assessing offenders’ characteristics and tailoring treatment accordingly (Andrews & Bonta, 2006; Andrews, Bonta, & Wormith, 2006). The findings in these two related areas have contributed to the knowledge used to develop and refine best practice offender treat- ment programs.

Research has consistently revealed that the most effective treatment approaches for offenders in reducing recidivism relies on CBT (Hollin & Palmer, 2009; Landenberger & Lipsey, 2005). The two basic assumptions underlying CBT are that problematic thinking leads to problematic emotional and behavioral consequences and that prob- lematic thinking is either learned (i.e., the acquisition of cognitive distortions aka “thinking errors”) or results from a lack of learning (i.e., deficits in cognitive skills). The general treatment approach used in CBT is to identify the thinking errors and skills deficits that underlie the client’s targeted problematic behavior, to assist the client in correcting those thinking errors, and acquire the cognitive skills necessary to eliminate the problematic behavior. Such programs have generally focused on challenging the thinking errors that support violent and criminal behavior and on helping offenders to overcome cognitive skills deficits that contribute to violence and criminality. The fun- damental cognitive skill deficit is the inability to effectively engage in metacognition, which is defined as “thinking about thinking”—the process of critically evaluating the validity and utility of one’s own thoughts. The lack of general metacognitive abilities may decrease social skills, coping skills, and emotion management. Metacognition is also used to identify, challenge, and change thinking errors. A recent meta-analysis

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identifying treatment components that moderate the general positive effect of CBT-based treatment on offenders’ recidivism found that interventions targeting anger control and interpersonal problem solving independently contributed to larger reductions in recidi- vism (Lipsey, Landenberger, & Wilson, 2007).

As evidence has accumulated in support of CBT as an effective treatment interven- tion with offenders, investigators have also begun to examine the role that offender characteristics play in treatment efficacy. A meta-analysis of offender treatment stud- ies was conducted to evaluate the three general principles considered critical to effec- tive correctional treatment: risk, need, and responsivity (RNR; Andrews et al., 1990). The risk principle suggests that the intensity of an intervention should be matched to the offender’s recidivism risk, with higher risk offenders receiving more intensive services. The need principle states that the treatment should target the offender’s crim- inogenic needs, which are defined as the dynamic risk factors that directly relate to recidivism risk, such as antisocial attitudes or association with criminal friends. The responsivity principle consists of the following two levels: (a) general responsivity, which states that cognitive-behavioral interventions are the most effective means of changing behavior (b) and specific responsivity, which states that treatment interven- tions should be tailored to the individual characteristics that influence each offender’s ability to learn the material (e.g., intellectual capacity, personality traits, verbal ability, learning style, and so on; Andrews et al., 2006). The results of the meta-analysis showed that treatments adhering to the RNR principles resulted in reduced recidivism, whereas treatments that failed to follow these three principles actually increased recidivism rates (Andrews et al., 1990). Subsequent studies have replicated this pattern of results (Andrews & Dowden, 2006; Bonta & Andrews, 2007), and the RNR model under- scores the importance of considering individual differences when developing CBT- based offender treatment programs.

In summary, review of the literature suggests that in order for an offender treatment program to adhere to the current parameters of evidence-based best practice, it should target higher risk offenders, be based in CBT, include anger control and interpersonal problem-solving treatment components, target as many of the offender’s criminogenic needs as possible, and be tailored to the individual offender’s personal characteristics. The following sections will describe how art therapy was used to modify an existing treatment protocol to actuate these best practice criteria.

Manualized CBT-Based Anger Management Protocol CBT-based anger management groups are offered in most FDOC institutions through the Mental Health Department to target emotional or behavioral problems considered general risk factors for recidivism. It does so through anger management, social skills training, and stress management activities, as opposed to targeting specific emotional or behavioral problems associated with serious mental health disorders and substantial impairment in adaptive functioning. The anger management treatment program offered at WACI uses a CBT treatment protocol published by the Center for Substance Abuse

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Treatment (Reilly & Shopshire, 2002; Reilly, Shopshire, Durazzo & Campbell, 2002). The treatment program, called Anger Management for Substance Abuse and Mental Health Clients (AMSAMHC), was designed for administration in a group format and consists of twelve 90-min weekly group sessions. Seven main CBT anger management components were addressed within the existing program curriculum: anger meter, anger triggers and cues, anger control strategies, relaxation strategies, the aggression cycle, cognitive restructuring, and assertiveness and conflict resolution. As it was not specifically designed for use with offenders, some modifications were made to accommodate the curriculum for use with this population.

Although the authors of the AMSAMHC program do not specifically present their program in terms of the RNR model, analysis of the protocol reveals that when imple- mented at WACI, the program met several of the best practice parameters. The program targets higher risk offenders, which include incarcerated offenders with anger manage- ment deficits or a history of violence, and is CBT-based and includes both anger control and interpersonal problem-solving treatment components. Anger management is one of the two intervention goals associated with antisocial personality pattern, which is defined as a tendency to be impulsive, adventurous and pleasure-seeking, and restlessly aggressive and irritable (Andrews et al., 2006).

Another important evidence-based best practice requires that treatment should be tailored to the individual offender’s personal characteristics so that each offender’s ability to learn the material is maximized. By definition, manualized group treatment protocols are standardized so that the main treatment elements are delivered consis- tently across groups. However, like most CBT-based manualized treatment protocols, the AMSAMHC protocol allows therapists to paraphrase the material as needed, directs participants to use examples from their own lives, and encourages responses to ques- tions based on personal experiences. The workbook also includes images to illustrate two of the seven main CBT elements already delineated: the anger meter and the aggres- sion cycle. Together, these features provide the potential for some degree of individu- alization, with respect to offenders’ intellectual capacity, verbal ability, and visual versus verbal learning styles. Accordingly, art tasks were created for inmate participants with a range of learning styles and cognitive capabilities.

Creating the Art Therapy Anger Management Protocol (ATAM) The facility’s psychologist and two art therapy graduate student interns coled the art therapy anger management groups. The group structure was based on the AMSAMHC program, and an AMSAMHC participant’s workbook was given to each group member to write in and retain as a resource. At least one art therapy directive was developed to address each of the CBT anger management curriculum sessions, including review and termination. Each art therapy directive was designed to enhance the curriculum and further the inmates’ comprehension and retention of the discussion topic. As well, the directives were designed to help the participants access and manage their emotions

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while engaging in the therapy process. Overall, the art directives had the potential to generate multiple effects, which varied somewhat among the individual group members.

Four groups of inmates were formed and met once a week for a total of 13 weeks. The sessions lasted from 1 hr to 2 hr, depending on when the group members arrived to the session, the complexity of the art directive, the number of topics covered, and the depth of the group discussion. Each group consisted of five to six members with ages ranging from 24 to 66 years.

As the AMSAMHC program was not specifically designed for use with offender populations, the role of antisocial cognition in anger and aggression was incorporated into the curriculum to address a dynamic predominantly germane to the offender popu- lation. Antisocial cognition is a general term for the constellation of thoughts, attitudes, values, beliefs, and rationalizations that support violence and crime (Andrews et al., 2006). Although offenders exhibit a range of antisocial cognition, not all subsets of antisocial cognition are related to anger management. Therefore, only the two subsets of antisocial cognition that support anger and aggression—hostile cognitions and pred- atory cognitions—were added to the curriculum.

Hostile cognitions. Hostile cognitions reinforce an offender’s perception of self as a victim or target of malicious intent (Beck, 1999). They see themselves as vulnerable and perceive others as enemies who are seeking to harm, exploit, or diminish them. They misinterpret others’ ambiguous or impersonal actions as intentional threats or efforts to harm, and they may react aggressively to perceived or actual slights. Aggres- sive acts serve to restore offenders’ self-confidence by neutralizing uncomfortable thoughts. These offenders view their aggression as provoked self-defense and hence see their aggression as completely justified, even though they may feel remorseful for the damage they inflicted once the “heat of the moment” has passed. These offenders experience the normal range of human emotion, and when not believing themselves to be under attack, they seek to establish and maintain interpersonal connections. How- ever, their ability to form relationships may be hampered by poorly developed social skills and by their skewed perceptions of themselves and others. In general, most aggressive offenders reflect a hostile mind-set, although individual differences in a range of other personality and cognitive characteristics create significant unpredict- ability in their outward appearance (Beck, 1999).

Predatory cognitions. A much smaller group of offenders operates completely within a mind-set of predatory cognitions. These cognitions promote the offenders’ views of themselves as invulnerable and superior to others, allowing them to exploit others as resources and to dismiss others’ rights and feelings as insignificant (Beck, 1999). When these offenders behave aggressively, their acts are usually designed to obtain a desired object or outcome or achieve a goal. Offenders with a purely predatory mind- set may use aggression to control, dominate, or punish others. These offenders may or may not experience anger when they act aggressively. When anger is present, it can be characterized as contempt for the transgressor or outrage at the audacity of the trans- gressor. Predatory offenders generally lack empathy and remorse, and interpersonal relationships are used based on a potential for exploitation rather than on emotional

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connection. Although only a small group of offenders are purely predatory in their cognitions, many individuals within the larger group of generally hostilely biased offenders at times display and act on predatory cognitions. Thus, it is important to account for and explicitly address both types of antisocial thinking when working with groups of offenders (Beck, 1999).

Integrating Art Therapy Into the Curriculum—Two Examples. The choices cycle. The AMSAMHC program uses the aggression cycle (Walker, 1979)

to describe and explain the three phases of an aggressive episode: escalation of anger, explosion of aggression, and postexplosion consequences. Included in the participant’s workbook is a diagram that illustrates these three phases and highlights the central con- cept of the aggression cycle, which is that aggressive individuals tend to respond to anger triggers in a habitually problematic manner. As these response patterns tend to be habitual, the individual may repeatedly engage in aggressive behavior. The aggression cycle diagram also shows that individuals tend to focus on the immediate antecedents and consequences of an aggressive act and are much less aware of the consequences.

A principal goal of this section is to help participants become more aware of the thoughts that serve to escalate anger (i.e., antisocial cognition and other thinking errors) and of the physical, behavioral, and emotional cues that, if noticed, can serve as warning signs that anger is escalating. The workbook asserts that interrupting the escalation phase, thereby deescalating the anger so that the explosion phase never occurs, can break the cycle of aggression. However, the diagram depicting Walker’s aggression cycle does not include a component that illustrates the deescalation process (i.e., the effective use of coping skills). Thus, it was believed necessary to expand the diagram to include an alternate pathway that illustrated the process of recognizing the warning signs associated with escalating anger, which in turn would then focus on engaging cognitive and behavioral coping skills to reduce anger and prevent aggression. The art therapy interns created a modified two-pathway diagram (see Figure 1) that was named the choices cycle.

An art task was designed to introduce the choices cycle and to illustrate the process of anger escalation and deescalation. Group members completed the art directive before they read the section of the workbook related to the aggression cycle.

Illustrating the choices cycle through paper vehicles. The group leaders introduced the paper vehicle directive, in which the participants were instructed to construct a vehi- cle using only glue and colored construction paper. The only requirement was that the vehicle had to conceivably be able to travel on land. The members had 1 hr to com- plete the vehicle and were encouraged to work with one another, asking their peers for ideas and assistance if they had any difficulties. After they completed the vehicles, a guided imagery exercise was conducted.

The participants were instructed to imagine themselves sitting in their vehicle, trav- eling forward on a dirt road in thick woods. There were tall pine trees on either side with the scent of dirt and pine in the air. As the members kept traveling forward, they

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began to see the trees become sparse and the dirt turned to sand. The smell of the air began to change, the breeze picked up, and they were told that they could smell salt water. Sea gulls could be heard, and sand dunes appeared in the distance. The vehicles even- tually arrived at a beach with the ocean spread out before them; their vehicles became stuck in the sand. The participants were told that their vehicles could not park, move backwards, left, or right; they could only move forward toward the water. They

Figure 1. The choices cycle

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were then instructed to think about how they could alter their vehicles to ensure they did not sink on entering the water. The members were instructed to make changes to their vehicle within 15 min to ensure it would not sink. At the end, the participants were prompted to read the section in the workbook related to the aggression cycle, to reflect on the paper vehicle directive, and contemplate possible connections it may have to the aggression cycle.

In the follow-up session, the group members discussed the previous session’s art therapy activity in the context of the aggression cycle chapter of the workbook. It was also during this session that the leaders introduced their expanded choices cycle dia- gram (Figure 1), in which an alternate route was added to demonstrate how the aggres- sive act and its negative consequences could be avoided. The choices cycle diagram was designed to visually coordinate with the guided imagery used in the paper vehicle directive. The purpose of this directive was to provide the group members the opportu- nity to experience the process of changing their thoughts about a situation and then taking action based on the revised thoughts. It required them to complete a difficult and potentially frustrating initial task; the directive was also designed to have the par- ticipants process their emotional reactions to being asked to alter their initial products. As the directive progressed, group members found and shared new ways to cut the paper without scissors (e.g., scoring the paper with the point of a pencil). Although some of the participants were initially resistant for unclear reasons, all of them eventually

Figure 2. Example of paper vehicle sculpture

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embraced the directive and ultimately came to understand the relationship between the directive and the curriculum. Figure 2 is an example of a participant’s paper vehicle.

To illustrate the responses to this directive, the following is a vignette of a group member, A.M.

A.M.—A case vignette. A.M. was a member of a group composed of five members whose ages ranged from 31 to 57 years. He was 57-year-old, Hispanic male serving a 10-year sentence. Initially, A.M. seemed to be anxious and resistant and refused to create a vehicle. A.M. characteristically became uncomfortable when confronted with a directive that required him to step out of his typical artistic modalities. Before his incarceration, he had worked on the lettering of signs, and he indicated on several occa- sions throughout the group that he preferred controlled and precise artwork techniques. When he did eventually begin to create a vehicle, he quietly repeated the words patience and relax to himself. At one point, he asked the leaders in a somewhat accusatory tone whether the directive was intended to cause feelings of anger and frustration. Despite his apparent distress, he eventually completed a small paper sculpture replica of a scooter-like vehicle that he remembered constructing in his childhood (Figure 3).

Figure 3. A.M.’s scooter-like vehicle

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When he finished, A.M. seemed pleased with the result and smiled continuously as he talked about his creation.

During the second session, A.M. expressed how the directive helped him look at his anger differently. He was able to connect the art directive to the choices cycle and relate it to his own habitual response pattern. He identified some of his own recurrent aggressive thinking and behavior, acknowledging his need to change them. Along with helping him recognize his habitual reactions, the process seemed to allow him to iden- tify with other members of the group. He also seemed proud of his creation, often refer- ring to his vehicle in later sessions. The directive also required problem solving and patience, encouraging him to take creative chances. He was encouraged to look on his willingness and ability to take part in the activity as evidence that he could be success- ful in changing his habitual aggressive thinking and behavior.

Cognitive restructuring using the ABCD model. Following the sessions of connecting the art directive to the choices cycle, a cognitive restructuring model was introduced to the group participants. This model, which the workbook identified as the ABCD model, is based on the work of Albert Ellis (Ellis, 2006). This is a standard CBT for- mulation describing the process through which cognition mediates emotion and behavior, illustrating how an individual can change his or her thoughts about a situ- ation, which in turn changes the individual’s response. “A”, or the activating event, is the event to which the individual is responding, also known as the anger trigger. “B” is the beliefs or thoughts that the individual has in response to the event, which leads to “C”, the consequence or emotional response. Hostile beliefs about the event will lead to anger, resulting in defensively aggressive tendencies. For example, “A” a perceived slight (an acquaintance fails to say “hello” as he walks by) leads to “B” hostile bias underlined by uncomfortable self-doubt (“He disrespected me; maybe I’m not respect-worthy”), which in turn leads to “C” defensive anger and aggressive thoughts designed to restore self-confidence (“He has no right to treat me that way, I’ll show him!”).

If one engages in predatory beliefs, such a slight, it may lead to thoughts about instrumental aggression: The slight “A” may lead to “B,” predatory bias produces self- serving calculations (“He disrespected me; it would cost me to let him get away with that”). This in turn can lead to “C,” righteous anger and aggressive thoughts designed to restore momentarily diminished power (“He’s weak; I’ll put him in his place”).

“D” is defined as the process of identifying and disputing the problematic beliefs and maladaptive responses, and replacing them with new thoughts that lead to appropri- ate emotional and behavioral responses (Ellis & Harper, 1975). To illustrate using the “perceived slight” example described above, hostile biased thoughts might be dis- puted with thoughts that depersonalize the event or remove the assumption of inten- tionality (“He must have something on his mind” or “Maybe he didn’t see me”). Alternatively, predatory thoughts can be disputed by thoughts that highlight choice, control, and the potential negative consequences of aggression (“I can choose to let that go; it’s not worth getting into a fight and getting into trouble over”).

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Two modifications were made to this section of the curriculum when it was presented to the participants. First, it was pointed out that the emotional consequences of beliefs could either lead directly to an emotion-congruent range of behavioral responses or to additional similarly themed thoughts about the activating event, which in turn can generate more intense feelings. Second, it was emphasized that disputing thoughts (“D”) lead to a different range of emotional consequences, and labeled “E” (the emotional effect of the disputing thoughts). Separating these two sets of thoughts and emotional consequences creates an image of two separate pathways, each with its own unique outcome. The image of separate pathways brought clarity to the model by highlighting the role that thoughts play in determining an outcome of a situation, corresponding to the two pathways presented in the choices cycle. Illustrating the positive consequences was important to increase offenders’ acceptance of the model’s utility and concomitantly provide incentive to challenge and change their maladaptive thinking habits.

A final addition to the curriculum followed the presentation of the ABCD (and now “E”) model. In this session, participants were taught to make a distinction between the thoughts they have in immediate reaction to an activating event (i.e., “B” in the ABCDE Model) and the attitudes and belief systems that underlie those thoughts. The process of identifying one’s attitudes and belief systems involves several levels of metacognition. First, participants must learn to discern impulsive thoughts they have in response to activating events, then they must learn how to trace these momentary thoughts back to the belief systems that generate them. Attitudes and beliefs tend to be difficult to identify, so participants were taught various strategies to discern them, such as looking for emotion-laden language clues in their immediate thoughts, asking them- selves questions about their personal and family history with regard to the activating event, and asking themselves what personal beliefs they have that relate to the event. The main purpose for adding this component was to encourage participants to identify, challenge, and change their antisocial (i.e., hostile or predatory) attitudes and beliefs. Participants were taught to critically evaluate their attitudes in terms of whether they are helpful (i.e., keep them out of trouble and unharmed, get them the results they want, maintain their relationships, move them closer to desired goals, etc.) or unhelpful (i.e., produce harmful consequences and impede their progress toward goals). Participants also were taught that unhelpful attitudes can be disputed and replaced with more adap- tive beliefs. Although it takes much more effort, an advantage to changing attitudes rather than relying only on changing in-the-moment thoughts is that once a particular attitude is modified adaptively, it will no longer automatically generate problematic thoughts. Using this strategy, offenders can acquire the capacity to reduce the number of potentially volatile situations they experience. The discussion about this process led to the next art directive, the Water Contamination Exercise.

Illustrating the ABCDE model with the water contamination directive. An art therapy direc- tive, known as “The Water Contamination Exercise,” was designed to help the inmates understand how underlying attitudes generate the thoughts that occur in response to a trigger. The directive involved a series of three line drawings, created on pieces of white 8.5” × 11” sized paper. The three pages included a predrawn image of a water reservoir

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and an X-ray view of underground pipes leading from the reservoir to a spigot from which water is flowing. However, there were slight variations to the three separate pages. The first page included a tree and clear sky around the water, the second included a hand pouring oil into the water, and the third showed a factory spilling toxins into the water reserve, with a cloudy sky and a hazy sun. Participants were provided oil pastels and watercolors which, when used together, creates an interesting effect. The partici- pants were instructed to examine the environment in each drawing and determine what the water’s color and clarity would look like when flowing from the spigot. They were then asked to color the images in any order using the watercolors and oil pastels, mak- ing sure to depict the water as they thought it would look given the specific elements in each picture. At the end of the session, the group members were told to think about how this directive might relate to the ABCDE Model. Figure 4 provides an example of one participant’s drawing.

The next session began with a discussion of the drawings. The participants taped the pictures to the wall in groups by image content. The group leaders facilitated a dis- cussion about the content of the pictures, emphasizing the similarities and differences among the three images. The participants were prompted to determine the relationship between their pictures and the ABCDE material they were taught. To help them get

Figure 4. Example of water contamination directive

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started, they were asked to focus on “B.” With guidance, the participants identified the element in the scenes that metaphorically represented their immediate thoughts in response to a trigger, represented as the water pouring out of the spigot. Subsequently, their attitudes or belief systems were identified as the reservoir in the images. The par- ticipants then discussed what various elements in the paintings might represent in refer- ence to their thoughts and attitudes. As needed, the leaders helped the participants identify each part of the metaphor because it was important that they understood the symbols to continue with the discussion.

As the discussion proceeded, group members progressed in their understanding that the unpolluted scene (the first drawing of the tree and clear sky above the water reser- voir) represents how nonaggressive thoughts flow from adaptive, helpful, and healthy attitudes and beliefs, and thus do not cause harmful behavior. The second scene, in which an inmate’s hand is shown pouring oil into the water, represents the process through which a person can “poison his own water supply” by adopting and building on negative belief systems and attitudes such as racial stereotypes, street, and prison gang doctrine. The third scene, in which a factory is spewing pollutants into the air and water, represents how the external influences of one’s past and present (i.e., family, friends, community, entertainment media, etc.) can negatively influence one’s attitudes and beliefs.

After the inmates understood these symbols, they were prompted to brainstorm about changes they could make to the oil and factory pollution scenes to make the water safe for drinking. Regarding the second scene, participants tended to realize rather quickly that the most important intervention they could make would be to stop pouring oil into the water, that is, to stop allowing themselves to perpetuate and expand their harmful belief systems by continuing to assimilate their new experiences into their existing harmful attitudinal frameworks. They were reminded that they still had to contend with the oil already introduced into the reservoir. Similarly, although they controlled the hand in the second scene, the factory in the third scene was not under their control. Thus, they needed to find another way to cope with the pollution. Eventually, the group members agreed that filtering the water would be a viable solution.

As the discussion about filtering the water progressed, group leaders posed ques- tions as needed to guide the participants into recognizing that they essentially had two options for filtering the water: The water could be filtered after it came from the spigot each time they needed water or they could install a permanent filtration system some- where in the pipeline. Participants discussed the advantages and drawbacks of the two filtration options and the metaphorical meaning of each option. Through this visual metaphor, participants came to understand that using the ABCDE model to discern and change problematic thoughts that occur in the moment in response to triggers is a use- ful and important strategy to “filter out” the angry and problem producing thoughts. However, in the long term, changing one’s underlying problematic attitudes has the potential to create a “permanent filter” that leads to a general reduction in reactivity to triggers, resulting in a reduced need to engage in thought-changing strategies.

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J.B.—A case vignette. J.B. was in a group of six members, whose ages ranged from 26 to 44 years. All had sentences that related to violent and hostile crimes. The sessions spent on the watercolor directive began with a discussion about triggers and involved verbally working them through the cognitive restructuring model. After 30 min, the group was given the art directive. They appeared invested in the art process and focused attentively on the assigned painting task. After completing the art directive, they were asked to think about how this exercise related to the curriculum, particularly regarding their thoughts and beliefs.

In the following session, J.B. and two other group members were present to discuss their work. With minimal prompting, they were able to identify the different elements of the paintings and provide examples of attitudes adopted from their own experiences as well as from others’ experiences. With the purpose of identifying filters they needed to put in place, the members were guided to examine their own triggers and to cogni- tively “dig” for the attitudes that lay underground.

J.B. offered his recollections of a trigger that would historically elicit an angry and violent response. The triggering event was his observation of a truck driving recklessly while he was driving on the same highway. J.B. reported feeling outraged, and he traced his feelings to his thought that the other driver should not be putting lives in danger. At the same time, he reacted to his thoughts by speeding up himself in an attempt to overtake the truck, wanting to “teach the man a lesson.” After examining the roots of his thoughts, J.B. identified his underlying attitude. He identified his belief that when he saw others doing something he judged as wrong, it was his right to correct them. As he explored this belief with the help of the group leaders, J.B. recognized that under certain circumstances he erroneously believed he was entitled to take the law into his own hands. Furthermore, he realized that when he actually did so, he engaged in the very behavior for which he was condemning the other per- son. After reaching this conclusion, he seemed contemplative, looking down at the table for several minutes. At the end of the session, he indicated that the group leaders had “given him a lot to chew on.”

During the final session of the series, the group was asked about the effectiveness of the art directives. J.B. indicated that the art allowed him to put his thoughts on paper to objectively reflect on them, bringing what was “underground” to the surface. The water contamination exercise in particular helped him “identify the hot spots” so he could be better prepared for future triggering situations.

The ATAM Program: A Summary The foremost reason for incorporating art therapy components into the existing CBT Anger Management protocol was to tailor the treatment to the individual offender’s personal characteristics beyond the extent possible using only the CBT protocol. Although CBT provided some accommodations in presenting the material to partici- pants with divergent levels of verbal ability and intellectual capacity, the flexibility

1140 International Journal of Offender Therapy and Comparative Criminology 56(7)

and variability inherent in art therapy made it an ideal choice for increasing the poten- tial for the participants.

There were two primary ways in which art therapy was found beneficial within the CBT format. First, art therapy techniques were used to help participants engage in the therapy process by helping group members access emotions that are difficult or uncomfortable to express and/or by calming participants who were nervous or dis- tressed about being in the group or are experiencing unrelated stressors. Second, art therapy tasks were used to present and complement the CBT material so that it could be more readily understood by participants with varying learning styles, intellectual abilities, personality traits, and other individual differences that impact their ability to process the material. As well, regardless of the type of antisocial cognition offenders may possess—hostile, predatory, or both—art therapy directives seemed to help par- ticipants understand how their thoughts and beliefs about themselves and others influ- ence their behavior.

Within each of these two broad uses of art therapy, the techniques were used in a variety of ways to accomplish specific therapeutic objectives. To help participants become engaged in the therapy process, the art process was used to promote relaxation, to pro- vide a safe outlet of uncomfortable emotions, and to sublimate or process negative emotions.

Moreover, it quickly became evident that art therapy directives could be used in addi- tional ways to significantly enhance the overall potential for tailoring the material to the individual offenders’ particular characteristics. What emerged were four key ways that art therapy directives were used to present or complement the CBT material:

• At the simplest level, art can be used as a visual aid to represent, explain, or cue curriculum elements or concepts, for example, the use of the drawing to illustrate the two pathways of the choices cycle.

• At a higher level of complexity, art therapy directives can be used as tools to provide a visual metaphor for the concept being presented, as was done in the water contamination exercise.

• Similarly, complex is the use of an art directive to teach a particular concept, where the process of creating the art project becomes an in vivo experience of the concept being presented. (For example, this occurs in our curriculum when participants create art as a relaxation strategy.)

• At the highest level of complexity, the latter two mechanisms can be combined such that participants use art materials to create a visual metaphor and, during the creating process, experience the actual concept being presented.

An example of this in our curriculum is the paper vehicle exercise; the vehicle and its accompanying guided imagery and modification task serve as a metaphor for the choices cycle. The process of creating and modifying the vehicle encouraged the par- ticipants to manage their frustration through changing one’s thoughts. In addition, art therapy elements were used as informal assessment tools to assess needs and abilities,

Breiner et al. 1141

to measure emotional distress, to gauge progress over time, to assess comprehension and mastery of the material, and to discern attempts at manipulation by evaluating the level of congruence between participants’ art and their verbalizations. Furthermore, the inherent flexibility of art directives in general allows for group leaders to modify direc- tives as needed to meet the needs, abilities, and characteristics of individuals or groups.

The current setting for the ATAM program highlights its utility among inmates who are preparing to be released from prison and return to society; for these inmates, the ability to effectively and adaptively manage anger is an important skill that has the potential to reduce their likelihood to reoffend and return to prison. In addition to serv- ing as a reentry tool, the ATAM program also has the potential to positively impact inmates at other stages of incarceration. The program could prove beneficial to inmates who are currently housed in high-security settings as a result of displaying aggressive behavior in prison, ultimately helping them to self-manage their behavior and transi- tion to less stringently controlled settings within the prison system. Similarly, the ATAM program could benefit inmates who have been placed in inpatient mental health units in part because they have poor coping and emotion management skills by providing them with the tools they need to cope more effectively with the stressors of the prison environment.

Like all effective treatment protocols, this program continues to evolve with new interns and group participants; new directives are continuously developed to address anger management from a CBT perspective. The evolving and innovative ATAM pro- gram directives continue to demonstrate the valuable relationship developed in the prison settings between art therapy and a cognitive-behavioral curriculum.

However, despite the strength of the anecdotal evidence presented in this manuscript, a rigorous evaluation of the program will be needed to find out whether the ATAM program does indeed help the participating inmates improve behavior. Therefore, it is anticipated that future studies will be developed to empirically determine and support its efficacy. Establishing and using standard evaluation tools and creating a control group may strengthen the integrity of these conclusions.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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