The First Step Series: Art therapy for early substance abuse treatment

Abstract

The First Step Series (FSS) is a protocol of five art therapy directives designed for the initial stages of substance abuse treatment. These directives target denial to facilitate client identification of ambivalence and eventual acceptance of lifestyle changes necessary for recovery. Motivational Interviewing (MI) [Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people to change (2nd ed.). New York: Guilford Press] informs a conceptualization of denial as normal ambivalence that occurs during any change process. Normalizing ambivalence sets the stage for the related therapeutic tasks of matching the client's attitude toward treatment, promoting trust in the therapeutic relationship, and gently supporting the client's internal desire for change.

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The Arts in Psychotherapy 36 (2009) 245–250
Contents lists available at ScienceDirect
The Arts in Psychotherapy
The First Step Series: Art therapy for early substance abuse treatment
Elizabeth Holt (MS, ATR-BC)a,∗, Donna H. Kaiser (PhD, ATR-BC)b
aThe Mychal Institute, Corolla, NC, USA
bAlbertus Magnus College, New Haven, CT, USA
article info
Keywords:
Art therapy
Substance abuse
Chemical dependency
Denial
First Step
Motivational Interviewing
abstract
The First Step Series (FSS) is a protocol of five art therapy directives designed for the initial stages of
substance abuse treatment. These directives target denial to facilitate client identification of ambiva-
lence and eventual acceptance of lifestyle changes necessary for recovery. Motivational Interviewing (MI)
[Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing: Preparing people to change (2nd ed.). New
York: Guilford Press] informs a conceptualization of denial as normal ambivalence that occurs during any
change process. Normalizing ambivalence sets the stage for the related therapeutic tasks of matching the
client’s attitude toward treatment, promoting trust in the therapeutic relationship, and gently supporting
the client’s internal desire for change.
© 2009 Elsevier Inc. All rights reserved.
The use of art therapy in substance abuse treatment (SAT) has a
long history. Many authors have described the benefits of art ther-
apy for those with chemical dependency such as bypassing defenses
(for example, Julliard, 1994; Moore, 1983), promoting emotional
expression (Cox & Price, 1990; Holt & Kaiser, 2007; Kaiser & Holt,
2002), encouraging a spiritual recovery (Feen-Calligan, 1995) and
fostering creativity (Allen, 1985; Johnson, 1990). In a review of the
literature on art therapy in SAT over 20 years ago, Moore (1983)
concluded that art therapy provides an activemeans of experiment-
ing with imagery to communicate symbolically, offers an outlet for
clarifying feelings and attitudes, reduces distorted thinking, and
fosters increased insight. Since her review, several art therapists
have developed interventions and assessments aimed at decreas-
ing defenses and increasing acceptance of step one in a twelve-step
recovery model.
In relation to acceptance of the first step, it is well recognized
that one of the major objectives in the initial stages of SAT is over-
coming denial so that clients may begin to accept the need for
adopting behavioral changes that support recovery (Kesten, 2004).
“Denial is the mental mechanism that enables addicts to give up
more and more of the things that they find valuable in life...Denial
is the foundation of addiction, the fertile soil in which it grows and
flourishes” (Conyers, 2003, p. 23). Even though this conceptual-
ization of SAT is long-standing and widely used it is beneficial to
consider an alternative perspective.
Perhaps a more pragmatic and therapeutic way to approach
client defensive strategies like denial and minimization of sub-
stance use is to understand why and how people change. Miller and
∗Corresponding author.
E-mail address: esholt@aol.com (E. Holt).
Rollnick (2002) developed Motivational Interviewing (MI), a treat-
ment model based on a client-centered counseling approach that
seeks to enhance intrinsic motivation for change. This approach
is often integrated with the framework of the transtheoretical
model that suggests behavior change occurs as a series of grad-
ual stages as outlined by Prochaska and colleagues (DiClemente
& Velasquez, 2002; Prochaska, Norcross, & DiClemente, 1994;
Velasquez, Maurer, Crouch, & DiClemente, 2001). Designated
the Stages of Change (SOC) model, it delineates client readi-
ness for change as spanning a five-stage continuum, progressing
from precontemplation, where the client has not yet considered
change, through contemplation,preparation, and action, and finally
to the maintenance stage where the client works to sustain
long-term change. This is in contrast to the often dichotomous
position taken when treatment providers view a client as either
being in denial or ready to accept the need for treatment and
change.
Each stage is viewed as predictable, well defined, taking place
over time, and associated with a set of cognitions or behaviors.
Change is seen as ongoing as a client—given the optimal conditions
and interventions—moves from being unconcerned with altering
behavior or attitude to considering change as possibly desirable,
then later on to deciding and preparing for changes, until even-
tually genuine, internally motivated action is taken and, with time,
attempts to maintain new behaviors are set in motion. Based on the
belief that motivation is necessary for change to occur, DiClemente
and Velasquez (2002) emphasized that MI is particularly effective
for clients assessed to be in the early stages of change. It has also
been found to be effective with clients in the later stages of change,
as they prepare for the action and maintenance stages.
MI frames motivation as a dynamic interpersonal process that
is fundamental to change, not a personal trait. As such, each
0197-4556/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.aip.2009.05.00 4

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246 E. Holt, D.H. Kaiser / The Arts in Psychotherapy 36 (2009) 245–250
client is viewed as having the inherent potential for change and
responsible for his or her own personal change process (Miller &
Rollnick, 2002). Therefore, the task of the therapist is to create a set
of conditions that will enhance the client’s own intrinsic motivation
for, and commitment to altering behavior. MI is a systematic and
directive clinical approach for evoking internally motivated change
with the primary goal of resolving ambivalence.Ambivalence is nor-
malized as part of a natural process of change, and any resistance or
reluctance is understood as inherent to the change process. In this
framework resistance is reframed as the therapist’s responsibility.
Accordingly the therapist’s task is to empathize with the client’s
perspective, however ambivalent he or she may be about accepting
treatment.
Research supports the use of MI and the SOC model (also
referred to as Motivational Enhancement Therapy) for helping those
with chemical dependency (Brown & Miller, 1993; Project MATCH
Research Group, cited in Polcin, 2002). Evidence suggests that
the use of MET more effectively promotes client engagement in
treatment, leads to more positive outcomes at follow-up, and sig-
nificantly decreases the alcohol consumption of clients with mild
to moderate drinking problems (Polcin, 2002).
We were intrigued with the idea of applying MI and SOC to
the early stages of substance abuse treatment using art therapy.
While developing the FSS, an article describing the use of MI and
art therapy was published by Horay (2006). His approach is similar
to ours in that he noted that “art therapy seems uniquely capable
of bridging the psychological gap between the cognitive-behavioral
concerns of MI and the traditional psychodynamic focus on clini-
cal narcissism” (Horay, 2006, p. 17). However, we diverge from his
perspective in that we view MI as conceptually compatible with
the twelve-step model while he seems to regard it as disparate. The
twelve-step philosophy is one of attraction, which supports “work-
ing” the program, developing hope, conducting self-inventories of
personal shortcomings, examining consequences of drinking, and
changing maladaptive thinking. For example, the “Big Book” of
Alcoholics Anonymous (1976) emphasizes that the principles are
guides to progress, that self-evaluationis paramount, and that inter-
personal connections through fellowship promote life in recovery.
Miller and Rollnick (2002) stated that three critical components of
motivation are “readiness, willingness, and ability” (p. 10), similar
to twelve-step principles.
As we reviewed our own clinical experiences, the art ther-
apy literature, and principles of MI and SOC we recognized the
value of a model that is research-based, is well-matched with
the twelve-step model, and corresponds to our beliefs about
the importance of relational processes in any clinical approach.
DiClemente and Velasquez (2002) noted, “The motivational inter-
viewing philosophy, approach, and methods are uniquely suited to
addressing the tasks and emotional reactions of individuals who
are moving through the first two stages” (p. 203). Further we
believe that MI links well to what has been traditionally viewed
as overcoming denial in early SAT. Considering that each stage
of change requires that certain tasks be accomplished and spe-
cific therapeutic processes be used to evoke change, we reasoned
that particular art therapy tasks could be designed to achieve
each task.
In this paper we focus primarily on the first two stages, pre-
contemplation and contemplation. Fostering the movement from
precontemplation to contemplation by promoting motivation for
change requires interventions that are engaging and action-based
(Miller & Rollnick, 2002). These qualities are inherent to art therapy
in that clients choose their materials, decide how to approach par-
ticular directives, and make decisions about their artwork as they
revise and rework their imagery. These processes can reduce defen-
siveness and denial while opening the door for considering change
as a viable option. The final artistic product coupled with therapist-
facilitated discussion can provide an opportunity to communicate
important feedback that may enable the client to “see” more clearly
the reality of the negative consequences of substance abuse and the
positive ones associated with recovery.
At precontemplation the person does not see a problem—this is
commonly viewed as denial or resistance in SAT but is reframed in
MI as normal ambivalence. There is lack of awareness that prob-
lem behaviors exists or even an unwillingness to consider the need
for change. Individuals engage in little activity that might shift
their views, and can exhibit defensive strategies when problem
behaviors are pointed out. They are not convinced that negative
aspects of their problem behaviors outweigh the positive ones they
seem to experience. DiClemente and Velasquez (2002) identified
four patterns of thinking and feeling that characterize precon-
templators: “reluctance, rebellion, resignation, and rationalization”
(p. 204).
In the second stage, contemplation, the person recognizes a
problem and also considers whether and how to take action toward
a solution. Thus, the problem is acknowledged and possible solu-
tions are explored but there is not yet a commitment to take
solution-based action. The aim of the therapist is to help the client
“tip the balance” in favor of change(DiClemente & Velasquez, 2002).
Understanding these two early stages of change compelled us to
reflect on the kinds of art tasks that might help move a client
in SAT from precontemplation to contemplation and then toward
preparation to change. We next describe the FSS and then turn to
the therapeutic processes that are key to successful implementa-
tion.
The First Step Series
We began with the premise that “Any activity that you initi-
ate to help modify your thinking, feeling, or behavior is a change
process” (Prochaska et al., 1994, p. 25). In line with this and based
on our clinical experiences we developed five directives adapted
from our previous work, the art therapy literature, and the MI/SOC
framework: the Crisis Directive, the Recovery Bridge Drawing, the
Costs–Benefits Collage, the Year from Now Directive, and the Barri-
ers to Recovery Directive.
We reasoned that these tasks would encourage motivation as
clients actively engaged in the treatment process and depicted
their situations, thoughts, feelings, and attitudes. A goal of MI is
to evoke “change talk” and statements of problem perception from
the client, with the ultimate goal of fostering a client shift in per-
spective toward perception of a need for change. The client’s active
process of constructing a concrete and tangible representation of
their inner and outer realities and creating personal images fos-
ters a self-evaluation process that reveals his or her reality and
makes it difficult to erect defenses that hide critical issues related
to treatment concerns. As Harms (1973) asserted:
...The [client] moves from simple doodling and doing some-
thing with color to a self-involvement which tries to work out
the idea of the drawing or painting [he or she] wants to create.
This step of inner involvement gives art its first chance to set foot
in the [client’s] confused inner experience ...[and subsequently
he or she] goes into a state of independent creation (pp. 58–59).
This can be empowering and lead to greater insight, help reduce
ambivalence, and eventually promote movement toward action.
Thus, the act of creating can stimulate active engagement and opti-
mally, set the stage for a change process.
Velasquez et al. (2001) described 10 processes of change that
support movement from one stage to the next. We focus on the
first group, the “experiential processes,” as these give attention
to the internal thought processes pertinent to the early stages of

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E. Holt, D.H. Kaiser / The Arts in Psychotherapy 36 (2009) 245–250 247
Fig. 1. Crisis Directive.
change when the goal is to increase motivation for revising feel-
ings, perceptions and thoughts. These early processes of change
are: consciousness raising (gaining knowledgeof self and b ehavior),
self-reevaluation (recognition of how current behavior conflicts
with values and goals), dramatic relief (an emotional experience
related to the problem), environmental reevaluation (the ability
to see the effects of one’s behavior on others and the environ-
ment), and social liberation (recognition of alternative behavior in
the social environment).
Next we describe each directive and provide examples of client
responses. These FSS directivesare most commonly done in art ther-
apy groups, either as an individual or group task; however, they
can also be used when working with clients individually. Alterna-
tively the list of directives can be given as choices to group therapy
participants directing participants to choose the one that is most
relevant; presenting choices tends to be viewed more favorably,
provides clues to change readiness, and promotes ownership and
empowerment.
Crisis Directive
This directive is: “Depict the crisis or incident that brought you
to treatment,” which is tied to the initial written therapy assign-
ment, “The crisis that brought you here,” for clients we have worked
with. The written assignment asks clients to describe the situation
or combination of events that led them to admission to treatment
in detail. Further, they are asked to concentrate on identifying the
feelings that come up as they complete the assignment. Based on
this, the Crisis Directive wasdesigne d for evaluating clients’ percep-
tions of their situations and their readiness to engage in treatment.
Clients often clearly portray their stage of readiness to engage in
treatment or their struggles that impede their engagement. Cox and
Price (1990) created a similar art therapy they called an Incident
Drawing based on Incident Writings for trauma resolution (Collins
& Carson, cited in Cox & Price, 1990): “draw about an incident that
occurred during the time you were drinking/drugging.” The Cri-
sis Directive is more focused in that it portrays a significant and
particular incident directly related to admission to the treatment
program.
Imagery produced in response to the Crisis Directive often
depicts the client’s ambivalence about letting go of their substance
of choice. An example is seen in Fig. 1 in which a client drew
himself bowing down to a life-sized glass of wine. Some clients
depict images of danger characterized by images of turmoil and
high energy, whichsuggest anxiety but also, on a more positive note,
may indicate the individual has the necessary energy to prepare
for change. For example, in a collage created by another client pic-
tures of hurricanes, the word “whirlwind,” and the phrase “where
currents collide” were all included, which suggests anxiety along
with high levels of energy—the energy portrayed can be reframed
as a strength. Often clients will illustrate a personal dilemma or a
traumatic experience that led to the decision to enter treatment,
thereby expressing issues heretofore unacknowledged; this new
information is then available for processing and can be incorpo-
rated into treatment planning. Issues such as incidents of trauma
may not be disclosed so readily in verbal intake interviews but are
more likely to be expressed in art tasks such as the Crisis Directive.
Fortunately when they emerge in imagery they can be addressed
in ongoing treatment rather that resurfacing later when they might
interfere with the recovery process.
Clients usually respond openly and eagerly to the Crisis Direc-
tive, especially in the context of group therapy as the process
discussions frequently reflect the change processes described in
the MI literature. In this manner consciousness raising, dramatic
relief, self-reevaluation, and environmental reevaluation related to
the imagery of a crisis or incident that brought each person to
treatment, commonly emerge.
Recovery Bridge Drawing
The task directive used is, “Complete a bridge depicting where
you have been, where you are now, and where you want to be in
relation to your recovery.” This diverges from the instructions to
draw a picture of a bridge going from some place to another place
devised by Hays and Lyons (1981). The Recovery Bridge Drawing
provides a useful visual image that frequently reveals the anx-
iety and ambivalence a client may have about the prospects of
embarking on change. This drawing is particularly helpful for com-
municating in visual form any hesitation regarding the current
changes being considered during treatment.
As in Fig. 2, often fire or other dangerous images aredrawn in the
area that presumably represents present experience, on the right
side of center of the image. These images of danger extend from
the present into areas viewed as indicating the future, further to
the right. It is helpful for the therapist to recognize this kind of
representation of danger suggests anxiety and ambivalence and it
will be constructive to focus on therapeutic principles inherent in
a client-centered MI approach. Affirming, reflective listening, and
open-ended questions were used with the client who created Fig. 2
and this helped to provide the support needed to more clearly iden-
Fig. 2. Recovery Bridge Drawing.

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248 E. Holt, D.H. Kaiser / The Arts in Psychotherapy 36 (2009) 245–250
Fig. 3. Costs–Benefits Collage.
tify his fears and ambivalence about change. This led the client
to experience increased emotional engagement as he recognized
he had depicted dangers and ultimately he developed, in conjunc-
tion with his primary therapist and the treatment team, a relapse
recovery plan that addressed his fears and ambivalence.
Costs–Benefits Collage
This task is based on strategies found in the SOC literature and
manuals and helps both client and therapist evaluate and acknowl-
edge the existing degree of readiness for change. The directive is:
“Make a collage exploring the costs and benefits of staying the same,
and the costs and benefits of changing.” The Costs–Benefits Collage
is similar to, but was devised independently from, one described by
Horay (2006) which he called a Pro/Con Collage; since both these
directives arose directly from MI principles the similarity is under-
standable. Ours differs in that the client has a choice of completing
either one or two collages.
Usually we present this directive as an individual task done in a
group therapy context but it has also been successfullypresented as
a group task. Based on group dynamics and current client issues, we
may use either one or both tasks. The Costs–Benefits Collage allows
clients to freely explore the possibility of not changing; giving them
permission to consider that, in reality, this is always an option. As
an exploratory directive it also provides an opportunity to openly
discuss ambivalence. It can help clients to identify and verbalize
their attraction to substance use—something they seldom do dur-
ing treatment—and express their fears or ambivalence about letting
go of substances. Often a discussion emerges that includes client
disclosure of honest thoughts and feelings about changing versus
not changing. We have found this collage may provoke thoughts,
urges, or cravings to use, so it is important to check this out for the
individual who completed the collage as well as others in the group.
This directive has the additional benefit of supporting relapse
prevention since talking openly about fears and problems provides
the client an experience for reduction of cravings while allow-
Fig. 4. Depict Yourself a Year From Now.

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E. Holt, D.H. Kaiser / The Arts in Psychotherapy 36 (2009) 245–250 249
ing for therapist–client collaboration with regard to identifying
problem-solving options for relapse prevention and the manage-
ment of cravings. The collage is useful for promoting an interactive
processing of the realistic choices that clients face as they con-
front the reality of a future without chemicals. When presented
as a task to be completed as a group, there are additional bene-
fits of group interaction and problem-solving talk. The collage in
Fig. 3 demonstrates how a group approached the task using a man-
dala. They placed words and objects associated with benefits of
recovery inside the circle and those related to costs associated with
continued substance use outside the circle.
This exercise can quantifiably depict a client’s stage of readi-
ness through the number of costs and benefits identified, with
the shift toward readiness evident when the benefits outweigh the
costs (DiClemente, cited in Velasquez et al., 2001). Creatingconcrete
images that represent how clients perceive the costs and bene-
fits opens the door to an experiential expression of change in self,
consciousness raising, and environmental reevaluation.
Depict Yourself a Year From Now
This directive is an adaptation of the popular art therapy tasks
that encourage portrayals of future scenarios and was designed
specifically as a strategy to foster the processes of self-reevaluation,
consciousness raising, and dramatic relief. The task has two parts.
The first is “Depict yourself as you imagine you will be in a year if
you make the changes that support recovery.” The second is “Depict
yourself as you imagine you will be in a year if you do not make
the changes.” This allows the client to visually explore the reality
of changing versus the reality and associated consequences of not
changing. Many complete this task on one page, as in Fig. 4 where
the client divided the paper in half with a line and drew an image
of himself in jail on one side and himself and a friend riding a bike
on the other. The images created can provide visual evidence to
further support any increased motivation for change. Along with
subsequent discussion of the differences in divergent futures, an
emotional experience supporting consciousness raising change talk
can be elicited.
This task helps the client “see” the problem in a tangible form
and how using substances will logically interfere with life goals
and even life itself, as some often do depict their own demise
as the result of substance use. The tangible image helps to fos-
ter increased emotional awareness of the choices involved and the
need for change if negative consequences are to be prevented. This
directive appears also to promote awareness of the reality of the
consequences of continued use and support the development of
internal motivation for change.
Barriers to Recovery
This final directive was also developed from the concepts found
in the MI literature. The basis for the task is similar to the
Costs–Benefits Collage, while being directed more toward support-
ing those clients assessed to be moving from contemplation into the
preparation stage. The directive is “Make a picture that illustrates
the barriers you see to making the changes necessary for recovery.”
Many clients chose to complete this as a road drawing such as that
seen in Fig. 5, where hopeful imagery (the sunrise) is depicted at
the end of the road. Alongside this the client has included hints
about important concerns. The client depicted the barriers of lone-
liness, depression, isolation, and a disturbed self-image that were
not apparent to the staff until he created this drawing.
Images such as this are often observed to emerge with this task
and may be associated with feelings of anxiety surrounding stress-
ful events such as impending discharge or visits by particular family
members. These kinds of images are particularly helpful for treat-
ment planning as additional issues and problems are potentially
exposed. These concerns can then be addressed with collabora-
tive problem solving, revisions of relapse prevention plans, or other
modifications to the client treatment plans. For this particular client
it led to crucial self-awareness but additionally it was critical to
relay these issues to the treatment team since he was nearing dis-
charge. Each of the issues he depicted in the Barriers to Recovery
helped the treatment team more fully understand his ambivalence
and fears about an abstinence-based recovery life. Subsequent to
this drawing they worked with him to develop behavioral and
psychopharmacological interventions to better meet his needs for
discharge and ongoing outpatient care.
Art therapy processes and the FSS
The art therapist’s response to the client and his or her artwork
is critically important for fostering motivation for change. Providing
Fig. 5. Barriers to Recovery.

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250 E. Holt, D.H. Kaiser / The Arts in Psychotherapy 36 (2009) 245–250
empathic reflection related to the client’s imagery and offering non-
confrontational feedback while responding to any discrepancies
in the imagery and the client’s discourse, helps to create a ther-
apeutic environment that strengthens change motivation. Then,
respectfully pointing out discrepancies and how these may repre-
sent normal ambivalence allows the client to own his or her degree
of motivation no matter how minimal it may appear. Other criti-
cal aspects of therapeutic engagement that enable the art therapist
to communicate support as individuals move through one stage of
change into the next include techniques and motivational strate-
gies such as providing sincere affirmations and empathy; asking
open-ended questions; eliciting change talk and self-motivating
statements; providing reinforcement that supports self-efficacy;
and framing cautious, tentative reflections and summaries. These
techniques in the art therapist’s repertoire are used more intention-
ally in conjunction with an MI approach.
Art therapy is an active, mind–body strategy that fits naturally
with the principles and techniques of MI. The hands-on process
of art making provides concrete feedback to the client, while he
or she is engaged in a pleasurable and experiential process, that
evokes self-reevaluation and provides the emotional relief that is
gained through self-expression. Communicating acceptance sets
the stage for increased internal motivation that encourages further
self-examination and associated self-disclosure. The gentle guid-
ance of a compassionate art therapist who uses MI strategies to
elicit “change-talk” supports the processes of change, and appears
to enhance and possibly quicken this internalprogression to change
motivation.
Such a therapeutic style is the core of MI, and creates the con-
ditions for internally driven change. Miller and Rollnick (2002)
identified that motivation is an interpersonal process, not a per-
sonal trait, and state that “motivation for change can not only be
influenced by but in a very real sense arises from an interper-
sonal context” (p. 22). They stated that the fundamental spirit of
MI is based on “collaboration, evocation and autonomy,” which are
helpful concepts to keep in mind when integrating the FSS into
treatment settings.
Conclusion
As art therapists, we are acquainted with the healing nature of
art making through our own experiences; in our work we have
seen the dynamics of this at play over the course of treatment
many times. The act of creating is an active process, which may
include both conscious and unconscious expressions. The artwork
can be a safe container for exploration of emotions, thoughts, per-
ceptions, beliefs, and experiences with the art created serving as
a tangible image that provides opportunity for immediate feed-
back, an avenue for self-assessment, a means of emotional relief,
and ultimately opens the door for building the internal motivation
for change.
In contrast to the art therapy approaches to SAT that focus on
overcoming denial, the FSS draws from MI and SOC to address client
motivation and ambivalence in the early stages of treatment. MI
is a systematic client-centered approach for enhancing motivation
and nurturing consideration of change in the client. DiClemente
and Velasquez (2002) state, “it is apparent that motivational inter-
viewing and the stages of change are a ‘natural fit’ for one another”
(p. 203). Art therapy is a natural fit in that it compliments these
models and the art therapist is in a unique position to emphasize
the client’s ability to change via the client’s creation of imagery.
The very action of creating artwork catalyzes internal and exter-
nal processes linked to interpersonal connection that can enhance
motivation, a key factor for generating lasting change.
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