Theoretical Lens Case Comparison: ACT Art Therapy and Positive Art Therapy

Introduction

This paper compares two possible theoretical lenses, ACT Art Therapy, and Positive Art Therapy, to the case of Emma, a 16-year-old European-American female at an inpatient psychiatric clinic for eating disorders. In addition to Emma's extreme dieting habits and subsequent physical issues, she presents with self-cutting behavior, feelings of sadness and isolation, and depression. I suspect these underlying issues are significant contributors to her extreme dieting, and by addressing them (the roots), Emma will turn to healthier ways to deal with her feelings, and her eating disorder will improve. I chose two modalities that not only deal directly with Emma's more challenging feelings but also focus on increased positive feelings to combat and outweigh them.

ACT Art Therapy

Acceptance and Commitment Therapy (ACT) was developed by Steven C. Hayes and is based on the premise that psychological events (cognitions, feelings, and memories) in and of themselves are not problematic. Instead, it is about the context of psychological events, the language used to relate to them, and how they influence behaviors (Neukrug & Hays, 2022). More specifically, "in ACT, a disliked/unwanted thought is treated as a behavior, and the goal is to develop psychological flexibility in how we respond to the thought" (Backos, 2023, p. 34). Psychological inflexibility includes habitual, narrow, and fear-based coping strategies (Backos, 2023), and changing how a person relates to psychological events can profoundly impact their actions and overall life satisfaction.

Six core processes are central to the ACT modality: acceptance, cognitive defusion, present-moment awareness, self-as-context, values, and committed action. These processes are working parts in the overarching goal of increasing psychological flexibility. Harris (2019) eloquently describes the goal of ACT in simple terms: "the aim of ACT is to maximize human potential for a rich and meaningful life, while effectively handling the pain that inevitably goes with it" (p. 3). The integration of ACT and art therapy serves as a creative and therapeutic means to help clients make behavioral choices that align with their values and are less related to psychologically inflexible reactions.

In the case of Emma, her eating disorder may be a coping mechanism for various challenges she is experiencing. ACT can help her learn new and healthier ways to relate to her body and the foods she eats to sustain it. ACT can also help her sit with her uncomfortable feelings and thoughts at the root of her behaviors and find a more profound sense of self-worth through self-control, focusing on values, and ultimately finding greater flexibility and self-inclusivity. In particular, I would work with Emma to help her find healthier coping strategies when difficult feelings and thoughts arise and provide an educational environment about the power of how she relates to the context behind them (a thought is just a thought and not problematic by itself). I would help her to increase mindfulness in her life (being present), identify what is important to her (her values), and help her to discover actions she can commit to that aid her in moving closer to her values and finding greater meaning in her life. 

I suspect that Emma's extreme dieting and cutting habits are both outlets to help her deal with feelings of depression, sadness, and isolation by giving her a sense of control (dieting) and release (cutting). In terms of healthier ways of relating to challenging feelings, specific exercises that would be beneficial to invite Emma to try are The Breathexercise and the Just One Line exercise. The Breath exercise is a way of visualizing and being more present with your breathing pattern. It is simply using a pencil, pen, paint, or marker (whatever media is most comfortable) and moving it on the paper to the movement of your breath: upward movements as you breathe in, downward movements as you breathe out (Backos, 2023). It can create a sense of calm and presence with the breath and externalize anxiety. The Just One Lineexercise can help externalize and visualize various thoughts and feelings at any moment. It involves simply drawing a line that represents what you are feeling. For example, it might have sharp peaks, valleys, rolling hills, soft wrinkles, etc. The client is invited to journal about the line, what it means to them, what it says to them, and any overarching messages or themes it portrays. Both exercises could help Emma move away from her cutting behavior because they help with release and mindfulness. Additionally, practicing mindfulness helps to create a judgment-free zone to view thoughts. That can help Emma externalize negative self-talk or body rumination and instead approach such thoughts with caring and compassion.

Another exercise that may benefit Emma and others in the group therapy setting is a cognitive defusion collage. The exercise invites each group member to choose one image from a magazine that is symbolic of their negative body image, cut it into ten pieces, and rearrange them on paper as a collage (Backos, 2023). Seeing the image no longer in its whole state and instead arranged in broken-up bits, the negative body image is externalized and loses its power in the pieces. Along with these exercises, helping Emma establish what is important to her and solidify her values would make a world of difference. Values consideration can help with eating disorders where rigidity or rules around food and body are employed by helping clients increase their actions' flexibility and shift their relationship to food. For example, based on Emma's obsession with fitness accounts, health and fitness might be included in her values. Helping her make decisions that align with those values rather than pushing her farther from them would be a place to start. If Emma values relationships (her family, for example), we can work through some action plans to improve her relationships with her parents.

ACT Art Therapy is a culturally responsive modality due to its extensive applicability and, according to Backos (2023), "yields positive impacts across race, ethnicity, and gender" (p. 22). As a 16-year-old European-American female, Emma fits the modality well. Furthermore, the power structure inherent in some of the older therapeutic approaches is deconstructed in ACT Art Therapy and viewed as a "shared human experience" (Backos, 2023, p. 30). Teenagers often have issues with authority, so this deconstructed power framework is a good fit for her.

Positive Art Therapy

Positive Art Therapy emerged from Positive Psychology, defined as "the study of the conditions and processes that contribute to the optimal functioning of people, groups, and institutions" (Wilkinson & Chilton, 2018, p. 1). The power of art therapy is combined with Positive Psychology to increase well-being, both individually and globally, by emphasizing the relationship with the positive elements in our lives (Wilkinson & Chilton, 2018). That concept was a radical shift from traditional means of focusing on pathology and what is wrong with people. That is not to say that the negative is ignored; it is not. Positive Psychology and Positive Art Therapy simply shift the focus to underscore the positive.

Many consider Martin Seligman the father of Positive Psychology and trace its beginnings to when he was elected the APA's president in 1996 (Cheavens & Feldman, 2021). Seligman significantly influenced Positive Psychology with his brainchild concept of PERMA, a framework that outlines "the most important pathways to well-being" (Chilton & Wilkinson, 2016, p. 251). PERMA is now a core tenant of Positive Psychology and Positive Art Therapy and encompasses positive emotions, engagement, relationships, meaning, and achievement. These areas are working parts in the overarching Positive Psychology goal of heightened well-being and ability to flourish.

In the case of Emma, helping her in the PERMA areas, I believe, will alleviate some of her underlying stressors likely influencing her eating disorder. Having an increased sense of well-being can, in turn, have a positive and healing impact on her eating disorder. Again, I suspect that Emma's extreme dieting and her cutting habit are coping strategies to help her deal with depression, sadness, and isolation. I would help Emma shift her focus away from her challenging emotions and perceived flaws and toward her positive qualities and strengths. Once she has established some strengths she is proud of, I would encourage her to find new ways to use those strengths more often in her life. I believe utilizing her strengths strategically would increase her overall self-love and self-acceptance. Additionally, I would invite her to find meaning in some of her more challenging feelings and find ways to increase the quality of her relationships with others.

Specific art interventions that could benefit Emma are the Good Wolf/Bad Wolf exercise and the Strengths Realized and Unrealized exercise. The Good Wolf/Bad Wolf involves a conversation between a grandfather and his grandson about a battle between two wolves living inside each of us, one representing negativity and the other positivity (Wilkinson & Chilton, 2018). When the grandson asks his grandfather which wolf wins, he says, "The one you feed" (Wilkinson & Chilton, 2018, p. 225). I would invite Emma to create artwork based on this story and its meaning. For the Strengths Realized and Unrealized exercise, I would invite Emma to create artwork about her strengths, other ways she could use them, and strengths she would like to use more often (Wilkinson & Chilton, 2018). I would also encourage her to keep a journal and, each morning, write three things she is grateful for, and each evening, write three good things that happened that day. I would invite the group to create a collaborative collage of their collective strengths for group therapy. That would encourage positive relationship building and highlight important individual and collective strengths.

There are some significant differences in the way Western culture and Eastern culture view the concept of well-being. Historically, what constitutes happiness has differed across cultures regarding hedonic and eudaimonic happiness (Cheavens & Feldman, 2021). However, since Emma is a European-American female, there should be no cultural challenges with this particular lens. My role as a therapist working with Emma through the lens of Positive Art Therapy would be to facilitate a safe environment that promotes positive expression and personal growth in a manner more in tune with a guide and cheerleader rather than a more traditional therapist-patient relationship.

Conclusion

In conclusion, there are several ways to approach therapy in the case of Emma. However, approaching it from an angle that addresses the underlying roots of Emma's challenges rather than her eating disorder directly could have positive results. ACT Art Therapy and Positive Art Therapy are both modalities that can achieve that. In addition, both are in alignment with Emma, given her age and cultural background. It is also important to highlight that Positive Psychology and Positive Art Therapy can be a lens that influences another modality. In other words, ACT Art Therapy can be the primary modality applied through the lens of Positive Art Therapy. Perhaps that is how to best serve Emma. By combining the two, Emma can gain the positive effects of both therapeutic ways of seeing. While these approaches differ from the more traditional method of using CBT to address eating disorders, they have a substantial chance of success while at the same time empowering Emma and bringing a renewed sense of accomplishment, meaning, and well-being to her life.

References:

Backos, A. (2023). ACT art therapy: Creative approaches to acceptance and commitment therapy. Jessica Kingsley Publishers.

Cheavens, J.S. and Feldman, D.B. (2021). The science and application of positive psychology. Cambridge University Press.

Chilton G. and Wilkinson, R. (2016).  Positive Art Therapy. In J.A. Rubin (Ed.) Approaches to art therapy: Theory & technique (3rd Ed.). New York, NY: Routledge.

Harris, R. (2019). ACT made simple. New Harbinger Publications, Inc. (2nd Ed.).

Neukrug & Hays, E., & Hays, D. G. (2022). Acceptance and commitment therapy. In Counseling theory and practice (3rd ed., pp. 431–457.

Wilkinson, R.A. and Chilton, G. (2018). Positive art therapy theory and practice: Integrating positive psychology with art therapy. Routledge.