Art Therapy for Adolescent Self-Harm and Suicidality Art Therapy as an Intervention for Adolescent Self-Harm and Suicidality Marissa L. Loner Department of Counseling, PennWest University Dr. Penelope Orr November 11, 2024 1 Art Therapy for Adolescent Self-Harm and Suicidality 2 Abstract Adolescence is a key developmental period marked by significant social, emotional, and cognitive changes, which also brings an increased risk of mental health issues such as anxiety, depression, and suicidal thoughts. Non-suicidal self-injury (NSSI) is common among adolescents, and suicide is a leading cause of death in youth aged 10-19 worldwide. Additionally, in the United States alone, suicide death rates have increased dramatically, nearly tripling between 2007 and 2017 among children between the ages of 10 and 14 years-old (American Academy of Pediatrics, 2020). Despite these concerns, effective interventions for adolescents with suicidal thoughts and NSSI are limited. This study aims to explore the use of art therapy to help reduce NSSI and suicidality in adolescents at an outpatient counseling center. The goal is to develop a treatment approach that fills gaps in current research and provides additional support for these adolescents. Art therapy, particularly when combined with techniques from cognitivebehavioral therapy (CBT) and dialectical-behavioral therapy for adolescents (DBT-A), can help teach skills like emotion regulation, problem-solving, and mindfulness. This review will contribute to the development of a more effective, integrated approach to address the mental health needs of adolescents and reduce the risks of suicide and self-harm. Keywords: Adolescence, art therapy, suicide, non-suicidal self-injury (NSSI), cognitivebehavioral therapy, dialectical-behavioral therapy Art Therapy for Adolescent Self-Harm and Suicidality 3 Table of Contents Section I: Introduction ............................................................................................. 4 Problem ......................................................................................................................................... 5 Purpose of the Study ........................................................................................................................ 5 Justification .................................................................................................................................... 5 Terms Related to the Study ............................................................................................................... 7 Conclusion ..................................................................................................................................... 8 Section II: Review of Literature ................................................................................ 10 Understanding Self-Harm and Suicidality in Adolescents ................................................................... 10 Risk Factors of Suicidality and NSSI in Adolescents ........................................................................... 11 Adolescents and the Pandemic of 2020 ............................................................................................ 12 Suicide Screening and Non-Suicidal Self-Harm Assessments to Examine Risk ..................................... 13 Current Treatment Approaches for Adolescent Self-Harm and Suicidality ............................................ 15 Art Therapy Approaches for Adolescent Self-Harm and Suicidality ...................................................... 16 Art Therapy Ethical Considerations with Adolescents ......................................................................... 17 Conclusion ................................................................................................................................... 18 Section III: Methodology ......................................................................................... 20 Target Audience............................................................................................................................. 20 Curricular Structure ....................................................................................................................... 21 Curricular Outline.......................................................................................................................... 22 Conclusion ................................................................................................................................... 24 Section IV: Curriculum ........................................................................................... 25 Section V: Discussion ............................................................................................. 26 Appendix A ............................................................................................................ 39 Art Therapy for Adolescent Self-Harm and Suicidality 4 Section I: Introduction Adolescence is a critical developmental period that comes with various social, emotional, and cognitive changes that become essential in mental health development. Adolescence can be a time of growth consisting of complex thinking and self-discovery. Adolescence is also a stage marked by an increased risk of mental health challenges. According to Call et al., there is an increase in mental health challenges in adolescents before the age of 25 years old (2002), and this is because of the physical, cognitive, and social changes and mood fluctuations that occur during adolescent development (Lahey et al., 2017). These mental health challenges can cause uncomfortable symptoms like anxiety and depression. With this increase in mental health symptoms in adolescence there is a concerning increase in instances of suicidality and maladaptive behaviors like non-suicidal self-harm. Non suicidal self-harm is one of the most prevalent maladaptive behaviors among adolescents (Esposito et al., 2022). Also, according to the American Academy of Pediatrics (AAP), suicide is responsible for more deaths among youth between the ages of 10 and 24 years old compared to any other medical illness (2020). Additionally, in the United States, suicide rates have nearly tripled among youth between the ages of 10 and 14 years old between 2007 and 2017 (American Academy of Pediatrics, 2020). Art Therapy for Adolescent Self-Harm and Suicidality 5 Problem Globally, suicide is found to be a leading cause of death among youth, specifically between the ages of 10 and 19 years old (Glenn et al., 2019). Non-suicidal self-injury (NSSI) is found to be the most common maladaptive behavior reported in adolescence, with community sample rates ranging between 18 and 22% (Esposito et al., 2022). Even with these statistics, there is limited research on effective interventions for adolescents who struggle with suicidal ideation and engage in NSSI (Gilbert et al., 2020). Exploring more treatment options that will reduce instances of suicidality and NSSI amongst adolescents is needed due to the limited research on effective interventions for adolescents who struggle with suicidal ideation and NSSI. Purpose of the Study This study expands on the benefits of art therapy as an intervention for adolescent nonsuicidal self-harm and suicidality in an outpatient counseling setting. The purpose of the study is to seek existing literature on adolescent non-suicidal self-harm and suicidality to create a curriculum for an outpatient counseling setting to provide additional resources and interventions to reduce suicidality and non-suicidal self-harm in adolescents. Justification Adolescence is a time when mood fluctuations and many physical, cognitive, and social changes occur which can lead to an increase in psychological distress, crises, or mental health issues (Lahey et al., 2017). Adolescence involves higher risks relating to “sensation-seeking, risk-taking behaviors, and susceptibility to influence” (APA, 2019). The higher risk of mental health disorders in adolescents increases the risk of suicide and self-harm (Gyori et al., 2023; Art Therapy for Adolescent Self-Harm and Suicidality 6 Sheftall et al., 2016). To address these factors in adolescence and work towards reducing the risk of suicide and self-harm, therapeutic interventions like Cognitive-Behavioral Therapy (CBT) and Dialectical-Behavioral Therapy (DBT)-based art therapies are utilized due to their nature in providing psychoeducation regarding emotion regulation, problem-solving skills, and mindfulness. Expressive art therapy allows adolescents to express and explore emotions nonverbally, providing a safe, therapeutic space (Zakaria & Ahmad, 2023). This literature review will explore art therapy as an intervention for adolescent self-harm and suicidality, focusing on the use of CBT and DBT-A in an outpatient setting. Art Therapy for Adolescent Self-Harm and Suicidality 7 Terms Related to the Study Adolescence. The period of development marked by the beginning of puberty in which young people transition from childhood to adulthood. Art therapy. A type of psychotherapy that utilizes the expressive arts like drawing, painting, clay, and many more materials that allow individuals to express themselves using artwork rather than solely focusing on the use of words. Cognitive-Behavioral Therapy. A type of psychotherapy that focuses on assisting the individual with changing the way they think by looking at their thoughts, behaviors, and actions in situations. Dialectical-Behavioral Therapy for Adolescents. A type of psychotherapy used with adolescents struggling with mood disorders, suicidal ideation, and self-harm and their families that focuses on the use of mindfulness and cognitive-behavioral techniques to change the way they think by looking at their thoughts, behaviors, and actions in situations. Expressive Arts Therapy. The combination of psychotherapy and the use of the creative arts that consists of various media and materials like drawing, painting, and clay. LGBTQIA+. An abbreviation for Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and “the + holds space for the expanding and new understanding of different parts of the very diverse gender and sexual identities” (Princeton Gender & Sexuality Resource Center, n.d.). Maladaptive Behaviors. Actions or behaviors that are harmful or inappropriate and can negatively impact an individual's development. Non-Suicidal Self-Harm. Non-suicidal self-harm (NSSI) is the act of deliberately injuring oneself without the intention of dying by suicide (World Health Organization, 2020). Art Therapy for Adolescent Self-Harm and Suicidality 8 Outpatient Setting. A mental health setting outside a hospital setting where the individual is free to leave after receiving assessment, diagnosis, and treatment. Protective Factors. Individual and environmental characteristics that reduce the instances of stress and risks associated with self-harm, suicide attempts, and suicide. Risk Factors. Individual and environmental characteristics that increase the instances of stress and mental health challenges, leading to an increased risk of self-harm, suicide attempts, and suicide. Self-Concept. What a person perceives about themselves. This can consist of talents, qualities, or goals. Self-Esteem. What a person feels about their self-concept, values, and self-worth. Suicide Attempt. When an individual tries to die by suicide but is unsuccessful and survives. Suicide. Voluntarily and intentionally causing one’s own death. Conclusion Adolescence is a developmental stage where individuals begin to show complex thinking and self-discovery. Mental health challenges also begin to arise in adolescence, and this is when symptoms like anxiety and depression start to present. Unfortunately, with the increase of anxiety and depression symptoms, there is also an increase in instances of self-harm and suicidality. The increase of self-harm and suicidality is concerning and shows a need for more effective interventions to build upon the importance of reducing risk through psychoeducation that provides information on emotion regulation, problem-solving skills, and mindfulness. CBT and DBT-A are two interventions that can provide information on these skills that will reduce suicidality and self-harm. The combination of CBT and DBT-A with art therapy will utilize the Art Therapy for Adolescent Self-Harm and Suicidality 9 non-verbal, safe, and creative nature of art with the psychoeducational aspects of CBT and DBTA with adolescents who struggle with self-harm and suicidality. Art Therapy for Adolescent Self-Harm and Suicidality 10 Section II: Review of Literature Adolescence is a pivotal stage that occurs before adulthood and involves the development of various cognitive milestones. Adolescents display an increase in complex thinking that consists of advanced reasoning skills, abstract thinking, and the ability to consider how they feel and what they are thinking (McNeely & Blanchard, 2009). Adolescence is also a time of selfdiscovery. Psychoanalyst Erik Erikson referred to adolescence as the stage of Identity vs. Identity Confusion (Orenstein and Lewis, 2022) and this is when self-discovery and identity development begin to take place (Sedillo-Hamann, 2021). McNeely and Blanchard (2009) refer to adolescence as the first time a person begins to ask the question, “Who am I?” Identity consists of two aspects, self-concept and self-esteem. Self-concept is what a person perceives about themselves. This can consist of talents, qualities, or goals. Self-esteem is what a person feels about their selfconcept. For adolescents, “self-esteem is affected by approval from parents and other adults, the level of support received from friends and family, and personal success” (pp.45-46). With the progression of complex thinking and identity discovery, it is apparent that adolescence is a pivotal development stage. Understanding Self-Harm and Suicidality in Adolescents Adolescence is typically when new mental health symptoms occur. With this emergence of mental health symptoms in adolescence comes maladaptive, risk-taking behaviors with nonsuicidal self-harm being one of the most prevalent (Esposito et al., 2022). Non-suicidal self-harm (NSSI) is the act of deliberately injuring oneself without the intention of dying by suicide (World Health Organization, 2020). Because of the emergence of uncomfortable mental health symptoms in adolescence, NSSI is a maladaptive behavior that begins to occur to deal with these Art Therapy for Adolescent Self-Harm and Suicidality 11 intense emotions (Wood, 2009). Although NSSI is a maladaptive behavior, it is something that adolescents use to ease the uncomfortable mental health symptoms they experience daily. Along with self-harm, suicide and suicide attempts are factors that occur from the emergence of mental health symptoms in adolescence. Call et al. (2002) state that symptoms of mental illness tend to emerge before the age of 25 due to the physical, cognitive, and social changes and mood fluctuations that occur during adolescent development (Lahey et al., 2017). A suicide attempt is when somebody injures themselves with the intent of dying by suicide, but they do not die, and Suicide is death caused by injuring oneself with the intent to die (CDC, 2023). According to Ong et al. (2021), suicide is a leading cause of death among adolescents, and “mental health disorders are a contributing factor” (p. 134). Because of the emergence of mental health symptoms in adolescence, we see an increase in suicide. Risk Factors of Suicidality and NSSI in Adolescents There are multiple potential risk factors that can lead to the emergence of suicidality and NSSI in adolescents. Weissinger et al. (2023) state that “suicide risk is a complex interaction of social, psychological, and physiological factors (p. 6).” For instance, these factors can include prior suicide attempts, substance use, bullying, and unstable households (Macalli et al., 2018; Van Meter et al., 2019). It is also important to recognize the adolescent populations that show a higher risk of suicidality. Adolescent suicide rates are shown to be higher in specific racial and ethnic groups. For example, using data between 1991 to 2017 from the Youth Risk Behavior Survey, Lindsey et al. (2019) found a trend of increasing suicide rates among black adolescents in which of the 198,000 high school students involved, suicide attempts increased by 73%. There are also higher rates of suicide in the indigenous communities in the United States. According to Art Therapy for Adolescent Self-Harm and Suicidality 12 Stone et al. (2023), American Indian and Alaska Native youth had a rate of suicide consisting of 36.3 per 100,000 in 2021. Another group that displays a high risk of suicide is adolescents who identify as being a part of the LGBTQIA+ community. In the United States, The Trevor Project estimates that more than 1.8 million LGBTQ+ young people consider suicide each year and at least one attempts suicide every 45 seconds (2024). According to Aranmolate et al. (2017), Adolescents a part of the LGBTQIA+ community show a higher risk of suicide and self-harm in comparison to their heterosexual peers. This can be attributed to the lack of peer acceptance, discrimination, family rejection, and difficulty in school (Aranmolate et al., 2017). Aranmolate also states that LGBTQIA+ youth struggle with low self-esteem and depression due to the discrimination and isolation they experience daily, leading to increased instances of suicidal ideation, suicide attempts, and death by suicide (2017). Self-harm is also prevalent in specific populations. According to research conducted by Millon (2022), the populations who reported the most NSSI were females, 12 to 14-year-olds, and White patients (compared to youth of other races and ethnicities). Also, according to Madge et al. (2011), NSSI is prevalent in adolescents who have experienced the loss of a loved one or peer to suicide or self-harm, physical and sexual abuse, and concerns about sexual orientation. Adolescents and the Pandemic of 2020 With adolescence being a time of social acceptance and belonging, having this ability to interact with peers can be a protective factor. The protective factor of social interaction was taken away during the pandemic of 2020. The negative impact of the pandemic on adolescents continues today. According to Gotlib et al. (2022), comparing the mental health of a pre- Art Therapy for Adolescent Self-Harm and Suicidality 13 pandemic adolescent group and a post-pandemic adolescent group, the adolescents in the postpandemic group were found to have increased symptoms of anxiety and depression. Mental health declined in the adolescent population due to an increase in isolation which led to an increase in instances of suicidality and self-harm (Mucci et al., 2023). Because of this decline in mental health and increased instances of suicidality and self-harm after the pandemic, there is an increased need for mental health support, services, and the use of suicide screening and risk assessments. Suicide Screening and Non-Suicidal Self-Harm Assessments to Examine Risk Looking for both protective and risk factors of suicide is an important tool to prevent suicide and suicide attempts. Suicide screening and risk assessments look for the potential risks of suicide consisting of maltreatment, trauma, abuse, and bullying while also looking for the need for potential hospitalization (Asarnow and Mehlum, 2019). Screening and assessments also look for protective factors that can be used in forming interventions and a safety plan. Protective factors can consist of positive social relationships and role models, extra-curricular activities, and hobbies (Asarnow and Mehlum, 2019). The Columbia Suicide Severity Rating Scale (C-SSRS) measures suicidal ideation that has occurred over recent months while providing a scale ranging from low, moderate, and high risk for suicide (Cwik et al., 2020). The C-SSRS consists of a 5-point scale ranging from 1 “Wish to be dead” to 5 “Suicide intent with a plan,” each question seeks to find four factors: Severity of ideation, intensity of ideation, behavior, and actual attempts (Cwik et al., 2020). Strengths of the C-SSRS consist of uses with both adults and adolescents that show validated results (Gipson et Art Therapy for Adolescent Self-Harm and Suicidality 14 al., 2015; Posner et al., 2011) and the ability to “predict short-term suicidal behavior among high-risk adolescents” (Conway et al., 2016). Another assessment commonly used in suicide assessment is the Ask Suicide-Screening Questions tool (ASQ). The ASQ, according to the National Institute of Mental Health (n.d), is a toolkit that includes a brief suicide safety assessment (BSSA) that helps “triage patients after a positive screen” and “consists of the best practices from clinical interviews for suicide risk developed through a combination of consulting the literature and suicide experts” (Cwik et al., 2020). The ASQ asks questions relating to frequency, plan, and behavior; symptoms such as isolation, depression, and irritability; support and safety consisting of family, social status at school, bullying, and reasons for living (Cwik et al., 2020). In addition to suicide risk assessments, assessments also take place to evaluate the frequency and intensity of non-suicidal self-harm in individuals. The Self-Harm Screening Inventory (SHSI) measures self-harm over a duration of the year. The assessment asks the client if they have ever engaged in intentional self-harm. The SHSI also looks at whether the self-harm that occurred was suicidal or non-suicidal. Assessments looking at suicidal ideation and self-harm intensity and frequency are important, but, with the increase of mental health symptoms in adolescents, it is also important to utilize assessments that look at the overall mental health symptoms being experienced by the adolescent. The PHQ-2 is a shorter version of the PHQ-9 that uses the first 2 of the PHQ-9’s questions. The PHQ-2 asks the patient if they have been struggling with 1. A depressed mood, and/or 2. A lack of pleasure in usual activities over the past 2 weeks (Pereira et al., 2010). The PHQ-2 can identify depressive symptoms in adolescents. This is important because teens with depressive disorders are at a higher risk for suicide (Zuckerbrot et al., 2007; Bhatia and Bhatia, Art Therapy for Adolescent Self-Harm and Suicidality 15 2007). With the PHQ-2 being significantly shorter, the assessment is not as time-consuming and is more likely to be performed during routine medical visits. Current Treatment Approaches for Adolescent Self-Harm and Suicidality According to Asarnow and Mehlum (2020), treatments for adolescent NSSI and suicidality should work toward reducing and treating hopelessness. This is achieved through providing psychoeducation to teach coping skills, identifying unhelpful behaviors, and relating these to treatment goals while also instilling hope toward the benefits of treatment. This focus on psychoeducation regarding coping skills and identifying unhelpful behaviors is found in Adolescent-based Dialectical Behavioral Therapy (DBT-A) and Cognitive Behavioral Therapy. Because of this, both are useful interventions for reducing NSSI and suicidal ideation. Adolescent-based Dialectical Behavioral Therapy (DBT-A) focuses on building skills that will reduce risk factors of suicidal ideation and NSSI such as mood instability, unstable relationships, impulsive behaviors, and identity confusion (Hiller and Hughes, 2023; Miller et al., 2007). Based on research conducted by Hiller and Hughes (2023), DBT-A was shown to reduce problem behaviors and improve the ability to problem-solve per the results of the survey taken by the adolescent and caregiver participants. The use of Cognitive Behavioral Therapy focuses on a goal-oriented approach to reduce instances of NSSI and suicidal ideation that includes learning skills and implementing tools. Such tools consist of the development of a safety plan and learning emotion regulation like relaxation and mindfulness (Sinyor et al., 2020; Bryan and Rudd,Based on research from Alavi et al. (2013), CBT contributed to a decrease in scores on the inventories used (Scale for Suicidal Ideation; Beck’s Helplessness Inventory; and Beck’s Depression Inventory). Art Therapy for Adolescent Self-Harm and Suicidality 16 Youth Suicide Prevention Programs In addition to CBT and DBT-A, youth suicide prevention programs are effective in reducing isolation and increasing peer interaction while increasing mental health awareness, protective factors, and coping skills for stress and suicidality (Barzilay et al., 2019; Wasserman et al., 2015). The goal of youth suicide prevention programs is to provide activities and curricula that focus on building awareness, coping skills, problem-solving, and promoting interactions to reduce isolation (Stone et al., 2017). For example, The Youth Aware of Mental Health Program (YAM) is for adolescents between the ages of 14 to 16 years old and places a focus on interactive dialogue and role-playing to teach adolescents about the risk and protective factors surrounding suicide (Stone et al., 2017). Another suicide prevention program for adolescents is Signs of Suicide (SOS). This is a school-based suicide prevention program designed for youths between 11 to 17 years old that teaches students how to recognize the risk of suicide within themselves and others (Katz et al., 2013). Because both the YAM and SOS prevention programs taught adolescents various skills and information regarding suicide risk and protective factors, there was a reduction in suicide attempts and ideation (Calear et al., 2016; Katz et al., 2013). Art Therapy Approaches for Adolescent Self-Harm and Suicidality Along with current treatment approaches and youth suicide programs, art therapy is another tool that can be used for reducing instances of self-harm and suicidality. Art therapy uses expressive arts to aid clients with expressing their feelings and emotions that may otherwise be difficult for them to express verbally. The use of expressive arts as a means of communication can be especially beneficial for adolescents because it allows them to use art to communicate their powerful emotions and feelings. The benefits of art-therapy-based approaches with Art Therapy for Adolescent Self-Harm and Suicidality 17 adolescents consist of developing coping skills, emotion regulation (McGreevy and Boland, 2020), and finding both environments and tools to build hope, confidence, and social supports (Pavarini et al., 2021). In a study conducted by Zakaria and Ahmad (2023), the participant expressed her feelings and navigated the challenges of self-harm behaviors (p. 198). Dialectical Behavioral and Cognitive Behavioral art therapy combine artmaking with psychoeducation associated with teaching the skills involved with reducing NSSI and suicidality. The use of Dialectical Behavioral Therapy-based art therapy works toward the reduction of self-harm and the prevention of suicide. This involves art interventions that are based on the skills of DBT. DBT skills consist of reducing black-and-white thinking (dialectical thinking), mindfulness, distress tolerance, emotion regulation, metaphor, mastery (engaging in challenging and rewarding activities), and opposite action (Schorr, 2022). The use of Cognitive Behavioral Therapy-based art therapy according to Rosal (2016), focuses on CBT skills in combination with artmaking. CBT skills consist of reality shaping (organizing dysfunctional thinking using images), problem-solving, emotion identification and regulation, modeling (positive behaviors being modeled by the art therapist), relaxation and mindful techniques using mental imagery, stress reduction, and coping skills. Art Therapy Ethical Considerations with Adolescents The American Art Therapy Association’s (2013) Ethical Principles for Art Therapists seeks to “safeguard the welfare of the individuals, families, groups, and communities with whom art therapists work and to promote the education of members, students, and the public (p. 1). It is first important to ensure that the adolescent you are working with has the consent of their parents or caregivers. Informed consent should also be provided to the child and their parents or Art Therapy for Adolescent Self-Harm and Suicidality 18 caregivers, so they are aware that they are participating in art therapy, not art class (Moriya, 2006). Confidentiality is another ethical obligation we have as art therapists. The American Art Therapy Association (2013, Section 2.0) states that “art therapists do not disclose confidential information for consultation or supervision without clients’ explicit consent unless there is reason to believe that those clients or others are in immediate, severe danger to health or life” (p. 4). Safety is another large aspect that needs to be considered when practicing art therapy with adolescents. Moon (2000) states that art therapists are ethically responsible for creating a sense of predictability. The art therapist is responsible for providing a safe space where the client feels comfortable in the studio and with the art therapist. Safety also applies to the intentionality of media and materials being used for adolescents with a history of NSSI and suicidality. Art therapists are required to understand media properties to ensure the safety of clients. This allows art therapists to pick appropriate media and materials that suit the needs of the client (Hinz, 2016). For example, if we are working with an adolescent who has a history of using sharp objects to injure themselves with or without the intention of suicide, it would be advisable to avoid using sharp tools like scissors or X-ACTO knives and instead have the client rip the paper rather than cutting the paper. The client can also use non-toxic materials like paints, pastels, and conte crayons. Conclusion The rates of suicide among adolescents are at an all-time high, especially among people of color and individuals of the LGBTQIA+ community due to the discrimination experienced by both groups. Along with suicide, we have also seen an increase in non-suicidal self-harm (NSSI) among adolescents. Because of the increase in NSSI and suicidality in adolescents, there is a Art Therapy for Adolescent Self-Harm and Suicidality 19 need for interventions that teach various skills that focus on identifying risk factors and protective factors. An example of interventions that teach these skills are Dialectical Behavioral Therapy for Adolescents (DBT-A), Cognitive Behavioral Therapy (CBT), and suicide prevention programs. These interventions have shown a reduction in suicidality and NSSI rates in adolescents. Alongside the use of DBT-A and CBT, art therapy is also shown to be an effective form that allows adolescents to freely express themselves and discuss suicidality and self-harm's impact on their lives. There seems to be limited research on art therapy interventions with adolescents who struggle with suicidality and NSSI as evidenced by difficult-to-find peerreviewed articles. Due to this increased number of suicides and high prevalence of NSSI among adolescents, further research on what therapeutic interventions is the most effective for reducing suicidality and NSSI within adolescents is needed. Art Therapy for Adolescent Self-Harm and Suicidality 20 Section III: Methodology This section discusses a curriculum intended for adolescents who are struggling with suicidal ideation, past suicide attempts, and self-harm. The curriculum will consist of art therapy interventions used in individual therapy sessions that focus on the ideas of Cognitive-Behavioral Therapy and Dialectical-Behavioral Therapy for Adolescents. The art therapy interventions used will take place for nine weeks in an outpatient setting, with each session taking place once a week. Each art intervention will focus on mindfulness, emotion regulation, and practicing problem-solving skills regarding the use of personal protective factors and effective coping skills such as finding distractors and urge surfing. Various media and materials will be used throughout the curriculum. The first session will be an intake session involving the Columbia-Suicide Severity Rating Scale to ensure the client is in the appropriate level of care. The eight sessions after will consist of the use of art interventions focusing on Cognitive-Behavioral and Dialectical-Behavioral interventions. Target Audience The curriculum is designed for licensed art therapists working with adolescents who selfharm and struggle with suicidality in individual, 1-hour long sessions at an outpatient setting. The art therapist should be educated and experienced in working with individuals with a history of suicidal ideation. The art therapist should also have the training to implement appropriate suicide risk assessments like the Columbia- Suicide Severity Risk Scale to ensure the client is in an appropriate level of care. The curriculum will begin with an intake process involving the Columbia-Suicide Severity Rating Scale to assess if there is current ideation, plan, or intent of suicide. If the results of the C-SSRS show an increased risk of suicidal ideation with plan or Art Therapy for Adolescent Self-Harm and Suicidality 21 intent, the client should be referred to a higher level of care. Additionally, the Self-Harm Screening Inventory (SHSI) will be completed with the adolescent to get a better idea of the intensity and severity of non-suicidal self-harm based on questions that ask about self-harm that has taken place over the duration of a year. The SHSI will also help the clinician determine whether the self-harm that has taken place is non-suicidal or suicidal (Kim et al., 2022). Lastly, the intake will involve developing a safety plan the client can use in between sessions when having thoughts of suicide, including providing them with resources they may use in a crisis. After the intake, eight sessions will take place. Each session will be one hour long and take place once a week. Each session will focus on using art interventions that teach the client skills based on aspects of CBT and DBT. Curricular Structure Each 1-hour session will occur once a week for fifteen weeks and utilize an art-based intervention involving psychoeducation based on the components of both Cognitive-Behavioral Therapy and Dialectical Behavioral Therapy for Adolescents. The factors of CognitiveBehavioral Therapy that will be focused on in sessions are problem-solving, cognitive restructuring, psychoeducation, and modeling by the therapist. The aspects of DBT that will be applied in sessions are reducing black-and-white thinking (dialectical thinking), mindfulness, distress tolerance, emotion regulation, metaphor, and opposite action (Schorr, 2022). Various media and materials will be used throughout the curriculum. The curriculum will begin with an intake process involving the Columbia-Suicide Severity Rating Scale to assess if there is current ideation, plan, or intent of suicide. If the results of the C-SSRS show an increased risk of suicidal ideation with plan or intent, the client should Art Therapy for Adolescent Self-Harm and Suicidality 22 be referred to a higher level of care. After administering the C-SSRS, the clinician will gather information from the client on the frequency and severity of self-harm. This will involve questions looking for when the self-harm began and when the last time self-harm occurred, how often the self-harm is happening, how the self-harm usually occurs, and what emotions arise before and after self-harm occurs. Lastly, the first initial session will include the development of a safety plan that consists of warning signs (thoughts, behaviors, mood, situation), internal coping strategies (things the client can do on their own without contacting another person), and listing supportive people including personal relationships, professionals, and agencies like the 988 Crisis Hotline. Curricular Outline Session One - Intake Session Two – Establishing safety and building rapport Session Three – Setting boundaries and expectations Session Four – Setting goals Session Five – Visualizing triggers of self-harm Session Six – Creating a safe environment and finding alternatives to self-harm Session Seven – Emotion identification and acceptance Session Eight – Learning distress tolerance skills Session Nine – Urge surfing Session Ten – Mindfulness and relaxation Session Eleven – Exploring the DBT States of Mind Session Twelve – Using metaphor for identifying emotions and problem-solving Art Therapy for Adolescent Self-Harm and Suicidality 23 Session Thirteen – Cognitive restructuring Session Fourteen – Identifying and reducing black-and-white thinking Session Fifteen – Termination session, recap of skills learned The following fifteen sessions will offer various art interventions that utilize the framework of both Dialectical-Behavioral Therapy and Cognitive-Behavioral Therapy. The goal of the use of the DBT and CBT frameworks is to provide the client with the necessary knowledge and skills for identifying the emotions leading to suicidality and self-harm, finding effective coping skills like mindfulness and urge surfing, emotion regulation and problem-solving skills, and the importance of reaching out for help and utilizing a support system. The use of art as an intervention will provide the client with an opportunity to express themselves in a creative manner rather than solely using verbal communication. This will allow the client to use their voice in a different way to encourage problem-solving and communication skills to reduce instances of suicidality and self-harm. The intake is the first session and involves the therapist using a suicide risk and self-harm assessment and the creation of a safety plan with the client. Each session will begin with the use of checking in and a grounding or mindfulness practice that the client can also use in between sessions on their own. In between sessions, the client will be given a journal or sketchbook prompt to complete. The prompts will be based on the psychoeducation provided in the session that has just taken place. Each session will begin with going over the journal or sketchbook prompt. Art Therapy for Adolescent Self-Harm and Suicidality 24 Conclusion The curriculum provided will be used with adolescent clients with a history of suicidal ideation and self-harm with the tools and skills needed to reduce and manage the mental health symptoms that increase in adolescence. These tools and skills gathered from the use of art interventions using the skills taught from CBT and DBT can provide adolescents with the confidence to recognize their own signs and symptoms that begin to present themselves when self-harm and suicidal thoughts occur. These tools and skills provided to adolescents in this curriculum include a safety plan that can be utilized in between sessions. Adolescents will also gather information on helpful coping skills, problem-solving skills, and emotion regulation. The use of art with the skills taught with DBT and CBT provides adolescents with a unique way to communicate their needs and the powerful emotions they are experiencing daily. Art Therapy for Adolescent Self-Harm and Suicidality 25 Section IV: Curriculum The following curriculum focuses on the use of art therapy in combination with the behavioral orientations of Cognitive-Behavioral Therapy and Dialectical-Behavioral Therapy for Adolescents. The goal of using these two orientations with art therapy is to provide psychoeducation regarding emotion regulation, problem-solving skills, and mindfulness in combination with creative practices to encourage a safe, healing space for adolescents who may struggle expressing their emotions with the use of words. The curriculum will take place in an outpatient setting where each of the eight sessions will provide the client with the necessary knowledge and skills for identifying the emotions leading to suicidality and self-harm, finding effective coping skills like mindfulness and urge surfing, emotion regulation and problemsolving skills, and the importance of reaching out for help and utilizing a support system. With this being in an outpatient setting, clients will be able to leave each session with the newly attained information and utilize the skills at home. Conclusion The goal of this curriculum is to provide a professional art therapist with a guide to utilize various DBT-A and CBT-based art therapy intervention to assist adolescents with reducing and eliminating both suicidality and NSSI. CBT and DBT-A are being utilized due to their nature of focusing on emotion regulation, problem-solving skills, and mindfulness. The combination with art therapy is to encourage creative practices in a safe and healing space for adolescents who may struggle with expressing difficult emotions with words. Art Therapy for Adolescent Self-Harm and Suicidality 26 Section V: Discussion The purpose of this study was to gain a better understanding of the growing mental health crisis among adolescents. Rates of suicidality and non-suicidal self-injury (NSSI) continue to increase at concerning levels, and the intersection of discrimination, social stressors, and mental health outcomes is a critical area of concern. In response, orientations like dialectical behavioral therapy for adolescents (DBT-A) and cognitive-behavioral therapy-based programs have demonstrated an effectiveness in reducing suicidality and NSSI among adolescents. This study also highlights the gap in literature regarding alternative therapeutic interventions, especially art therapy, for this population. Brief Summary of the Research The effectiveness of DBT-A and CBT in reducing suicidality and NSSI in adolescents has been well-documented in existing research. These theoretical orientations emphasize emotion regulation, coping skills, and cognitive restructuring to address the underlying psychological and emotional factors contributing to NSSI and suicidal behaviors in adolescents. This study also suggests that the incorporation of art therapy in addition to the behavioral theories offers benefits for adolescents struggling with suicidal ideation and NSSI. Art therapy gives adolescence the opportunity to use creativity to communicate difficult and intense emotions and experiences that may be difficult to express with words alone. This is support with findings discovered by Kapitan (2014), that art therapy provides the client with an opportunity to process trauma, promote emotional healing, and encourages self-expression. Art Therapy for Adolescent Self-Harm and Suicidality 27 Discussion The findings of this study highlight the effectiveness of art therapy in combination with CBT and DBT-A as evident by the literature suggesting and increase of internal coping strategies utilized by the adolescent participants. For example, McGreevy and Boland (2020) identify the benefits of art-therapy-based approaches with adolescents that allow for the development of coping skills, emotion regulation (McGreevy and Boland, 2020), and finding both environments and tools to build hope, confidence, and social supports (Pavarini et al., 2021). Additionally, in a study conducted by Zakaria and Ahmad (2023), a participant was able to utilize the creative artmaking process to explore her feelings and navigate the challenges of self-harm behaviors (p. 198). Limitations Although the present results support the advantages of combining art therapy with CBT and DBT-A, it is also important to recognize several potential limitations. First, the sample size was relatively small. There is a need for further research on the combination of art therapy and the behavioral-therapies in various populations and environments. Second, there is a lack of peerreviewed studies in this specific area that suggests a great need for more robust, large-scale studies to further explore the benefits of combining art therapy with the use of CBT and DBT-A. Further research is needed to understand how art therapy compares with other therapeutic modalities across diverse populations and setting. Art Therapy for Adolescent Self-Harm and Suicidality 28 Future Research In terms of future research, it would be useful to extend the current findings by examining larger populations in more diverse setting. Also, it would be useful to have larger sample sizes in future research to further support the effectiveness of art therapy in combination with DBT-A and CBT. Lastly, the development of culturally competent art therapy programs that address the needs of marginalized youth could provide a more inclusive and effective approach to mental health care. This can be accomplished through establishing environments that are accessible and affirming while also reducing mental health disparities in vulnerable populations. Conclusion This study highlights the growing need for effective ways to support adolescents dealing with suicidality and self-harm. DBT-A and CBT are therapies found to be useful when used with adolescence struggling with symptoms of suicidal ideation and NSSI. The use of DBT-A and CBT in combination with art therapy could offer a unique and valuable approach. It allows adolescents to express their emotions and struggles in a creative, non-verbal way, which may be especially helpful for those who find it hard to talk tough emotions. More research is needed to better understand how art therapy works for adolescents, particularly over time, and in combination with other therapies. Larger, more diverse studies could help confirm its benefits and how it might be best integrated into existing treatments. In conclusion, art therapy in combination with DBT-A and CBT has the potential to help adolescents struggling with symptoms of suicidality and NSSI express themselves and begin to heal. Art Therapy for Adolescent Self-Harm and Suicidality 29 References Alavi, A., Sharifi, B., Ghanizadeh, A., & Dehbozorgi, G. (2013). 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Art Therapy for Adolescent Self-Harm and Suicidality Appendix A 39 Art Therapy for Adolescent Self-Harm and Suicidality 40 Art Therapy for Adolescent Self-Harm and Suicidality 41 Table of Contents Curricular Outline ................................................................................................................... 42 Session Format (Excluding Intake Session) ....................................................................................... 42 Session One – Intake ................................................................................................................ 43 Session Two – Establishing Safety and Building Rapport Using Protective Containers .................. 44 Session Three – Setting Boundaries and Expectations in Therapy................................................ 45 Assignment Handout – SMART Goals ............................................................................................... 46 Session Four – Setting Goals with a Vision Board ....................................................................... 47 Assignment Handout: Distress Tolerance – TIPP Skills ........................................................................ 48 Session Five – Visualizing Triggers of Self-Harm ......................................................................... 49 Session Six– Creating a Safe Environment and Finding Alternatives to Self-Harm ........................ 51 Session Seven – Emotion Identification and Acceptance Using a Self-Made Emotion Scale ......... 52 Session Eight- Learning Distress Tolerance Techniques .............................................................. 53 Session Nine – Urge Surfing/” Riding the Wave” ........................................................................ 54 Session Ten – Creating and Using a Worry Stone for Mindfulness and Relaxation ......................... 55 Session Eleven - Exploring and defining the di\erent DBT States of Mind using states of mind mandalas ................................................................................................................................ 56 Assignment Handout: Accepts Skill ................................................................................................. 57 Session Twelve – Using Metaphor for Identifying Emotions and Problem-solving Coping Skills ..... 58 Session Thirteen - Cognitive Restructuring Using Collage........................................................... 59 CBT Cognitive Restructuring Session Handout .................................................................................. 60 Assignment Handout: Black & White Thinking ................................................................................... 61 Session Fourteen – Identifying and Reducing Black-and-White Thinking through Opposites ......... 62 Session Fifteen – Write a Postcard to Your Future Self – A Summary of Therapy ........................... 63 Art Therapy for Adolescent Self-Harm and Suicidality 42 Curricular Outline The curriculum was created for adolescents struggling with suicidality and non-suicidal self-harm (NSSI), incorporating interventions aimed at reducing suicidal thoughts and self-harm behaviors. It was specifically designed for one-on-one use with adolescents aged 10 to 19 in a therapeutic outpatient setting. These adolescents participated in a school-based Partial Hospitalization Program (PHP), attending Monday through Friday and engaging in 3 to 4 hours of daily mental health treatment, including both individual and group therapy sessions. The curriculum consists of fifteen individual therapy sessions, each lasting one hour, conducted with an art therapist. The arts-based interventions incorporated both Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy for Adolescents (DBT-A), two evidence-based approaches shown to reduce suicidal ideation and nonsuicidal self-harm (NSSI) in adolescents. Both therapies emphasize psychoeducation and skill-building, making them effective in addressing these issues. CBT is a goal-oriented method that teaches skills such as creating safety plans and developing emotion regulation strategies, like relaxation and mindfulness techniques (Sinyor et al., 2020; Bryan & Rudd, 2018). DBT-A focuses on addressing risk factors for suicidal ideation and NSSI by targeting mood instability, impulsivity, relationship difficulties, and identity confusion (Hiller & Hughes, 2023; Miller et al., 2007). Session Format (Excluding Intake Session) • Check-in: Go over the homework assignment and learning new DBT-A or CBT skill (10 minutes). • Psychoeducation and Intro to topic (10 minutes). • Art therapy Intervention (30 minutes). • Verbal Processing and discussion of homework for the next session (10 minutes). Art Therapy for Adolescent Self-Harm and Suicidality 43 Session One – Intake Goals: 1. Complete biopsychosocial, determining the needs of the clients. 2. Creating a treatment plan. 3. Creating a safety plan. Objectives: 1. To determine if there is an increased suicide risk that requires inpatient hospitalization to ensure the client's safety. 2. To get an idea of the client’s access to means, support systems, and internal coping skills. 3. To give the client a sketchbook for use in completing weekly homework assignments. 4. To gather information on the client’s experience with the Partial Program they are participating in. Procedure: The art therapist is to use the intake to complete a Suicide Risk and Self-Harm Assessment to ensure the client is not at risk of harming themselves or others. The Suicide Risk and Self-Harm Assessment will also inform the therapist that the client is in the appropriate treatment setting. The intake is where the creation of the safety plan will take place. The safety plan needs to be completed in collaboration with the client to increase the likelihood of the client using the plan when having thoughts of suicide or the urge to self-harm. The safety plan includes internal and external coping strategies: personal coping skills like distractors and possible supports, such as personal and professional individuals the client can reach out to during a crisis. After the completion of the risk assessment and the safety plan, the art therapist is to gather information on the client’s experience with the Partial Program, including what they have found to be useful or not useful and what they have learned so far. The information gathered from this will assist the therapist with conducting the curriculum in a way that is most beneficial for the client and their needs. Lastly, the intake will be where the therapist provides the client with a sketchbook. The sketchbook is to be used by the client for completing homework assignments. The art therapist will need to explain to the client that the sketchbook is to be used for assignments, which will include visual and verbal processing prompts, and should not be used for anything else. Assignment Prompt: In your sketchbook, please write or draw an image displaying any worries or concerns about participating in individual therapy. We will reflect on this in the next session. Art Therapy for Adolescent Self-Harm and Suicidality 44 Session Two – Establishing Safety and Building Rapport Using Protective Containers1 Session two centers around the concept of establishing safety and building rapport. Safety and rapport are important factors in the beginning stages of therapy. For therapy to be effective, there needs to be trust between the client and the therapist. Due to the topic of suicidality and self-harm being approached in these sessions, it is important that the adolescent client feels safe and not judged when discussing sensitive topics. Goals: 1. Establishing safety and rapport. 2. Promoting confidence and empowerment in asking questions and addressing concerns. Objectives: 1. By the end of this session, the client will have been able to address any questions, concerns, feelings of fear, or nervousness regarding therapy. 2. The client will develop a sense of safety in therapy with the therapist. Materials: - Small cardboard or wooden box - 9x12 drawing paper - Acrylic paint brushes - Drawing and writing materials: crayons, markers, pens, etc. Procedure: Session two utilizes the protective container art intervention. The purpose of the protective container art intervention is for the art therapist to get an idea of what the client’s questions, concerns, feelings of fear, or nervousness are toward therapy. The protective container will allow the client to either use a box or draw an image of the box consisting of possible questions, concerns, fears, or nervousness. After the client is complete with the intervention, the processing questions will involve the therapist gathering information from the client regarding any trepidation about attending therapy. The box or container will act as a way to contain these concerns in a protected place and will allow the therapist and client to revisit them in future sessions. The therapist will then leave it up to the client where this container will be stored, giving the client a sense of control and safety. During the processing, confidentiality and its limits are discussed. This aspect is important because of the potential concern of stigma and embarrassment being experienced by the client (Radez et al., 2020). Discussion: - When looking at your protective container, what is the significance and purpose of each characteristic or feature you included? - What are some of your fears, questions, or concerns regarding therapy? - Where can you keep this box, so it is in a safe and private place? Assignment Prompt: Pause for a moment and think about the word “boundary.” In your journal, write or draw what this word means to you. Take a moment to reflect on how you set boundaries in your daily life. 1 Mehlomakulu, C. (2019, February 23). Protective containers – using art to strengthen the metaphor. Creativity in Therapy. https://creativityintherapy.com/2019/02/protective-containers-using-art-strengthen-metaphor/ Art Therapy for Adolescent Self-Harm and Suicidality 45 Session Three – Setting Boundaries and Expectations in Therapy In the beginning of any therapeutic relationship, it is important to establish and implement boundaries. The client should be made aware that therapy is their space, and they cannot be forced to do anything they are not okay with. Also, setting boundaries early in the therapeutic relationship is needed due to confidentiality reasons, being sure to explain confidentiality to the client. For example, “If I see you out in public, I will not say hi to you, but you can say hi to me if you would like.” This session is a continuation of the previous session which focused on establishing safety. Setting boundaries and expectations both relate to building a safe environment. Goals: 1. Defining boundaries 2. Establishing rapport Objectives: 1. By the end of this session, the client will be able to gather what their boundaries and expectations are in therapy. 2. The client will be able to continue to describe what safety in therapy means to them. Materials: - 9x12 drawing or mixed media paper - Pens and pencils - Markers - Crayons - Oil or chalk pastels Procedure: Session three focuses on the "Create Your Own Castle" art therapy prompt. This activity helps the client express their boundaries and expectations, both in therapy and in life. It gives the therapist a better understanding of the client's view on boundaries and offers a chance to teach the importance of healthy boundaries in therapy. Setting these boundaries is key to creating a safe and supportive space for the client. Discussion: - When looking at your castle, what is the significance and purpose of each characteristic or feature you included? - What do you know about boundaries? - How do you set boundaries in your personal life? - What are some of your boundaries and expectations regarding therapy? Assignment Prompt: Looking at the SMART Goals worksheet, I want you to brainstorm what your goals are. Then, think about the small steps you will take to reach these goals. Lastly, what new skills are you hoping to get out of these goals being made? You may draw or write your response and create a chart if that will be helpful for you. *Provide the client with a handout visualizing the SMART Goals Art Therapy for Adolescent Self-Harm and Suicidality Assignment Handout – SMART Goals 46 Art Therapy for Adolescent Self-Harm and Suicidality 47 Session Four – Setting Goals with a Vision Board2 Session four involves the use of a vision board for the client to set realistic, reachable goals. Setting goals collaboratively with the client early in therapy is important as it increases client motivation and will increase the likelihood of them showing up for the next session. Setting goals with clients allows them to create goals unique to them and who they are as an individual. The purpose of the vision board is to provide the client with a tangible object they may refer to when feeling discouraged or unmotivated as a reminder of what their shortterm and long-term goals are. Goals: 1. Defining and practicing the goal-making process in therapy Objectives: 1. By the end of this session the client will establish realistic, reachable short-term and long-term goals. 2. By the end of this session, the client will have a tangible object to refer back to when needing a reminder of their treatment and life goals. Materials: - 11x14-inch mixed media paper - Precut magazine images and words - Colored paper - Bits of cloth - String or yarn - Beads Procedure: Session four centers around the client setting long-term and short-term goals. Such goals can relate specifically to therapy or the client’s personal life: treatment goals and goals at school, with family, at work, future career and education, etc. Using open-ended questions, the therapist is to ask the client to create a list of their longterm and short-term goals and to think about imagery relating to these goals and changes the client would like to make in their life. Some examples of open-ended questions: - Where do you see yourself in ten years? - What do you value? - Where will you live? - Who would you help? After the client is completed with their list of goals, the client is then asked to identify precut images and words that represent their identified goals. The client will then arrange the images and words in a way that is meaningful to them on the piece of paper. The client may use other materials like yarn, beads, and cloth to make their vision board more personalized to them. Discussion: - What are the goals you identified? - How will you achieve these goals? - Are there any barriers that may come up for you when trying to achieve these goals? If yes, how can you overcome or remove these barriers? Where will you put your vision board so that you can easily look at it when feeling discouraged or less motivated? 2 Burton, L., & Lent, J. (2016). The use of vision boards as a therapeutic intervention. Journal of Creativity in Mental Health, 11(1), 52–65. Art Therapy for Adolescent Self-Harm and Suicidality 48 Assignment Prompt: Read over the TIPP Skills (Temperature, Intense Exercise, Paced Breathing, Paired Muscle Relaxation) handout. Write or draw how these skills may be useful for you when experiencing intense emotions. Are there any barriers that may come up for you in practicing any of these skills. *Provide the client with a TIPP Skills handout. Assignment Handout: Distress Tolerance – TIPP Skills Art Therapy for Adolescent Self-Harm and Suicidality 49 Session Five – Visualizing Triggers of Self-Harm3 Session five focuses on working with the client on visualizing triggers of self-harm. Triggers can vary and typically consist of people, places, and things – things typically being uncomfortable, intense emotions. Assisting the client with becoming aware of what their triggers are and the physical sensations that occur can provide them with the ability to know which coping skills need to be used for different situations. Goals: 1. Develop an increased awareness of certain emotions, events, people, etc. that may trigger an urge for them to self-harm. 2. Identify coping strategies when having the urge to self-harm. Objectives: 1. Define the word “trigger.” 2. The client will be able to identify warning signs leading up to self-harm. 3. The client will be able to identify helpful strategies to manage the urge to self-harm whenever triggered. Materials: - 9x12 drawing or mixed media paper - Pens and pencils - Markers - Crayons - Oil or chalk pastels Procedure: Session five begins with the therapist providing the client with information on trigger awareness and the possible bodily sensations that may occur when triggered, leading to the urge to self-harm. These bodily sensations can include sweating, shaking, and much more. These bodily sensations are typically ignited by feelings of stress, anger, sadness, etc. Session five involves having the client use crayons, markers, or colored pencils to create a simple outline of their body. The client is asked to write or draw the triggers and trigger signs in and around the body. These triggers can include physical or emotional. Learning to identify the triggers will allow the client to establish strategies they may use when these triggers occur, allowing the client to manage the urge. Discussion: - What were you able to identify as your triggers that may lead to the urge to self-harm? What were you able to learn about the bodily sensations that occur when you are triggered? What are some of the coping strategies you can use when feeling these body sensations? Assignment Prompt: When doing this assignment, make sure you are sitting comfortably in a place where you feel safe. Take a moment to visual in your mind a real or imaginary place where you feel relaxed and safe. This can be your bedroom, the beach, a forest, etc. Create an image visualizing this space while keeping the following questions in mind: 3 Zakaria, W. P. N. I., & Ahmad, N. (2023). EXPRESSIVE ART THERAPY APPROACH IN REDUCING SELF-HARM AMONG ADOLESCENT. International Journal of Education Psychology and Counseling, 8(52), 189–200. https://doi.org/10.35631/ijepc.852016 Art Therapy for Adolescent Self-Harm and Suicidality - What safe place did you choose? How does this safe place make you feel? What emotions came up for you as you visualized your safe place? How can looking back at this visualization of your safe space help you in the future when experiencing intense emotions? 50 Art Therapy for Adolescent Self-Harm and Suicidality 51 Session Six– Creating a Safe Environment and Finding Alternatives to SelfHarm Session six empowers the client to make their own choices in their personal space to make it safer for themselves when having the urge to self-harm or if having suicidal thoughts. This conversation of safety also gives the therapist the ability to review the safety plan and ask the client if any changes need to be made. It is important that the safety plan is done in collaboration with the client as this will increase the likelihood of them using it during crisis events. Goal: 1. Gaining knowledge on limiting access to means in their living environment. Objectives: 1. The client will explore and practice alternatives to self-harm that they will be likely to try. 2. The client will review their safety plan created at intake and make any changes as needed. Materials: - 9x12 drawing or mixed media paper - Pens and pencils - Markers - Crayons - Oil or chalk pastels Procedure: Session six focuses on identifying a safe environment through the "My Safe Space" art intervention. The client is asked to create an image of their bedroom or another space they consider safe. Within the image, the client is encouraged to identify any potential risks or access to harmful means. Then, the client brainstorms and either draws or writes ways to safely remove or reduce these risks. Discussion: - Where did you identify as your safe space? Is it real or imaginary? - Imagine yourself standing in this safe place. What would you see to the left and right of you, in front of you, and above and below you? - Under what circumstances would your safe space be most helpful to you? - Is there anything unsafe in your space? What are you able to do to make it safe? Assignment Prompt: In your journal, draw four to five clouds. Take a moment to notice your thoughts and emotions that are coming up for you. Just like your thoughts and mood, the clouds in the sky are constantly changing while the sky remains unchanged. In the clouds you drew, write down the thoughts and/or emotions that came up. When complete, take a moment and imagine these thoughts and emotions passing by on clouds, accepting them as they come rather than judging them as right or wrong. Art Therapy for Adolescent Self-Harm and Suicidality 52 Session Seven – Emotion Identification and Acceptance Using a Self-Made Emotion Scale or Thermometer Emotion identification is especially important when working with clients who struggle with suicidal ideation and self-harm. Sometimes when the emotions get to be too much, the thought of suicide or self-harm occurs as a solution to relieve these emotions. Working with the client to identify their emotions will allow them to refer to their safe space when needed which will consist of their coping strategies and safety plan. Goals: 1. Be able to name their emotions and identify what coping strategy they need in response to each specific emotion. Objectives: 1. The client will be able to communicate tough emotions they are experiencing and what their needs are in the moment of having that emotion. 2. The client will be able to normalize all emotions, even the “negative” ones like anger and sadness. Materials: - 9x12 drawing or mixed media paper - Pens and pencils - Markers - Crayons - Oil or chalk pastels Procedure: During session seven, the client is asked to create an image of a scale, thermometer, or any other imagery that resonates with them for displaying a variety of emotions they may experience on a daily basis. These emotions can range from joy, excitement, anger, anxiety, etc. The client can be creative as they would like in creating this as it is a tool they will be using in their daily lives and will be used in the next session. Lastly, somewhere in or around the thermometer, the client is asked to draw or write potential coping strategies for the emotions of anger, stress, anxiety, etc. Discussion: - How can you use this scale/thermometer in your daily life? - What are some coping strategies you can use when feeling angry, sad, stressed, etc.? - What colors did you use to symbolize each emotion? Why? Assignment Prompt: Find a quiet, comfortable space to sit in private and take the time to focus on your breathing. When ready, use the 5-4-3-2-1 grounding technique handout to identify: - Five things you can see. Four things you can touch. Three things you can hear. Two things you can smell. One thing you can taste. 1. How did it feel for you to use this technique? Is this something that you feel could be useful when you are having intense emotions? Why or why not? 2. Please take a moment to write down or draw everything you noticed in your space. Art Therapy for Adolescent Self-Harm and Suicidality 53 Session Eight- Learning Distress Tolerance (Mindfulness, Distracting, and Self-Soothing Techniques Used to Cope with Uncomfortable Emotions) with Do-It-Yourself Zen Gardens4 Session eight focuses on the DBT skill of distress tolerance, which is crucial for adolescents dealing with nonsuicidal self-injury (NSSI) and suicidal thoughts. Distress tolerance helps clients pause and use coping strategies before acting on self-harm or suicidal urges. The Zen Garden created in this session provides an additional tool for clients to manage emotional triggers, whether they stem from people, places, or situations. Goal: 1. Establishing various coping skills to use in response to suicidal ideation and non-suicidal self-harm. Objectives: 1. The client will be able to practice use of the emotion scale/thermometer created last session. 2. The client will be able to define distress tolerance. 3. The client will be able to identify other ways they can use mindfulness, distracting, or self-soothing skills when experiencing uncomfortable, intense emotions. Materials: - Plain, 5x7 photo frame (with glass removed before giving to client) - Pre-cut 5x7 foam board - Fine grain craft sand - Seashells, stones/pebbles, sea glass, etc. - Small craft sticks/sticks/twigs to create a rake Procedure: During session eight, the client is asked to create their own usable, three-dimensional Zen Garden. This is something that the client will use as a way to practice mindfulness, distraction, and self-soothing whenever they are experiencing uncomfortable or intense emotions. The client will review their emotion thermometer/scale image from the previous session and brainstorm the different ways they can use mindfulness, distraction, or self-soothing skills for more difficult emotions. The client can identify the Zen Garden and any other effective coping skills that they will likely try. Discussion: - How can you use your Zen Garden in your daily life? - What did you choose to include in your Zen Garden? Why? - How likely are you to use this as a coping strategy when having tough emotions? Which emotions do you think this would be useful for? Assignment Prompt: Draw an image or write a prompt in response to the following question: When you hear the word urge, what does this mean to you? What are some urges you have experienced in the past or are currently experiencing? What triggers these urges? If you give into the urges, how do you feel? How do you speak to yourself? 4 Clark, S. M. (2017). DBT-Informed Art Therapy: Mindfulness, cognitive behavior therapy, and the creative process. Jessica Kingsley Publishers. Art Therapy for Adolescent Self-Harm and Suicidality 54 Session Nine – Urge Surfing/” Riding the Wave” Art Intervention for Learning About the Urge to Self-Harm and How to Not Give in to That Urge5 Session nine focuses on urge surfing. Urge surfing involves taking the time to pause, recognize the feeling, and practicing an alternative rather than immediately giving into the urge to self-harm. This session will continue to build on the previous sessions in which the therapist is collaborating with the client on identifying more healthy and effective coping strategies the client can use when feeling intense emotions. Goal: 1. Establishing various coping skills to use in response to suicidal ideation and non-suicidal self-harm. 2. Normalize urges as a human experience. 3. Remove shame from experiencing urges. Objectives: 1. The client will be able to define urge surfing. 2. The client will be able to identify potential desirable consequences of not acting on the urge. Materials: - Chalk or oil pastels - Markers - Crayons - Pen and/or pencil Procedure: In session nine, the client will create an image of their urge to self-harm in the image of a wave. The wave does not need to be water, it can be anything that resonates with the client. The purpose of the “wave” is to associate the characteristics of the self-harm urge such as using color, lines, shapes, etc. to show the emotional, mental, and/or physical impact of the urge. After this step is complete, the client is asked to create themselves riding or surfing on that wave. The client is encouraged to include affirmations, images, symbols, etc. that empower the client, and remind them that they are capable of riding the wave out, and the positive outcomes of riding out the wave. Discussion: - What are some urges or cravings you have had in the past? - What typically occurs when you give into your urge to self-harm? - What do you think would happen if you did not give into your urge to self-harm? - What are some coping strategies you can use when having the urge to self-harm? Assignment Prompt: Find a quiet, private space where you can comfortably sit or lie down. Take 5 or 10 minutes to close your eyes (if you are comfortable with this) and take deep breaths, with your hand on your belly while you focus on the rising and lowering of your hand. As you are doing this, I want you to think of one word you can repeat to use as an anchor during moments of distress. For example, “relax,” “clam,” “peace.” When you finish, I want you to draw an image representing this word, or write the word down in large letters, decorating them if you would prefer. 5 Clark, S. M. (2017). DBT-Informed Art Therapy: Mindfulness, cognitive behavior therapy, and the creative process. Jessica Kingsley Publishers. Art Therapy for Adolescent Self-Harm and Suicidality 55 Session Ten – Creating and Using a Worry Stone for Mindfulness and Relaxation Session ten continues working with the client on exploring and creating new effective coping skills they can use when having intense emotions. The worry stone created in this session provides the client with another tool for their self-soothing toolbox. The worry stone can be used as a simple grounding tool that is also small enough to fit in the client’s pocket so they can take it everywhere with them and use it inconspicuously out in public as needed. Goal: 1. Establishing various coping skills to use in response to suicidal ideation and non-suicidal self-harm. Objectives: 1. The client will be able to name ways they can utilize mindfulness and relaxation during crises or periods of experiencing intense emotions. 2. The client will be able to name ways they can use for mindfulness and relaxation that they will personally utilize on a daily basis. Materials: - Various colors of Crayola Model Magic air-dry clay - Hands, fingers, and thumbs Procedure: During session ten, the client creates their own personal worry stone out of different colored air-dry clay. The client is asked to create “thumb stones,” in which they flatten a ball of clay with their thumb. The client may use whichever colors resonate with them (colors that are calming, make them feel joy, etc.). and roll them together to marbleize the stone. The therapist should demonstrate how these are used (rubbing it between your thumb and index finger). The therapist should educate the client on the purpose of worry stones as a grounding tool when experiencing upsetting emotions like anger, sadness, anxiety, etc. Lastly, the therapist and client should work together to brainstorm additional strategies that can be used for mindfulness and relaxation (one potentially being the Zen Garden if the client finds it to be useful). Discussion: - Looking back at your emotion scale/thermometer, what emotions do you think your worry stone would be helpful for self-soothing? - What other coping strategies have you learned recently that would be useful for working through specific tough emotions? Assignment Prompt: After reading the definitions of the different DBT States of Mind on the provided handout, answer the following question through drawing or writing: - 6 How would you describe yourself in terms of the balance of rational mind and emotional mind? Which one is more active and available? Which one tends to hide in the background?6 Pipitone, E., LCSW, & Doel, A., MS. (2020). The DBT Homework Assignment Workbook: 50 worksheets based on Dialectical Behavior Therapy. In The DBT Homework Assignment Workbook: 50 Worksheets Based on Dialectical Behavior Therapy. Between Sessions Resources. Art Therapy for Adolescent Self-Harm and Suicidality 56 Session Eleven - Exploring and defining the different DBT States of Mind using states of mind mandalas7 Session eleven explores and defines the different DBT States of Mind: Emotion Mind, Wise Mind, Reasonable Mind. Knowing the three states of mind is important because it allows the client to develop self-awareness of their emotions and reactions to certain situations and triggers. Also, knowing the three states of mind encourages the client to find a balance of the three states of mind when making decisions. Goal: 1. Identify and name examples of own personal experiences of the three DBT States of Mind to encourage mindfulness and self-reflection. Objectives: 1. By the end of the session, the client will be able to define each of the DBT states of mind: Emotion Mind, Reasonable Mind, and Wise Mind. 2. The client will be able to identify their own personal examples of the DBT mind states in their life. 3. To client will be able to practice identifying and understanding different emotions. Figure 1. What is DBT Wise Mind? (Source: Ogle, 2018) Materials: - 9x12 drawing or mixed media paper with a pre-drawn circle - Pens - Colored pencils - Oil pastels - Chalk pastels - Markers Procedure: Session eleven begins with defining the DBT states of mind. The client creates a mandala to visualize each of the DBT states of mind without the use of common words and symbols (hearts, smiley faces, etc.). The client will use their own personal visual language using color, shape, and metaphor. Before beginning each mandala, the client and therapist will participate in meditation in which the client is asked to take deep breaths and think about the state of mind. As the meditation occurs, the therapist should describe each state of mind in detail. The client is also encouraged to think of their own personal life experiences with each of the DBT states of mind. Discussion: - What is an example of a state of mind occurring in your everyday life? (What is an example of the Wise Mind in your life?) 7 Clark, S. M. (2017). DBT-Informed Art Therapy: Mindfulness, cognitive behavior therapy, and the creative process. Jessica Kingsley Publishers. Art Therapy for Adolescent Self-Harm and Suicidality - What words or symbols did you choose to represent each state of mind? Why? What was it like for you to participate in meditation before drawing each mandala? Assignment Prompt: Read and complete the handout on the DBT Skill: ACCEPTS. *Provide the client with the worksheet on ACCEPTS Assignment Handout: Accepts Skill 57 Art Therapy for Adolescent Self-Harm and Suicidality 58 Session Twelve – Using Metaphor for Identifying Emotions and Problemsolving Coping Skills Session twelve focuses on the use of metaphors to identify emotions and problem-solving coping skills the client can use when struggling with intense emotions. Metaphor is used in cognitive and dialectical behavioral therapies because it individualizes complex concepts for the client, helping them understand the meaning and importance. Also, using metaphors can make discussing emotions less distressing and even more enjoyable than simply just talking about the emotions. Goal: 1. To identify emotions and establish effective coping strategies in response to each emotion. Objectives: 1. By the end of this session, the client will be able to identify tough emotions (anger, sadness, anxiety, etc.). and use metaphors to describe them in a personal way. 2. By the end of this session, the client will be able to identify current and new coping skills they will be likely to use when struggling with intense emotions. Materials: - 9x12-inch drawing or mixed media paper - Pens - Colored pencils - Markers Procedure: During session twelve, the client participates in The Person in the Rain (PITR) art intervention and assessment. The client uses crayons, markers, and/or colored pencils to draw a person in the rain. The PITR activity allows the client to explore emotions such as sadness, anger, and stress. The client also brainstorms potential healthy coping strategies they can use when experiencing intense emotions. These coping strategies may be represented by items like an umbrella, rainboots, or a jacket. The intensity of the emotions may be symbolized by the heaviness of the rain, wind, and other weather conditions. Discussion: 1. If your drawing could tell a story, what would it say? 2. Tell me about the way you drew the rain (clouds, lightning, etc.), in what way does this weather represent tough emotions? 3. What is your umbrella? What coping skills can you use in the event of these intense emotions? 4. What can you do in a crisis? Have you used your safety plan in the event of a crisis? Why or why not? Assignment Prompt: Next session we will be talking about cognitive distortions (inaccurate ways we think about ourselves) and the ways we can restructure these distortions (ways we challenge these thoughts). In your journal, I want you to answer the following questions: 1. 2. 3. 4. Think about a situation that put you in a bad mood, what happened? What were you thinking in response to the situation that was happening? Were the thoughts true? What were you feeling in response to your thoughts about the situation that was happening? Art Therapy for Adolescent Self-Harm and Suicidality 59 Session Thirteen - Cognitive Restructuring Using Collage, Turning Negative Thoughts into Something New Session thirteen focuses on cognitive restructuring. Cognitive restructuring is a cognitive-behavioral technique that focuses on the client identifying unhelpful and inaccurate thoughts (“I am a bad person,” “I am stupid). Cognitive restructuring involves changing the unhelpful thought into a more helpful or neutral thought (“I made a bad choice; however, I am not a bad person,” “I made a mistake, I am not stupid.”). This is an important skill for adolescents with suicidal thoughts and thoughts of self-harm because unhelpful thoughts can feed the urge to self-harm or die by suicide. Goal: 1. To learn cognitive and behavioral strategies to reduce or alleviate thoughts of suicide and self-harm. 2. To identify negative thought patterns and replace them with healthier thoughts. Objectives: 1. After this session, the client will be able to define cognitive restructuring and provide examples. 2. The client will be able to identify their own cognitive distortions. 3. The client will be able to identify ways to reframe cognitive distortions. 4. The client will be able to define and name each part of the CBT triangle. Materials: - 9x12-in Mixed Media paper - Glue or Mod Podge - Construction paper in various colors. - Writing and drawing tools: colored pencils, markers, graphite pencil, etc. Procedure: Before beginning, take a moment to explain the CBT triangle to the client and how thoughts, feelings, and behaviors are all connected. Take a moment with the client to close their eyes if they are comfortable and take a few deep breaths. Ask the client to think about a time they had a tough emotion (anger, sadness, anxiety). Have the client pick the emotion and think about the physical sensations that this emotion has caused. Then, have the client express this emotion using various pieces of construction paper by crumbling, ripping, and tearing the paper. When complete, the client will grab a handful of ripped paper and toss it to the side. With the remaining paper, the client will create a collage. The client should be encouraged to create something new. with the use of collage, including using drawing utensils to create positive and hopeful images on the collage. Discussion: - What was it like for you to express your tough emotions through destroying the paper? - What did you learn by recreating something new with collage? - What was it like for you to have control of the paper? - Can you think of a time when this restructuring skill would be helpful for you in your own life? Assignment Prompt: Next session we will be discussing black-and-white thinking. Please complete the blackand-white thinking handout so you may get a better understanding of black-and-white thinking. *Provide client with handout on black-and-white-thinking Art Therapy for Adolescent Self-Harm and Suicidality CBT Cognitive Restructuring Session Handout 60 Art Therapy for Adolescent Self-Harm and Suicidality Assignment Handout: Black & White Thinking 61 Art Therapy for Adolescent Self-Harm and Suicidality 62 Session Fourteen – Identifying and Reducing Black-and-White Thinking through Opposites8 Session fourteen discusses dichotomous or black-and-white thinking and exploring the opposites to reduce such thinking to integrate the black-and-white thinking towards gray. Black-and-white thinking is a cognitive distortion that can lead to increased thoughts of suicide and instances of self-harm. Black-and-white thinking can contribute to poor self-image and emotional distress, which is what increases the risk of self-harm and suicidality. The following session utilized a line art intervention, allowing the client to see a visual of opposites. Goal: 1. To learn cognitive and behavioral strategies to reduce or alleviate thoughts of suicide and self-harm. Objectives: 1. After this session, the client will be able to define and provide examples of black-and-white thinking. 2. The client will be able to have increased self-awareness and insight regarding their emotions. 3. The client will be able to find personal balance and acceptance of their strengths and weaknesses. Materials: - 9x12-in drawing or mixed media paper - Graphite pencil - Pens - Markers - Oil pastels or crayons - Glue or Mod Podge Procedure: The client begins by drawing lines that represent their current emotions, followed by creating exaggerated lines to emphasize these feelings. On a separate sheet of paper, the client focuses on the opposite emotions and creates a drawing that reflects these contrasting feelings. The client then rips both images, glues the pieces together, and merges them into one unified artwork, symbolizing the process of integration. Discussion: - What was it like working with opposites? - What was it like integrating both papers into one piece? - How do you think working with opposites could be helpful for you in your daily life? Assignment Prompt: The next session is our final session together. In your journal, I would like you to write or create an image expressing what you learned from our sessions together. Was there anything specific that stuck out to you? Was there anything that you did not find helpful? What about it was unhelpful? Do you have any barriers to practicing anything that we have worked on together in sessions? 8 Haeyen, S., Ziskoven, J., Heijman, J., & Joosten, E. (2022). Dealing with opposites as a mechanism of change in art therapy in personality disorders: A mixed methods study. Frontiers in psychology, 13, 1025773. https://doi.org/10.3389/fpsyg.2022.1025773 Art Therapy for Adolescent Self-Harm and Suicidality 63 Session Fifteen – Write a Postcard to Your Future Self – A Summary of Therapy Because session fifteen is the final session of the curriculum, the goal is for the client to summarize and reflect on everything they have learned, whether they found certain skills to be helpful or not helpful, if they have any critiques, and how they are planning on using the skills they have learned in their daily life. The use of the postcard will encourage the client to reflect and summarize their experience and explore the potential personal growth that has occurred from attending these therapy sessions. Goal: 1. To terminate therapy and reflect skills learned and practiced. Objectives: 1. After this session, the client will be able to summarize and reflect on all the CBT and DBT skills they learned. 2. The client will be able to utilize their artworks and journal responses as reminders in the future during crises. Materials: - Blank postcard or 4x6-in index card - Graphite pencil - Colored pencils - Markers - Crayons or oil pastels Procedure: On the blank side of the card, the client begins by creating an image that represents their hope for the future. This could relate to areas such as their mental health, school, family, or work. Once the image is complete, the client flips the card and writes a note to their future self—five to ten years from now. The client reflects on what they have learned in therapy, how they plan to use their new skills, and how this knowledge will impact their life. The client is also encouraged to list their strengths and outline their future goals. Discussion: - What skills did you learn in therapy? - What is the most helpful skill you have learned? Most unhelpful? - Where do you see yourself, five to ten years from now? - Was there anything about this program that you really liked? Disliked?