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THE INTEGRATION TRAUAMA
FOCUSED COGNITIVE
BEHAVIORAL THERAPY WITH
ART THERAPY
FOR SEXUALLY ABUSED CHILDREN AND ADOLESCENTS
EXHIBITING PTSD SYMPTOMOLOGY
R. ALEATHA THRUSH
ARTT/790 SUMMER 2024
INTRODUCTION
• Sexual abuse is an egregious form of trauma that impacts
children and adolescents.
• The unique needs of sexually abused children must be met.
• It is important for this population to receive appropriate and
timely mental health support.
• They need to effectively process and cope with their traumatic
experiences.
PURPOSE OF RESEARCH
• TO STUDY THE IMPLICATIONS OF TRAUMA AND POST TRAUMATIC STRESS
DISORDER WITH SEXUALLY ABUSED CHILDREN AND ADOLESCENTS.
• TO PROVIDE A HOLISTIC APPROACH TO TRAUMA TREATMENT THROUGH
THE INTEGRATION OF TRAUMA FOCUSED COGNITIVE BEHAVIORAL
THERAPY AND ART THERAPY.
• TO OFFER A UNIQUE PERSPECTIVE ON THE STRENGTHS BOTH MODALITIES
HAVE COMBINING EMOTIONAL EXPRESSION AND COGNITIVE
RESTRUCTURING.
JUSTIFICATION
• CHILD SEXUAL ABUSE IS A PREVALENT AND
DEVASTATING ISSUE AMONG YOUNG SURVIVORS.
• BOTH ART THERAPY AND TF-CBT ARE EFFECTIVE AS
STAND-ALONE APPROACHES TO TRAUMA
TREATMENT.
• UNFORTUNATELY, THERE IS A GAP IN RESEARCH
REGARDING AN INTEGRATIVE APPROACH.
• MORE NEEDS TO BE DONE TO SHOW
EFFECTIVENESS NOT ONLY WITH THE USE OF ART
THERAPY BUT AS AN ADJUNCT TO TF-CBT.
TERMS
• SEXUAL ABUSE
• TRAUMA
• TRAUMA FOCUSED COGNITIVE BEHAVIORAL THERAPY
• ART THERAPY
• POST TRAUMATIC STRESS DISORDER
POST TRAUMATIC STRESS DISORDER
• According to the DSM5 (2013), PTSD is defined as actual or threatened sexual violence by
direct exposure, witnessing, or learning about trauma,
• The trauma must be reexperienced by unwanted upsetting memories, nightmares,
flashbacks, emotional distress after trauma reminders, or physical reactivity to those
reminders.
• Avoidance of trauma or trauma related thoughts, feelings, or related reminders.
• An inability to recall key features of the trauma accompanied by overly negative thoughts
and assumptions about oneself or the world,
• Symptoms must last for more than one month, create distress and functional impairment,
and not due to medication, substance use or illness.
LITERATURE REVIEW
Sexual Abuse
• About one in four girls and one in thirteen boys will experience sexual abuse before
they reach the age of eighteen (Centers for Disease Control and Prevention, 2021).
• A study of 14 reviews with 270,000 persons in 586 studies reveals the lifelong effect of
child sexual abuse can have on children leading to a variety of complications (Maniglio,
2009).
• The impact of sexual abuse on victims can be overwhelming, affecting their physical,
emotional, and psychological well-being, as well as their relationships and overall
development.
• Research has also shown that the effects of sexual abuse can extend to adulthood,
making it essential for receiving treatment early (“Committee Opinion No. 498: Adult
Manifestations of Childhood Sexual Abuse,” 2011).
LITERATURE REVIEW CONT/
Post Traumatic Stress Disorder
• Child sexual abuse is linked to multiple long-term negative effects. Risk factors include
psychological disorders such as depression, suicidal ideations, anxiety, and PTSD (Hébert et al.,
2021).
• The development of PTSD is the most common disorder among children and adolescents
who have been sexually abused (McLean et al., 2014).
• Treatments include medications, EMDR, CBT, Expressive Arts Therapy, and specifically for
children and adolescents TF-CBT.
LITERATURE REVIEW/
Trauma Focused- Cognitive Behavioral Therapy
• TF-CBT is an evidence-based treatment that helps individuals process their traumatic experiences, develop
coping skills, and address negative thoughts and beliefs about related abuse (Cohen et al., 2017).
• It consists of various components in a structured approach to help individuals who have experienced trauma.
• P.R.A.C.T.I.C.E. (Pollio & Deblinger, 2017). (Mannarino et al., 2004).
• Psychoeducation
• Relaxation
• Affect Modulation
• Cognitive Restructuring
• Trauma Narrative
• In Vivo Mastery
• Conjoint Sessions
• Enhancing Safety
LITERATURE REVIEW
Art Therapy
• Art therapy is a form of therapy that utilizes the creative process of making art to improve a person’s
physical, mental, and emotional well-being (Shukla et al., 2022).
• An individual can improve their value and self-esteem by utilizing this visual and symbolic language
through art therapy (Shukla et al., 2022).
• By allowing the client to create distance they can utilize implicit expressions, making the therapeutic
process less confrontational (Moon, 2007).
• Through art therapy, individuals can explore and make sense of their experiences, helping them
integrate their trauma into their personal narrative, fostering a sense of coherence and
understanding(Pifalo, 2009).
• Through therapy, individuals can reclaim their sense of control (Pifalo, 2009).
LITERATURE REVIEW
Why Integrate Art Therapy and TF-CBT?
• The TF-CBT approach is flexible and adaptable yet structured enough to make it a good fit for art
therapy integration (Wymer et al., 2020).
• This pairing can be a powerful combination in combating trauma (Pifalo, 2007).
• Art therapy is a place to not only obtain information but to process information (Pifalo, 2002).
• TF-CBT is based on cognitive learning theories designed to help reduce the negative behavioral
responses of the traumatized child (Pifalo, 2007).
• Children and adolescents can express themselves and make meaning of experiences through a variety
of art modalities (Wymer et al., 2020).
• Symbolic representations of triggers allow individuals to approach and engage with those triggers in a
safe and contained manner (Malchiodi, 2012).
METHODOLOGY
• TF-CBT and art therapy are both evidence-based treatments shown to reduce PTSD symptoms.
• Addressing these issues early on, individuals can learn valuable coping techniques that will take them from victim
to survivor.
• The curriculum will incorporate key components of TF-CBT to provide a structured and comprehensive
approach to helping the targeted population cope with the effects of sexual abuse and PTSD,
Target Audience
• A curriculum with an integrative approach to both art therapy ant TF-CBT for children and adolescents who have
been sexually abused.
• Done by a professionally trained therapist in both TF-CBT and Art Therapy.
Curriculum Structure
Based on P.R.A.C.T.I.C.E components of TF-CBT
CURRICULUM OVERVIEW
THIS SECTION WILL CONSIST OF ART THERAPY
INTERVENTIONS, GOALS, DIRECTIVES, AND PROCESSING
PROMPTS FOR EACH OF THE P.R.A.C.T.I.C.E COMPONENTS
WITHIN TF-CBT.
EACH SESSION IS 50 MINUTES LONG AND SOME
SESSIONS/PHASES OF TF-CBT TAKE LONGER THAN OTHERS.
TRAUMA FOCUSED
COGNITIVE
BEHAVIORAL
ART THERAPY
For Sexually
Abused Children
and Adolescents
HOW TO USE THIS CURRICULUM
• It is essential to have a thorough understanding of both art therapy and TF-CBT.
• It is structured with activities and interventions that incorporate various forms of artistic expression, such as
drawing, painting, sculpting, and collage to be used alongside TF-CBT techniques such as cognitive
restructuring and exposure therapy.
• Clients are introduced to art-based interventions to help clients explore, and process their emotions,
thoughts, and traumatic memories.
• The curriculum can be modified to meet the specific needs and age of the individual client. Not all
interventions are suitable for all clients.
• The interventions provided will serve as a non-threatening way for clients to express themselves, build
coping skills, and promote healing.
RISKS AND BENEFITS
• The benefits include enhancing emotional expression and creative exploration.
• The use of this curriculum may trigger intense emotions and memories related to
trauma which can be distressing to some individuals.
• Without proper guidance from a trained art therapist specializing in TF-CBT, clients
may inadvertently re-traumatize themselves through the process of creating art and
revisiting traumatic experiences.
• Some individuals may even be resistant to the process of either art or processing
traumatic experiences.
• Therapists must be mindful of if and when to use this guide. They should assess the
appropriateness of when to use art therapy in combination with TF-CBT in
treatment planning.
Intervention
Visual info graphic using
symbols and metaphors
Warm-up
Continuous lines
with patterns and
colors
Guided visualization technique
Breathing exercises Practice relaxation skills
Psychoeducation
Relaxation skills
Emotional color wheel.
Affect Modulation
Collage distortions
Goals
Body safety, violence on
teens, setting boundaries,
establishing consent
Prompts
What are boundaries? What are
the rules for your body?
What do you hear, feel, see,
taste?
What body sensations do you
feel?
Identify self as a
Communicate emotions
What feeling are associated
color
with each color? How are
emotional experiences
expressed?
Intuitively selecting Challenge negative
How can distorting images help
images for collage thoughts, beliefs or patterns reframe negative thoughts?
Cognitive Coping
Trauma explosion box
Visualize a safe
place
Processing trauma
reminders and reactions
Exposure through drawing and
painting
Sensory exploration Develop emotional
through art materials regulation, promote
empowerment and agency
Collaborative finger puppets
Present moment
feelings
Building relationship
bonds.
What connections are made
between trauma and art? What
is happening in the present
moment?
How can we process feelings
together?
Vision boards/goal setting
Bridge assessment
Visualize goals and
aspirations for the future
What are goals hopes and
dreams for moving forward?
Trauma Narrative
In Vivo Mastery
How is the initial impact,
aftermath, and healing of
trauma represented?
Conjoint Sessions
Enhancing Safety
PSYCHOEDUCATION
Body safety infographic
Objectives: learning about body safety, setting boundaries,
and the effects of violence on teens.
Warm up: Play calming music and create one continuous line
using markers or color pencils. Fill in the spaces with patterns or
colors to represent emotions.
Materials: Various fact sheets about body safety and teen
violence, paper, pencils, markers, crayons, and a variety of
collage materials.
Directive: Create and infographic or visual aid using
symbols or metaphors.
Processing Prompts: Use symbols or metaphors to
describe body safety. What do those symbols mean to
you? Reflect on any past experiences of trauma or abuse
that may have impacted your sense of safety. How have
these experiences shaped your understanding of consent?
Modifications for younger children: pre -cut symbols, rules
and, body maps for children to create with.
Teenagers & Sexual Violence
Who Experiences Teen Sexual Violence?
Rates of sexual violence against youth aged 12-18 are very high,1 and the survivor normally knows the
person who committed the offense.2 Nationally, about 8% or 10 million girls and 0.7% or 791,000 boys
under the age of 18 have experienced either rape or attempted rape.2 Experiencing sexual violence as
a child or teen makes it more likely the survivor will experience re-victimization in adulthood.2 One in
three (30.1%) victims of completed rape experienced their first rape between ages 11-17.3
It is difficult to determine the full impact of sexual violence against teenagers since most research
focuses on children or college-aged youth. There are many gaps in research on sexual violence
against teens, especially those from marginalized, unserved, and underserved communities.
Throughout this document we will alternate
between using teen, youth, and young people
to reflect the variety of ways people identify.
1 in 4 girls and 1 in 6 boys
have been sexually abused
before the age of 18.4
Who Commits Sexual Violence Against Teens?
Youth who experience sexual violence are more likely to be victimized by a peer
or someone they know.2
10.1% of girls were
victimized by a
stranger.
28%
43%
43.6% of girls were
victimized by an
acquaintance.
28.8% of girls were victimized by a
current or former intimate partner.
35%
27%
27.7% of girls were
victimized by a
family member.
victimize someone else (completed
or attempted) by an acquaintance.
Effects of Sexual Violence
Young people who experience sexual violence may experience: Poor academic performance,5
Sexual risk taking behavior,6 Pregnancy,7 and Self-harm.8
Sexual assaults against youth happen in
familiar places.
10-31% Survivor’s home9,10
24% Survivor’s neighborhood10
15-44% Survivor’s school9,10
Teens who experience sexual violence may
suffer from mental health conditions:
Post-Traumatic Stress Disorder11
Substance abuse12
Low self-esteem14
Eating disorders13
Depression15
Anxiety16
Consider or attempt suicide17
National Sexual Violence Resource Center • www.nsvrc.org • 1-877-739-3895
RELAXATION SKILLS
Guided Imagery
Objectives: To practice relaxation skills through guided visualization.
To explore inner thoughts, feelings, and experiences.
Warm up: Practice breath work through watercolor painting. Allow
the paint to move across the page with each inhale and exhale. For
example, painting a mountain as the lines go up inhale and as the
lines go down exhale.
Materials: A sample of a guided visualization, a variety of
mediums for clients to choose from: watercolor paints, oil pastels,
color pencils, markers, and 8 ½ x 11 or larger paper.
Directive: Encourage the client to use all their senses to fully
immerse themselves in this imaginary space. Once the client is fully
connected with their visualization, invite them to begin creating art
that expresses their experience.
Processing Prompts: What do you see, hear, smell, or even taste?
What emotions are coming up as you create? How does this artwork
relate to your inner thoughts and feelings?
Modifications for younger children: choose a simplified version
of a guided visualization, or they can choose a place that
makes them feel safe.
AFFECT MODULATION
Feelings Color Wheel
Objectives: For the client to effectively identify and
communicate emotions and feelings.
Warm up: If you could be any color, what would you be and
why? Using markers draw what your color looks like or feels
like
Materials: Feelings chart, color wheel, a six-inch diameter
round circle on drawing paper or a paper plate, watercolor
paints, paintbrush, markers.
Directive: Create a color wheel based on emotions felt in
the moment.
Processing Prompts: What feelings are associated with each
color? Why do they make you feel a specific way? Are there
different shades and tones or levels of emotions that are felt?
No modifications are needed for younger children.
COGNITIVE COPING
Collage Distortions
Objectives: To challenge negative thought patterns, beliefs, or selfperceptions. To express emotions through collage.
Warm up: Clients will collect images for collage distortions. Intuitive
selection of images will help tap into the subconscious and uncover
certain emotions and themes.
Materials: Various collage materials such as magazine clippings,
embellishments, scissors, glue, markers, paint
Directive: Distort images by changing them from their original form.
Discuss negative or distorted thought patterns and reframe them into
positive thoughts. Add a reframed thought to the image.
Processing Prompts: How does the distortion or manipulation of
images reflect the ways in which negative thoughts distort your
perception of reality? What emotions arose when created the
distorted images?
Modifications for younger children: Provide pre-cut images for
distortions, choose age-appropriate words for discussion cognitive
distortions like “stinkin thinkin”, “fixed or growth mindset”
TRAUMA NARRATIVE
Trauma Explosion Box
Objective: To facilitate narrative exploration. To visually represent different aspects
of their trauma narrative, such as the event itself, their feelings during and after the
event, and their coping mechanisms.
Materials: Box template, 12x12 cardstock, scissors, glue, embellishments
Warm up: Guide the client through a relaxation exercise by having them close
their eyes and visualize a safe and peaceful place in which they feel secure and
comfortable.
Directive: Follow the instructions for the template and assemble the box and lid.
Use various processing prompts on the pockets of each section. Decorate the box
with intention for meaning and purpose.
Processing prompts: How does the trauma box represent different aspects of your
trauma narrative such as the initial impact, the aftermath, and the healing process?
What emotions arose as you created each layer of the box?
Modifications for younger children: have a premade box in which embellishments
and collage materials can be added. Talk about the box as a place to “hold” things
such as emotions, or events.
INVIVO MASTERY
Exposure through Drawing and Painting
Objectives: To help clients develop better emotional regulation skills. To
encourage mindfulness and present moment awareness. To increase coping skills
when exposed to trauma.
Warm up: Free drawing or painting with a focus on sensory exploration.
By engaging in free-form art making, clients can access inner thoughts
and feelings more easily, allowing for a deeper exploration of traumarelated issues.
Materials: Drawing and painting supplies, paper, canvas, pencils, markers, pastels,
paintbrushes. Other materials may include blending stumps, sponges, and other
tools for creating textures.
Directive: Talk about actual trauma triggers, practice regulating emotions with
present moment painting.
Processing Prompts: What emotions or memories are coming up as you engage
in this artistic process? Are there specific colors, shapes, or symbols that resonate
with you as you create artwork? How does this relate to your experience of
trauma? What connections do you see between the trauma and art? What
strengths or coping skills are you using as you work through this artistic process?
No modifications are needed for younger children.
CONJOINT SESSIONS
Collaborative Storytelling with Finger Puppets
Objective: To strengthen parent/guardian and child bond. To enhance communication skills. To
create a safe and supportive environment to talk about traumatic experiences.
Warm up: Provide each participant with a piece of paper and crayons, pencils, or markers.
Each person will draw a simple image of how they are feeling in the present moment.
Materials: White or colored model magic. If using white add markers to color the clay and
draw details once dry.
Directives: Both the child and parent will decide on a theme such as animals, or people. They
will create at least three characters out of model magic. Once the characters have dried the
clients will use the characters to tell a story. More complex themes can be addressed once
safety has been established.
Processing Prompts: What key emotions do you notice being expressed through storytelling?
How can we process these feelings together? What themes or symbols are emerging through
the storytelling?
No modifications needed for younger children.
ENHANCING SAFETY
Vision Board
Objectives: To help clients identify and visualize their goals aspirations, and desires through the
creation of visual representations on a vision board. To encourage self-awareness and insight.
Warm up: Completing the Bridge Assessment. This will serve as a foundation for the creation
of the vision board.
Materials: Collage materials.
Directive: Collaboratively set goals, intentions, and areas of focus. Clients should reflect on their
strengths, values, and aspirations. Choose images, words, and symbols that resonate with them
that represent their goals and intentions. Choose and arrange elements that feel meaningful
and visually appealing to them.
Processing Prompts: What goals, hopes, and dreams do you have for moving forward? How do
you envision feeling and behaving in a healthy and positive way? How does the use of symbols
represent your desired future?
Modifications for younger children: pre-cut phrases, and images, use kid friendly images from
coloring books or children's magazines.
• This curriculum aims to enhance the TF-CBT model with the use of art
therapy.
• Many of the interventions provided have been used in practice with clients
who have been sexually abused and exhibit PTSD symptomology and has
shown to be effective in their healing journey.
• Many clients not only worked through the P.R.A.C.T.I.C.E components in TFCBT in culmination with art therapy but have also used art therapy as a
coping mechanism outside individual sessions.
• The combination of both show promising results, but not without its limits.
LIMITATIONS
• Lack of standardized protocols for integrating TF-CBT and art therapy, leading to variability in how
the two modalities are combined in practice.
• While evidence suggests that both interventions can be effective in treating trauma-related
symptoms, there is a need for more research to establish clear guidelines for how these guidelines
can be combined in a cohesive systematic manner.
• Availability of trained art therapists who are also proficient in TF-CBT techniques may be limited,
making it challenging to implement interventions in certain settings
• The small sample sizes typically seen in studies examining the effectiveness of combining TF-CBT and
art therapy
• Larger scale studies with diverse participant populations are needed to provide more robust
evidence of the benefits of integrating these two therapeutic approaches.
FUTURE EXPLORATION/RESEARCH
• Research could investigate the long-term effects of combining TF-CBT and art
therapy on sexually abused children with PTSD.
• Comparative studies could be conducted to compare effectiveness of the
combination of the two modalities.
• By examining the process of change in therapy sessions, researchers can gain insight
into how art therapy enhances the effectiveness of TF-CBT and identify key elements
that contribute to positive outcomes.
• Research could also focus in on developing training programs for mental health
professionals to effectively integrate both approaches
CONCLUDING THOUGHTS
• Integrating the components of TF-CBT with art therapy has shown to be an effective holistic approach for
treating sexually abused children who suffer from PTSD.
• By combining evidence-based techniques with the creative process or art making, therapists can provide a
safe and empowering environment for clients to process their trauma, develop coping skills, and ultimately
heal from their experiences.
• This integrated approach not only addresses the psychological and emotional needs of the clients, but also
allows for non-verbal expression of emotions.
• By using the strength of both modalities, therapists can help clients build resilience, regain a sense of
control and agency, and move towards a path of recovery and healing. This curriculum aims to do that.
Q&A
REFERENCES
Centers for Disease Control and Prevention. (2021, May 11). Fast Facts: Preventing Child Sexual Abuse.
https://www.cdc.gov/violenceprevention/childsexualabuse/fastfact.html
Www.cdc.gov.
•
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2017). Treating trauma and traumatic grief in children and adolescents (2nd ed.). The Guilford Press.
•
Committee Opinion No. 498: Adult Manifestations of Childhood Sexual Abuse. (2011). Obstetrics & Gynecology, 118(2, Part 1), 392–395. https://doi.org/10.1097/aog.0b013e31822c994d
•
Deblinger, E., Stauffer, L. B., & Steer, R. A. (2001). Comparative Efficacies of Supportive and Cognitive Behavioral Group Therapies for Young Children Who have been Sexually Abused and
their Nonoffending Mothers. Child Maltreatment, 6(4), 332–343. https://doi.org/10.1177/1077559501006004006
•
Malchiodi, C. A. (2012). Handbook of Art Therapy (2nd ed.). Guilford Press.
•
Maniglio, R. (2009). The impact of child sexual abuse on health: A systematic review of reviews. Clinical Psychology Review, 29(7), 647–657. https://doi.org/10.1016/j.cpr.2009.08.003
•
Mannarino, A., Mallah, K., Amaya-Jackson, L., Bennett, F., Berliner, L., Cohen, J., Deblilinger, E., Gully, K., Putman, F., & Radingan, D. (2004). Learning from Research and Clinical Practice
Core Child Sexual Abuse Task Force National Child Traumatic Stress Network How to Implement Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).
https://www.nctsn.org/sites/default/files/resources//how_to_implement_tfcbt.pdf
•
Moon, B. (2007). The Role of Metaphor in Art Therapy. Charles. C. Thomas. https://research.ebsco.com/c/356ple/viewer/html/z6hittnb55
•
Pifalo, T. (2002). Pulling Out the Thorns: Art Therapy with Sexually Abused Children and Adolescents. Art Therapy, 19(1), 12–22. https://doi.org/10.1080/07421656.2002.10129724
•
Pifalo, T. (2009). Mapping the Maze: An Art Therapy Intervention Following Disclosure of Sexual Abuse. Art Therapy, 26(1), 12–18. https://doi.org/10.1080/07421656.2009.10129313
•
Pifalo, T. (2007). Jogging the Cogs: Trauma-Focused Art Therapy and Cognitive Behavioral Therapy with Sexually Abused Children. Art Therapy, 24(4), 170–175.
https://doi.org/10.1080/07421656.2007.10129471
•
Pollio, E., & Deblinger, E. (2017). Trauma-focused cognitive behavioral therapy for young children: clinical considerations. European Journal of Psychotraumatology, 8(7), 1433929.
https://doi.org/10.1080/20008198.2018.1433929
•
Wymer, B., Ohrt, J. H., Morey, D., & Swisher, S. (2020). Integrating Expressive Arts Techniques into Trauma-Focused Treatment with Children. Journal of Mental Health Counseling, 42(2),
124–139. https://doi.org/10.17744/mehc.42.2.03
FOCUSED COGNITIVE
BEHAVIORAL THERAPY WITH
ART THERAPY
FOR SEXUALLY ABUSED CHILDREN AND ADOLESCENTS
EXHIBITING PTSD SYMPTOMOLOGY
R. ALEATHA THRUSH
ARTT/790 SUMMER 2024
INTRODUCTION
• Sexual abuse is an egregious form of trauma that impacts
children and adolescents.
• The unique needs of sexually abused children must be met.
• It is important for this population to receive appropriate and
timely mental health support.
• They need to effectively process and cope with their traumatic
experiences.
PURPOSE OF RESEARCH
• TO STUDY THE IMPLICATIONS OF TRAUMA AND POST TRAUMATIC STRESS
DISORDER WITH SEXUALLY ABUSED CHILDREN AND ADOLESCENTS.
• TO PROVIDE A HOLISTIC APPROACH TO TRAUMA TREATMENT THROUGH
THE INTEGRATION OF TRAUMA FOCUSED COGNITIVE BEHAVIORAL
THERAPY AND ART THERAPY.
• TO OFFER A UNIQUE PERSPECTIVE ON THE STRENGTHS BOTH MODALITIES
HAVE COMBINING EMOTIONAL EXPRESSION AND COGNITIVE
RESTRUCTURING.
JUSTIFICATION
• CHILD SEXUAL ABUSE IS A PREVALENT AND
DEVASTATING ISSUE AMONG YOUNG SURVIVORS.
• BOTH ART THERAPY AND TF-CBT ARE EFFECTIVE AS
STAND-ALONE APPROACHES TO TRAUMA
TREATMENT.
• UNFORTUNATELY, THERE IS A GAP IN RESEARCH
REGARDING AN INTEGRATIVE APPROACH.
• MORE NEEDS TO BE DONE TO SHOW
EFFECTIVENESS NOT ONLY WITH THE USE OF ART
THERAPY BUT AS AN ADJUNCT TO TF-CBT.
TERMS
• SEXUAL ABUSE
• TRAUMA
• TRAUMA FOCUSED COGNITIVE BEHAVIORAL THERAPY
• ART THERAPY
• POST TRAUMATIC STRESS DISORDER
POST TRAUMATIC STRESS DISORDER
• According to the DSM5 (2013), PTSD is defined as actual or threatened sexual violence by
direct exposure, witnessing, or learning about trauma,
• The trauma must be reexperienced by unwanted upsetting memories, nightmares,
flashbacks, emotional distress after trauma reminders, or physical reactivity to those
reminders.
• Avoidance of trauma or trauma related thoughts, feelings, or related reminders.
• An inability to recall key features of the trauma accompanied by overly negative thoughts
and assumptions about oneself or the world,
• Symptoms must last for more than one month, create distress and functional impairment,
and not due to medication, substance use or illness.
LITERATURE REVIEW
Sexual Abuse
• About one in four girls and one in thirteen boys will experience sexual abuse before
they reach the age of eighteen (Centers for Disease Control and Prevention, 2021).
• A study of 14 reviews with 270,000 persons in 586 studies reveals the lifelong effect of
child sexual abuse can have on children leading to a variety of complications (Maniglio,
2009).
• The impact of sexual abuse on victims can be overwhelming, affecting their physical,
emotional, and psychological well-being, as well as their relationships and overall
development.
• Research has also shown that the effects of sexual abuse can extend to adulthood,
making it essential for receiving treatment early (“Committee Opinion No. 498: Adult
Manifestations of Childhood Sexual Abuse,” 2011).
LITERATURE REVIEW CONT/
Post Traumatic Stress Disorder
• Child sexual abuse is linked to multiple long-term negative effects. Risk factors include
psychological disorders such as depression, suicidal ideations, anxiety, and PTSD (Hébert et al.,
2021).
• The development of PTSD is the most common disorder among children and adolescents
who have been sexually abused (McLean et al., 2014).
• Treatments include medications, EMDR, CBT, Expressive Arts Therapy, and specifically for
children and adolescents TF-CBT.
LITERATURE REVIEW/
Trauma Focused- Cognitive Behavioral Therapy
• TF-CBT is an evidence-based treatment that helps individuals process their traumatic experiences, develop
coping skills, and address negative thoughts and beliefs about related abuse (Cohen et al., 2017).
• It consists of various components in a structured approach to help individuals who have experienced trauma.
• P.R.A.C.T.I.C.E. (Pollio & Deblinger, 2017). (Mannarino et al., 2004).
• Psychoeducation
• Relaxation
• Affect Modulation
• Cognitive Restructuring
• Trauma Narrative
• In Vivo Mastery
• Conjoint Sessions
• Enhancing Safety
LITERATURE REVIEW
Art Therapy
• Art therapy is a form of therapy that utilizes the creative process of making art to improve a person’s
physical, mental, and emotional well-being (Shukla et al., 2022).
• An individual can improve their value and self-esteem by utilizing this visual and symbolic language
through art therapy (Shukla et al., 2022).
• By allowing the client to create distance they can utilize implicit expressions, making the therapeutic
process less confrontational (Moon, 2007).
• Through art therapy, individuals can explore and make sense of their experiences, helping them
integrate their trauma into their personal narrative, fostering a sense of coherence and
understanding(Pifalo, 2009).
• Through therapy, individuals can reclaim their sense of control (Pifalo, 2009).
LITERATURE REVIEW
Why Integrate Art Therapy and TF-CBT?
• The TF-CBT approach is flexible and adaptable yet structured enough to make it a good fit for art
therapy integration (Wymer et al., 2020).
• This pairing can be a powerful combination in combating trauma (Pifalo, 2007).
• Art therapy is a place to not only obtain information but to process information (Pifalo, 2002).
• TF-CBT is based on cognitive learning theories designed to help reduce the negative behavioral
responses of the traumatized child (Pifalo, 2007).
• Children and adolescents can express themselves and make meaning of experiences through a variety
of art modalities (Wymer et al., 2020).
• Symbolic representations of triggers allow individuals to approach and engage with those triggers in a
safe and contained manner (Malchiodi, 2012).
METHODOLOGY
• TF-CBT and art therapy are both evidence-based treatments shown to reduce PTSD symptoms.
• Addressing these issues early on, individuals can learn valuable coping techniques that will take them from victim
to survivor.
• The curriculum will incorporate key components of TF-CBT to provide a structured and comprehensive
approach to helping the targeted population cope with the effects of sexual abuse and PTSD,
Target Audience
• A curriculum with an integrative approach to both art therapy ant TF-CBT for children and adolescents who have
been sexually abused.
• Done by a professionally trained therapist in both TF-CBT and Art Therapy.
Curriculum Structure
Based on P.R.A.C.T.I.C.E components of TF-CBT
CURRICULUM OVERVIEW
THIS SECTION WILL CONSIST OF ART THERAPY
INTERVENTIONS, GOALS, DIRECTIVES, AND PROCESSING
PROMPTS FOR EACH OF THE P.R.A.C.T.I.C.E COMPONENTS
WITHIN TF-CBT.
EACH SESSION IS 50 MINUTES LONG AND SOME
SESSIONS/PHASES OF TF-CBT TAKE LONGER THAN OTHERS.
TRAUMA FOCUSED
COGNITIVE
BEHAVIORAL
ART THERAPY
For Sexually
Abused Children
and Adolescents
HOW TO USE THIS CURRICULUM
• It is essential to have a thorough understanding of both art therapy and TF-CBT.
• It is structured with activities and interventions that incorporate various forms of artistic expression, such as
drawing, painting, sculpting, and collage to be used alongside TF-CBT techniques such as cognitive
restructuring and exposure therapy.
• Clients are introduced to art-based interventions to help clients explore, and process their emotions,
thoughts, and traumatic memories.
• The curriculum can be modified to meet the specific needs and age of the individual client. Not all
interventions are suitable for all clients.
• The interventions provided will serve as a non-threatening way for clients to express themselves, build
coping skills, and promote healing.
RISKS AND BENEFITS
• The benefits include enhancing emotional expression and creative exploration.
• The use of this curriculum may trigger intense emotions and memories related to
trauma which can be distressing to some individuals.
• Without proper guidance from a trained art therapist specializing in TF-CBT, clients
may inadvertently re-traumatize themselves through the process of creating art and
revisiting traumatic experiences.
• Some individuals may even be resistant to the process of either art or processing
traumatic experiences.
• Therapists must be mindful of if and when to use this guide. They should assess the
appropriateness of when to use art therapy in combination with TF-CBT in
treatment planning.
Intervention
Visual info graphic using
symbols and metaphors
Warm-up
Continuous lines
with patterns and
colors
Guided visualization technique
Breathing exercises Practice relaxation skills
Psychoeducation
Relaxation skills
Emotional color wheel.
Affect Modulation
Collage distortions
Goals
Body safety, violence on
teens, setting boundaries,
establishing consent
Prompts
What are boundaries? What are
the rules for your body?
What do you hear, feel, see,
taste?
What body sensations do you
feel?
Identify self as a
Communicate emotions
What feeling are associated
color
with each color? How are
emotional experiences
expressed?
Intuitively selecting Challenge negative
How can distorting images help
images for collage thoughts, beliefs or patterns reframe negative thoughts?
Cognitive Coping
Trauma explosion box
Visualize a safe
place
Processing trauma
reminders and reactions
Exposure through drawing and
painting
Sensory exploration Develop emotional
through art materials regulation, promote
empowerment and agency
Collaborative finger puppets
Present moment
feelings
Building relationship
bonds.
What connections are made
between trauma and art? What
is happening in the present
moment?
How can we process feelings
together?
Vision boards/goal setting
Bridge assessment
Visualize goals and
aspirations for the future
What are goals hopes and
dreams for moving forward?
Trauma Narrative
In Vivo Mastery
How is the initial impact,
aftermath, and healing of
trauma represented?
Conjoint Sessions
Enhancing Safety
PSYCHOEDUCATION
Body safety infographic
Objectives: learning about body safety, setting boundaries,
and the effects of violence on teens.
Warm up: Play calming music and create one continuous line
using markers or color pencils. Fill in the spaces with patterns or
colors to represent emotions.
Materials: Various fact sheets about body safety and teen
violence, paper, pencils, markers, crayons, and a variety of
collage materials.
Directive: Create and infographic or visual aid using
symbols or metaphors.
Processing Prompts: Use symbols or metaphors to
describe body safety. What do those symbols mean to
you? Reflect on any past experiences of trauma or abuse
that may have impacted your sense of safety. How have
these experiences shaped your understanding of consent?
Modifications for younger children: pre -cut symbols, rules
and, body maps for children to create with.
Teenagers & Sexual Violence
Who Experiences Teen Sexual Violence?
Rates of sexual violence against youth aged 12-18 are very high,1 and the survivor normally knows the
person who committed the offense.2 Nationally, about 8% or 10 million girls and 0.7% or 791,000 boys
under the age of 18 have experienced either rape or attempted rape.2 Experiencing sexual violence as
a child or teen makes it more likely the survivor will experience re-victimization in adulthood.2 One in
three (30.1%) victims of completed rape experienced their first rape between ages 11-17.3
It is difficult to determine the full impact of sexual violence against teenagers since most research
focuses on children or college-aged youth. There are many gaps in research on sexual violence
against teens, especially those from marginalized, unserved, and underserved communities.
Throughout this document we will alternate
between using teen, youth, and young people
to reflect the variety of ways people identify.
1 in 4 girls and 1 in 6 boys
have been sexually abused
before the age of 18.4
Who Commits Sexual Violence Against Teens?
Youth who experience sexual violence are more likely to be victimized by a peer
or someone they know.2
10.1% of girls were
victimized by a
stranger.
28%
43%
43.6% of girls were
victimized by an
acquaintance.
28.8% of girls were victimized by a
current or former intimate partner.
35%
27%
27.7% of girls were
victimized by a
family member.
victimize someone else (completed
or attempted) by an acquaintance.
Effects of Sexual Violence
Young people who experience sexual violence may experience: Poor academic performance,5
Sexual risk taking behavior,6 Pregnancy,7 and Self-harm.8
Sexual assaults against youth happen in
familiar places.
10-31% Survivor’s home9,10
24% Survivor’s neighborhood10
15-44% Survivor’s school9,10
Teens who experience sexual violence may
suffer from mental health conditions:
Post-Traumatic Stress Disorder11
Substance abuse12
Low self-esteem14
Eating disorders13
Depression15
Anxiety16
Consider or attempt suicide17
National Sexual Violence Resource Center • www.nsvrc.org • 1-877-739-3895
RELAXATION SKILLS
Guided Imagery
Objectives: To practice relaxation skills through guided visualization.
To explore inner thoughts, feelings, and experiences.
Warm up: Practice breath work through watercolor painting. Allow
the paint to move across the page with each inhale and exhale. For
example, painting a mountain as the lines go up inhale and as the
lines go down exhale.
Materials: A sample of a guided visualization, a variety of
mediums for clients to choose from: watercolor paints, oil pastels,
color pencils, markers, and 8 ½ x 11 or larger paper.
Directive: Encourage the client to use all their senses to fully
immerse themselves in this imaginary space. Once the client is fully
connected with their visualization, invite them to begin creating art
that expresses their experience.
Processing Prompts: What do you see, hear, smell, or even taste?
What emotions are coming up as you create? How does this artwork
relate to your inner thoughts and feelings?
Modifications for younger children: choose a simplified version
of a guided visualization, or they can choose a place that
makes them feel safe.
AFFECT MODULATION
Feelings Color Wheel
Objectives: For the client to effectively identify and
communicate emotions and feelings.
Warm up: If you could be any color, what would you be and
why? Using markers draw what your color looks like or feels
like
Materials: Feelings chart, color wheel, a six-inch diameter
round circle on drawing paper or a paper plate, watercolor
paints, paintbrush, markers.
Directive: Create a color wheel based on emotions felt in
the moment.
Processing Prompts: What feelings are associated with each
color? Why do they make you feel a specific way? Are there
different shades and tones or levels of emotions that are felt?
No modifications are needed for younger children.
COGNITIVE COPING
Collage Distortions
Objectives: To challenge negative thought patterns, beliefs, or selfperceptions. To express emotions through collage.
Warm up: Clients will collect images for collage distortions. Intuitive
selection of images will help tap into the subconscious and uncover
certain emotions and themes.
Materials: Various collage materials such as magazine clippings,
embellishments, scissors, glue, markers, paint
Directive: Distort images by changing them from their original form.
Discuss negative or distorted thought patterns and reframe them into
positive thoughts. Add a reframed thought to the image.
Processing Prompts: How does the distortion or manipulation of
images reflect the ways in which negative thoughts distort your
perception of reality? What emotions arose when created the
distorted images?
Modifications for younger children: Provide pre-cut images for
distortions, choose age-appropriate words for discussion cognitive
distortions like “stinkin thinkin”, “fixed or growth mindset”
TRAUMA NARRATIVE
Trauma Explosion Box
Objective: To facilitate narrative exploration. To visually represent different aspects
of their trauma narrative, such as the event itself, their feelings during and after the
event, and their coping mechanisms.
Materials: Box template, 12x12 cardstock, scissors, glue, embellishments
Warm up: Guide the client through a relaxation exercise by having them close
their eyes and visualize a safe and peaceful place in which they feel secure and
comfortable.
Directive: Follow the instructions for the template and assemble the box and lid.
Use various processing prompts on the pockets of each section. Decorate the box
with intention for meaning and purpose.
Processing prompts: How does the trauma box represent different aspects of your
trauma narrative such as the initial impact, the aftermath, and the healing process?
What emotions arose as you created each layer of the box?
Modifications for younger children: have a premade box in which embellishments
and collage materials can be added. Talk about the box as a place to “hold” things
such as emotions, or events.
INVIVO MASTERY
Exposure through Drawing and Painting
Objectives: To help clients develop better emotional regulation skills. To
encourage mindfulness and present moment awareness. To increase coping skills
when exposed to trauma.
Warm up: Free drawing or painting with a focus on sensory exploration.
By engaging in free-form art making, clients can access inner thoughts
and feelings more easily, allowing for a deeper exploration of traumarelated issues.
Materials: Drawing and painting supplies, paper, canvas, pencils, markers, pastels,
paintbrushes. Other materials may include blending stumps, sponges, and other
tools for creating textures.
Directive: Talk about actual trauma triggers, practice regulating emotions with
present moment painting.
Processing Prompts: What emotions or memories are coming up as you engage
in this artistic process? Are there specific colors, shapes, or symbols that resonate
with you as you create artwork? How does this relate to your experience of
trauma? What connections do you see between the trauma and art? What
strengths or coping skills are you using as you work through this artistic process?
No modifications are needed for younger children.
CONJOINT SESSIONS
Collaborative Storytelling with Finger Puppets
Objective: To strengthen parent/guardian and child bond. To enhance communication skills. To
create a safe and supportive environment to talk about traumatic experiences.
Warm up: Provide each participant with a piece of paper and crayons, pencils, or markers.
Each person will draw a simple image of how they are feeling in the present moment.
Materials: White or colored model magic. If using white add markers to color the clay and
draw details once dry.
Directives: Both the child and parent will decide on a theme such as animals, or people. They
will create at least three characters out of model magic. Once the characters have dried the
clients will use the characters to tell a story. More complex themes can be addressed once
safety has been established.
Processing Prompts: What key emotions do you notice being expressed through storytelling?
How can we process these feelings together? What themes or symbols are emerging through
the storytelling?
No modifications needed for younger children.
ENHANCING SAFETY
Vision Board
Objectives: To help clients identify and visualize their goals aspirations, and desires through the
creation of visual representations on a vision board. To encourage self-awareness and insight.
Warm up: Completing the Bridge Assessment. This will serve as a foundation for the creation
of the vision board.
Materials: Collage materials.
Directive: Collaboratively set goals, intentions, and areas of focus. Clients should reflect on their
strengths, values, and aspirations. Choose images, words, and symbols that resonate with them
that represent their goals and intentions. Choose and arrange elements that feel meaningful
and visually appealing to them.
Processing Prompts: What goals, hopes, and dreams do you have for moving forward? How do
you envision feeling and behaving in a healthy and positive way? How does the use of symbols
represent your desired future?
Modifications for younger children: pre-cut phrases, and images, use kid friendly images from
coloring books or children's magazines.
• This curriculum aims to enhance the TF-CBT model with the use of art
therapy.
• Many of the interventions provided have been used in practice with clients
who have been sexually abused and exhibit PTSD symptomology and has
shown to be effective in their healing journey.
• Many clients not only worked through the P.R.A.C.T.I.C.E components in TFCBT in culmination with art therapy but have also used art therapy as a
coping mechanism outside individual sessions.
• The combination of both show promising results, but not without its limits.
LIMITATIONS
• Lack of standardized protocols for integrating TF-CBT and art therapy, leading to variability in how
the two modalities are combined in practice.
• While evidence suggests that both interventions can be effective in treating trauma-related
symptoms, there is a need for more research to establish clear guidelines for how these guidelines
can be combined in a cohesive systematic manner.
• Availability of trained art therapists who are also proficient in TF-CBT techniques may be limited,
making it challenging to implement interventions in certain settings
• The small sample sizes typically seen in studies examining the effectiveness of combining TF-CBT and
art therapy
• Larger scale studies with diverse participant populations are needed to provide more robust
evidence of the benefits of integrating these two therapeutic approaches.
FUTURE EXPLORATION/RESEARCH
• Research could investigate the long-term effects of combining TF-CBT and art
therapy on sexually abused children with PTSD.
• Comparative studies could be conducted to compare effectiveness of the
combination of the two modalities.
• By examining the process of change in therapy sessions, researchers can gain insight
into how art therapy enhances the effectiveness of TF-CBT and identify key elements
that contribute to positive outcomes.
• Research could also focus in on developing training programs for mental health
professionals to effectively integrate both approaches
CONCLUDING THOUGHTS
• Integrating the components of TF-CBT with art therapy has shown to be an effective holistic approach for
treating sexually abused children who suffer from PTSD.
• By combining evidence-based techniques with the creative process or art making, therapists can provide a
safe and empowering environment for clients to process their trauma, develop coping skills, and ultimately
heal from their experiences.
• This integrated approach not only addresses the psychological and emotional needs of the clients, but also
allows for non-verbal expression of emotions.
• By using the strength of both modalities, therapists can help clients build resilience, regain a sense of
control and agency, and move towards a path of recovery and healing. This curriculum aims to do that.
Q&A
REFERENCES
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https://www.cdc.gov/violenceprevention/childsexualabuse/fastfact.html
Www.cdc.gov.
•
Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2017). Treating trauma and traumatic grief in children and adolescents (2nd ed.). The Guilford Press.
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Deblinger, E., Stauffer, L. B., & Steer, R. A. (2001). Comparative Efficacies of Supportive and Cognitive Behavioral Group Therapies for Young Children Who have been Sexually Abused and
their Nonoffending Mothers. Child Maltreatment, 6(4), 332–343. https://doi.org/10.1177/1077559501006004006
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Malchiodi, C. A. (2012). Handbook of Art Therapy (2nd ed.). Guilford Press.
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Maniglio, R. (2009). The impact of child sexual abuse on health: A systematic review of reviews. Clinical Psychology Review, 29(7), 647–657. https://doi.org/10.1016/j.cpr.2009.08.003
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Mannarino, A., Mallah, K., Amaya-Jackson, L., Bennett, F., Berliner, L., Cohen, J., Deblilinger, E., Gully, K., Putman, F., & Radingan, D. (2004). Learning from Research and Clinical Practice
Core Child Sexual Abuse Task Force National Child Traumatic Stress Network How to Implement Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).
https://www.nctsn.org/sites/default/files/resources//how_to_implement_tfcbt.pdf
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Moon, B. (2007). The Role of Metaphor in Art Therapy. Charles. C. Thomas. https://research.ebsco.com/c/356ple/viewer/html/z6hittnb55
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Pifalo, T. (2009). Mapping the Maze: An Art Therapy Intervention Following Disclosure of Sexual Abuse. Art Therapy, 26(1), 12–18. https://doi.org/10.1080/07421656.2009.10129313
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Pifalo, T. (2007). Jogging the Cogs: Trauma-Focused Art Therapy and Cognitive Behavioral Therapy with Sexually Abused Children. Art Therapy, 24(4), 170–175.
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