Research Article
Art therapy drawing protocols for chronic pain: Quantitative results from a mixed method pilot study

https://doi.org/10.1016/j.aip.2020.101749Get rights and content

Highlights

  • One-time drawing protocol for improving chronic pain, resiliency, and psychosocial factors.

  • Significant results for pain, depression, anxiety, relationships, helplessness, and resources.

  • Similar effectiveness for pre-pandemic and pandemic, and online versus in-person outcomes.

  • Similar effectiveness for both versions of the protocol.

  • Similar effectiveness for both memory reconsolidation reminder conditions.

Abstract

This pilot study explored the effects of a psychosocial empirically supported arts drawing protocol for trauma on chronic pain reduction, positive and negative affect, as well as relationships and resources. Additional aims were to explore memory reconsolidation as a change factor in art therapy. The study examined three- and four-drawing protocols and two resource reminder conditions to evaluate which version of the protocol was most helpful. Significant improvements were found in ratings of pain, depression, anxiety, relationship quality, and helplessness from pre-test to post-test, and in the frequency of experiencing pain, depression, fear, anger, relationship problems, and endorsed resources. There were significant differences between groups for anger, and a time by resource reminder condition interaction effect for fear. Exploratory analyses showed similar results for those who participated in the study before and during the first three months of the COVID-19 pandemic, and online versus in-person participation. However, pre-pandemic participants reported an increase in frequency of hopefulness over time, yet participants during the pandemic reported a decrease in frequency of experiencing hopefulness over time. Also, online participants reported a greater decrease in hopefulness frequencies when compared to in-person participants. There were no significant differences between the two versions of the protocol or the memory reconsolidation reminder conditions.

Section snippets

Risk factors and protective resources

There are bidirectional relationships between pain and life experiences, social engagement and psychological and physiological functions. Adverse childhood experiences, which negatively impact relational security and social connectivity throughout the life span, have been shown to increase the risk of chronic pain (Jones, Power, & Macfarlane, 2009), and contribute to heightened perceptions of threat and pain (Nelson, Cunningham, & Kashikar-Zuck, 2017). Medically, low social support at the time

Memory reconsolidation

Memory Reconsolidation (MR) is considered a common factor of change for psychotherapy (Ecker, Ticic, & Hulley, 2015; Lane, Ryan, Nadel, & Greenberg, 2015) and art therapy (Hass-Cohen & Clyde Findlay, 2019; Hass-Cohen, 2016). MR occurs when retrieved memories are updated with new information and reconsolidated. During recall, there is a destabilization of proteins in the memory and fear brain areas, while a re-synthesis occurs within a 4 -h time frame (Nader, Schafe, & LeDoux, 2000). For

Hypotheses

It was hypothesized (H1) that there would be significant differences over time for the outcome variables of pain and psychological factors (RQ1a, RQ2a). The second hypothesis (H2) was that the three-drawing protocol would have better outcomes than the four-drawing protocol, due to reduced burden from testing fatigue and emphasis on changing the perception of the problem rather than the perception of self (RQ1b, RQ1d, RQ2b, RQ2d). Thirdly (H3), it was hypothesized that the MR condition that

Research design

A mixed-method pilot study using a pre-test post-test experimental control group design included quantitative data from the assessment of pain and psychosocial factor ratings and frequencies. Because there are many research questions and hypotheses, there were limits to statistical conclusion validity, as power was moderate; however, it was important to explore all possible outcomes due to the exploratory nature of this pilot study. Qualitative data will be reported elsewhere.

Participants

There were 34

Analyses

Data was screened for missing data and outliers, and three extreme univariate outliers were removed. Assumptions were checked, such as reliability for standardized measures (Cronbach’s alpha), normality of distributions (square root transformations were used for five positively skewed variables), sphericity (Mauchly’s test of sphericity), homogeneity of variance (Levene’s test), and homogeneity of variance-covariance (Box’s M test).

Mixed within-between repeated measures analysis of variances

Discussion

This pilot study demonstrated the potential of both the three- and four-drawing protocols with or without a resource reminder for the psychological treatment of chronic pain, and associated factors: anxiety, depression, fear, anger, relationship problems, and helplessness. Furthermore, results suggested the protocol’s potential to instigate and maintain affective, cognitive, behavioral intrapersonal changes, and social interpersonal changes. Both online and in-person administrations were

Limitations

Some of the limitations included small sample size, moderate statistical power, lack of a no treatment control group, and a large number of outcome variables. Future studies should reduce the outcome variables to anxiety, depression, and trauma, as those seem to be consistently improved by the protocol intervention. The research team adapted implementation of the protocol online due to the impact of the COVID-19 pandemic however, this change also allowed for an expansion of data collection and

Conclusion

Participation in the three- and four-drawing protocols resulted in a significant reduction in negative affect, specifically as it is related to anxiety and depression; thus, suggesting the utility of participation in the drawing protocol for clinical applications. Exploratory analyses revealed that the drawing protocol could be equally effective before and during the COVID-19 pandemic for online and in-person participation. Partial funding provided by Noah Hass-Cohen's Silver Rawley Research

References (57)

  • K. Kroenke et al.

    Reciprocal relationship between pain and depression: A 12-month longitudinal analysis in primary care

    Journal of Pain

    (2011)
  • C. Ostrom et al.

    Demographic predictors of pain sensitivity: Results from the OPPERA study

    Journal of Pain

    (2017)
  • R. Sheinberg et al.

    Childhood adversity linked to heightened pain sensitivity in adults [Abstract]

    Journal of Pain

    (2019)
  • T.A. Shella

    Art therapy improves mood and reduces pain and anxiety when offered at bedside during acute hospital treatment

    The Arts in Psychotherapy

    (2018)
  • A. Surah et al.

    Chronic pain and depression

    Continuing Education in Anaesthesia Critical Care & Pain

    (2014)
  • M. Zhuo

    Neural mechanisms underlying anxiety-chronic pain interactions

    Trends in Neurosciences

    (2016)
  • D. Betts

    A review of the principles for culturally appropriate art therapy assessment tools

    Art Therapy Journal of the American Art Therapy Association

    (2013)
  • C.R. Brewin

    Memory and forgetting

    Current Psychiatry Reports

    (2018)
  • J.W. Burns et al.

    Anger arousal and behavioral anger regulation in everyday life among patients with chronic low back pain: Relationships to patient pain and function

    Health Psychology

    (2015)
  • A. Bussières et al.

    Adverse childhood experience and adult persistent pain and disability: Protocol for a systematic review and meta-analysis

    Systematic Reviews

    (2020)
  • C.S. Carver

    Life Orientation Test-Revised (LOT-R) [measurement instrument]

    (2013)
  • Center for Youth Wellness

    Adverse Childhood Experiences [measurement instrument]

    (2017)
  • Centers for Disease Control and Prevention

    Annual surveillance report of drug-related risks and outcomes — United States surveillance special report [Data set]

    (2019)
  • X. Che et al.

    A systematic review of the processes underlying the main and the buffering effect of social support on the experience of pain

    The Clinical Journal of Pain

    (2018)
  • L. Chuang et al.

    Reliability and validity of a vertical numerical rating scale supplemented with a faces rating scale in measuring fatigue after stroke

    Health and Quality of Life Outcomes

    (2015)
  • B. Ecker et al.

    A primer on memory reconsolidation and its psychotherapeutic use as a core process of profound change

    The Neuropsychotherapist

    (2015)
  • R.R. Edwards et al.

    Changes in pain sensitivity and pain modulation during oral opioid treatment: The impact of negative affect

    Pain Medicine

    (2016)
  • D. Erbe et al.

    Blending face-to-face and internet-based interventions for the treatment of mental disorders in adults: Systematic review

    Journal of Medical Internet Research

    (2017)
  • Cited by (10)

    • A year later: The pain protocol study findings and memory reconsolidation factors

      2022, Arts in Psychotherapy
      Citation Excerpt :

      The pain protocol study results showed significant quantitative improvements in ratings of pain, depression, anxiety, relationship quality, and helplessness, as well as frequency of pain, depression, fear, anger, relationship problems, and endorsement of resources. Reported efficacy was similar for participants who participated in the three- and four-drawing protocols with or without a reminder of the resources that they drew, as well as for participants who received the protocol in-person pre-COVID-19 pandemic and participants who participated in the protocol online during the COVID-19 pandemic (Hass-Cohen et al., 2021). This follow-up study included interviews that were conducted a year after participants completed the pain protocol study.

    • Online Group Art Therapy: Encouraging Creative Healing in the Virtual Space

      2023, The Virtual Group Therapy Circle: Advances in Online Group Theory and Practice
    View all citing articles on Scopus
    View full text