CONCEPTUAL FRAMEWORKS PHASE 2 EXECUTIVE SUMMARY …

CONCEPTUAL FRAMEWORKS PHASE 2EXECUTIVE SUMMARY REPORT

DECEMBER 30, 2020

December 2020

Prepared for Creative Forces®: NEA Military Healing Arts NetworkAmericans for the ArtsNational Endowment for the ArtsU.S. Department of DefenseU.S. Department of Veterans Affairs

Prepared by ProgramWorksShawn Bachtler, Ph.D.Candace Gratama, Ed.D.

The authors wish to acknowledge the members of the technical review group, who provided valuable expertise and guidance throughout this project: Sharon Goodill, Ph.D., Clinical Professor and Chairperson, Creative Arts Therapies Department, College of Nursing and Health Professions, Drexel University; Lori Gooding, Ph.D., Assistant Professor, Music Therapy, Florida State University; Girija Kaimal, Ed.D., Associate Professor, Creative Arts Therapies Department, College of Nursing and Health Professions, Drexel University; and Nicholas Mazza, Ph.D., Dean Emeritus, Patricia V. Vance Professor of Social Work Emeritus, Florida State University.

TABLE OF CONTENTS

INTRODUCTION ...................................................................................................................................................... 2

CREATIVE FORCES CLINICAL RESEARCH .............................................................................................................. 2

CREATIVE ARTS THERAPIES CONCEPTUAL FRAMEWORKS ....................................................................................... 6

CONCEPTUAL FRAMEWORK DEVELOPMENT PROCESS ...................................................................................... 6

ART THERAPY CONCEPTUAL FRAMEWORK ............................................................................................................. 9

PRIORITIZED RESEARCH QUESTION ................................................................................................................... 9

RESEARCH DESIGN .............................................................................................................................................. 9

PROTOCOLS AND MEASURES ........................................................................................................................... 11

CONCEPTUAL MODEL ....................................................................................................................................... 11

MUSIC THERAPY CONCEPTUAL FRAMEWORK ...................................................................................................... 17

PRIORITIZED RESEARCH QUESTION .................................................................................................................. 17

RESEARCH DESIGN ............................................................................................................................................ 18



DANCE/MOVEMENT THERAPY CONCEPTUAL FRAMEWORK ................................................................................. 27

RESEARCH DEVELOPMENT ............................................................................................................................... 27

RESEARCH DESIGN ............................................................................................................................................ 30



THERAPEUTIC WRITING CONCEPTUAL FRAMEWORK (UNDER DEVELOPMENT) ................................................... 35

THERAPEUTIC WRITING PRACTICES AND RESEARCH ....................................................................................... 36

PROCESS FOR MOVING FORWARD ................................................................................................................... 38

SELECT RESOURCES .......................................................................................................................................... 43

APPENDIX A – TEAM AND WORKING GROUP AFFILIATIONS ................................................................................ 44

APPENDIX B – ORIGINAL RESEARCH QUESTIONS ................................................................................................. 47

APPENDIX C – PROTOCOLS AND MEASURES ......................................................................................................... 50

2CONCEPTUAL FRAMEWORKS PHASE 2 EXECUTIVE SUMMARY REPORT | DECEMBER 30, 2020CREATIVE FORCES®: NEA MILITARY HEALING ARTS NETWORK | CREATIVEFORCESNRC.ARTS.GOV

INTRODUCTION

CREATIVE FORCES CLINICAL RESEARCH

The Creative Forces®: NEA Military Healing Arts Network is committed to conducting and disseminating rigorous biomedical and behavioral research conducted in clinical settings, focusing on the biological, psycho-social, and comparative cost effectiveness of impacts and effectiveness of art therapy, music therapy, dance/movement therapy, and therapeutic writing on service members, veterans, families and social networks. Creative Forces has already published a number of studies of creative arts therapies and is now gearing up to implement a systematic research program. Findings will be used to further advance research and treatment for military-connected populations, as well as other clinical treatment groups. Creative Forces also aims to promote research collaboration across the partnering federal agencies, private foundations, state agencies, etc., to advance knowledge, leverage subject-matter expertise, and promote the use of best practices to benefit targeted patient populations. Specifically, the research will identify the optimal content, timing, frequency, duration, and candidates for these therapies.

The Creative Forces Research Strategic Framework identified three priority research areas for the Five-Year Research Agenda (2018-2022).1 Two additional priorities, telehealth and neuroimaging, have been incorporated to yield the following Creative Forces research priorities:

• Targeted Deployment of Creative Arts Therapies Interventions

• Creative Arts Therapies in Integrated Care, Co-Treatment, and Telehealth

• Population Characteristics and Relationships to Creative Arts Therapies Implementation and Outcomes

• Neuroimaging and Creative Arts Therapies

Creative Forces is committed to improving clinical outcomes for the military-connected populations, and this commitment drives the research into creative arts therapies and therapeutic practices. Creative Forces seeks objective, evidence-based answers to the following questions about creative arts therapies and therapeutic writing.

1. Do these therapies affect outcomes for traumatized military-connected populations (i.e., traumatic brain injury (TBI), psychological/behavioral health conditions including post-traumatic stress disorder, and chronic pain)? If so, how extensive and durable are treatment effects?

2. What are the relationships among population/patient characteristics, treatment variables, and outcomes?

3. How does the treatment context affect patient outcomes? How can treatment contexts be optimized?

4. What are the mechanisms of action of the various therapies?

To advance the use of creative arts therapies and therapeutic writing in military-connected populations, Creative Forces research will initially focus on the first three questions. These questions assess the effectiveness of the

1 https://www.arts.gov/sites/default/files/CF-Clinical-Research-Framework-and-Agenda-6.26.18.pdf

https://www.creativeforcesnrc.arts.gov/

https://www.arts.gov/sites/default/files/CF-Clinical-Research-Framework-and-Agenda-6.26.18.pdf


interventions and identify the participant variables (e.g., diagnosis, length of time since injury, previous exposure and experience with the arts, self-efficacy), intervention variables (e.g., timing, intensity, duration, delivery method, individual or group therapy), and treatment context (e.g., integrated versus stand-alone treatment, telehealth) associated with outcomes. Findings from these questions should point to potential underlying mechanisms to investigate for the fourth question. Neuroimaging represents a powerful pathway for uncovering underlying mechanisms of injury and recovery. Future studies of mechanisms will be guided by Creative Forces research, the theoretical bases of the therapies, and research in those fields. The Creative Forces priority research areas map onto these questions as shown in the table below.

The creative arts therapies bear similarities with some other psychotherapies, emphasizing the therapeutic relationship, having clear clinical goals, and occurring in individual, family, and group settings. Creative arts therapies draw from similar theoretical foundations, particularly object relations, psychodynamic, cognitive developmental, and humanistic theories.2 However, the creative arts therapies distinctly integrate creative practices into the therapeutic process through self-expression, active participation, imagination/creativity, and mind-body connections. Unlike most standard psychotherapies, the patient generates a physical manifestation of the therapeutic process, which is witnessed by the therapist and, in some settings, by peers.

While there are differences among the creative arts therapies in clinical practice and artistic media used, they are grounded in the “therapeutic relationship” or “therapeutic alliance.” The American Psychological Association defines this as:

a cooperative working relationship between client and therapist, considered by many to be an essential aspect of successful therapy. Derived from the concept of the psychoanalytic working alliance, the therapeutic alliance comprises bonds, goals, and tasks. Bonds are constituted by the core conditions of therapy, the client’s attitude toward the therapist, and the therapist’s style of relating to the client; goals are the mutually negotiated, understood, agreed upon, and regularly reviewed aims of the therapy; and tasks are the activities carried out by both client and therapist.3

Creative Forces clinical research will study the relationships between variables associated with the delivery of creative arts therapies (patient, therapist, therapeutic alliance/relationship, intervention, and treatment milieu) and their impact on patient and system outcomes. The figure below illustrates the relationships among the elements of creative arts therapies and the intended outcomes for Creative Forces patients and similar populations. Treatment Protocol refers to therapeutic activities, such as mask making or lyric analysis, which are

Creative Forces Creative Arts Therapies (CATs) Research Priorities and Overarching Questions

2 Karkou, Vicky. (2006). Therapeutic Trends across Arts Therapies. 10.1016/B978-0-443-07256-7.50008-5. 3 https://dictionary.apa.org/therapeutic-alliance; When the term therapeutic alliance is used, it is recognized that the term is similar in meaning to therapeutic relationship, a term also used frequently in the literature to describe the same phenomenon.


https://dictionary.apa.org/therapeutic-alliance


implemented using standardized, discipline-specific protocols (duration, frequency, etc.). The Creative Process is the patient’s therapeutic journey, documented through behavioral observation and self-report. The Creative Product is created by the patient and may be tangible, such as a drawing, or intangible, as with movement or singing. The creative arts therapies occur within a Treatment Milieu, such as the integrated care setting of the National Intrepid Center of Excellence, or within an inpatient or outpatient setting in a DoD or VHA facility.

Based on Creative Forces research, clinician observations at Creative Forces sites, and the theoretical models and research in creative arts therapies covered later in this document,4 it is hypothesized that service members and veterans participating in creative arts therapies will experience one or more short-term benefits and, ultimately, accelerated healing, enhanced readiness to serve and/or to navigate the challenges of daily life, improved transitions within the military and from military to civilian life, and enhanced resilience. Research, using an array of measures, will determine the effects of the creative arts therapies for patients.

4 See also Phase 2 inputs, page 7


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CREATIVE ARTS THERAPIES CONCEPTUAL FRAMEWORKS

CONCEPTUAL FRAMEWORK DEVELOPMENT PROCESS

Conceptual frameworks for art therapy, music therapy, dance/movement therapy, and therapeutic writing will guide Creative Forces research proposals toward the clinical needs of military-connected patients served by Creative Forces patients and similar programs. The Creative Forces Research Strategic Framework and Five-Year Research Agenda (2018-2022) stated:

There are many layers of complexity surrounding discipline-specific interventions and research. The creative arts therapies differ on multiple dimensions [such as scopes of practice, standards of practice, education standards, and credentialing/licensure requirements]. Further, within each discipline, a variety of theoretical frameworks are currently used to drive clinical practices and explain treatment outcomes. For an effective and rigorous research program within and across creative arts therapies, there is a need for theory-driven research guided by compelling research questions and hypotheses. To that end, a Conceptual Framework will be developed for each Creative Forces creative arts therapies discipline. The Conceptual Framework will identify the intended outcomes for that discipline and explain how the intervention achieves those outcomes. This is essential groundwork for theory-driven research.5

To establish a theoretical foundation for its research activities, Creative Forces has been developing Conceptual Frameworks for its clinical therapeutic practices.

5 https://www.arts.gov/sites/default/files/CF-Clinical-Research-Framework-and-Agenda-6.26.18.pdf, page 19

As programmatic clinical research gets underway, Creative Forces will concentrate on one or two larger experimental, prospective studies using a randomized controlled design (RCT) in partnership with the Department of Defense or the Department of Veterans Affairs. The rigor of RCTs allows greater understanding of the cause-effect relationships between interventions and outcomes. Creative Forces will solicit proposals to advance research and to strengthen outcomes for military-connected populations through creative arts therapies.

Development of Creative Forces Conceptual Frameworks occurred in two phases. Phase 1 convened separate clinical research workgroups in art therapy, music therapy, dance/movement therapy, and therapeutic writing to develop an inventory of research in the respective areas, draft logic models, conceptual models, concept maps, and research questions for each area. Phase 1 was a combined work effort over five months to facilitate and coordinate the efforts of four workgroups comprised of Creative Forces creative arts therapists and researchers with subject matter expertise in their respective discipline as pertaining to military-connected populations. Phase 2 built on this work, refining these materials toward creation of Conceptual Frameworks for research in the four clinical areas, each consisting of:

• A prioritized research question based on Creative Forces clinical priorities, Creative Forces existing research, and the field’s theoretical and research foundations;

• Research study scaffolds to address the prioritized research question;

• Inventory of current, vetted research protocols and measures appropriate for use in studies in and across clinical areas that address prioritized research questions; and

• Conceptual model that describes the primary, theoretically-based mechanisms of the four therapeutic practices and the outcomes within the context of an integrated care system such as Creative Forces.


https://www.arts.gov/sites/default/files/CF-Clinical-Research-Framework-and-Agenda-6.26.18.pdf,


While commonalities exist across the creative arts therapies and therapeutic writing, they differ in theoretical explanations, status of research development, and availability of valid and reliable measures. Within Creative Forces, there are also differences in implementation of creative arts therapies and in research practices across sites. These distinctions impact how Creative Forces research will unfold. While the “next steps” in research for the creative arts therapies and therapeutic writing are customized accordingly, all proposed studies are hypothesis-driven targeting priority, well-defined outcomes. With the development of standardized protocols, they will provide opportunities from multi-site research.

PHASE 2 INPUTS In addition to accessing Creative Forces materials, Phase 2 relied heavily on input from key stakeholders. The following sources contributed to Phase 2.

• Phase 1 Creative Forces Conceptual Frameworks for Clinical Research (August 6, 2019)

• Creative Forces Research Strategic Framework with Five-Year Research Agenda (2018-2022)

• Supplemental literature review

• Interviews with representatives of: • Veterans Health Administration • Defense and Veterans Brain Injury Center/Military Health System TBI Pathway of Care • Department of Defense

• One or more input sessions with each of the following: • Creative Forces National Leadership Team (see Appendix A for members and affiliations) • Creative Forces Technical Working Group (see Appendix A for members and affiliations) • Creative Forces Core Planning Team (see Appendix A for members and affiliations) • Arts Endowment Office of Research and Analysis • Creative Forces art therapists • Creative Forces music therapists • Creative Forces dance/movement therapists • Creative Forces creative arts therapist subgroup for writing

• Review process with a Technical Review Group established exclusively for Phase 2 to develop and review the Conceptual Frameworks and consisting of four external researchers and subject matter experts in art therapy, dance/movement therapy, music therapy, and poetry therapy, identified by the Creative Forces Senior Military Medical Advisor, Clinical Research Advisor, and other members of the Phase 2 project team established (see Appendix A for members and affiliations)

CREATING CONCEPTUAL FRAMEWORKS

Art therapy, music therapy, dance/movement therapy and therapeutic writing are at different stages of clinical and research development in the Creative Forces program, and this is reflected in the individual Conceptual Frameworks. Phase 2 resulted in full Conceptual Frameworks for art therapy and music therapy. A progressive research program was designed for dance/movement therapy, leading to a Conceptual Framework. The proposal for therapeutic writing creates a foundation for using common protocols across Creative Forces sites and for exploratory research.



The process began with identification of multiple research questions for each area. Criteria for research questions were:

1. Focused, yet suitable for generating programmatic research;

2. Specific to the intervention area (art therapy, music therapy, dance/movement therapy, therapeutic writing);

3. Directed toward the health conditions or wellness indicators which are high priorities for Creative Forces clinical partner sites at the Department of Defense and Veterans Affairs; and

4. Expected results should be important to civilian populations.

Note: the identification of the research priorities is not intended to exclude other Creative Forces research investments.

The conceptual frameworks reflect the differences in the level of development of clinical practice and research in art therapy, music therapy, dance/movement therapy, and therapeutic writing. For art therapy and music therapy, the proposed research questions included underlying hypotheses based on theory and research in the respective fields. Through stakeholder input and an iterative review process, one question was prioritized for each of the two disciplines and serves as the basis for the RCT proposed in those Conceptual Frameworks. For dance/movement therapy and therapeutic writing, initial research questions were more exploratory and aimed at developing research protocols and lines of study. Stakeholder feedback suggested all of the original questions are relevant to Creative Forces clinical and research programs, and they have been documented in Appendix B.

FINAL CONCEPTUAL FRAMEWORKS

The following sections present the Conceptual Frameworks for art therapy, music therapy, and dance/movement therapy. Art therapy and music therapy frameworks include a prioritized research question, an RCT to address that question, and a conceptual model supporting the question and study. The Conceptual Framework for dance/movement therapy identifies a series of research questions and studies that will move the discipline toward an eventual RCT. The Conceptual Framework for therapeutic writing is under development and currently reflects next steps for clinical and research efforts.

In addition to research questions, study designs, and a conceptual model, the Conceptual Frameworks identify current research protocols and measures appropriate for use in the studies. They are organized into three categories (see Appendix C):

Creative Forces standardized protocols/measures for use across all four Creative Forces therapeutic practices to collect patient, therapist, implementation, and treatment context data.

Practice-based and research standardized protocols/measures used within specific creative arts therapies or therapeutic writing practice or research.

General outcomes measures of behavioral, physical, social, and biological measures relevant to the therapeutic outcomes of Creative Forces patients and applicable across disciplines.



ART THERAPY CONCEPTUAL FRAMEWORK

PRIORITIZED RESEARCH QUESTIONCreative Forces has produced a body of research in in art therapy, primarily through case studies and retrospective studies. The priority research question, while focused, allows for development of ongoing prospective research using RCT designs and mixed-methods data collection and analyses.

Art therapy research question: How and to what extent does art therapy affect emotional processing and self-regulation for service members and veterans?

Underlying hypothesis: Art therapy interventions improve self-expression, emotional awareness, and self-regulation (Collie et al., 2006; Haeyen et al., 2018; Haeyen, 2019; Johnson, Lahad, & Gray, 2009; Kaimal et al., 2018b). These changes are associated with improved executive functioning and increased activity in the speech centers of the brain (Walker et al., 2016; Rauch et al., 1998, Shin et al., 1997). Participation in art therapy should result in improved emotional regulation and communication leading to improved affect and goal-directed behavior, ultimately resulting in improved community integration.

Rationale: In clinical case studies and correlational examinations, art therapy has been found to help most with self-expression and emotional processing (Kaimal et al., 2019; Kaimal et al., 2018b; Jones et al., 2018; Walker et al., 2017; Walker et al., 2016) These outcomes need to be studied systematically to confirm initial findings.

KEY DEFINITIONS

Emotional processing is “the process of becoming aware of, expressing, and having a non-judgmental and accepting attitude toward emotions as they arise and are experienced” (Czamanski-Cohen et al., 2019, p. 2).

Emotional regulation “refers to a collection of cognitive and behavioral strategies that effect when, for how long and with how much intensity an emotion is experienced and expressed” (Czamanski-Cohen & Weihs, 2016, p. 9).

Self-regulation is “the capacity not only to control one’s impulses, but also to be able to soothe and calm the body’s reactions to stress. It is the ability to modulate affective, sensory, and somatic responses that impact all functioning, including emotions, somatic responses, and cognition. Additionally, it refers to the brain’s executive function, which can delay actions or initiate them if necessary” (Malchiodi, 2020, p. 165).

RESEARCH DESIGNTo date, Creative Forces has conducted program evaluations, clinical case studies, and correlational studies to document patient experiences and outcomes from art therapy interventions. Findings have suggested art therapy improves patient self-expression and emotional processing (Jones et al., 2019). Researchers have noted that the need for further investigation using more rigorous research paradigms is necessary to understand the nature of patient outcomes in these areas (e.g., Berberian et al., 2018; Kaimal et al., 2018b). Two proposed study designs address the priority research question: a pre/post feasibility study followed by an RCT. The studies



will use a standardized intervention protocol (to hold constant, e.g., duration and frequency) and art therapy directive (e.g., mask-making, painting, collage).

Study 1: A feasibility study will determine how and to what extent service members with TBI who participate in a series of art therapy sessions experience improvements in emotional processing and self-regulation. The study may also measure perceived stress, affect, and post-traumatic stress disorder (PTSD) symptoms, to study their relationships to the primary outcomes. The purpose of the study is to develop and test protocols and to identify target outcomes for the RCT, as well as to get information needed for power analyses. The prospective design increases rigor and may suggest causality (Thiese, 2014).

Study 2: An RCT based on the efficacy study and comparing outcomes for art therapy patients with controls. Primary outcomes include emotional processing and self-regulation. The study will also measure perceived stress, affect, and post-traumatic stress symptoms, to study the relationships to the primary outcomes.



PROTOCOLS AND MEASURESThe proposed studies will use Creative Forces standardized protocols to document (see Appendix C):

Patient variables Therapist variables Implementation variables Treatment context variables

General outcomes measures include (see Appendix C for details):

Emotional Processing Scale (EPS) General Self Efficacy Scale (GSES) Generalized Anxiety Disorder-7 (GAD-7) Patient Health Questionnaire (PHQ-9) Perceived Stress Scale (PSS) Positive and Negative Affect Schedule (PANAS) Post-Traumatic Stress Disorder/PTSD Checklist – 5 (PCL-5) Self-regulation Questionnaire (SRQ)

There are no measures specific to art therapy in the study designs.

CONCEPTUAL MODELTHEORIES OF ART THERAPY AND MECHANISMS OF CHANGE

Several prominent theories identify therapeutic outcomes and explain mechanisms of change associated with art therapy. Relevant to the priority research question for Creative Forces art therapy research, the following theories address emotional processing and self-regulation, although from different perspectives. Drawing from the substantial, long-standing bodies of literature on the neural and physiological mechanisms involved in perception, emotion, attention, and cognition, there is growing theoretical and scientific development on the physiological and neurological systems related to art therapy.

The Expressive Therapies Continuum (Lusebrink et al., 2013) asserts there are three sequential levels through which the patient progresses: 1) kinesthetic/sensory, 2) perceptual/affective, and 3) cognitive/symbolic. Across these levels, the patient moves from preverbal experience and expression of emotion, to identification and healthy expression of emotion, to symbolic expression and ultimately integration of emotion. This process enhances self-regulation. The three levels are interconnected by a creative axis, which is characterized by wholeness, healing, and well-being resulting from engaging in the creative process and self-expression at any of the three levels.

The Art Therapy Relational Neuroscience model (ATR-N; Hass-Cohen & Clyde Findlay, 2015) integrates art therapy, interpersonal neurobiology, and relational neuroscience. The model suggests there are six principles in “conceptualizing how interpersonal neurobiology of emotion, cognition, and action are expressed in the dynamic interplay of brain and bodily systems during art therapy.” Those principals are creative embodiment, relational resonating, expressive communicating, adaptive responding, transformative integrating, and empathizing and compassion. Together, these principles take into account the relational aspect of art therapy, as well as the interpersonal neurobiology of emotion, cognition and action of art therapy. Multiple ART-N principles address emotional processing and self-regulation. For example, social interactions that occur during art therapy and their underlying neurological processes have the potential to stabilize emotional regulation.



The Bodymind model delineates specific psychological and physiological mechanisms that account for changes that result from art therapy (Czamanski-Cohen & Weihs, 2016). The model highlights interacting neural systems that are involved in the generation, perception, and regulation of emotion. The model postulates four core therapeutic processes of art therapy: 1) a triangular relationship between the art therapist, the art process and the art product leads to attachment similar to a patient’s primary relationships; 2) patient self-engagement with balanced arousal and attention occurs within the framework of that triangular relationship and the safety of the space for art making; 3) self-expression through art making enables patients to express somatic knowledge that is not easily translatable into words; and 4) the opportunity to engage in art making allows the patient to externalize emotional and cognitive material in a concrete form and then take time to engage in a reflective process provides the opportunity for both perspective taking and meaning making.

The Adaptive Response Theory (ART; Kaimal, 2019) explains the mechanisms of change in art therapy from the lens of evolutionary biology and human development. The theory is based on human instinctual survival responses to threats to well-being (bio-physiological and psycho-social-spiritual) and on how art making and imaginative processes align with the conceptualization of the brain as a predictive machine. The theory suggests that art therapy works through the dynamic interplay of the art therapist, the patient, the art making process, and the art product, which enables patients to shift from maladaptive to adaptive responses through the interpersonal and intrapersonal learning that occurs in the session. The art therapist encourages creative self-expression to improve mood and affect and reduce stress, among other outcomes. Relevant to emotional processing and self-regulation, patients learn to recognize their responses to threats and make adaptive choices.

These models of art therapy and possible mechanisms of change consider the general population in therapy. However, they highlight the interplay between art making, the artwork, and the patient-therapist relationship, and address areas of research interest for military-connected patients with PTSD and TBI. In identifying and overcoming challenges during art making, and in viewing and describing their art products, patients develop empathy for themselves and others and are better able to communicate their feelings and experiences in a healthy way, improving self-reflection, emotional processing, self-regulation, communication, relationships, and sense of belonging (Walker et al., 2016; Walker et al., 2017). Being witnessed and bearing witness to the art therapy process and products provide valuable information to both the patient and therapist (Jones, Drass, & Kaimal, 2019; Walker et al., 2016). The therapist can better assess the patient’s needs, and the patient can better assess his/her own needs. In the group setting, the patient also feels more connected to others through shared feelings and experiences (Jones, Drass, & Kaimal, 2019). These shared connections create a sense of community and belonging for patients, decreasing isolation and empowering them to open up to others, as well as encouraging others to open up. This decreases feelings of guilt and shame, and patients also become more open with their other health providers, their families, and their peers (Kaimal et al., 2021). They often do this by sharing their art therapy products – sometimes in the media and in public exhibits.

IMPLICATIONS FOR CREATIVE FORCES RESEARCH

Improved emotional processing and self-regulation are key outcomes for Creative Forces. Emotional processing consists of emotional awareness, emotional expression, and emotional acceptance (Czamanski-Cohen et al., 2019). Emotional awareness occurs when sensorimotor or other bodily information become explicit and enter consciousness. In emotional expression, feelings are conveyed to others. Finally, emotional acceptance occurs when the patient develops a nurturing attitude toward their feelings and emotional state. Emotional awareness and acceptance are essential elements of emotional and self-regulation, as they enable patients to make choices about how to attend and respond to their emotions.



The art therapy process within a personalized, patient-centered care model begins with patient assessment, evaluation and treatment planning by the therapist, and aims to be a mechanism of change for the patient, the providers, the patient’s community (family, military unit, peers), and society. Within the art therapy process at a micro/clinical level, exists relationships between the patient, the art therapist, the art making, and the art product. While art therapy provides nonverbal methods of expression and communication, verbal communication of thoughts and feelings are part of the process (Walker, Kaimal, Gonzaga, et al., 2017). Verbalization occurs in planning stages, in production, and in processing the end result (Berberian, Walker, & Kaimal, 2018; Kaimal et al., 2018a; Kaimal et al., 2018b).

The graphics below present art therapy research within the Creative Forces research model (top model) and feature one theoretical approach to emotional processing and regulation (bottom model). Through art therapy and as part of emotional processing, patients develop verbal and nonverbal self-expression to improve their ability to communicate with others. This model is a simplified understanding. In practice, emotional processing and self-expression are integrated, complex, and individualized.


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Czamanski-Cohen, J., & Weihs, K. L. (2016). The Bodymind Model: A platform for studying the mechanisms of change induced by art therapy. The Arts in psychotherapy, 51, 63–71 https://DOI.org/10.1016/j.aip.2016.08.006

Czamanski-Cohen, J., Wiley, J., Sela, N., Caspi, O., & Weihs, K. (2019). The role of emotional processing in art therapy (REPAT) for breast cancer patients. Journal of Psychosocial Oncology, 37, 1-13. DOI: 10.1080/07347332.2019.1590491

Hass-Cohen, N., and Findlay, J. C. (2015). Art therapy and the neuroscience of relationships, creativity, and resiliency: Skills and practices. New York: W.W. Norton and Company.

Haeyen, S. (2019). Strengthening the healthy adult self in art therapy: Using schema therapy as a positive psychological intervention for people diagnosed with personality disorders. Frontiers in Psychology, 10, 644. https://DOI.org/10.3389/fpsyg.2019.00644

Haeyen, S., van Hooren, S., van der Veld, W., & Hutschemaekers, G. (2018). Measuring the contribution of art therapy in multidisciplinary treatment of personality disorders: The construction of the Self-Expression and Emotion Regulation in Art Therapy Scale (SERATS). Personality and Mental Health, 12(1), 3-14.

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https://DOI.org/10.3389/fpsyg.2019.00644

http://10.1016/j.aip.2019.04.004

https://doi.org/10.1016/j.aip.2018.10.003

http://10.1080/08995605.2020.1842639


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Lusebrink, V. B., Mārtinsone, K., & Dzilna-Šilova, I. (2013). The Expressive Therapies Continuum (ETC): Interdisciplinary bases of the ETC. International Journal of Art Therapy, 18(2), 75-85. DOI: 10.1080/17454832.2012.713370

Malchiodi, C. (2020). Trauma and Expressive Arts Therapy: Brain, Body, and Imagination in the Healing Process. New York: Guilford Press.

Rauch, S. L., Savage, C. R., Alpert, N. M., et al. (1997). The functional neuroanatomy of anxiety: A study of three disorders using positron emission tomography and symptom provocation. Biological Psychiatry, 42, 446–52.

Shin, L. M., McNally, R. J., Kosslyn, S.M., et al. (1997). A positron emission tomographic study of symptom provocation in PTSD. Annals of the New York Academy of Sciences, 821, 521–3.

Thiese, M. (2014). Observational and interventional study design types; an overview. Biochemia medica, 24, 199-210. DOI: 10.11613/BM.2014.022.

Walker, M., Kaimal, G. Koffman, R., & DeGraba, T. J. (2016). Art therapy for PTSD and TBI: A senior active duty military service member’s therapeutic journey. The Arts in Psychotherapy 49(2), 10-16. DOI: 10.1016/j.aip.2016.05.015

Walker, M., Kaimal, G. Myers-Coffman, K., Gonzaga, A.M.L., & DeGraba, T. J. (2017). Active duty military service members visual representations of PTSD and TBI. Therapeutic journey. International Journal of Qualitative Studies on Health and Well-being, 12(1). DOI: 10.1080/17482631.2016.1267317

Walker, M., Kaimal, G., Gonzaga, A. M. L., Myers-Coffman, K. A., & DeGraba, T. J. (2017). Active duty military service members’ visual representations of PTSD and TBI in masks. International Journal of Qualitative Studies on Health and Well-being, 12(1). DOI: 10.1080/17482631.2016.1267317


http://10.1136/bmjopen-2017-021448

http://10.1080/17454832.2012.713370

http://10.11613/BM.2014.022

http://10.1016/j.aip.2016.05.015

http://10.1080/17482631.2016.1267317

http://10.1080/17482631.2016.1267317


MUSIC THERAPY CONCEPTUAL FRAMEWORK

PRIORITIZED RESEARCH QUESTION

Creative Forces has produced eight studies in music therapy primarily through case and retrospective studies. The priority research question allows for development of programmatic research. It points to an RCT and mixed-methods data collection and analyses.

Music therapy research question: How and to what extent does music therapy affect the perception of chronic pain in service members and/or veterans who experience chronic pain?

Secondary outcomes include the impact of music therapy on anxiety and emotional state, along with pain medication use (number of agents, dose, frequency). Music therapy specific factors will be integrated, including willingness to use the techniques outside of the session and identifying aspects of the intervention perceived as helpful and engaging by patients.

Underlying hypothesis: Adherence to a specified regimen of music therapy perception diminishes negative pain perception (e.g., frequency, intensity, duration, distress) in service members and/or veterans experiencing chronic pain.

Secondary hypothesis: Adherence to a specific regimen of music therapy will reduce medication use, decrease anxiety and stress, improve emotional regulation, support community integration, etc.

Rationale: Chronic pain is a common reason for medical evaluation and medical boards among active duty service members, and 66% of veterans with PTSD also experience chronic pain (Center for Deployment Psychology, n.d.).6

Nonpharmacological treatment of service members in the United States Army with chronic pain is associated with fewer adverse outcomes after transition to the Veterans Health Administration (Meerwijk et al., 2020).

Music interventions have been shown to improve management of chronic pain (e.g., Bradt, 2010; Bradt et al., 2016a; Bradt et al., 2016b; Garza-Villarreal et al., 2017; Low et al., 2020).

The FY20 Defense Appropriations Act provides funding to the Department of Defense Chronic Pain Management Research Program (CPMRP) that supports research intended to improve the health and quality of life of service members and veterans living with chronic pain (CDMRP, 2020).7

6 See https://deploymentpsych.org/ 7 See https://cdmrp.army.mil/


https://deploymentpsych.org/

https://cdmrp.army.mil/


RESEARCH DESIGNTwo studies address the priority research question: an interim study, which serves as a pilot and feasibility study, followed by an RCT.

Study 1: The purpose of the pilot or feasibility study is to explore the impact of music therapy on pain perception in service members and/or veterans who experience chronic pain. The study design should explore the impact of a music therapy protocol on pain perception, emotional state (e.g., anxiety, depression, etc.), music therapy factors such as willingness to use various music therapy interventions and intervention characteristics perceived as helpful and engaging. Participants will engage in a music therapy protocol with pre, post, and longer-term follow-up measurements of pain, emotional state, and music therapy factors (e.g., willingness to use techniques outside of therapy, helpfulness of different interventions). Follow-up could occur 24 hours post-session, at the conclusion of the course of treatment, and at specified time post treatment (i.e., 3-6 months post treatment). Analgesic use could be gathered from the medical record following the music therapy session, at pre-determined intervals, to gauge whether or not use was impacted.



Study 2: The purpose of this study is to explore the effects of music therapy intervention and psychoeducation on the perception of chronic pain in service members and/or veterans experiencing chronic pain. Secondary outcomes, including the impact of the music therapy intervention on emotional state (e.g., anxiety, depression, etc.), and opioid use, will also be explored, along with music therapy factors such as willingness to continue using the music intervention and identifying the music therapy intervention characteristics perceived as helpful/engaging. An option to include QST or other neuroimaging measures may be included.



PROTOCOLS AND MEASURESThe proposed studies will use Creative Forces standardized protocols to document (see Appendix C):

Patient variables Therapist variables Implementation variables Treatment context variables

General outcomes measures may include (see Appendix C for details):

Bond Lader VAS Brief Pain Inventory Defense and Veterans Pain Rating Scale Defense and Veterans Pain Rating Scale Generalized Anxiety Disorder (GAD-7) Hospital and Anxiety and Depression Scale International Classification of Functioning, Disability, and Health (ICF) Pain Catastrophizing Scale Patient Reported Outcomes Measurement Information System (PROMIS) instruments short forms for anxiety, depression, and sleep disturbance Quantitative Sensory Testing

CONCEPUTAL MODELThe section below comes from the Arts Endowment’s Phase 1 Work (2019) Conceptual Frameworks for Clinical Research. Through that work, the following descriptions emerged.

CLINICAL MUSIC THERAPY

The Therapeutic Process The music therapy clinical process is based on the therapeutic alliance between the music therapist and the patient to address the needs, goal areas, and presenting symptomatology of the patient. Throughout the Creative Forces Network, music therapy is employed within an interdisciplinary, patient-centered care model that encompasses assessment, evaluation, goal setting, treatment planning, clinical intervention, termination, and strategies for continued music engagement to support community integration. Engagement in music therapy interventions can assist in the treatment of patients’ functional rehabilitation and behavioral health issues. Specifically, music therapy can be used to address areas of cognition, motor, speech and language, and psychosocial status to assist with emotional and psychological processing.

Music as an Art Form As an art form, music is uniquely social and requires verbal and non-verbal communication, using lyrical and instrumental structure, prose, and/or sound-associations to relay information. Considerations of social order are also a factor in music therapy, specifically during active music making, where the non-verbal interplay between instruments can demonstrate harmonies and/or tensions in relationships. In music therapy, patients are empowered to find and use their voices, whether it be the literal voice, through spoken word or singing, or conveying emotion through intentional sound selection and instrumentation. Rhythm is a fundamental component of music that is intertwined with communication and conveys both physiological and psychological state across physical, psychological, conceptual, spiritual, and emotional realms.



Individual Music Therapy Expectations of individual music therapy treatment are presented and discussed during initial evaluation session. The patient role in individual music therapy is to utilize self-insight gleaned from clinical experiences and expertise of the music therapist to identify ways that assist in personal goal attainment, specific areas of personal growth and development, and overall well-being. The music therapist encourages the patient to be present and mindful throughout various components of the music therapy process.

Group Music Therapy Group music therapy sessions focus on individual identity within a group context with consideration to social dynamics, functional roles, communication, and awareness-building. The patient role in group music therapy is to gain perspective and insight of self and others through the process of fostering understanding of others’ situations, perceptions, and responses and establishing roles and relationships in the therapeutic setting. The music therapist supports the patients in being open to new experiences and perspectives by being attuned to the needs of individuals and the group.

Music Therapist’s Role Whether facilitating individual or group sessions, the music therapist is actively involved in the therapeutic process from commencement to completion. Direct participation of the music therapist includes facilitating the patients’ engagement in task-oriented musical behavior, providing supportive music or accompaniment to engage the patients, enhancing the patient experience, offering feedback on patient progress and performance throughout the music therapy process, and presenting a plan for follow-up music therapy and/or resources for continued music engagement outside of the clinical environment.

MUSIC THERAPY AND PAIN

Early research found that over forty-nine percent of music therapists used music for pain management (Michel & Chesky, 1995), and music therapy is believed to impact pain. From a neurological standpoint, research has shown that attention-based activities can attenuate the activation of areas associated with pain processing (Petrovic et al., 2000). Overlap in pain and music processing is seen in the anterior cingulate cortex, which suggests that both pain and music processing have the ability to elicit attention (Hernandez-Ruiz, 2019; Petrovic et al., 2000; Rodriguez-Wolfe, 2014). Likewise, the anterior cingulate cortex is involved in both pain and anxiety conditions (Zhuo, 2016). As such, music, especially preferred music , may elicit attention and be a successful tool for managing pain perception (Mitchell & MacDonald, 2006; Rodriguez-Wolfe, 2014). Research also suggests that music is effective as an analgesic because of its ability to serve as cognitive distraction, ties to emotional associations, and neurobiological underpinnings (Lunde et al., 2019).

Music therapy has been shown to diminish negative pain (Tan et al., 2010). Music therapy interventions refocus attention, thereby reducing the individual’s ability to focus on the competing pain stimulus. Previous research has shown that music interventions can reduce state anxiety (Davis & Thaut, 1989) and reduce both pain and anxiety in those with chronic pain (Guetin et al., 2012). Music interventions to promote relaxation and distraction in pain management have resulted in decreased pain scores and successful use outside of music therapy sessions (Colwell, 1997).

The theoretical constructs for music therapy as a pain management strategy is based on (a) constructivism, or the idea that task engagement can establish a construction of reality that replaces pain as a competing construction (Bradshaw et al., 2012), (b) affective components, (c) entrainment, or the linking of diverse behaviors, like heart rate or respiration, to an external beat (Stegemoller, 2017) (d) the Iso-Principle, altering musical characteristics to promote relaxation response (Altschuler, 1948), and (e) sociocultural factors (e.g., patient preference, culturally-relevant music, clinical empathy). These constructs are explained as follows:



• Constructivism: Music can be used to capture attention, thereby managing pain perception. Music that is culturally relevant, familiar, and preferred has been shown to be most effective at capturing attention (Flowers, 2001; Zhu et al., 2009), and research has suggested that the music must be meaningful to be effective (Mitchel et al., 2006).

• Constructivism and Affect/Emotional State: Music assisted relaxation has been shown to improve pain perception (Tan et al., 2010). Essentially, music intervention such as deep breathing to music, is used to refocus attention, thereby reducing the individual’s ability to focus on the competing pain stimulus.

• Entrainment and Iso-Principal: Music assisted relaxation integrates not only attentional engagement, but also the use of music to reduce pain and/or anxiety. It involves the use of rhythmic and/or auditory cues to promote entrainment, and when paired with the Iso-Principle, which is the altering of musical characteristics to increase the relaxation response (Altschuler, 1948), music therapy has the potential to decrease physiological arousal. Music assisted relaxation techniques that use verbal communication have been shown to be most effective (Pelletier, 2004). Therefore, these techniques would not only integrate entrainment and the Iso-Principle, but also verbal facilitation to increase effectiveness. Use of music therapy paired with relaxation is important because music entrainment has been shown to positively impact emotional state (Bradt, 2010).

• Social Cultural Factors: Music that is culturally relevant, familiar, and preferred has been shown to be most effective at capturing attention (Flowers, 2001; Zhu et al., 2009), and research has suggested that the music must be meaningful to be effective (Mitchel et al., 2006).

The graphic on page 23 presents music therapy research within the Creative Forces research model. On page 24 is an illustration of one theoretical approach to chronic pain perception (Griffiths, 2017). Music therapy helps patients gain in-sight in multiple realms and develop skills to reach their goal of pain management, which transfers outside the clinical music therapy session. The model is simplified as chronic pain is complex and individualized.


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REFERENCES

Altschuler, I. M. (1948). A psychiatrist’s experience with music as a therapeutic agent. In D. Schullian & M. Schoen (Eds.), Music and medicine (pp. 250-275). New York: Books for Libraries Press.

Bradshaw, D. H., Chapman, C. R., Jacobson, R. C., & Donaldson, G. W. (2012). Effects of music engagement on responses to painful stimulation. The Clinical Journal of Pain, 28(5), 418–427. https://DOI.org/10.1097/AJP.0b013e318236c8ca

Bradt, J. (2010). The effects of music entrainment on postoperative pain perception in pediatric patients. Music and Medicine, 2(3), 150-157.

Bradt. J., Dileo, C., Magill, L., & Teague A. (2016a). Music interventions for improving psychological and physical outcomes in cancer patients [update]. Cochrane Database of Systematic Reviews, 2016(8). Art. No.: CD006911. DOI: 10.1002/14651858.CD006911.pub3.

Bradt, J., Norris, M., Shim, M., Gracely, E. J., & Gerrity, P. (2016b). Vocal music therapy for chronic pain management in inner-city African Americans: A mixed methods feasibility study. Journal of Music Therapy, 53(2), 178-206, DOI: 10.1093/jmt/thw004. PubMed PMID: 27090149 (IF = 1.694; Rehabilitation: 28/69)

Colwell, C. M. (1997). Music as distraction and relaxation to reduce chronic pain and narcotic ingestion: A case study. Music Therapy Perspectives, 15(1), 24–31. https://DOI-org.proxy.lib.fsu.edu/10.1093/mtp/15.1.24

Davis, W. B. & Thaut, M. H. (1989). The influence of preferred relaxing music on measures of state anxiety, relaxation, and physiological responses. Journal of Music Therapy, 26(4), 168–187. https://DOI-org.proxy.lib.fsu.edu/10.1093/jmt/26.4.168

Flowers, P. J. (2001). Patterns of attention in music listening. Bulletin of the Council for Research in Music Education, 148, 48-59.

Garza-Villarreal, E. A., Pando, V., Buust, P., & Parsons, C. (2017). Music-induced analgesia in chronic pain conditions: A systematic review and meta-analysis. Pain Physician, 20(7), 597-610.

Griffiths, M. (2017). Living well with chronic or persistent pain: A guide for patients and relatives. Aintree University Hospital NHS Foundation Trust. https://www.aintreehospital.nhs.uk/media/6478/living-well- with-chronic-pain-patient-guide.pdf

Guétin, S., Giniès, P., Siou, D. K. A., et al. (2012). The effects of music intervention in the management of chronic pain: A single-blind, randomized, controlled trial. The Clinical Journal of Pain, 28(4).

Hernandez-Ruiz, E. (2019). How is music processed? Tentative answers from cognitive neuroscience. Nordic Journal of Music Therapy, 28(4), 315–332.

Low, M., Lacson, C., Zhang, F., Kesslick, A., & Bradt, J. (2020). Vocal music therapy for chronic pain: A mixed methods feasibility study. The Journal of Alternative and Complementary Medicine, 26(2), 113-122. https://DOI.org/10.1089/acm.2019.0249

Lunde, S. J., Vuust, P., Garza-Villarreal, E. A., & Vase, L. (2019). Music- induced analgesia: How does music alleviate pain? Pain, 160(5), 989-993.


https://DOI.org/10.1097/AJP.0b013e318236c8ca

http://10.1002/14651858.CD006911.pub3

https://doi.org/10.1093/jmt/thw004

https://DOI-org.proxy.lib.fsu.edu/10.1093/mtp/15.1.24

https://DOI-org.proxy.lib.fsu.edu/10.1093/jmt/26.4.168

https://www.aintreehospital.nhs.uk/media/6478/living-well- with-chronic-pain-patient-guide.pdf

https://www.aintreehospital.nhs.uk/media/6478/living-well- with-chronic-pain-patient-guide.pdf

https://DOI.org/10.1089/acm.2019.0249


Meerwijk, E. L., Larson., M. J., Schmidt, E. M., et al. (2020). Nonpharmacological treatment of army service members with chronic pain is associate with fewer adverse outcomes after transition to Veterans Health Administration. Journal of General Internal Medicine, 35(3), 775-783.

Michel, D. E., & Chesky, K. S. (1995). A survey of music therapists using music for pain relief. The Arts in Psychotherapy, 22(1), 49-51.

Mitchell, L. A., & MacDonald, R. A. R. (2006). An experimental investigation of the effects of preferred and relaxing music on pain perception. Journal of Music Therapy, 63, 295–316. https://DOI-org.proxy.lib.fsu.edu/10.1093/jmt/43.4.295.

Pelletier, C. L. (2004). The effects of music on decreasing arousal due to stress: A meta-analysis. Journal of Music Therapy, 41(3), 192-214.

Petrovic, P., Petersson, K. M., Ghatan, P. H., Stone-Elander, S., & Ingvar, M. (2000). Pain-related cerebral activation is altered by a distracting cognitive task. Pain, 85(1), 19–30. https://DOI.org/10.1016/S0304- 3959(99)00232-8.

Rodriguez-Wolfe, M. (2014). The effect of music listening on cold-pressor pain perception, tolerance, and attention. 10.13140/2.1.1396.8965.

Stegemöller, E. L. (2017). The neuroscience of speech and language. Music Therapy Perspectives, 35(2), 107–112. DOI.org/10.1093/mtp/mix007.

Tan, X., Yowler, C. J., Super, D. M., & Fratianne, R. B. (2010). The efficacy of music therapy protocols for decreasing pain, anxiety, and muscle tension levels during burn dressing changes: A prospective randomized crossover trial. Journal of Burn Care & Research, 31(4), 590–597. https://DOI.org/10.1097/BCR.0b013e3181e4d71b

Zhuo, M. (2016). Neural mechanisms underlying anxiety–chronic pain interactions. Trends in Neurosciences, 39(3), 136–145. https://DOI.org/10.1016/j.tins.2016.01.006.

Zhu, W., Zhang, J., Ding, X., Zhou, C., Ma, Y., & Xu, D. (2009). Crossmodal effects of Guqin and piano music on selective attention: An event-related potential study. Neuroscience Letters, 466, 21-26.


https://DOI-org.proxy.lib.fsu.edu/10.1093/jmt/43.4.295

http://10.1016/s0304-3959(99)00232-8

http://10.1016/s0304-3959(99)00232-8

http://10.13140/2.1.1396.8965

http://DOI.org/10.1093/mtp/mix007

https://DOI.org/10.1097/BCR.0b013e3181e4d71b

https://DOI.org/10.1016/j.tins.2016.01.006


DANCE/MOVEMENT THERAPY CONCEPTUAL FRAMEWORK

RESEARCH DEVELOPMENT

Dance/movement therapy (DMT) is newer to Creative Forces and still developing at the National Intrepid Center of Excellence (NICoE), where it has been integrated into the Intensive Outpatient Program (IOP) as well as longitudinal programming. As a newer program, therapists are in the process of developing, executing, and revising protocols, while also establishing a research program. An initial, unpublished case study found that IOP patients experienced improvements in self-expression, social connection, mind-body integration, self-efficacy, and overall sense of well-being while participating in the DMT program (Freeman, 2018).

Researchers suggest that building standardized treatment protocols or manuals and testing both the treatment and the outcomes can improve research quality, as well as progress to a randomized controlled study (Bryl & Goodill, 2020; Roslvsjord et al., 2005). The figure below details the progression of research for Creative Forces DMT, as the program develops research capacity, conducts studies, builds upon knowledge, and is adapted from suggestions from other researchers (Bryl & Goodill, 2020; Rolvsjord et al., 2005).

The capacity building phase is designed to develop partnerships to conduct research (academic institutions, researchers), publish results using extant data to build the program, develop treatment protocols for use in an initial case study, incorporate training, adopt the use of routine dance/movement therapy assessments, and develop processes to obtain consent and videotape sessions to conduct retrospective studies. The revise and adapt phases focus on learning from the previous research, improving treatment protocols and manuals, and identifying the salient outcomes to be tested in the research program.


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The research questions are designed to inform development and targeted outcomes of DMT research. The proposed research progression begins with case studies and progresses toward a randomized controlled trial (RCT), advancing the rigor of the program.

Using this progression, the initial case study will focus on several dependent variables: coping, resilience, interoception, emotional expression/regulation, readiness for life transitions, and family relationships. The findings from the early studies will inform which dependent variables will be included in the pre-experimental and RCT.

Throughout the process, retrospective studies can be conducted by collecting data, systemically from previous studies and with permission, through the treatment program. This will require standard protocols, routine DMT assessments, and a process to systematically document clinical data (see examples, Jones, Drass, & Kaimal, 2019; Walker et al., 2016).



RESEARCH DESIGN

The case study, described below, is the first step in advancing the clinical and research program. This study will provide pilot data and findings to inform future studies, help develop the clinical program protocol for future studies, and produce a publication. It will also help develop a clearer therapy program, with sequenced therapeutic treatments and associated outcomes. It will also facilitate development of data collection and outcome measures for future studies.

This study uses a mixed methods, randomized, multiple single case study design. In this design, data are collected on days patients participate in DMT as well as on days with no DMT to compare across conditions. The randomized multiple single case study design (Stewart, McMullen, & Ruben, 1994) controls for the multiple treatment confounds and isolates the impact of DMT. This approach can also identify when outcomes will be met using a staged treatment approach. Interviews at the beginning and end of the study will provide information about transitions and the subjective experience of DMT.



PROTOCOLS AND MEASURES

The proposed studies will use Creative Forces standardized protocols to document (see Appendix C): Patient variables Therapist variables Implementation variables Treatment context variables

Measures specific to dance/movement therapy include (see Appendix C for details): DMT Outcomes Framework with Movement Assessment and Reporting App (MARA) Multidimensional Assessment of Interceptive Awareness (MAIA)

General outcomes measures include (see Appendix C for details): Interviews COPE Inventory PROMIS Measures

CONCEPTUAL MODEL

Service members (SMs) recovering from TBI and associated psychological health conditions are engaged in DMT treatment at the NICoE. The NICoE program is built on a 4-week integrative treatment model. Based on the acute nature of the program, the population served, and the emphasis on group therapy, the initial focus of DMT work is on establishing safety among patients. This is achieved through addressing expectations and establishing a foundation of basic mindfulness concepts. The work then shifts to resource building through individual development of confidence in mind-body skills (i.e., diaphragmatic breath, meditation, yoga, and biofeedback), with a focus on helping SMs better understand their own mind-body connection and how to use that as a resource to address their needs in any situation. To build their capacity for flexible coping strategies, the DMT therapists provide opportunities for SMs to build personal resilience, appropriately regulate and express affect, and increase their interpersonal communication skills by expanding their movement repertoire.

As SMs become more able to tolerate the present moment and increase feelings of safety, creative movement work is introduced as clinically indicated. Expressive movement-based interventions can allow SMs to reflect on the past and present and visualize the future, creating embodied rehearsals for life to help SMs begin to actualize change and transition between roles with greater ease (i.e., parent, service member, and spouse) (Krantz, 2012). Creative movement can also help SMs build kinesthetic empathy and reciprocity, increase their ability to improvise, increase their understanding of how to create physical, mental and emotional comfort, increase feelings of self-efficacy, process and heal trauma, and to increase regulatory flexibility.

The graphic below combines the treatment conceptual model from Phase 1 and the Phase 2 proposed research design. While the underlying treatment model remains the same, the study will identify which activities accomplish each goal and outcome, as well as the order in which patients should expect to accomplish the goals and outcomes. Because the research is developmental, the activities may change as protocols are developed. Below is a list of constructs this study should impact.



MODEL CONSTRUCTS

Coping: Healthy strategies people adopt to face specific stressors. As measured through the COPE Inventory, these include problem-focused coping strategies and emotion-focused coping strategies (Carver et al., 1989).

Emotional Expression/Regulation: On the DMT Outcomes Framework, emotional expression is the “ability to express an internal emotional or affective state through embodied behaviours or movement and vocal (including verbal) expressions.” Emotional regulation is the “response to ongoing demands of experience with a range of emotions, that is socially tolerable and sufficiently flexible, and both permits and delays spontaneous reactions.” (Dunphy et al., 2020, p. 25)

Family Relationships: The DMT Outcomes Framework includes a social domain that focuses on the therapeutic experience around relationships, the connections between people, and the way they communicate with each other. The instrument includes three subdomains which can be applied to family, including: embodied (non-verbal) communication, social reciprocity, and expressive (verbal and vocal) communication (Dunphy et al., 2020).

Interoception: Interoceptive awareness is the awareness of inner body sensations, involving the sensory process of receiving, accessing, and appraising internal bodily signals (Craig, 2015). In DMT, the MAIA is used to measure interoception through several subscales: noticing, not-distracting, not-worrying, attention regulation, emotional awareness, self-regulation, body listening, and trusting (Mehling et al., 2012).

Readiness for Life’s Transitions: (Still under development) – may include a self-efficacy measure or Outcome Domain 6: On the DMT Outcomes Framework: Integration: Wholeness, Vitality, Aliveness.

Resilience: Psychological resilience is the ability to grow and adapt in the face of stressors. For example, resilience related to pain is associated with attitudes and beliefs, catastrophizing tendencies, social responses, coping style, and health care and medication usage. The COPE Inventory has been used in previous DMT research to measure resilience (Shim et al., 2017).

Therapeutic Alliance: The therapeutic relationship is developed between the DMT therapist and the patient, and characteristics include personal awareness and insight, trust, respect, safety, authenticity, acceptable, empathy and collaboration. DMT focuses on movement behavior as it emerges in the therapeutic relationship, and expressive, communicative, and adaptive behaviors are all considered for group and individual treatment.8

8 https://www.adta.org/what-is-dancemovement-therapy


https://www.adta.org/what-is-dancemovement-therapy

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REFERENCES

Bryl, K., & Goodill, S. (2020). Development, execution, and acceptance of a manualized dance/movement therapy treatment protocol for the clinical trial in the treatment of negative symptoms and psychosocial functioning in schizophrenia. American Journal of Dance Therapy, 42, 150-175. https://DOI.org/10.1007/s10465-019-09312-8.

Carver, C. S., Scheier, M. F., & Weintraub, J. K. (1989). Assessing coping strategies: A theoretically based approach. Journal of Personality and Social Psychology, 56, 267-283.

Craig, A. D. (2015). How do you feel? An interoceptive moment with your neurobiological self. Princeton, NJ: Princeton University Press.

Dunphy, K., Lebre, P., Mullane, S. (2020). Outcomes framework for dance movement therapy, 78. http://www.makingdancematter.com.au/

Freeman, L. K. (2018). Dance/movement therapy program review. Unpublished case study conducted at the National Intrepid Center of Excellence.

Jones, J. P., Drass, J. M., & Kaimal, G. (2019). Art therapy for military service members with post-traumatic stress and traumatic brain injury: Three case reports highlighting trajectories of treatment and recovery. The Arts in Psychotherapy, 63, 18-30.

Krantz, A. M. (2012). Let the body speak: Commentary on paper by Jon Sletvold. Psychoanalytic Dialogues: The International Journal of Relational Perspectives, 22(4), 437-448.

Mehling, W. E., Price, C., Daubenmier, J. J., Acree, M., Bartmess, E., Stewart, A. (2012). The multidimensional assessment of interoceptive awareness (MAIA). PLoS One, 7(11). https://DOI.org/10.1371/journal.pone.0048230

Rolvsjord, R., Gold, C., & Stige, B. (2005). Research rigour and therapeutic flexibility: Rationale for a therapy manual developed for a randomized controlled trial. Nordic Journal of Music Therapy, 14(1), 15-32.

Shim, M., Johnson., R. B., Gasson, S., Goodill, S., Jermyn, R., Bradt., J. (2017). A model of dance/movement therapy for reliance-building in people living with chronic pain. European Journal of Integrative Medicine, 9, 27-40.

Stewart, N. J., McMullen, L. M., & Rubin, L. D. (1994). Movement therapy with depressed inpatients: A randomized multiple single case design. Archives of Psychiatric Nursing, 7(1), 22-29.

Walker, M. S., Kaimal, G., Koffman, R., & DeGraba, T. J. (2016). Art therapy for PTSD and TBI: A senior active during military service member’s therapeutic journey. The Arts in Psychotherapy, 49, 10-18.


https://DOI.org/10.1007/s10465-019-09312-8

http://www.makingdancematter.com.au/

https://DOI.org/10.1371/journal.pone.0048230


THERAPEUTIC WRITING CONCEPTUAL FRAMEWORK (UNDER DEVELOPMENT)

THERAPEUTIC WRITING IN CREATIVE FORCES Therapeutic writing (or “expressive writing”) is the use of writing activities to achieve therapeutic outcomes, either as a stand-alone intervention or in combination with other therapies. Poetry therapy is the only credentialed therapeutic writing discipline. As a practice, it requires minimal resources and can be easily implemented. It is adaptable to telehealth and can be self-directed outside clinical settings. When used as a stand-alone intervention, the effects are typically smaller than resource-intensive psychotherapies. However, given the potential for larger reach, the total population effect could be greater than those resource-intensive therapies (Sayer et al., 2015).

Although Creative Forces does not currently have a comprehensive writing program or a team member with a Poetry Therapy credential or other writing certification, a number of Creative Forces therapists received training in writing techniques in their therapy training programs or through workshops. Several incorporate elements of writing into their clinical directives. Each method of writing is unique to the therapeutic goals of the patient and associated art, music, or movement interventions.

Creative Forces therapists either use existing protocols or developed their own for the writing activities they use. The table below reflects therapeutic writing interventions used within Creative Forces as of August 2020.



THERAPEUTIC WRITING PRACTICES AND RESEARCHPRACTICES

The practices and impacts of therapeutic writing have been championed for several decades (for example: Adams, 2013; Anderson & MacCurdy, 2000; Mazza, 2017; Pennebaker, 1997; Smyth, 1998). Therapeutic writing interventions may occur in single or multiple sessions and take many forms: journal entries, poetry, lyrics, stories, letters, etc. Similar to the creative arts therapies, therapeutic writing occurs within and as part of the therapeutic alliance. It is used as individual and group interventions and results in individual or collective writing products. Creative arts therapists may use writing as a response to a creative activity or incorporate music, art, or movement as an alternative form of response to writing (for example: Beaumont, 2018; Garland et al., 2007; Jones et al., 2019; Landless et al., 2019; Pizarro, 2004).



Additional examples of therapeutic writing and poetry therapy activities appear in the following table.

With military-connected populations, patients may write about traumatic events and transition processes. The Veterans Health Administration Office of Patient Centered Care and Cultural Transformation has produced a tool for clinicians and patients (see Resources section below). Writing may not only be beneficial for the veteran or service member: it has the potential to contribute to societal reflection and discourse on conflict, war, and military service (Usbeck, 2018). Self-expressive writing as a therapeutic intervention has also been used with veterans and their families (Nevinski, 2013).

RESEARCH

Research on the clinical use of therapeutic writing is difficult to synthesize. Part of the problem is terminology. Therapeutic writing has been linked to poetry therapy, journal therapy, autobiography, narrative therapy, bibliotherapy, reading therapy, literatherapy, scriptotherapy, writing therapy, and biblionarrative therapy. In addition, studies have used a variety of writing forms and implementation protocols across a wide range of population and treatment variables (e.g., clinical setting, demographics, diagnoses). In spite of these challenges, literature reviews typically report benefits to therapeutic writing (Frattaroli, 2006; Pavlacic et al., 2019; Sloan et al., 2015; Smyth, 1998). Further, rigor in research is moving the field forward through RCTs (Regev & Cohen-Yatziv, 2018). However, these findings are not universal (Meads & Nouwen, 2005; Mogk et al., 2006). Researchers note that outcomes vary with specific writing instructions, parameters of the experimental design, the type of trauma or illness studied, setting, and participating population, among other variables. Further, disparate outcome measures and comparison groups have been used. Mugerwa (2012) cautioned, “Because writing may be thought of as a psychotherapeutic activity, it is reasonable to compare it with other therapies aimed at the same end.”



PROCESS FOR MOVING FORWARDAmong Creative Forces therapists who integrate writing into their interventions, there is commitment to expanding the tools, practices, and research for therapeutic writing. Creative Forces presents opportunities to: 1) develop and implement evidence-based writing techniques for use with creative arts therapies, 2) evaluate use of writing activities within Creative Forces treatment milieus, and 3) research outcomes related to use of writing activities within creative arts therapies for military-connected populations.

RECOMMENDATIONS FOR NEXT STEPS

Stakeholders and subject matter experts believe Creative Forces should consider adapting existing, evidence-based clinical writing models to the military populations served in Creative Forces clinical settings. In addition, telehealth and on-line self-directed options should be explored. Research can be advanced using case studies, group comparisons, and Computerized Content Analysis (LIWC). While there is interest in eventually developing a conceptual model for and conducting research in therapeutic writing, additional development is needed beforehand. Recommended steps, with approximate timeframes over 12 months, are:

1. Gather all writing protocols and ad hoc writing practices currently in use within Creative Forces. (Month 1)

2. Select a subset of writing activities currently in use within Creative Forces to advance for further development. (Month 1)

3. Develop a Creative Forces playbook for specific therapeutic writing practices to expand and align writing practices across sites and create an implementation plan. (Months 2 – 3)

4. Develop an evaluation plan. (Month 4)

5. Evaluate the use of therapeutic writing in Creative Forces (see below). (Months 5 – 10)

6. Develop a conceptual model and research plan for therapeutic writing. (Months 11 – 12)

Individual studies have shown benefits for military-connected individuals. A study compared veterans using online expressive writing about transitioning to civilian life compared to controls using factual writing or no writing. The findings showed greater reductions in physical complaints, anger, and distress compared with veterans who wrote factually and greater reductions in PTSD symptoms, distress, anger, physical complaints, and reintegration difficulty compared with veterans who did not write at all. Veterans who wrote expressively also experienced greater improvement in social support compared to those who did not write (Sayer et al., 2015).

A study of the effectiveness of a brief expressive writing intervention on the marital adjustment of military couples reuniting post-deployment found that when soldiers, but not spouses, wrote expressively, the couple’s marital satisfaction increased over the following month (Baddeley & Pennebaker, 2011). Observational and qualitative results from an 18-month poetry therapy group conducted in a veteran’s center suggested the group built camaraderie and bonding (Deshpande, 2010). Potential benefits were also found in a case study with veterans using therapeutic writing (Nevinski, 2013).

Theories about the mechanisms of change are based in emotional catharsis, cognitive processing of traumatic memories, the process of finding meaning in the traumatic experience, exposure, and emotional inhibition and confrontation (Baikie & Wilhelm, 2005; Mugerwa & Holden, 2012).



Therapeutic Writing Playbook (#3). Creative Forces therapists recommended developing a playbook for therapeutic writing to serve as a resource for practice and to align writing practices across therapists. The playbook should provide descriptions and tools/protocols for each writing activity and a cross-referencing table with key variables allowing therapists to match the activity to the patient and practice. Standardized protocols enable Creative Forces to evaluate and conduct research on therapeutic writing.

Recommended contents of the playbook include:

I. Full description of activity, including prompts, amount of time required, and whether the activity is single or multiple session

II. Resources for the activity

III. A table that can assist therapists in choosing the writing intervention in alignment with therapeutic goals. Variables may include:

• Therapeutic goals • Pre/post outcome measures • Diagnoses most responsive to intervention • Length of time needed for activity • Prerequisites (Is the intervention appropriate for novice patients? For patients experienced with therapeutic writing?) • Number of sessions required • Suitability for individual, group, couple, and family therapy • Suitability for treatment settings (inpatient/outpatient, telehealth/in-person, integrated/stand- alone treatment)

Therapeutic Writing Evaluation (#4, #5). During Phase 1, Creative Forces developed a logic model and evaluation questions to guide evaluation of therapeutic writing at Creative Forces sites (see the 2019 Creative Forces Conceptual Frameworks for Clinical Research, Phase 1 document, pages 87-91). Once the playbook is completed, Creative Forces will need to 1) update the logic model and evaluation questions, 2) develop an implementation plan for the selected therapeutic writing activities, 3) develop and execute an evaluation plan, and 4) adjust protocols and implementation plans based on evaluation results. At the outset of this work, it will be important to confirm the intended outcomes of therapeutic writing for Creative Forces.

Conceptual Framework and Research Plan (#6). The therapeutic writing protocols, playbook, and evaluation, together with the Phase 1 concept maps, provide the foundation for a conceptual framework and research plan. Additional resources may be needed, depending on target outcomes and whether therapeutic writing occurs adjunctive to the creative arts therapies and/or a standalone intervention.

The following figure graphically displays the developmental steps for Creative Forces therapeutic writing from current practices to development of a research plan.


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REFERENCES

Adams, K. (2013). Expressive writing: Foundations of practice. New York: R & L Education.

Anderson, C. N. & MacCurdy, M. N. (Eds.) (2000). Writing & healing: Toward an informed practice. Urbana, IL: National Council of Teachers of English.

Baddeley, J., & Pennebaker, J. (2011. A postdeployment expressive writing intervention for military couples: a randomized controlled trial. Journal of Traumatic Stress, 24(5). 581-5. DOI: 10.1002/jts.20679

Baikie, K., & Wilhelm, K. (2005). Emotional and physical benefits of expressive writing. Advances in Psychiatric Treatment, 11. 338-346. DOI: 10.1192/apt.11.5.338.

Beaumont, S. L. (2018) The art of words: Expressive writing as reflective practice in art therapy. Canadian Art Therapy Association Journal, 31(2), 55-60. DOI: 10.1080/08322473.2018.1527610

Creative Forces (2019). Creative Forces conceptual frameworks for clinical research: Phase 1. Unpublished report. Washington, DC: Author.

Deshpande, A. (2010). Recon mission: Familiarizing veterans with their changed emotional landscape through Poetry. Journal of Poetry Therapy, 23(4), 239-251. DOI: 10.1080/08893675.2010.528222

Garland, S., Carlson, L., Cook, S., et al. (2007). A non-randomized comparison of mindfulness-based stress reduction and healing arts programs for facilitating post-traumatic growth and spirituality in cancer outpatients. Supportive Care in Cancer, 15, 949–961. DOI: https://DOI.org/10.1007/s00520-007-0280-5

Jones, J., Drass, J., & Kaimal, G. (2019). Art therapy for military service members with post-traumatic stress and traumatic brain injury: Three case reports highlighting trajectories of treatment and recovery. The Arts in Psychotherapy, 63. 10.1016/j.aip.2019.04.004.

Landless, B. M., Walker, M., & Kaimal, G. (2019). Using human and computer-based text analysis of clinical notes to understand military service members’ experiences with therapeutic writing. The Arts in Psychotherapy, 62, 77-84. DOI: 10.1016/j.aip.2018.10.002.

Mazza, N. (2017). Poetry therapy: Theory and practice, 2nd Ed. New York: Routledge.

Meads, C., & Nouwen, A. (2005). Does emotional disclosure have any effects? A systematic review of the literature with meta-analyses. International Journal of Technology Assessment in Health Care, 21(2), 153-64. PMID: 15921054.

Mogk, C., Otte, S., Reinhold-Hurley, B., & Kröner-Herwig, B. (2006). Health effects of expressive writing on stressful or traumatic experiences - a meta-analysis. Psycho-social medicine, 3, Doc06.

Mugerwa, S., & Holden, J. D. (2012). Writing therapy: A new tool for general practice? The British Journal of General Practice, 62(605), 661–663. https://DOI.org/10.3399/bjgp12X659457

Nevinski, R. L. (2013). Self-expressive writing as a therapeutic intervention for veterans and family members. Journal of Poetry Therapy, 26(4), 201-221. DOI: 10.1080/08893675.2013.849044

Pavlacic, J. M., Buchanan, E. M., Maxwell, N. P., Hopke, T. G., & Schulenberg, S. E. (2019). A meta-analysis of expressive writing on posttraumatic stress, posttraumatic growth, and quality of life. Review of General Psychology, 23(2), 230–250. https://DOI.org/10.1177/1089268019831645


http://10.1002/jts.20679

https://doi.org/10.1192/apt.11.5.338

https://doi.org/10.1080/08322473.2018.1527610

https://doi.org/10.1080/08893675.2010.528222

https://DOI.org/10.1007/s00520-007-0280-5



https://DOI.org/10.3399/bjgp12X659457

https://doi.org/10.1080/08893675.2013.849044

https://DOI.org/10.1177/1089268019831645


Pennebaker, J. W. (1997). Writing about emotional experiences as a therapeutic process. Psychological Science, 8(3), 162–166.

Pizarro J. (2004). The efficacy of art and writing therapy: Increasing positive mental health outcomes and participant retention after exposure to traumatic experience. Art Therapy, 21, 5–12. DOI: 10.1080/07421656.2004.10129327

Regev, D., & Cohen-Yatziv, L. (2018). Effectiveness of art therapy with adult clients in 2018-What Progress Has Been Made? Frontiers in psychology, 9, 1531. https://DOI.org/10.3389/fpsyg.2018.01531

Sayer, N. A., Noorbaloochi, S., Frazier, P. A., Pennebaker, J. W., et al. (2015). Randomized controlled trial of online expressive writing to address readjustment difficulties among U.S. Afghanistan and Iraq war veterans. Journal of Traumatic Stress, 28(5):3, 81-90. DOI: 10.1002/jts.22047. PMID: 26467326.

Sloan, D. M., Sawyer, A. T., Lowmaster, S. E., Wernick, J., & Marx, B. P. (2015). Efficacy of narrative writing as an intervention for PTSD: Does the evidence support its use? Journal of Contemporary Psychotherapy, 45(4), 215–225. https://DOI.org/10.1007/s10879-014-9292-x

Smyth, J. M. (1998). Written emotional expression: Effect sizes, outcome types, and moderating variables. Journal of Consulting and Clinical Psychology, 66, 174–184.

Usbeck, F. (2018) Writing yourself home: US veterans, creative writing, and social activism. European Journal of American Studies, 13-2. DOI : https://DOI.org/10.4000/ejas.12567.


https://doi.org/10.1080/07421656.2004.10129327

https://doi.org/10.1002/jts.22047

https://DOI.org/10.1007/s10879-014-9292-x

https://DOI.org/10.4000/ejas.1256


SELECT RESOURCES

Center for Journal Therapy (https://journaltherapy.com/) Kay Adams and the Center for Journal Therapy provides resources and training in journal writing and instruction. The Therapeutic Writing Institute (TWI) is the professional training division of the Center for Journal Therapy, Inc.

Dulwich Centre (https://dulwichcentre.com.au/) Dulwich Center supports practitioners in different parts of the world through narrative approaches to therapy and community work through training, publishing, and co-hosting international conferences.

International Federation for Biblio/Poetry Therapy (https://ifbpt.org/) The International Federation for Biblio/Poetry Therapy “sets standards of excellence in the training and credentialing of practitioners in the field of biblio/poetry therapy and authorizes qualified individuals to practice as mentor/supervisors.”

Journaling.com (https://www.journaling.com) Journaling.com provides journaling activities and resources in collaboration with researchers and practitioners.

National Association for Poetry Therapy, Inc. (https://poetrytherapy.org) The National Association for Poetry Therapy, Inc. is an international and interdisciplinary nonprofit organization promoting growth and healing through written language, symbol, and story. Members represent a wide range of professional disciplines and writers of all styles. The site provides information about credentialing, academic programs, conferences, and journals.

Pongo (https://www.pongoteenwriting.org) Pongo is a nonprofit organization that uses personal poetry writing to heal youth who have experienced trauma and other difficult experiences. The website includes writing activities and teaching resources.

Veterans Writing Project and O-Dark-Thirty (https://veteranswriting.org; https://o-dark-thirty.org) The Veterans Writing Project provide no-cost creative writing seminars and songwriting workshops for veterans, service members, and their adult family members and publishes a quarterly literary review of writing, O-Dark-Thirty.

VHA Office of Patient Centered Care and Cultural Transformation: Therapeutic Journaling Clinical Tool (patient https://www.va.gov/WHOLEHEALTHLIBRARY/tools/therapeutic-journaling.asp); clinician http://projects.hsl.wisc.edu/SERVICE/modules/12/M12_CT_Therapeutic_Journaling.pdf) The Therapeutic Journaling Clinical Tool, with different versions for patients and clinicians, explains the use of journaling and provides a protocol and research.


https://journaltherapy.com/

https://journaltherapy.com/

https://dulwichcentre.com.au/

https://ifbpt.org/

https://www.journaling.com

https://poetrytherapy.org

https://www.pongoteenwriting.org

https://veteranswriting.org

https://o-dark-thirty.org

https://www.va.gov/WHOLEHEALTHLIBRARY/tools/therapeutic-journaling.asp

http://projects.hsl.wisc.edu/SERVICE/modules/12/M12_CT_Therapeutic_Journaling.pdf

http://projects.hsl.wisc.edu/SERVICE/modules/12/M12_CT_Therapeutic_Journaling.pdf


APPENDIX A – TEAM AND WORKING GROUP AFFILIATIONSPHASE 2 TEAM AND WORKING GROUP AFFILIATIONS

Phase 2 engaged four teams/working groups: Creative Forces National Leadership Team, Creative Forces Core Planning Team, Creative Forces Technical Working Group, and the Phase 2 Technical Review Group. Members and affiliations for each are provided below.

Acronyms AFTA – Americans for the Arts DHA – Defense Health Agency DoD – Department of Defense DVBIC – Defense and Veterans Brain Injury Center HJF – Henry M. Jackson Foundation for the Advancement of Military Medicine NCCIH – National Center for Complementary and Integrative Health NEA – National Endowment for the Arts NICoE – National Intrepid Center of Excellence NIH – National Institutes of Health VA – Veterans Affairs VHA – Veterans Health Administration WRNMMC – Walter Reed National Military Medical Center







APPENDIX B – ORIGINAL RESEARCH QUESTIONSDevelopment of the conceptual frameworks began with multiple research questions in each area, all of which were deemed relevant and important by stakeholders. For art therapy and music therapy, proposed research questions included underlying hypotheses related to existing research in the field and were aimed at RCT(s). For dance/movement therapy and therapeutic writing, initial research questions were exploratory and aimed at developing research protocols and lines of study. The table below documents the original research questions considered but not selected for development at this time. The many discussions with Creative Forces and stakeholders throughout this project revealed there is also considerable interest in research that spans two or more creative art therapies. A sample of those topics is also included at the end of the table. See Phase 1 documentation for additional research questions, as well as program evaluation questions and models.







50

APPENDIX C – PROTOCOLS AND MEASURES

Creative Forces standardized protocols to document: Patient variables • Demographics (age, gender) • Diagnosis (PTSD, TBI, comorbid conditions) and disease state • Trauma exposures (lifetime) • Combat exposure • Medical utilization • Service status (active duty, transition within active duty, transition to veteran, veteran) • Military history (branch, component, rank, time since deployment) • Time since injury • Employment status • Occupation • Housing status • Marital/family status (includes caregivers) • Medications (for neuro/bio studies) • Art/music/dance/writing exposure • Art/music/dance/writing identity

Therapist variables • Years of experience

Implementation variables • Individual or co-treatment (creative arts therapies) • Therapeutic discipline • Therapeutic activity • Individual, family, couple, or group therapy • Number of sessions • Length of sessions • Art products • Telehealth (including hybrid)

Treatment context variables • Setting • Individual or co-treatment (integrative medicine)

Appendix C provides protocols and measures in the following sections:

• Creative Forces Standardized Protocols and Measures • Art Therapy Protocols and Measures • Music Therapy Protocols and Measures • Dance/Movement Therapy Protocols and Measures • Therapeutic Writing Protocols and Measures • General Outcome Measures • Outcome Measures used by the Department of Defense and Veterans Affairs

CREATIVE FORCES STANDARDIZED PROTOCOLS AND MEASURES


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k M

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g Pr

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alke

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. S.,

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al.

Obs

erva

tiona

l st

udy

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ssoc

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etw

een

visu

al im

ager

y an

d m

easu

res o

f dep

ress

ion,

anx

iety

and

pos

t-tra

umati

c st

ress

am

ong

activ

e-du

ty m

ilita

ry se

rvic

e m

embe

rs

with

trau

mati

c br

ain

inju

ry a

t the

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ter R

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ilita

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al C

ente

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e021

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ps:/

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jope

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2144

8

Neu

rolo

gica

l/Bi

olog

ical

Mar

kers

EEG

, fN

IRS,

fMRI

, Mob

ile

B

rain

/Bod

y Im

agin

g (M

OBI

)

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gica

l and

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siolo

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l acti

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rt T

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sing

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nolo

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ntier

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an n

euro

scie

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expr

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nd E

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on R

egul

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in A

rt

Ther

apy

Scal

e (S

ERAT

S)9-

item

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e as

sess

es se

lf-ex

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sion

and

emoti

onal

re

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eld

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easu

ring

the

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on o

f ar

t the

rapy

in m

ultid

iscip

linar

y tr

eatm

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f per

sona

lity

diso

rder

s: T

he c

onst

ructi

on o

f the

Sel

f-exp

ress

ion

and

Emoti

on R

egul

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rt T

hera

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rson

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Men

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t, ite

ms,

psy

chom

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s

MU

SIC

THER

APY

PRO

TOCO

LS A

ND

MEA

SURE

SM

easu

re (a

lpha

betic

al b

y na

me)

Dom

ain

Whe

re to

Fin

d In

form

ation

/Exa

mpl

esM

usic

Moo

d-Re

gula

tion

Scal

e (M

MRS

) O

ther

ver

sion:

Brie

f Mus

ic in

M

ood

Regu

latio

n Sc

ale

(B-M

MR)

40-it

em (o

r 21-

item

) sel

f-re

port

surv

ey to

ass

ess s

even

di

ffere

nt m

usic

rela

ted

moo

d-re

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velo

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t and

initi

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usic

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t, va

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allio

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velo

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d Re

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https://DOI.org/10.1002/pmh.1379

https://www.researchgate.net/publication/32117374_Development_and_initial_validation_of_the_Music_Mood-Regulation_Scale

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53CO

NCE

PTU

AL

FRA

MEW

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S PH

ASE

2 E

XECU

TIVE

SU

MM

ARY

REP

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| D

ECEM

BER

30, 2

020

CREA

TIVE

FO

RCES

®: N

EA M

ILIT

ARY

HEA

LIN

G A

RTS

NET

WO

RK |

CRE

ATIV

EFO

RCES

NRC

.ART

S.G

OV

DAN

CE/M

OVE

MEN

T TH

ERAP

Y PR

OTO

COLS

AN

D M

EASU

RES

Mea

sure

(alp

habe

tical

by

nam

e)Do

mai

nW

here

to F

ind

Info

rmati

on/E

xam

ples

DMT

Out

com

es F

ram

ewor

k w

ith

Mov

emen

t Ass

essm

ent a

nd

Repo

rting

App

(MAR

A)

An a

sses

smen

t with

six

dom

ains

: Ph

ysic

al, C

ultu

ral,

Emoti

onal

, Co

gniti

ve, S

ocia

l, an

d In

tegr

ation

.

https

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ww

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ingd

ance

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er.c

om.a

u/w

p-co

nten

t/up

load

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utco

mes

-fram

ewor

k-fo

r-DM

T-V.

-70-

Engl

ish-2

5.4.

2020

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x (D

unph

y, Le

bre,

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ulla

ne, 2

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ps:/

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gdan

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atter

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abou

t/m

ara-

feat

ures

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nctio

nal A

naly

sis o

f Mov

emen

t an

d Pe

rcep

tion

(FAM

P)20

-item

inst

rum

ent a

ddre

ssin

g 8

cate

gorie

s: b

ody

sche

me,

sp

atial

orie

ntati

on a

nd ju

dgm

ent,

perc

eptu

al m

otor

abi

lities

, rhy

thm

ic

disc

rimin

ation

, mot

or p

lann

ing,

tim

ed

mot

or a

ctivi

ty, d

elay

ed m

otor

acti

vity

, an

d fu

nctio

nal r

ange

of m

otion

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Berr

ol, C

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oi, W

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ance

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emen

t The

rapy

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er A

dults

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ve S

usta

ined

Neu

rolo

gica

l Ins

ult:

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mon

stra

tion

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ect.

Amer

ican

Jour

nal o

f Da

nce

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apy

19, 1

35–1

60 (1

997)

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0223

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2961

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tego

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enbe

rg M

ovem

ent P

rofil

e (K

MP)

Asse

sses

mov

emen

t patt

erns

in

dica

tive

of in

trap

sych

ic a

nd re

latio

nal

func

tioni

ng w

ithin

the

dyna

mic

s of

natu

rally

occ

urrin

g m

ovem

ent.

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ww

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tenb

ergm

ovem

entp

rofil

e.or

g/ap

plic

ation

sres

earc

h.ht

mde

scrip

tion,

rese

arch

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iagn

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t Stu

dy.

Amer

ican

Jour

nal o

f Dan

ce T

hera

py 3

1: 1

22.

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OI.o

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fere

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Mul

tidim

ensi

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essm

ent o

f In

terc

eptiv

e Aw

aren

ess (

MAI

A)

and

vers

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2 (M

AIA-

2)

32- i

tem

inst

rum

ent (

vers

ion

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s 37

item

s) m

easu

re m

ultip

le d

imen

sions

of

inte

roce

ption

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ales

)

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https://www.makingdancematter.com.au/wp-content/uploads/Outcomes-framework-for-DMT-V.-70-English-25.4.2020.docx

https://www.makingdancematter.com.au/about/mara-features

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PTU

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FRA

MEW

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S PH

ASE

2 E

XECU

TIVE

SU

MM

ARY

REP

ORT

| D

ECEM

BER

30, 2

020

CREA

TIVE

FO

RCES

®: N

EA M

ILIT

ARY

HEA

LIN

G A

RTS

NET

WO

RK |

CRE

ATIV

EFO

RCES

NRC

.ART

S.G

OV

THER

APEU

TIC

WRI

TIN

G P

ROTO

COLS

AN

D M

EASU

RES

Mea

sure

(alp

habe

tical

by

nam

e)Do

mai

nW

here

to F

ind

Info

rmati

on/E

xam

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Poeti

c In

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ediu

m fo

r qua

litati

ve re

sear

chM

cCul

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13).

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c in

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mul

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iplin

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oetr

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114.

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I: 10

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0/08

8936

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7945

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Ling

uisti

c In

quiry

and

Wor

d Co

unt

Ling

uisti

c In

quiry

and

Wor

d Co

unt

(LIW

C) is

a w

ord

coun

ting

softw

are

prog

ram

that

refe

renc

es a

dic

tiona

ry

of g

ram

mati

cal,

psyc

holo

gica

l, an

d co

nten

t wor

d ca

tego

ries.

LIW

C ha

s be

en u

sed

to e

ffici

ently

cla

ssify

text

s al

ong

psyc

holo

gica

l dim

ensio

ns a

nd to

pr

edic

t beh

avio

ral o

utco

mes

, mak

ing

it a

text

ana

lysis

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used

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e so

cial

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Chun

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WC)

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onou

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ke”

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othe

r use

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acts

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P. M

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arth

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C. B

oont

hum

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ecke

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ds.),

App

lied

Nat

ural

Lan

guag

e Pr

oces

sing:

Iden

tifica

tion,

Inve

stiga

tion

and

Reso

lutio

n (p

p. 2

06-2

29).

IGI G

loba

l. DO

I: 1

0.40

18/9

78-1

-609

60-7

41-8

.ch0

12

Penn

ebak

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. W.,

Boot

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. J.,

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ranc

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. E. (

2007

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ngui

stic

Inqu

iry a

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WC

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pute

r soft

war

e]. A

ustin

, TX:

LIW

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t.

Writt

en re

port

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repo

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n w

hich

pati

ents

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scrib

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eir s

ubje

ctive

exp

erie

nces

w

ith th

erap

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writi

ng a

fter

com

pleti

ng p

artic

ipati

on in

trea

tmen

t pr

ogra

m. T

he re

port

s are

resp

onse

s to

open

-end

ed q

uesti

ons:

• C

ould

you

talk

abo

ut h

ow y

ou

exp

erie

nced

writi

ng a

bout

wha

t

c

once

rns y

ou?

•

Cou

ld y

ou d

escr

ibe

how

it a

ffect

ed

you

then

and

affe

cts y

ou n

ow to

w

rite

abou

t you

r exp

erie

nces

,

t

houg

hts a

nd fe

elin

gs?

•

How

wou

ld y

ou d

escr

ibe

the

h

elp

that

writi

ng h

as g

iven

you

in

rai

sing

awar

enes

s of y

ours

elf

(th

roug

h th

ough

ts a

nd fe

elin

gs)

and

you

r situ

ation

?

Furn

es, B

. and

Dys

vik,

E. (

2012

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rape

utic

Writi

ng a

nd C

hron

ic P

ain:

Exp

erie

nces

of

Ther

apeu

tic W

riting

in a

Cog

nitiv

e Be

havi

oura

l Pro

gram

me

for P

eopl

e w

ith C

hron

ic P

ain.

Jo

urna

l of C

linic

al N

ursin

g, 2

1, 3

372-

3381

. htt

ps:/

/DO

I.org

/10.

1111

/j.13

65-2

702.

2012

.042

68.x


https://doi.org/10.1080/08893675.2013.794536

https://www.researchgate.net/publication/231608775_Linguistic_Inquiry_and_Word_Count_LIWC_pronounced_Luke_and_other_useful_facts

https://DOI.org/10.1111/j.1365-2702.2012.04268.x

55CO

NCE

PTU

AL

FRA

MEW

ORK

S PH

ASE

2 E

XECU

TIVE

SU

MM

ARY

REP

ORT

| D

ECEM

BER

30, 2

020

CREA

TIVE

FO

RCES

®: N

EA M

ILIT

ARY

HEA

LIN

G A

RTS

NET

WO

RK |

CRE

ATIV

EFO

RCES

NRC

.ART

S.G

OV

GEN

ERAL

OU

TCO

ME

MEA

SURE

SA

varie

ty o

f wid

ely-

used

mea

sure

s of b

ehav

iora

l, ph

ysic

al, a

nd b

iolo

gica

l mea

sure

s are

rele

vant

to th

e th

erap

eutic

out

com

es o

f Cre

ative

For

ces p

atien

ts a

nd

appl

icab

le a

cros

s the

rapi

es. T

his t

able

iden

tifies

mea

sure

s, th

eir d

omai

ns, a

nd li

nks t

o ba

sic in

form

ation

. Add

ition

al p

sych

omet

ric in

form

ation

for v

ario

us p

opul

ation

s an

d se

tting

s can

be

easil

y fo

und

for m

ost m

easu

res t

hrou

gh b

asic

sear

ches

(ent

er “

NAM

E O

F M

EASU

RE p

sych

omet

rics”

).M

easu

re (a

lpha

betic

al b

y na

me)

Dom

ain

Whe

re to

Fin

d In

form

ation

/Exa

mpl

esBe

ck D

epre

ssio

n In

vent

ory-

II (B

DI=I

I)21

-item

mea

sure

of d

epre

ssio

nhtt

ps:/

/ww

w.a

pa.o

rg/p

i/abo

ut/p

ublic

ation

s/ca

regi

vers

/pra

ctice

-setti

ngs/

asse

ssm

ent/

tool

s/be

ck-d

epre

ssio

n ps

ycho

met

rics,

refe

renc

es

https

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ww

.pea

rson

asse

ssm

ents

.com

/pro

fess

iona

l-ass

essm

ents

/pro

duct

s/pr

ogra

ms/

beck

-fam

ily-o

f-ass

essm

ents

.htm

lBe

ck fa

mily

of i

nstr

umen

ts, p

sych

omet

rics

Bond

Lad

er-V

AS16

- ite

m sc

ales

use

d to

rate

subj

ectiv

e fe

elin

gshtt

ps:/

/epr

ovid

e.m

api-t

rust

.org

/inst

rum

ents

/bon

d-la

der-v

as-m

ood-

ratin

g-sc

ale#

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_de

scrip

tion

Brie

f Pai

n In

vent

ory

– Sh

ort F

orm

O

ther

ver

sion:

Lo

ng F

orm

: Brie

f Pai

n In

vent

ory

(32

item

s)

9-ite

m q

uesti

onna

ire u

sed

to e

valu

ate

the

seve

rity

of a

pati

ent’s

pai

n an

d th

e im

pact

of t

his p

oint

on

the

patie

nt’s

daily

func

tioni

ng

https

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ww

.phy

sio-p

edia

.com

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f_Pa

in_I

nven

tory

_-_S

hort

_For

m

desc

riptio

n, re

fere

nces

DVBI

C Br

ief T

raum

atic

Brai

n In

jury

Scr

een

3-ite

m sc

reen

ing

tool

to id

entif

y se

rvic

e m

embe

rs w

ho m

ay n

eed

furt

her e

valu

ation

for m

ild tr

aum

atic

brai

n in

jury

https

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ww

.mire

cc.v

a.go

v/do

cs/v

isn6/

5_TB

I_3_

Que

stion

_Scr

eeni

ng_T

ool.p

dfin

stru

ction

s, sc

reen

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tool

Schw

ab, K

. A.,

Bake

r, G.

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uss-

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den,

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e Br

ief T

raum

atic

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jury

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IS):

Inve

stiga

ting

the

valid

ity o

f a se

lf-re

port

inst

rum

ent f

or d

etec

ting

trau

mati

c br

ain

inju

ry (T

BI) i

n tr

oops

retu

rnin

g fr

om

depl

oym

ent i

n Af

ghan

istan

and

Iraq

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rolo

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p. 2

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https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/beck-depression

https://www.apa.org/pi/about/publications/caregivers/practice-settings/assessment/tools/beck-depression

https://www.pearsonassessments.com/professional-assessments/products/programs/beck-family-of-assessments.html

https://www.pearsonassessments.com/professional-assessments/products/programs/beck-family-of-assessments.html

https://eprovide.mapi-trust.org/instruments/bond-lader-vas-mood-rating-scale#basic_description

https://eprovide.mapi-trust.org/instruments/bond-lader-vas-mood-rating-scale#basic_description

https://www.physio-pedia.com/Brief_Pain_Inventory_-_Short_Form

https://www.mirecc.va.gov/docs/visn6/5_TBI_3_Question_Screening_Tool.pd

56CO

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MEW

ORK

S PH

ASE

2 E

XECU

TIVE

SU

MM

ARY

REP

ORT

| D

ECEM

BER

30, 2

020

CREA

TIVE

FO

RCES

®: N

EA M

ILIT

ARY

HEA

LIN

G A

RTS

NET

WO

RK |

CRE

ATIV

EFO

RCES

NRC

.ART

S.G

OV

Depl

oym

ent R

isk

and

Resi

lienc

e In

vent

ory-

2 (D

RRI-2

) Com

bat

Expe

rienc

e Sc

ale

(CES

)

Mul

tiple

scal

es m

easu

re e

xpos

ure

to

com

bat-r

elat

ed c

ircum

stan

ces

https

://w

ww

.pts

d.va

.gov

/pro

fess

iona

l/ass

essm

ent/

depl

oym

ent/

com

bat-e

xper

ienc

es-

scal

e.as

p#ob

tain

m

anua

l, in

stru

men

t

Vogt

DS,

Pro

ctor

SP,

Kin

g DW

, Kin

g LA

, Vas

terli

ng JJ

. (20

08).

Valid

ation

of s

cale

s fro

m

the

Depl

oym

ent R

isk a

nd R

esili

ence

Inve

ntor

y in

a sa

mpl

e of

Ope

ratio

n Ira

qi F

reed

om

vete

rans

. Ass

essm

ent,1

5(4)

: 391

-403

.htt

ps:/

/DO

I.org

/10.

1177

/107

3191

1083

1603

0va

lidati

on st

udy

COPE

Inve

ntor

y O

ther

ver

sion:

Sh

ort F

orm

: Car

ver B

rief C

OPE

In

vent

ory

(28

item

s)

60-it

em m

ulti-

dim

ensio

nal i

nven

tory

to

ass

ess c

opin

g st

rate

gies

, with

five

sc

ales

: 1) a

ctive

cop

ing;

2) p

lann

ing;

3)

supp

ress

ion

of c

ompe

ting

activ

ities

; 4)

rest

rain

t cop

ing;

and

5) s

eeki

ng o

f in

stru

men

tal s

ocia

l sup

port

.

http:

//em

otion

alpr

oces

sings

cale

.org

/ de

scrip

tion,

inst

rum

ent,

psyc

hom

etric

s, re

fere

nces

Emoti

on R

egul

ation

Str

ateg

ies f

or

Artis

tic C

reati

ve A

ctivi

ties S

cale

(E

RS-A

CA)

18 it

em m

easu

ring

inst

rum

ent

mea

sure

s em

otion

al re

gula

tion

stra

tegi

es (a

void

ance

stra

tegi

es,

appr

oach

stra

tegi

es, s

elf-d

evel

opm

ent

used

whe

n en

gagi

ng in

arti

stic

crea

tive

activ

ities

Fanc

ourt

, D.,

Garn

ett, C

., Sp

iro, N

., W

est,

R., &

Mül

lens

iefe

n, D

. (20

19).

How

do

artis

tic c

reati

ve a

ctivi

ties r

egul

ate

our e

moti

ons?

Val

idati

on o

f the

Em

otion

Reg

ulati

on

Stra

tegi

es fo

r Arti

stic

Crea

tive

Activ

ities

Sca

le (E

RS-A

CA).

PloS

one

, 14(

2), e

0211

362.

htt

ps:/

/DO

I.org

/10.

1371

/jour

nal.p

one.

0211

362

Emoti

onal

Pro

cess

ing

Scal

e (E

PS)

25-it

em q

uesti

onna

ire to

iden

tify

emoti

onal

pro

cess

ing

styl

es a

nd

pote

ntial

defi

cits

with

fie

subs

cale

s: 1

) su

ppre

ssio

n; 2

) sig

ns o

f unp

roce

ssed

em

otion

; 3) c

ontr

olla

bilit

y of

em

otion

; 4)

avo

idan

ce; a

nd 5

) em

otion

al

expe

rienc

e

http:

//em

otion

alpr

oces

sings

cale

.org

/ de

scrip

tion,

dev

elop

men

t, ps

ycho

met

rics,

refe

renc

es


https://www.ptsd.va.gov/professional/assessment/deployment/combat-experiences-scale.asp#obtain

https://www.ptsd.va.gov/professional/assessment/deployment/combat-experiences-scale.asp#obtain

https://DOI.org/10.1177/1073191108316030

http://emotionalprocessingscale.org/

https://DOI.org/10.1371/journal.pone.0211362

http://emotionalprocessingscale.org/

57CO

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MEW

ORK

S PH

ASE

2 E

XECU

TIVE

SU

MM

ARY

REP

ORT

| D

ECEM

BER

30, 2

020

CREA

TIVE

FO

RCES

®: N

EA M

ILIT

ARY

HEA

LIN

G A

RTS

NET

WO

RK |

CRE

ATIV

EFO

RCES

NRC

.ART

S.G

OV

Gen

eral

Sel

f Effi

cacy

Sca

le

Oth

er v

ersio

n:

S

hort

For

m: G

ener

al S

elf-

E

ffica

cy S

cale

(GSE

-6)

10-it

em q

uesti

onna

ire m

easu

res

“a g

ener

al se

nse

of p

erce

ived

self-

effica

cy w

ith th

e ai

m in

min

d to

pre

dict

co

ping

with

dai

ly h

assle

s as w

ell a

s ad

apta

tion

after

exp

erie

ncin

g al

l kin

ds

of st

ress

ful l

ife e

vent

s”

http:

//us

erpa

ge.fu

-ber

lin.d

e/he

alth

/eng

scal

.htm

desc

riptio

n, in

stru

men

t, ps

ycho

met

rics,

refe

renc

es htt

ps:/

/ww

w.n

cbi.n

lm.n

ih.g

ov/p

mc/

artic

les/

PMC3

5782

00/

psyc

hom

etric

stud

y

Gen

eral

ized

Anxi

ety

Diso

rder

-7

(GAD

-7)

7-ite

m q

uesti

onna

ire m

easu

res a

nxie

ty

sym

ptom

seve

rity;

can

also

be

used

as

a sc

reen

ing

mea

sure

of p

anic

, soc

ial

anxi

ety,

and

PTSD

https

://w

ww

.phq

scre

ener

s.co

m/s

elec

t-scr

eene

rin

stru

men

t, in

stru

ction

man

ual,

refe

renc

es

https

://w

ww

.phq

scre

ener

s.co

m/im

ages

/site

s/g/

files

/g10

0162

61/f

/201

412/

inst

ructi

ons.

pdf

deve

lopm

ent,

psyc

hom

etric

s

https

://w

ww

.mire

cc.v

a.go

v/ci

h-vi

sn2/

Docu

men

ts/C

linic

al/G

AD_w

ith_I

nfo_

Shee

t.pdf

VA

info

shee

t: re

fere

nces

, int

erpr

etati

onHo

spita

l Anx

iety

and

Dep

ress

ion

Scal

e14

-item

que

stion

naire

that

det

erm

ines

le

vels

of a

nxie

ty a

nd d

epre

ssio

n a

pers

on is

exp

erie

ncin

g

https

://w

ww

.svri.

org/

sites

/def

ault/

files

/atta

chm

ents

/201

6-01

-13/

HADS

.pdf

in

stru

men

t

Leve

ls o

f Em

otion

al A

war

enes

s Sc

ale

(LEA

S)20

scen

ario

s pos

ed to

mea

sure

re

spon

dent

s’ a

war

enes

s of a

nd a

bilit

y to

des

crib

e em

otion

al e

xper

ienc

es

http:

//el

east

est.n

et/

desc

riptio

n, p

sych

omet

rics,

refe

renc

es, i

nstr

umen

t acc

ess

Inte

rnati

onal

Cla

ssifi

catio

n of

Fu

nctio

ning

, Dis

abili

ty, a

nd

Heal

th (I

CF)

A fr

amew

ork

for d

escr

ibin

g fu

nctio

n an

d di

sabi

lity.

Incl

udes

four

qua

lified

sc

ales

to re

cord

impa

irmen

t, ac

tivity

lim

itatio

ns, a

nd e

nviro

nmen

tal b

arrie

rs

and

faci

litat

ors

https

://w

ww

.phy

sio-p

edia

.com

/Int

erna

tiona

l_Cl

assifi

catio

n_of

_Fun

ction

ing,

_Disa

bilit

y_an

d_He

alth

_(IC

F)

desc

riptio

n, m

easu

rem

ent t

ools,

refe

renc

es, i

nstr

umen

t


http://userpage.fu-berlin.de/health/engscal.htm

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3578200/ psychometric study

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3578200/ psychometric study

https://www.phqscreeners.com/select-screener

https://www.phqscreeners.com/images/sites/g/files /g10016261/f/201412/instructions.pdf

https://www.phqscreeners.com/images/sites/g/files /g10016261/f/201412/instructions.pdf

https://www.mirecc.va.gov/cih-visn2/Documents/Clinical/GAD_with_Info_Sheet.pdf

https://www.svri.org/sites/default/files/attachments/2016-01-13/HADS.pdf

http://eleastest.net/

https://www.physio-pedia.com/International_Classification_of_Functioning,_Disability_and_Health_(ICF)

https://www.physio-pedia.com/International_Classification_of_Functioning,_Disability_and_Health_(ICF)

58CO

NCE

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FRA

MEW

ORK

S PH

ASE

2 E

XECU

TIVE

SU

MM

ARY

REP

ORT

| D

ECEM

BER

30, 2

020

CREA

TIVE

FO

RCES

®: N

EA M

ILIT

ARY

HEA

LIN

G A

RTS

NET

WO

RK |

CRE

ATIV

EFO

RCES

NRC

.ART

S.G

OV

Med

ical

Out

com

es S

tudy

Sho

rt-

Form

Hea

lth S

urve

y (S

F-36

) O

ther

ver

sion:

Vet

eran

s SF-

36

36-it

em q

uesti

onna

ire; g

ener

al

indi

cato

r of h

ealth

-rel

ated

qua

lity

of li

fe in

8 a

reas

: 1) l

imita

tions

in

phys

ical

acti

vitie

s bec

ause

of h

ealth

pr

oble

ms;

2) l

imita

tions

in so

cial

ac

tiviti

es b

ecau

se o

f phy

sical

or

emoti

onal

pro

blem

s; 3

) lim

itatio

ns in

us

ual r

ole

activ

ities

bec

ause

of p

hysic

al

heal

th p

robl

ems;

4) b

odily

pai

n; 5

) ge

nera

l men

tal h

ealth

; 6) l

imita

tions

in

usu

al ro

le a

ctivi

ties b

ecau

se o

f em

otion

al p

robl

ems;

7) v

italit

y (e

nerg

y an

d fa

tigue

); an

d 8)

gen

eral

hea

lth

perc

eptio

ns

War

e, J.

E., &

She

rbou

rne,

C.D

. (19

92) T

he M

OS

36-it

em sh

ort-f

orm

hea

lth su

rvey

(SF-

36):

conc

eptu

al fr

amew

ork

and

item

sele

ction

. Med

ical

Car

e, 3

0: 4

73-4

83

https

://w

ww

.cdc

.gov

/me-

cfs/

pdfs

/wic

hita

-dat

a-ac

cess

/sf3

6-do

c.pd

f SF

-36

inst

rum

ent

https

://w

ww

.ncb

i.nlm

.nih

.gov

/pm

c/ar

ticle

s/PM

C419

4890

/SF

-36

com

pare

d to

Vet

eran

s SF-

36

Mili

tary

to C

ivili

an Q

uesti

onna

ire

(M2C

-Q)

16-it

em in

stru

men

t ass

essin

g pa

st-

mon

th re

inte

grati

on d

ifficu

ltyhtt

ps:/

/ww

w.c

cdor

.rese

arch

.va.

gov/

CCDO

RRES

EARC

H/Re

sour

ces/

M2C

Q.p

df

inst

rum

ent

Saye

r, N

. et a

l. (2

011)

. Mili

tary

to C

ivili

an Q

uesti

onna

ire: A

mea

sure

of p

ostd

eplo

ymen

t co

mm

unity

rein

tegr

ation

diffi

culty

am

ong

vete

rans

usin

g De

part

men

t of V

eter

ans

Affai

rs m

edic

al c

are.

Jour

nal o

f Tra

umati

c St

ress

, 24:

660

-70.

htt

ps:/

/DO

I.org

/10.

1002

/jts.

2070

6 ps

ycho

met

ric st

udy

Pain

Cat

astr

ophi

zing

Sca

leTh

is sc

ale

mea

sure

s cat

astr

ophi

c th

inki

ng re

late

d to

pai

n an

d is

used

in

both

clin

ical

and

rese

arch

pra

ctice

s

https

://w

ww

.phy

sio-p

edia

.com

/Pai

n_Ca

tast

roph

izing

_Sca

lede

scrip

tion,

inst

rum

ent,

psyc

hom

etric

s, re

fere

nces

Patie

nt H

ealth

Que

stion

naire

(P

HQ-9

)9-

item

que

stion

naire

mea

sure

s em

otion

al a

nd so

mati

c de

pres

sion

indi

cato

rs

https

://w

ww

.phq

scre

ener

s.co

m/s

elec

t-scr

eene

rin

stru

men

t, in

stru

ction

man

ual,

refe

renc

es


https://www.cdc.gov/me-cfs/pdfs/wichita-data-access/sf36-doc.pdf

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4194890/

https://www.ccdor.research.va.gov/CCDORRESEARCH/Resources/M2CQ.pdf

https://DOI.org/10.1002/jts.20706

https://www.physio-pedia.com/Pain_Catastrophizing_Scale

https://www.phqscreeners.com/select-screener

59CO

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FRA

MEW

ORK

S PH

ASE

2 E

XECU

TIVE

SU

MM

ARY

REP

ORT

| D

ECEM

BER

30, 2

020

CREA

TIVE

FO

RCES

®: N

EA M

ILIT

ARY

HEA

LIN

G A

RTS

NET

WO

RK |

CRE

ATIV

EFO

RCES

NRC

.ART

S.G

OV

Patie

nt-R

epor

ted

Out

com

es

Mea

sure

men

t Inf

orm

ation

Sy

stem

(PRO

MIS

)

PRO

MIS

[NIH

Tool

box]

incl

udes

ov

er 3

00 m

easu

res o

f phy

sical

, m

enta

l, an

d so

cial

hea

lth fo

r use

w

ith th

e ge

nera

l pop

ulati

on a

nd

with

indi

vidu

als l

ivin

g w

ith c

hron

ic

cond

ition

s

https

://w

ww

.hea

lthm

easu

res.

net/

expl

ore-

mea

sure

men

t-sys

tem

s/pr

omis/

intr

o-to

-pr

omis

mea

sure

s, d

evel

opm

ent,

psyc

hom

etric

s, re

sear

ch

Perc

eive

d St

ress

Sca

le (P

SS)

10-it

em sc

ale

mea

sure

s the

leve

l of

per

ceiv

ed st

ress

deg

ree

in li

fe’s

situa

tions

http:

//w

ww

.min

dgar

den.

com

/doc

umen

ts/P

erce

ived

Stre

ssSc

ale.

pdf

inst

rum

ent

Inte

rper

sona

l Rea

ctivi

ty In

dex

(IRI)

Four

7-it

em su

bsca

les m

easu

ring

inte

rper

sona

l rea

ctivi

ty:

pers

pecti

ve ta

king

, em

path

ic

conc

ern,

per

sona

l dist

ress

, fan

tasy

https

://w

ww

.eck

erd.

edu/

psyc

holo

gy/ir

i/ in

stru

men

t, ps

ycho

met

rics,

refe

renc

es

Posi

tive

and

Neg

ative

Affe

ct

Sche

dule

(PAN

AS)

20-it

ems a

cros

s tw

o m

ood

scal

es,

one

mea

surin

g po

sitive

affe

ct, t

he

othe

r mea

surin

g ne

gativ

e aff

ect

https

://w

ww

.bra

ndei

s.ed

u/ro

ybal

/doc

s/PA

NAS

-GEN

_web

site_

PDF.p

df

info

shee

t: in

stru

men

t, ps

ycho

met

rics

Post

-Tra

umati

c St

ress

Dis

orde

r/PT

SD C

heck

list –

5 (P

CL-5

) O

ther

ver

sion:

PCL

-M (m

ilita

ry)

20-it

em se

lf-re

port

che

cklis

t of

PTSD

sym

ptom

s bas

ed o

n th

e DS

M-5

crit

eria

https

://is

tss.

org/

clin

ical

-res

ourc

es/a

sses

sing-

trau

ma

desc

riptio

n, in

terp

reta

tion,

psy

chom

etric

s, re

fere

nces

htt

ps:/

/ww

w.p

tsd.

va.g

ov/p

rofe

ssio

nal/a

sses

smen

t/ad

ult-s

r/pt

sd-c

heck

list.a

spin

stru

men

t, de

scrip

tion,

inte

rpre

tatio

n, re

fere

nces

Blev

ins,

C. A

., W

eath

ers,

F. W

., Da

vis,

M. T

., W

itte,

T. K

., &

Dom

ino,

J. L

. (20

15).

The

Postt

raum

atic

Stre

ss D

isord

er C

heck

list f

or D

SM-5

(PCL

-5):

Deve

lopm

ent a

nd in

itial

ps

ycho

met

ric e

valu

ation

. Jou

rnal

of T

raum

atic

Stre

ss, 2

8(6)

, 489

-498

. DO

I:

10.1

002/

jts.2

2059

de

velo

pmen

t, ps

ycho

met

rics

https

://d

eplo

ymen

tpsy

ch.o

rg/s

yste

m/fi

les/

mem

ber_

reso

urce

/4-P

CL-M

.pdf

PC

L-M

inst

rum

ent


https://www.healthmeasures.net/explore-measurement-systems/promis/intro-to-promis

https://www.healthmeasures.net/explore-measurement-systems/promis/intro-to-promis

http://www.mindgarden.com/documents/PerceivedStressScale.pdf

https://www.eckerd.edu/psychology/iri/

https://www.brandeis.edu/roybal/docs/PANAS-GEN_website_PDF.pdf

https://istss.org/clinical-resources/assessing-trauma

https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp

http://onlinelibrary.wiley.com/doi/10.1002/jts.22059/abstract



https://deploymentpsych.org/system/files/member_resource/4-PCL-M.pdf

60CO

NCE

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ORK

S PH

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TIVE

SU

MM

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Qua

lity

of L

ife S

cale

(QO

LS)

17-it

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f qua

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of li

fe

indi

cato

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ater

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nd p

hysic

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wel

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ips w

ith o

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pe

ople

; soc

ial,

com

mun

ity, a

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ac

tiviti

es; p

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nal d

evel

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nd

fulfi

llmen

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crea

tion

https

://li

nk.s

prin

ger.c

om/a

rticl

e/10

.118

6/14

77-7

525-

1-60

au

thor

’s de

scrip

tion,

dev

elop

men

t, ps

ycho

met

rics,

inst

rum

ent a

cces

s

Self-

regu

latio

n Q

uesti

onna

ire (S

RQ)

63-it

em m

easu

re o

f sel

f-reg

ulati

on:

the

abili

ty to

dev

elop

, im

plem

ent,

and

flexi

bly

mai

ntai

n pl

anne

d be

havi

or

https

://c

asaa

.unm

.edu

/inst

/Sel

fReg

ulati

on%

20Q

uesti

onna

ire%

20(S

RQ).p

df

info

shee

t: de

velo

pmen

t, ps

ycho

met

rics,

refe

renc

es, i

nstr

umen

t Br

own,

J. M

., M

iller

, W. R

., &

Law

endo

wsk

i, L.

A. (

1999

). Th

e se

lf-re

gula

tion

ques

tionn

aire

. In

L. V

ande

Cree

k &

T. L

. Jac

kson

(Eds

.), In

nova

tions

in c

linic

al p

racti

ce: A

sour

ce b

ook,

Vol

. 17

(p.

281–

292)

. Pro

fess

iona

l Res

ourc

e Pr

ess/

Prof

essio

nal R

esou

rce

Exch

ange

.Sy

mpt

om C

heck

list R

evis

ed

(SCL

-90-

R)90

-item

mea

sure

of 9

prim

ary

sym

ptom

dim

ensi

ons:

som

atiza

tion,

ob

sess

ive-

com

pulsi

ve, i

nter

pers

onal

se

nsiti

vity

, dep

ress

ion,

anx

iety

, ho

stilit

y, p

hobi

c an

xiet

y, pa

rano

id

idea

tion,

psy

choti

cism

https

://w

ww

.pea

rson

asse

ssm

ents

.com

/ in

stru

men

t

WHO

Qua

lity

of L

ife-B

REF

(WHO

QO

L-BR

EF)

26-

item

s mea

sure

of f

our q

ualit

y of

life

indi

cato

rs: p

hysic

al h

ealth

, ps

ycho

logi

cal h

ealth

, soc

ial

rela

tions

hips

, and

env

ironm

ent

https

://w

ww

.who

.int/

subs

tanc

e_ab

use/

rese

arch

_too

ls/w

hoqo

lbre

f/en

/ de

scrip

tion,

inst

rum

ent a

cces

s htt

ps:/

/dep

ts.w

ashi

ngto

n.ed

u/se

aqol

/WHO

QO

L-BR

EF

desc

riptio

n, d

evel

opm

ent,

psyc

hom

etric

s, re

fere

nces

Wor

king

Alli

ance

Inve

ntor

y (W

AI)

Oth

er v

ersio

n: W

orki

ng A

llian

ce In

vent

ory-

Sh

ort R

evise

d (W

AI-S

R)

36-it

em m

easu

re o

f the

ther

apeu

tic

allia

nce

https

://w

ai.p

rofh

orva

th.c

om/

auth

or’s

page

: dev

elop

men

t, in

stru

men

t Ho

rvat

h, A

. O.,

& G

reen

berg

, L. S

. (19

89).

Deve

lopm

ent a

nd v

alid

ation

of t

he W

orki

ng

Allia

nce

Inve

ntor

y. Jo

urna

l of C

ouns

elin

g Ps

ycho

logy

, 36(

2), 2

23–2

33.

https

://D

OI.o

rg/1

0.10

37/0

022-

0167

.36.

2.22

3

https

://p

ubm

ed.n

cbi.n

lm.n

ih.g

ov/2

0013

760/

WAI

-SR

com

para

tive

stud

y ps

ycho

met

rics


https://link.springer.com/article/10.1186/1477-7525-1-60

https://casaa.unm.edu/inst/SelfRegulation%20Questionnaire%20(SRQ).pdf

https://www.pearsonassessments.com/

https://www.who.int/substance_abuse/research_tools/whoqolbref/en/

https://depts.washington.edu/seaqol/WHOQOL-BREF

https://wai.profhorvath.com/

https://DOI.org/10.1037/0022-0167.36.2.223

https://pubmed.ncbi.nlm.nih.gov/20013760/

Qua

lity

of L

ife S

cale

(QO

LS)

17-it

em m

easu

re o

f qua

lity

of li

fe

indi

cato

rs: m

ater

ial a

nd p

hysic

al

wel

l-bei

ng; r

elati

onsh

ips w

ith o

ther

pe

ople

; soc

ial,

com

mun

ity, a

nd c

ivic

ac

tiviti

es; p

erso

nal d

evel

opm

ent a

nd

fulfi

llmen

t; re

crea

tion

https

://li

nk.s

prin

ger.c

om/a

rticl

e/10

.118

6/14

77-7

525-

1-60

au

thor

’s de

scrip

tion,

dev

elop

men

t, ps

ycho

met

rics,

inst

rum

ent a

cces

s

Self-

regu

latio

n Q

uesti

onna

ire (S

RQ)

63-it

em m

easu

re o

f sel

f-reg

ulati

on:

the

abili

ty to

dev

elop

, im

plem

ent,

and

flexi

bly

mai

ntai

n pl

anne

d be

havi

or

https

://c

asaa

.unm

.edu

/inst

/Sel

fReg

ulati

on%

20Q

uesti

onna

ire%

20(S

RQ).p

df

info

shee

t: de

velo

pmen

t, ps

ycho

met

rics,

refe

renc

es, i

nstr

umen

t Br

own,

J. M

., M

iller

, W. R

., &

Law

endo

wsk

i, L.

A. (

1999

). Th

e se

lf-re

gula

tion

ques

tionn

aire

. In

L. V

ande

Cree

k &

T. L

. Jac

kson

(Eds

.), In

nova

tions

in c

linic

al p

racti

ce: A

sour

ce b

ook,

Vol

. 17

(p.

281–

292)

. Pro

fess

iona

l Res

ourc

e Pr

ess/

Prof

essio

nal R

esou

rce

Exch

ange

.Sy

mpt

om C

heck

list R

evis

ed

(SCL

-90-

R)90

-item

mea

sure

of 9

prim

ary

sym

ptom

dim

ensi

ons:

som

atiza

tion,

ob

sess

ive-

com

pulsi

ve, i

nter

pers

onal

se

nsiti

vity

, dep

ress

ion,

anx

iety

, ho

stilit

y, p

hobi

c an

xiet

y, pa

rano

id

idea

tion,

psy

choti

cism

https

://w

ww

.pea

rson

asse

ssm

ents

.com

/ in

stru

men

t

WHO

Qua

lity

of L

ife-B

REF

(WHO

QO

L-BR

EF)

26-

item

s mea

sure

of f

our q

ualit

y of

life

indi

cato

rs: p

hysic

al h

ealth

, ps

ycho

logi

cal h

ealth

, soc

ial

rela

tions

hips

, and

env

ironm

ent

https

://w

ww

.who

.int/

subs

tanc

e_ab

use/

rese

arch

_too

ls/w

hoqo

lbre

f/en

/ de

scrip

tion,

inst

rum

ent a

cces

s htt

ps:/

/dep

ts.w

ashi

ngto

n.ed

u/se

aqol

/WHO

QO

L-BR

EF

desc

riptio

n, d

evel

opm

ent,

psyc

hom

etric

s, re

fere

nces

Wor

king

Alli

ance

Inve

ntor

y (W

AI)

Oth

er v

ersio

n: W

orki

ng A

llian

ce In

vent

ory-

Sh

ort R

evise

d (W

AI-S

R)

36-it

em m

easu

re o

f the

ther

apeu

tic

allia

nce

https

://w

ai.p

rofh

orva

th.c

om/

auth

or’s

page

: dev

elop

men

t, in

stru

men

t Ho

rvat

h, A

. O.,

& G

reen

berg

, L. S

. (19

89).

Deve

lopm

ent a

nd v

alid

ation

of t

he W

orki

ng

Allia

nce

Inve

ntor

y. Jo

urna

l of C

ouns

elin

g Ps

ycho

logy

, 36(

2), 2

23–2

33.

https

://D

OI.o

rg/1

0.10

37/0

022-

0167

.36.

2.22

3

https

://p

ubm

ed.n

cbi.n

lm.n

ih.g

ov/2

0013

760/

WAI

-SR

com

para

tive

stud

y ps

ycho

met

rics

61CO

NCE

PTU

AL

FRA

MEW

ORK

S PH

ASE

2 E

XECU

TIVE

SU

MM

ARY

REP

ORT

| D

ECEM

BER

30, 2

020

CREA

TIVE

FO

RCES

®: N

EA M

ILIT

ARY

HEA

LIN

G A

RTS

NET

WO

RK |

CRE

ATIV

EFO

RCES

NRC

.ART

S.G

OV

Neu

rolo

gica

l/Bi

olog

ical

Mar

kers

Biom

arke

rs: h

eart

rate

va

riabi

lity,

cor

tisol

, ne

uroi

nflam

mat

ory,

etc.

N

euro

imag

ing/

brai

n ac

tivity

: EE

G, fN

IRS,

fMRI

, Mob

ile

Brai

n/Bo

dy Im

agin

g (M

OBI

)

Galv

anic

skin

resp

onse

King

, J. L

., &

Kai

mal

, G. (

2019

). Ap

proa

ches

to R

esea

rch

in A

rt T

hera

py U

sing

Imag

ing

Tech

nolo

gies

. Fro

ntier

s in

hum

an n

euro

scie

nce,

13,

159

. htt

ps:/

/DO

I.org

/10.

3389

/fnh

um.2

019.

0015

9 M

icho

poul

os, V

., N

orrh

olm

, S. D

., &

Jova

novi

c, T.

(201

5). D

iagn

ostic

Bio

mar

kers

fo

r Pos

ttra

umati

c St

ress

Diso

rder

: Pro

misi

ng H

orizo

ns fr

om T

rans

latio

nal

Neu

rosc

ienc

e Re

sear

ch. B

iolo

gica

l psy

chia

try,

78(

5), 3

44–3

53.

https

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OI.o

rg/1

0.10

16/j.

biop

sych

.201

5.01

.005

Sc

hmid

t, U.

, Kal

twas

ser,

S. F.

, & W

otja

k, C

. T. (

2013

). Bi

omar

kers

in

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raum

atic

stre

ss d

isord

er: o

verv

iew

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icati

ons f

or fu

ture

rese

arch

. Di

seas

e m

arke

rs, 3

5(1)

, 43–

54. h

ttps

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OI.o

rg/1

0.11

55/2

013/

8358

76

Nor

rhol

m, S

. D.,

Jova

novi

c, T.

, Ger

ardi

, M.,

Brea

zeal

e, K

. G.,

Pric

e, M

., Da

vis,

M

., Du

ncan

, E.,

Ress

ler,

K. J.

, Bra

dley

, B.,

Rizz

o, A

., Tu

erk,

P. W

., &

Rot

hbau

m,

B. O

. (20

16).

Base

line

psyc

hoph

ysio

logi

cal a

nd c

ortis

ol re

activ

ity a

s a p

redi

ctor

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PTS

D tr

eatm

ent o

utco

me

in v

irtua

l rea

lity

expo

sure

ther

apy.

Beh

avio

ur

rese

arch

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82,

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37. h

ttps

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OI.o

rg/1

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brat

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https://link.springer.com/article/10.1186/1477-7525-1-60

https://casaa.unm.edu/inst/SelfRegulation%20Questionnaire%20(SRQ).pdf

https://www.pearsonassessments.com/

https://www.who.int/substance_abuse/research_tools/whoqolbref/en/

https://depts.washington.edu/seaqol/WHOQOL-BREF

https://wai.profhorvath.com/

https://DOI.org/10.1037/0022-0167.36.2.223

https://pubmed.ncbi.nlm.nih.gov/20013760/



https://DOI.org/10.1016/j.biopsych.2015.01.005

https://DOI.org/10.1155/2013/835876

https://DOI.org/10.1016/j.brat.2016.05.002

62CO

NCE

PTU

AL

FRA

MEW

ORK

S PH

ASE

2 E

XECU

TIVE

SU

MM

ARY

REP

ORT

| D

ECEM

BER

30, 2

020

CREA

TIVE

FO

RCES

®: N

EA M

ILIT

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HEA

LIN

G A

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NET

WO

RK |

CRE

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NRC

.ART

S.G

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