anales de psicología, 2018, vol. 34, nº 2 (may), 368-377                © Copyright 2018: Editum. Servicio de Publicaciones de la Universidad de Murcia. Murcia (Spain) 
                  
                 http://dx.doi.org/10.6018/analesps.34.2.286191                              ISSN print edition: 0212-9728. ISSN web edition (http://revistas.um.es/analesps): 1695-2294 
                  
                     Positive visual reframing: A randomised controlled trial using drawn visual imagery to 
                       defuse the intensity of negative experiences and regulate emotions in healthy adults 
                                                                                                 
                                                                                     1                                           2* 
                                                             Julia Clare Ruppert *, and Francisco José Eiroa-Orosa
                                                                                                 
                                                                                 1 Collective Arts (England, UK). 
                                                2 Department of Clinical Psychology and Psychobiology, Faculty of Psychology, University of Barcelona (Spain). 
                  
                 Título: Reformulación Visual Positiva: Un ensayo controlado aleatorizado      Abstract:  This  research  explores  the  outcome  of  positive  visual  reframing 
                 utilizando imágenes visuales para disminuir la intensidad de experiencias          (PVR), a single session intervention where drawn images of negative expe-
                 negativas y regular emociones en adultos sanos.                                    riences and open memories were redrawn and visually reframed to form 
                 Resumen: Se exploran los resultados de la reformulación visual positiva            new positive narratives. The study hypothesised that PVR would lead to 
                 (RVP), una intervención en la que imágenes de memorias abiertas y expe-            improvements to positive and negative affect, self-efficacy and the per-
                 riencias negativas son reformuladas visualmente para formar nuevas narra-          ceived intensity and perceived resolution of a selected negative experience. 
                 tivas positivas. El estudio plantea la hipótesis de que la RVP conduciría a        Healthy adults (n = 62) were randomly assigned to the PVR or control 
                 mejoras en el afecto positivo y negativo, autoeficacia e intensidad y resolu-      condition. For the experimental group, statistical significance was identi-
                 ción percibidas de experiencias negativas. 62 adultos sanos fueron aleatori-       fied for positive affect and the perceived intensity and resolution of the 
                 zados a condiciones de RVP o control. Se hallaron mejoras para el grupo            negative experience immediately following the PVR activity. Self-efficacy 
                 experimental en niveles de afecto positivo, así como intensidad percibida y        was marginally significant. The findings highlight the potential of positive 
                 resolución de la experiencia negativa inmediatamente después de comple-            visual reframing to enhance emotional regulation when negative emotions 
                 tar la actividad de RVP. Estos hallazgos ponen de relieve el potencial de la       are triggered. At two weeks‟ post-intervention, improvements were identi-
                 RVP para mejorar la regulación emocional cuando se activan emociones               fied in both conditions. This suggests that over time, the visual and senso-
                 negativas.                                                                         ry exposure created by drawing a negative memory may also lead to posi-
                 A las dos semanas se identificaron mejoras en ambas condiciones. Esto su-          tive gains. The study emphasises the potential of PVR to regulate emo-
                 giere que, con el tiempo, la exposición viso-sensorial creada al extraer un        tions and defuse the intensity of negative or open memories by visually 
                 recuerdo negativo también puede conducir a mejoría.                                transforming a moment of peak perceptual intensity. Future studies ex-
                 El estudio hace hincapié en el potencial de la RVP para regular emociones          ploring the effectiveness of positive visual reframing to shift negative emo-
                 y difuminar la intensidad de un recuerdo abierto mediante la transforma-           tions in clinical and non-clinical populations are recommended. 
                 ción  visual  de  un  momento  de  máxima  intensidad  perceptual.  Se  reco-      Keywords:  Drawn  imagery,  reframing,  negative  experiences,  open 
                 miendan estudios que exploren la efectividad de la RVP para cambiar per-           memory, emotional regulation. 
                 cepciones negativas en poblaciones clínicas y no clínicas. 
                 Palabras clave: Imágenes dibujadas, reformulación, recuerdos negativos, 
                 regulación emocional. 
                  
                 Introduction                                                                     more complex and less coherent narratives than closed or 
                                                                                                  positive memories (Bohanek, Fivush, & Walker, 2005), the 
                 Negative experiences are something we all share and general-                     negative  uncertainty  of  open  memories  further  enhances 
                 ly arise as a consequence of emotionally charged social inter-                   negative emotions (Bar-Anan, Wilson, & Gilbert, 2009) and 
                 actions and events (John & Gross, 2004). When attempts to                        perpetuate questioning about „why‟ the experience happened 
                 understand and explain the meaning of a negative experience                      (Abele, 1985). Finally, because open memories are so acces-
                 are successful, we generally find closure and move on (Wil-                      sible they make substantial contributions to current feelings 
                 son,  &  Gilbert,  2008).  Otherwise,  the  experience  remains                  and decision-making (Beike, & Writh-Beaumont, 2005). As 
                                                                                                  humans are highly motivated to make sense of themselves 
                 „open‟ and is easily triggered by reminiscent experiences and                    and  their  experiences,  these  poorly  understood  negative 
                 emotional and visual cues (Lazarus, 1991). Described collo-                      memories are also perceived as a source of threat (Wilson & 
                 quially  as  „unfinished business‟ (Beike, & Writh-Beaumont,                     Gilbert, 2008). This means when triggered, open memories 
                 2005), open memories are problematic for a variety of rea-                       receive  priority  cognitive  attention  (Allport  &  Postman, 
                 sons. For one, open memories contain high levels of emo-                         1946; Malle & Knobe, 1997) and are automatically selected 
                 tional detail, emotional significance, and information, which                    for  processing  and  appraisal  at  the  expense  of  working 
                 when combined greatly increases the likelihood the memory                        memory performance (Klein & Boals, 2001; Curci Lanciano, 
                 will  be  maintained  (Conway  et  al.,  1994;  Peeters,  &  Cza-                Soleti, & Rimé, 2013).  
                 pinski,  1990).  Because negative memories are perceived as                           To respond to the demands of a difficult emotion, open 
                 self-relevant, they lead to intensified affective reactions upon                 memories activate a range of emotional-regulation strategies 
                 recall (Frijda, 1988) and challenge effective emotional analy-                   (Ochsner, & Gross, 2005).  Cognitive reappraisal, for exam-
                 sis (Metcalfe, & Mischel, 1999). As these memories contain                       ple, is an adaptive regulation process, whereby reframing an 
                                                                                                  event is used to diminish emotional impact and shift a nega-
                 * Correspondence address [Dirección para correspondencia]:                       tive trajectory of response (John, & Gross, 2004; Lazarus, & 
                 Julia Ruppert. Collective Arts, 6 Beech Way, Twickenham. TW2 5JT, Eng-           Alfert, 1964). Demonstrating the benefits of adaptive emo-
                 land (UK). E-mail: info@collective-arts.org                                      tional  regulation  strategies,  frequent  use  of  cognitive  reap-
                 Francisco José Eiroa-Orosa. Section of Personality, Evaluation and Psycho-
                 logical Treatment. Faculty of Psychology, University of Barcelona. Passeig       praisal is related to higher levels of positive and lower levels 
                 Vall d'Hebron, 171, 08035 Barcelona (Spain). E-mail: feiroa@ub.edu 
                                                                                            - 368 - 
                            Positive visual reframing: A randomised controlled trial using drawn visual imagery to defuse the intensity of negative experiences and regulate emotions in healthy adults                   369 
                 
                of negative affect and is positively related to mood repair.          quality  of  visual  interventions  to  bolster  the  cognitive  re-
                Habitual reappraisers also display high self-esteem, high op-         sources open memories drain. Finally, whereas meaningful 
                timism  and  fewer  depressive  tendencies  (John,  &  Gross,         and relevant visual cues can unconsciously activate negative 
                2004).  Like  cognitive  reappraisal,  positive  reframing  is  a     emotional  responses  (Öhman,  &  Mineka,  2001;  Folkman, 
                regulatory process of perceiving an experience or event pre-          Lazarus, Dunkel-Schetter, DeLongis, & Gruen, 1986), visual 
                viously regarded as negative within a new context or frame-           cues can trigger positive emotional responses as well (Latu, 
                work (Lambert et al., 2009). Although both cognitive reap-            Mast, Lammers, & Bombardi, 2013; Winkielman, Berridge, 
                praisal  and  positive  reframing  are  generally  understood  as     & Wilbarger, 2005). 
                outcomes of disposition and personality traits (Packenham,                In related evidence, the effectiveness of venting negative 
                & Cox, 2008; Lambert et al., 2009), researchers argue there is        experiences through drawing and writing is investigated in 
                promised to be had by interventions that can highlight func-          several  empirical  studies.  Chan  and Horneffer (2006) (n = 
                tional  emotional  regulation  strategies  (Ehring,  Tuschen-         63) for example, found that in the short term, drawing mean-
                Caffier, Schnulle, et al., 2010).                                     ingful  negative  experiences  elicited  stronger  negative  emo-
                    Whereas  positively  reinterpreting  negative  experiences        tions and was less effective in decreasing social dysfunction 
                provides an adaptive response that boosts coping resources            than  writing  about  them.  Contrasting  findings  by  Pizarro 
                (Lyubomirsky, Sheldon, & Schkade 2005), intervention stud-            (2004) (n = 45), which show in the short-term writing about 
                ies exploring positive reframing of open memories have had            trauma leads to higher levels of negative affect than drawing, 
                limited  empirical  attention.  Instead,  research  on  open          suggests research is inconclusive in this area. However, when 
                memory closure has largely focused on emotional venting               the valence of drawn imagery is shifted from negative to pos-
                through  expressive  writing  paradigms  (Pennebaker,  1993).         itive or benign, interesting shifts arise. Using positive-themed 
                An important exception to this somewhat negatively focused            drawn imagery to distract attention away from a negatively 
                strategy  is  Watkins,  Cruz,  Holben,  and  Kolts  (2008)  who       induced mood was found more effective than using drawn 
                demonstrate  the  positive  impact  of  grateful  written  pro-       imagery to vent negative feelings (Dalebroux, Goldstein, & 
                cessing on open memory closure.                                       Winner, 2008; Drake & Winner, 2012). This suggests posi-
                    Despite  a  research  emphasis  on  expressive  writing  for      tive-focused  drawing  may  have  benefits  over  negative-
                negative memory closure, it is important to note that memo-           focused drawing. However, neither venting nor positive dis-
                ries and experiences are generally summarised as visual imag-         traction was sufficiently effective, in the short term, to re-
                es (Conway, 2009; Holmes & Mathews, 2010) and that nega-              duce the negative arousal created by either an induced nega-
                tive and traumatic memories are encoded as sensory percep-            tive  mood  (De  Petrillio  &  Winner,  2005)  or  an  authentic 
                tions (van der Kolk & van der Hart, 1995). Subsequently, as           open memory (Dalebroux et al., 2008). Subsequently, defus-
                emotional systems both respond to and store information us-           ing negative arousal may require a more meaningful strategy 
                ing sensory-based formats, these systems may actually be less         than venting or positive distraction currently provide. Finally, 
                responsive to non-sensory based interventions that use higher         it is plausible that like expressive writing, negative arousal in 
                order level conscious processing such as language and writ-           the  short-term  is  a  necessary  requirement  of  longer-term 
                ing (Holmes & Mathews, 2010). Based on this conclusion, as            positive gain (Pennebaker, Kiecolt-Glaser, & Glaser, 1988). 
                negative open memories arise from and are recorded as visu-               Empirical studies exploring the use of drawn visual im-
                al experiences, they might actually require sensory-based, (ie.       agery to tackle negative experiences are limited but include 
                visual)  interventions  to  shift  deeply  rooted  emotional  re-     Mercer, Warson, and Zhao (2010), who used a single group 
                sponses and perceptions (Holmes, Arntz, & Smucker, 2007;              (N=10), test-re-test design and a range of intervention tech-
                Mathews, Ridgeway, & Holmes, 2013). Furthermore, as im-               niques to explore the impact of drawing benign versions of 
                age-based memories are considered fragile (Beike & Writh-             work-related stress. Findings showed that while positive af-
                Beaumont,  2005),  malleable  (Conway,  2009;  Holmes  &              fect  remained  unchanged,  anxiety  and  negative  affect  de-
                Mathews, 2010) and progressively reconstructed over time              creased. In contrast, Holmes and Mathews (2010) found that 
                (Torralba, & Oliva, 2003), drawn visuals might provide an             imagining benign, ambiguous outcomes to a negative experi-
                especially  synergic  approach  for  reframing  and  supporting       ence was ineffective at decreasing anxiety, yet was later rem-
                memory closure.                                                       edied  when  participants  imagined  unambiguously  positive 
                    Additional  support  for  the  viability  of  visual  interven-   resolutions. In a more recent study, healthcare professionals 
                tions  comes  from  studies  that  show  art-making  enhances         (n  =  35)  took  part  in  a  multi-levelled  intervention  using 
                positive mood (Bell, & Robbins, 2007; De Petrillo & Winner,           drawn imagery to de-stress (Huss & Sarid, 2014). Measures 
                2005). A positive mood, in turn, leads to increased levels of         indicated that between pre and post-intervention, subjective 
                mental flexibility and creative thinking (Forgas, 1998; Isen,         levels  of  discomfort  were  halved.  The  authors  argue  their 
                2002),  facilitates  cognitive  processing  (Taylor,  1991)  and      finding lends support to links between the transformation of 
                primes  for  cognitive  change  (Kuvaasa,  &  Selart,  2004).         imagery  and  the  transformation  of  subjective  states.  They 
                Therefore, given the tendency of open memories to deplete             further propose that image-transformation may lead to per-
                cognitive resources (Klein, & Boals, 2001; Curci et al., 2013),       ceived control and provide a trigger for a more relaxed emo-
                there  is  an  additional  argument  for  the  mood-enhancing         tional state. Although not specifically highlighted, like Mercer 
                                                                                                                       anales de psicología, 2018, vol. 34, nº 2 (may) 
               370                                                                       Julia Clare Ruppert, and Francisco José Eiroa-Orosa 
               et al. (2010) it is also plausible that as based on peak and end        Method 
               theory  (Fredrickson,  2000),  visually  defusing  a  moment  of             
               peak intensity led to new, less negative perceptions of the                 Design 
               experience‟s ending.   While  each  of  these  studies  has  their           
               limitations  (lack  of  control  group  or  randomisation,  small           Due to a shortfall of empirical studies on drawn image-
               sample sizes, or the challenge of extracting key impacts from           based interventions, the present research was designed as a 
               a  multi-intervention  focus),  for  the  current  research  they       randomised control trial to explore between-group and with-
               provide an important springboard for exploration. At pre-               in-group outcomes. The research was developed as a practi-
               sent, drawn image-based interventions are an underexplored              cal and deliverable intervention through which the impact of 
               area  of  quantitative  investigation,  particularly  within  non-      a  single  independent  variable  (positive  visual  reframing) 
               clinical populations and currently lack representation in in-           could be assessed as a stand-alone activity. The dependent 
               tervention-led fields such as positive psychology.                      variables, positive and negative affect and self-efficacy were 
                   To address this gap in the literature, the present study            selected as clear indicators of emotional regulation and posi-
               explored the impact of Positive Visual Reframing (PVR) – de-            tive psychological gain. Ordinal scales measuring the intensi-
               scribed  here  as  a  functional  emotional  regulation  strategy       ty and resolution of the negative experience were included to 
               that uses drawn visual imagery to positively reframe and de-            add a richer nuance to the findings of the intervention and 
               fuse negative emotional experiences. The study hypothesised             provide clear data on perceptual shifts. Demographics, in-
               that after producing an image of an open memory or nega-                cluding the age of the negative experience, were also includ-
               tive  emotional  experience,  healthy  adults  who  used  drawn         ed in the design.  
               visual imagery to positively reframe their memory‟s narrative                
               would have higher scores on positive affect, self-efficacy and              Participants 
               perceived resolution and lower scores on negative affect and                 
               the  perceived  intensity  of  the  experience  than  a  control            Participants  were  healthy  adult  volunteers  (n  =  62)  of 
               group who undertook a neutral drawing activity.                         working age living in the UK. A total of 46 females and 14 
                                                                                       males took part in the study. Two participants did not identi-
                                                                                       fy their gender. See Consort Flow Diagram (fig. 1) and base-
                                                                                       line characteristics (table 1).  
                
                                                                    Figure 1. Flow diagram of the study.                                  
               anales de psicología, 2018, vol. 34, nº 2 (may) 
                            Positive visual reframing: A randomised controlled trial using drawn visual imagery to defuse the intensity of negative experiences and regulate emotions in healthy adults                   371 
                 
                    Over  a  three-month  time-frame,  participants  were  re-       (very  strong  positive  effect).  Participants  circled  one  re-
                cruited  widely  by  the  principal  investigator  through  Face-    sponse to describe the current intensity of their selected ex-
                book, LinkedIn shares, and call-outs for volunteers in vari-         perience or challenge. Perceived resolution of the negative 
                ous organisational, educational and vocational newsletters. A        experience  was  assessed  using  a  7-point  Likert  scale.  Re-
                sample size of 60+ participants was selected as, accepting an        sponses ranged from -3 (very unresolved) to +3 (very re-
                alpha risk of 0.05 and a beta risk of 0.2 in a two-sided test.       solved) based on the question, „How resolved or unresolved would 
                At least 29 subjects were needed to recognise as statistically       you currently rate your feelings toward this memory or experience?’  
                significant a difference greater than or equal to 0.5 standard            
                deviations, assuming a correlation coefficient between the in-           Procedure 
                itial  and  final  measurement of r = 0.8. All participants re-           
                ceived an introductory letter and a consent form prior to tak-           Following  written  instructions,  study  participants  com-
                ing part in the study.                                               pleted Time-1 baseline, measures for positive and negative 
                    A copy of a sealed, coded and shuffled intervention pack,        affect using the PANAS Scale (Watson & Clark, 1988), men-
                randomly allocating subjects to the experimental or control          tal  well-being  using  the  Warwick-Edinburgh  Mental  Well-
                condition  was  distributed  to  participants.  Each  pack  con-     being  Scale  (WEMWB)  (Tennant  et  al.,  2007),  and  self-
                tained  written  instructions,  blank  white  A4  paper,  study      efficacy  using  the  General  Self-Efficacy  Scale  (GSE) 
                measures  for  Time-1-3  and  Time-4  (two  weeks‟  post-            (Schwarzer  &  Jerusalem,  1995).  Next,  using  a  pencil  and 
                intervention) and a postage-paid return envelope for return-         blank paper, participants in both conditions created an im-
                ing the data. The two-week follow-up time frame was select-          age,  doodle  or  diagram  of  a  negative  experience,  open 
                ed as representative of when short-term intervention benefits        memory or challenge. After completing and reflecting on the 
                generally  wane  (Semmer,  2008).  The  study  was  double-          negative image, all participants completed Time-2 measures 
                blinded as neither the researcher nor the participants knew          for positive and negative affect, self-efficacy, ordinal scales 
                which packs participants would receive. The design of the            on the perceived intensity and perceived resolution of their 
                control and experimental activities aimed to encourage both          image‟s memory and details of the experience‟s age. 
                groups to view their activity as the main focus of the study.            At Time-3, the experimental group used positive visual 
                To counter the influence of participant bias or priming, par-        reframing to positively change the narrative of their image by 
                ticipants worked independently and self-selected a time and          drawing over the initial pencil drawing with a black pen or 
                location to complete the study.                                      felt-tip and making note of and including any fresh insight in 
                                                                                     their new image. Once complete, participants used a rubber 
                    Measures                                                         to remove any unwanted traces of the original negative pen-
                                                                                     cil drawing, re-told themselves the new positive story in their 
                    The healthiness of subsects to take part in the study was        mind and took a few moments to connect with any positive 
                assessed using Warwick-Edinburgh Mental Well-being Scale             feelings  created.  The  same  measures  used  at  Time-2  were 
                (WEMWB) (Tennant et al., 2007). The WEMWB is a vali-                 then  completed  for  Time-3.  In  the  control  group,  partici-
                dated, ordinal scale measuring mental health across 14 de-           pants covered a fresh sheet of blank A4 paper with triangles 
                scriptive phrases. For the purposes of this study, well-being        as a neutral, image-based activity, and then went on to com-
                was defined as “the balance between an individual‟s resource         plete the Time-3 repeat-measures. 
                pool and the challenges faced” (p. 230, Dodge, Daley, Huy-               After  completing the intervention, all participants were 
                ton, & Saunders, 2012).                                              instructed to take a photograph of their final image and set it 
                    Positive  and  negative  affect  were  measured  using  the      as  their  mobile  phone‟s  background  for  a  period  of  two 
                Positive and Negative Affect Schedule (PANAS) (Watson, &             weeks. This activity was selected as positive replay maintains 
                Clark, 1988). Positive affect is described as a high state of        positive  emotions  (Lyubomirsky,  Sousa  &  Dickerhoof, 
                concentration,  energy,  and  pleasurable  engagement  while         2006).  Intervention packs were returned in postage-paid en-
                negative affect is described an aversive mood state of un-           velopes  minus  the  drawings.  These  were  purposefully  ex-
                pleasurable  engagement  and  distress  (Watson,  &  Clark,          cluded from the study to encourage participant willingness to 
                1998).                                                               create meaningful personal narratives and pre-empt any anx-
                    Self-efficacy  was  measured  using  the  Generalized  Self-     ieties that drawings might be interpreted, or artistry judged. 
                Efficacy Scale (GSE) (Schwarzer & Jerusalem, 1995). Self-            Two  weeks  after  completing  the  intervention,  written  in-
                efficacy is concerned with an individual‟s perceptual belief in      structions requested participants in all conditions to mentally 
                their own capabilities and influences how people think, feel         recall the original negative experience before completing and 
                and behave (Bandura, 1977).                                          returning via post a final set of Time-4 repeat-measures. Up-
                    Ordinal scales assessing perceived competence and per-           on  receipt  of  the  measures,  participants  received  a  study-
                ceived resolution were based on Beike and Writh-Beaumont             debriefing sheet including a copy of the PVR instructions for 
                (2005) and Watkins et al. (2008). Perceived intensity of the         control group volunteers. 
                negative experience was assessed using a 9-point Likert scale.            
                Responses ranged from 1 (very strong negative effect) to 9 
                                                                                                                      anales de psicología, 2018, vol. 34, nº 2 (may)