International Journal of Art Therapy Formerly Inscape Art therapy interventions for active duty military service members with post-traumatic stress disorder and traumatic brain injury Art therapy interventions for active duty military service members with post-traumatic stress disorder and traumatic brain injury Background: PTSD and TBI in the military

Abstract

This paper provides an overview of short and long-term art therapy treatment approaches, used in the USA, for military service members with post-traumatic stress disorder and traumatic brain injury. The described clinical approaches are based on the theoretical foundations and the art therapists' experiences in providing individualised care for the unique needs of the patient population. The art therapy models and directives are designed to be more therapist-led in the short-term model, moving on to an increasingly patient-led format in the long-term treatment model. The overall objectives of art therapy are: to support identity integration, externalisation, and authentic self-expression; to promote group cohesion; and to process grief, loss, and trauma. In addition, programme evaluation is used in both settings as a means to understand participants' experiences and the perceived value of art therapy. ARTICLE HISTORY

Full text

Full Terms & Conditions of access and use can be found at
http://www.tandfonline.com/action/journalInformation?journalCode=rart20
Download by: [173.75.253.233] Date: 01 November 2017, At: 02:47
International Journal of Art Therapy
Formerly Inscape
ISSN: 1745-4832 (Print) 1745-4840 (Online) Journal homepage: http://www.tandfonline.com/loi/rart20
Art therapy interventions for active duty military
service members with post-traumatic stress
disorder and traumatic brain injury
Jacqueline P. Jones, Melissa S. Walker, Jessica Masino Drass & Girija Kaimal
To cite this article: Jacqueline P. Jones, Melissa S. Walker, Jessica Masino Drass & Girija Kaimal
(2017): Art therapy interventions for active duty military service members with post-traumatic stress
disorder and traumatic brain injury, International Journal of Art Therapy
To link to this article: http://dx.doi.org/10.1080/17454832.2017.1388263
© 2017 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Group
Published online: 01 Nov 2017.
Submit your article to this journal
View related articles
View Crossmark data

Art therapy interventions for active duty military service members with
post-traumatic stress disorder and traumatic brain injury
Jacqueline P. Jones , Melissa S. Walker , Jessica Masino Drass and Girija Kaimal
ABSTRACT
This paper provides an overview of short and long-term art therapy treatment approaches, used
in the USA, for military service members with post-traumatic stress disorder and traumatic brain
injury. The described clinical approaches are based on the theoretical foundations and the art
therapists’experiences in providing individualised care for the unique needs of the patient
population. The art therapy models and directives are designed to be more therapist-led in
the short-term model, moving on to an increasingly patient-led format in the long-term
treatment model. The overall objectives of art therapy are: to support identity integration,
externalisation, and authentic self-expression; to promote group cohesion; and to process
grief, loss, and trauma. In addition, programme evaluation is used in both settings as a
means to understand participants’experiences and the perceived value of art therapy.
ARTICLE HISTORY
Received 16 May 2017
Accepted 30 September 2017
KEYWORDS
Art therapy; military; post-
traumatic stress; PTSD; TBI;
service members; active duty
Background: PTSD and TBI in the military
As of 30 September 2011, the US Government Account-
ability Office (2011) reported that approximately 2.6
million US military service members had already been
deployed during the operation Enduring Freedom
(OEF) and Operation Iraqi Freedom (OIF) era. Among
a plethora of mental health issues, active-duty
members are highly vulnerable to acquiring post-trau-
matic stress disorder (PTSD) and traumatic brain injury
(TBI). PTSD is an anxiety disorder resulting from the wit-
nessing or experiencing of a physically and/or psycho-
logically traumatic event. Individuals with PTSD have
typically experienced intense fear, horror, or helpless-
ness in relation to traumatic events, leading to beha-
viours of hyperarousal, negative mood, or cognitive
associations, avoidance, and re-experiencing of the
trauma (Bahraini et al., 2014). TBI involves altered or dis-
rupted brain functioning caused by an external force
(e.g. being hit by an object in the head, exposure to
blasts), with memory loss, loss of consciousness,
altered mental states (e.g. confusion), or neurological
deficits (e.g. aphasia or loss of balance) experienced
immediately after the event (Bahraini et al., 2014;
Wall, 2012). Recent research has highlighted the co-
occurrence of these severe diagnoses in SMs, with
financial costs of treating these disorders estimated
as high as $6 billion for those with PTSD and $910
million for those with TBI (Tanielian & Jaycox, 2008). A
survey conducted from 2006 to 2010 estimated that
PTSD has affected about 480,748 SMs (US Government
Accountability Office, 2011). Additionally, 361,092 SMs
were diagnosed as having suffered a mild, moderate,
or severe TBI (Blakeley & Jansen, 2013; Defense and Veter-
ans Brain Injury Center, 2017). PTSD and TBI symptoms
can often overlap, where individuals may experience
anxiety, depression, cognitive deficits (e.g. memory loss,
attention difficulties), irritability, and sleep disruptions,
as well as embodied memory experiences (Kroch, 2009).
Co-occurring issues with psychosocial health and well-
being post deployment are an ongoing challenge for
both veterans and those on active duty. Successful treat-
ment of PTSD is difficult, and individuals struggling with
PTSD relive the trauma years and sometime decades
after the event(s) (Smyth, Hockemeyer, & Tulloch, 2008).
PTSD and related mood disorders are relevant to civilian
populations as well (e.g. victims of violence, natural disas-
ters, accidents) with symptoms impacting individual func-
tioning and social relationships.
Art therapy treatment for PTSD and TBI
Art therapy is a psychotherapeutic intervention that
helps patients safely express and non-verbally externa-
lise inner psychological experiences, especially frag-
mented memories resulting from trauma, as well as
the identity-related, emotional struggles of physical
and cognitive injuries sustained with TBI (Walker,
Kaimal, Koffman, & Degraba, 2016). When an art thera-
pist facilitates the art-making, the experience assists
service members (SMs) in externalising their PTSD
symptoms. Concurrently, individuals learn to manage
overwhelming negative emotions by channelling
them into creative expression. According to Collie,
Backos, Malchiodi, and Spiegel (2006), art-making,
© 2017 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-
nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or
built upon in any way.
CONTACT Melissa S. Walker melissa.s.walker12.civ@mail.mil, melissa.s.walker@gmail.com
INTERNATIONAL JOURNAL OF ART THERAPY, 2017
https://doi.org/10.1080/17454832.2017.1388263
Downloaded by [173.75.253.233] at 02:47 01 November 2017

especially in the context of PTSD and the military,
enhances feelings of safety and relaxation, generates
positive and more regulated emotions, and promotes
relational bonding. Art therapy furthermore can assist
in the integration of fragmentary and sensory traumatic
memories (Collie et al., 2006;Lobban,2016; Walker,
2017) and foster reward perception through positive
mood (Chilton et al., 2015;Kimport&Robbins,2012).
While research on TBI and art therapy is limited, individ-
ual and group art therapy have been found to be effec-
tive in helping TBI patients with emotional expression,
socialisation, emotional adaptation to mental and phys-
ical disabilities, and communication in a creative and
non-threatening way (Barker & Brunk, 1991;Dodd,
1975;Lazarus-Leff,1998). Kline (2016) points to the
value of art therapy in supporting brain plasticity and
highlights the art therapist’s ability to foster a safe and
supportive environment while stressing the need for
flexibility in TBI treatment. Herman (1992a,1992b)
offered a model of trauma treatment that includes
three stages: safety, remembrance and mourning, and
reconnection. Collie et al. (2006) extended this idea to
the field of art therapy with a model for trauma includ-
ing relaxation, self-expression, externalisation, positive
emotions, and social connection. Jain et al. (2012)and
Tedeschi and Calhoun (2004)arguedforthepotential
opportunities for psychosocial development and crea-
tive change as a result of PTSD. Art therapy can help
promote this creative developmental change with
patients and concretise the experience with the artistic
creation.
Integrating theory, practice, and programme
evaluation
There has been increasing awareness of the need to
publish articles linking theory and practice in art
therapy to complement research being done in the
field (Kaiser, 2015). This article will present the practices
of two art therapy programmes for SMs with PTSD, TBI
and comorbid mood disorders in multidisciplinary,
government-funded treatment programmes including
rationale and links for clinical programme choices.
The following sections describe the practices art
therapists used to implement both short-term inten-
sive and long-term clinical rehabilitation programmes.
The long-term practice was built upon a core model
created at the short-term treatment facility, pointing
to the models’ability to be expanded and successfully
implemented, then adapted to meet the needs of the
treatment setting. Using the structure of a practice
article written by Drass (2015), this article will provide
a framework of describing specific art interventions
while weaving in clinical theory, evaluation research,
and case vignettes to illustrate the model. All artwork
included in this article has been anonymised and
consent has been given for the publication of artworks
by their creators. The aim of this paper is to present the
material in a way that will allow art therapists to utilise
parts of this programme and adapt as necessary
according to their own clinical practice and site needs.
It is also important to note the role that programme
evaluation has had in the ongoing development of
the art therapy programmes presented in this article.
Kaimal and Blank (2015) propose that programme evalu-
ation can be a starting point for developing robust
research programmes that connect theory and practice.
As will be shown in the descriptions of the treatment
models in the next section, programme evaluation can
be integrated into practice in order to fine-tune the
treatment methods, provide preliminary evidence of
outcomes, and serve as a bridge to research.
Description of two treatment models
Model one: short term art therapy in an
integrative medical care context
Since 2010, art therapy has been utilised as a treatment
method for military SMs as part of a multi-disciplinary
approach at the National Intrepid Center of Excellence
(NICoE) at the Walter Reed National Military Medical
Center in Bethesda, MD. The art therapist at this site
established an intensive outpatient (IOP) treatment
model to treat TBI, PTSD, and co-occurring mood dis-
orders by incorporating both group and individual
weekly art therapy sessions in a dedicated studio
space (Walker, 2017; Walker et al., 2016).
Once enrolled in the four-week IOP NICoE pro-
gramme, up to six SMs are admitted weekly and
follow a cohort-based interdisciplinary template which
integrates strategically designed art therapy sessions
over the four-week period. All six service members
partake in group art therapy sessions to include mask-
making and montage painting, and each service
member receives at least one individual art therapy
evaluation which is tailored to the SMs’needs. If the
art therapy sessions are considered particularly ben-
eficial for an SM (based on the observations of the art
therapist, and SM and treatment team feedback),
follow-up sessions are scheduled over the final two
weeks of the programme. Walker’s(2017) rationale for
implementing the following directives can be found in
detail in Howie’sbook,Art Therapy with Military Popu-
lations: History, Innovation, and Applications.
At the end of Week 1 of the four-week programme,
SMs engage in a group art therapy mask-making direc-
tive. Masks were selected as the directive because they
help focus the patients on their own experiences with
TBI and PTSD and offer a means to express inner
mental states through a safe externalised represen-
tation (Walker, 2017). This is deliberately set up as a
group session to give SMs the opportunity to connect
with peers who undergo similar experiences, thus
2J. P. JONES ET AL.
Downloaded by [173.75.253.233] at 02:47 01 November 2017

reducing isolation. SMs are given a pre-made papier-
mâché mask and art media including paints, clay,
markers, and miscellaneous found objects to alter the
mask any way they choose. An example directive pro-
vided by the art therapist is as follows:
Masks are inherently connected to identity. You can
choose to focus on the identity of yourself or
someone significant to you. Themes that tend to
come up in the mask are identity, split sense of self,
who I am when I am deployed versus who I am
when I’m at home, negative side versus positive side,
outside-self versus inside-self, depiction of the injuries
themselves, transitions, grief and loss, or trauma. You
can choose to fall within any of these categories or
create a category of your own. You can create depic-
tions that are metaphorical or concrete. While you’re
starting to think about what you may do, I’m going
to walk around the room and I’ll show you everything
that I have available here. So you can either sketch,
plan out what you want to do, or you can just open
the cabinet and grab the first paint color that speaks
to you and dive right in and see where it guides you.
The SMs are able to use any materials in the art therapy
studio to add onto the mask; they may even choose to
incorporate personal materials. As the mask is already
formed, some of the anxiety that can be experienced
from creating something out of nothing can be dis-
pelled. This provides a suitable starting point to focus
on content rather than construction. In this safe
space, SMs can explore difficult emotions in relation
to their combat trauma. Simultaneously, the mask
may serve as a visual representation of positive and
negative aspects of self as SMs relate to individual per-
sonhood, relationships, community, society, and
changes over time (Walker, Kaimal, Gonzaga, Myers-
Coffman, & DeGraba, 2017). The mask becomes an
externalised functional object that helps SMs talk
about their inner experiences with peers, caregivers,
and family members. Some SMs find it beneficial to
work on the mask project for their entire four-week
treatment at the NICoE, while others continue on to
the subsequent projects in the curriculum. In addition,
some SMs decide to leave their masks at the NICoE to
inspire future SMs. The masks themselves can act as a
powerful starting point for conversations with family
members, friends, and medical professionals on
subject matter that the SMs had never been able to ver-
balise prior to art therapy (Walker, 2017)(Figure 1).
Woven between the group art therapy sessions are
individual art therapy treatment sessions during which
the art therapists explore SMs’personal goals for treatment
and implement projects based on these goals (Walker,
2017). SMs may return for follow-up sessions based on
need. The SMs are also invited to return to work on their
individual art therapy projects during open studio times
in the third and fourth week of treatment.
In the final week of treatment at the NICoE SMs are
introduced to montage paintings. Montage paintings
are a way to integrate patient experiences in one
space and form a layered and non-linear narrative
(Walker, 2017). Each SM is given an 20.32 cm ×
25.4 cm canvas, and the project is introduced as a
mixed media artwork in a group art therapy session.
The art therapist gives the following directive:
Some people choose to just paint and then they
might use collage to embellish certain things, or they
may collage and then paint to embellish certain
things or they may go back and forth. You can
document or process something from the past, or
focus on where you are currently, or on hopes, goals,
or concerns for the future. There are two different
ways to approach this, you can either have an idea in
your mind of exactly what you want it to look like
and you can spend the session actualising that
image, or you can have no idea of what you want it
to look like, no idea what you want it to be about
and just spend some time going through magazines,
cutting out any words or images that resonate with
you for whatever reason. It can be a really insightful
process to then organise what you’ve collected on to
your canvas.
This creative arts modality can be structured or
unstructured, depending on preference, and allows
expression of thoughts and processing of inner experi-
ences. At this point in treatment, many SMs have
gained an ability to talk about their traumatic experi-
ences and TBI symptoms for the first time. The overall
goals of this short-term trauma treatment are: increas-
ing stabilisation, establishing safety, and increasing
understanding about symptoms. These goals are built
into the art therapy directives. See Figure 2 for an
example of a montage painting.
In addition to the masks and montage paintings,
SMs have the opportunity to engage in therapeutic
writing sessions and creative writing workshops along
with several other treatments including, but not
limited to, medical and nursing care, physical therapy,
nutrition counselling, individual counselling, family
therapy, animal-assisted therapy, music therapy, and
mind–body based interventions. In order to determine
the comparative usefulness of the different
approaches, the site conducted an internal programme
evaluation. See Figure 3.
The responses in Figure 3 indicate that SMs in model
one rated their experiences with art therapy among the
top five most helpful techniques at the NICoE. This
finding elevated the value of art therapy at the site,
helped expand the programme to additional sites,
and enabled external funding support for research. In
addition, from 2015 onwards, the NICoE integrated
with the TBI Outpatient Clinic at Walter Reed and intro-
duced a long-term treatment component within the art
therapy programme. These referral-based individual
outpatient sessions occur once weekly at the NICoE
for an hour for as long as clinically appropriate for
the patient.
INTERNATIONAL JOURNAL OF ART THERAPY 3
Downloaded by [173.75.253.233] at 02:47 01 November 2017

Model two: long term art therapy in an
outpatient integrative medical care context
In addition to the NICoE at Walter Reed Medical
Center at Bethesda, active duty SMs are eligible to
receive art therapy services through a programme
at one of their satellite centres, the Intrepid Spirit
One (ISO) at the Fort Belvoir Community Hospital in
Northern Virginia. The art therapy programme at
ISO is modelled after the programme at the NICoE;
however, it extends beyond the four weeks and
touches upon later stages of trauma work. ISO is a
more traditional outpatient centre where active
duty and retired SMs live and work on the military
base or in the surrounding community. Upon enter-
ing the programme, physicians evaluate each SM
and refer an SM to art therapy based on the individ-
ual’s treatment goals. In accordance with widely
acceptable trauma treatment, emphasising structure
and safety, remembrance and mourning, and recon-
nection (Herman, 1992a), the art therapy programme
at ISO was created using a stage-based protocol. Art
therapy is offered at three levels of treatment proto-
cols, with programme evaluations occurring at the
completion of each level.
Level 1 treatment protocols
The ISO art therapist refers to Level 1 as an ‘introduc-
tion’to art therapy with process-focused art-making
projects that are based heavily on the art therapy pro-
gramme at the NICoE in Bethesda. SMs receive art
therapy as part of their treatment for TBI/PH needs
and, when referred to art therapy, make an initial
three-week commitment to group art therapy. For
majority of patients, art therapy is a new experience,
and the art therapist therefore provides an introduction
to the SMs as follows:
Figure 2. Montage painting. Each service member is given a
blank 20.32 cm × 25.4 cm canvas and invited to layer art
media to represent a theme, often resulting in the depiction
of past/present/future, and what the service member feels
has changed (or what they learned) during treatment. In this
montage painting, a sailor chose to integrate a box that has
ruptured under the pressure of keeping things (negative
words, feelings, images, dreams, and phrases) inside. The
work also features a meandering green arrow leading from
the NICoE logo with positive words of healing along its path.
Figure 1. Mask base and a completed mask. Each service member is given a blank papier-mâché mask (left) and asked to transform
the template to represent whatever he/she would like regarding their identity. A sailor chose to represent the different facets of
himself (right), depicting the face he shows the outer world in contrast with the dual parts of his inner personality, including a
bright, peaceful side and a dark, tumultuous side.
4J. P. JONES ET AL.
Downloaded by [173.75.253.233] at 02:47 01 November 2017

Art therapy is not like art class. Instead of being
product-oriented where you’re worried about what
something’s going to look like in the end, I’ll give you
pretty open-ended springboards, and it’s up to you
what direction you want to take things in. Follow
your intuition and be spontaneous in your art-
making. If you feel like using a certain color just use
it. If you feel like creating a certain image just create
it and then we’ll take a look at it, talk about it, and
make meaning from it.
Similar to the art therapy programme at the NICoE, the
three weeks at ISO incorporate mask-making and
montage painting. Therapeutic writing is also inte-
grated into this stage as a tool for self-expression.
The sessions are limited to five patients at a time
mainly due to space constraints. Level 1 provides an
introduction to spontaneous, process-oriented art-
making that allows for needs to surface. This type of
art-making in a group setting promotes goals of
increased insight, emotional regulation, and empathy
for self and others. Through the art therapy and
writing projects, SMs report being able to externalise
their inner experiences in a concrete way and gain a
better understanding of themselves, while establishing
a baseline of safety and containment. In programme
evaluation feedback surveys, patients from these
groups have stated that they have found group art
therapy to be a beneficial part of their treatment, and
about 80% of SMs move on to Level 2 Art Therapy at
this site. At the end of the three-week Level 1 group
commitment, SMs meet individually with the art thera-
pist to have an informed evaluation session in which
they discuss their experience with Level 1 groups,
state goals for their time in the clinic, identify which
goals can be best addressed through further art
therapy services, and then decide upon a plan for
ongoing art therapy treatment. SMs may also be dis-
charged from art therapy at this point if appropriate.
Level 2 treatment protocols
Level 2 provides further opportunity for art-making for
increased insight, identity development, emotional
regulation, and empathy and support for self and
others. Tasks allow service members to gain under-
standing into the effects of their past experiences
and identify who they want to be and how they will
get there. Through discussions and peer support,
patients develop stronger connections with cohort
peers. The projects help them explore a new sense of
identity, recognise positive aspects of self and career,
and tap directly into issues of grief and loss.
Level 2 groups are held in a cohort format for a two-
hour group that meets once a week for six weeks. Since
SMs have an introductory understanding of art therapy
and adequate comfort level with the art therapist and
the space, they can begin to explore deeper issues of
accepting changes in their lives. At the same time, it
is important for the art therapist to be able to gauge
the level of trauma treatment in relation to the SM’s
duties and responsibilities. Since the programme at
ISO is an outpatient model, SMs must juggle treatment
with their daily routines.
Art therapy is in the unique position of producing a
tangible product as a result of its process. Art also pro-
vides an opportunity to release and contain traumatic
Figure 3. Perceived usefulness of art therapy in an evaluation of the art therapy programme.
INTERNATIONAL JOURNAL OF ART THERAPY 5
Downloaded by [173.75.253.233] at 02:47 01 November 2017

material. Thus, art therapists are called to use their clini-
cal judgement and focus on the needs of individual
SMs throughout treatment. The following describes
the tasks of Level 2 in detail. It is important to note
that the following directives can be emotionally provo-
cative and are only facilitated by trained art therapists
who are able to safely process and contain traumatic
material. Service members enrolled in Level 2 groups
have been deemed appropriate for the sessions by
their clinical treatment team.
Week 1: greatest fear/greatest comfort. For this task,
the art therapist provides each SM with two pieces of
22.86 cm × 30.48 cm drawing paper and asks them to
depict their ‘greatest fear at the moment,’on one
page and ‘greatest comfort at the moment’on the
other. They are instructed to use any two-dimensional
media of their choosing and they can draw, paint, or
collage. Both directives are given at the same time,
allowing the SM to decide the order of task develop-
ment. This task allows SMs to externalise their main
areas of concern and creates an environment in
which they feel less alone in their struggles. It also
enables them to shed equal light on the positive
resources in their lives, providing an opportunity that
illuminates what elements of life they can focus on in
order to counteract negative feelings and experiences
in an effort to create greater balance (Figure 4).
Week 2: dialogue between self and entity of choice.
For this task, SMs are asked to choose two different
coloured pens and write a dialogue between them-
selves and an entity of their choice. The task is based
on the ‘dialogue journal exercise’described in Kathleen
Adams’s book Journal to the Self (1990). They are pro-
vided with a list of options of entities with which
they can write: a person, an event or circumstance,
something related to the body, an emotion, a society,
or inner wisdom. Options are expounded upon to
assist with their decision making process. For
example, they can select a person from: their past,
present, or future; or someone already dead, still
alive, or perhaps not yet born. Writing to a person is
helpful when working on an unresolved business or
to gain alternative points of view. They may also
choose to address an event or circumstance. Writing
to an event or circumstance can assist in ‘meaning
making’or clarification of unconscious desires. They
can choose to write to something related to the
body, such as a body part, an injury, an illness, pain,
or an addiction. They can also choose to write to
society or an emotion, such as anger or love. Some
write to inner wisdom, while others take a spiritual
approach and write to God, Jesus, or a spiritual voice
inside themselves. The SMs are instructed not to plan
this out but let it be a naturally unfolding dialogue.
This exercise yields material that is insightful and
expressive, and it typically leads to fruitful discussion
and dialogue among group members.
Week 3: depict your soul. For this task, each SM is
given one piece of paper and then told ‘Depict your
soul. You may use whichever drawing materials feel
right, to depict your soul.’They have 40 minutes for
this part of the project, and a variety of drawing
supplies are set out from which they may choose to
use. At the 40 minute mark they are given another
piece of paper and asked to: ‘Depict what your soul
Figure 4. Collage representing greatest fear and greatest comfort. A soldier created two collages, one to represent her greatest fear
at the moment and one to represent her greatest comfort at the moment. Her comfort collage represents herself, ‘little tiger’, as she
is currently working to find herself and take care of her own needs. Additional comforts depicted in the collage are the importance
of family, home as sanctuary, and enjoying nature. Her fear image is represented by a turbulent storm which alludes to her work,
feeling as if she’s drowning because of the constant painful experiences that make up her work, telling her case’s stories but not
getting a chance to tell her own (until now), feeling no peace, taking harsh words personally. Her image was created with vertical
lines, representing how she feels caged in, jailed. In sharing the images she spoke of taking the opportunity to tell her story now as
it is important for her to survive her last couple of years of her military career.
6J. P. JONES ET AL.
Downloaded by [173.75.253.233] at 02:47 01 November 2017

needs to be nourished to a state of greater well-being.’
(Figure 5)
The SMs find this project helpful because it provides
an opportunity to truly think about and externalise how
they see themselves at their core. It also illustrates the
inner resources and strengths they contain within from
which they can draw in order to become who they
want to be. This session often proves to be a turning
point in treatment where they begin to see the
changes they can make in the moment in order to
achieve positive change. They also tend to share
resources with each other during verbal processing.
One person might say, ‘I feel like I should get out in
nature more,’and someone else might say, ‘Oh these
are all the great nonprofits I’m part of. They take me
hiking, kayaking and stuff. It’s really helpful.’They
begin to start reaching out to each other and their
communities to see where opportunities for connec-
tion might lie.
Weeks 4–6: box project. During the fourth, fifth, and
sixth sessions of Level 2, SMs work on a long-term
box project. Boxes are frequently used in art therapy
and can help with containment of obtrusive emotions
or flashbacks as well as boundary setting and personal
control (Drass, 2015). The SMs are instructed to
celebrate their aspects of career and self on the
outside of the box and commemorate or memorialise
aspects of career or self, or lost friends and colleagues,
inside the box. When choosing the size and shape of
their container, SMs are reminded to think about
objects they have at home from their personal military
history that may be hidden but not thrown away, as
these may be meaningful and suggest they pick a con-
tainer sized to fit those items. Working on a longer-
term project in a structured setting such as this can
help the SMs not only plan and think ahead, but also
to take risks, make choices, and utilise problem-
solving skills (Drass, 2015). This project was created in
response to hearing SMs discuss their feelings of inva-
lidation and express frustration over doctors telling
them to accept their ‘new normal’. Here, SMs can
take as much time as needed to focus on all the
aspects of career and self that they are proud of and
recognise that these are important parts of their iden-
tity. Simultaneously, they can work on areas of grief
and loss on the inside of the box, which is more
private, and which can be opened or closed as the
SM desires, which helps increase their sense of control.
Some SMs create memorial spaces on the inside by
incorporating items such as remembrance bracelets or
photographs of lost comrades. Others use the inside to
Figure 5. Depicting the soul. A soldier created these drawings, the first a depiction of his soul, and the second a depiction of what
his soul needed to be nourished to a state of greater wellbeing. His soul depiction shows a soul ‘being attacked’by internal and
external elements, with a wall of anger as defence against the elements. There is a wall being broken down with ‘greener grass’on
the other side. His nourishment image shows a distorted clock, which represents his realisation that even when engaged in multiple
therapies, profound change, and ultimately the healing of the soul, ‘takes time’.
INTERNATIONAL JOURNAL OF ART THERAPY 7
Downloaded by [173.75.253.233] at 02:47 01 November 2017

depict the scene of a traumatic event, parts of them-
selves that they miss, or abilities that they don’t have
anymore. This project gives SMs a space to feel vali-
dated in their new reality and to begin to grieve and
address the invisible wounds of war that they have
yet to articulate. It also provides an opportunity to
accept the current moment in their lives and notice
positive aspects. These boxes serve as a concrete
reminder of both who they are and what they have
lost. Most SMs make a strong investment into this
box project and take it with them after treatment
(Figures 6 and 7).
Level 3 treatment protocols
Level 3 consists of further work to address specific goal
areas that were more clearly defined throughout work
created in Levels 1 and 2. Most of the Level 3 thera-
peutic sessions occur on an individual basis; however,
they can also be held in open studio groups and
through community arts participation. Level 3 com-
prises both open studio groups and individual art
therapy sessions and focuses on deeper self-
expression, externalisation, exploration, and processing
based on the individual.
Individual art therapy sessions. In these sessions,
patients delve deeper into self-expression, externalisa-
tion, exploration, and processing based on their
Figure 6. Celebration/commemoration box. A marine created
this box, collaging personal photographs around the outside
walls to show how on the outside ‘everything looks pretty’–
he looks good, whole, smiling with friends and family. The
inside of the box shows how internally he feels fractured by
memories that are burned into his soul, some of which is rep-
resented by photographs of comrades who have died collaged
onto the inside walls. The patch glued to the inside of the box
lid is upside down and torn apart to show feeling in distress.
The centre of the box contains a volcano with Pandora’s box
to show a hole into Hell he personally experiences.
Figure 7. Celebration/commemoration box. A marine created this celebration/commemoration box, on the outside walls of which
he rendered intricate emblems that represent the chronology of jobs he has had which have shaped him throughout his career, the
experiences, positive and negative, that make him who he is today. Within the box he carefully created a scene that is comprised of
elements that represent his four significant ‘close calls’from combat.
8J. P. JONES ET AL.
Downloaded by [173.75.253.233] at 02:47 01 November 2017

individual needs. The art therapy work tends to focus
on identity, sense of self, transition, relaxation strat-
egies, greater understanding of personal triggers for
trauma responses or emotional reactions. These experi-
ences are designed to lead to greater emotional regu-
lation and self-control, address disenfranchised and
complicated grief and loss (Doka, 2002; Shear, 2015),
process trauma, work through moral injury (Shay,
1994), and reconnect with others. The art therapist
meets individually with each SM to evaluate goals
and discuss moving forward with art therapy. Approxi-
mately 30% of the SMs naturally end art therapy treat-
ment at this time due to their treatment goals having
been met, or retiring and moving out of the area.
Almost 70% of the SMs continue with art therapy at
ISO to focus on individual goals such as processing
specific traumatic events and losses in accordance
with Stage 2 trauma treatment (Herman, 1992a,1992b).
The art therapy work addresses SMs’individual
needs including themes of identity, sense of self, tran-
sition, and relaxation strategies. It may also facilitate
greater understanding of personal triggers for trauma
responses or emotional reactions. This understanding
can lead to greater emotional regulation and self-
control and to address complicated and disenfran-
chised grief, trauma processing, work on moral injury,
and reconnecting with others.
The art therapist can select a variety of tasks for
these individual sessions. Depending on the individual
and their main goals for art therapy treatment, direc-
tives may focus more heavily on meditative or relax-
ation-based tasks, art experientials to further insight
and self-expression, or longer-term projects that
allow SMs to work through complicated trauma,
moral injury, or grief and loss. Individual sessions
may provide SMs an opportunity to engage in art
making that allows them to experience a state of
flow (Csikszentmihalyi, 1990). Sessions may also be
exploratory, for instance when SMs are directed by
the art therapist to externalise through visual meta-
phor their internal and external experiences in order
to gain deeper understand of self, specifically what
underlies their physiological and emotional reactions
to environmental triggers. Sessions can also include
the use of work that is more obviously therapist-
directed, such as use of the Intensive Trauma
Therapy graphic narrative, developed by Gantt and
Tinnin (2007,2009), in which the art therapist has
been trained. Through this technique, which includes
drawing a storyboard of the traumatic event accord-
ing to stages in the Instinctual Trauma Response
(Gantt & Tinnin, 2007) and creating a narrative based
on the drawings, the SMs are able to work through
detailed trauma memories in a safe and structured
manner.
Many SMs utilise art therapy to work through their
grief, which is done in a variety of ways, to include:
creating memorial stones (memorial collages on the
undersides of flat-bottom glass beads); memorial
books (handmade books in which each page
becomes the canvas for expressive artwork reflecting
on individuals who have died); compilation of memor-
ial tiles (tiles created for each deceased individual laid
together); sculptures of Kevlar helmet, boot, and rifle
combat cross memorials created to grieve specific indi-
viduals; and drawn, painted, or sculpted portraits of the
deceased (Jones, 2017; Mims & Jones, in press).
Additionally, SMs may also create a series of past,
present, and future self-portraits to work through iden-
tity issues (Carr, 2014,2017); develop artwork to
capture the culmination of one’s career; or engage in
a multitude of other art tasks to address stuck points
that were discovered in earlier stages of art therapy
treatment.
SMs who have reached a point where they are
working on longer-term, self-directed, product-
oriented artworks, are invited to join Open Studio
groups sessions where they gather to work side-by-
side on projects that allow them each to process
their experiences at a deeper level while simul-
taneously benefiting from the development of camar-
aderie that is fostered in the space.
Open studio art therapy groups. During the Level 3
open studio groups, SMs get to work on long term indi-
vidual art projects. At this point in treatment, there is
already a knowledge base and understanding of the
art therapy process; thus, SMs are able to work inde-
pendently on self-guided projects amongst a commu-
nity of their peers. The group meets each week for
two hours. At this stage, the role of the art therapist
is more of a consultant in the art-making journey,
rather than someone giving specific art tasks or inter-
ventions. Throughout this process of self-exploration,
the art therapist is able to actively process in ‘real-
time’what is happening for the SM as they are creating
their art. In the open studio, SMs are sharing a space
while they are all working on their own projects; at
times, the art therapist acts more like a teacher in
that environment. For example, one SM might want
to create an ominous charcoal drawing of a demon
that represents PTSD, and the art therapist might
help him learn some charcoal drawing techniques.
Another SM may want to create a realistic looking
self-portrait painting of his commander who was
killed; the art therapist might help him develop more
realistic painting techniques. By working in this way,
SMs can develop a sense of artistic sensibility which
Thompson (2009) described as ‘an awareness of the
artistic self that permits a certain freedom of respon-
siveness …[that] informs affective and cognitive reac-
tions to his or her internal process and the wider
environment’(p. 160). While this group may appear
to be more product-oriented, the cognitive problem-
INTERNATIONAL JOURNAL OF ART THERAPY 9
Downloaded by [173.75.253.233] at 02:47 01 November 2017

solving processes at play at this level of artistic pro-
duction can help to re-route neural pathways in the
brain that tend to go offline as a result of PTSD and/
or TBI. In addition to the open studio group, the art
therapist continues to meet individually with SMs,
twice a month, to have more personal and confidential
conversations about what they have been creating in
the group.
Figures 8–11 include examples of artwork made in
Level 3 individual sessions.
Programme evaluation and programme design
Programme evaluations for Model Two are built into all
levels of treatment through a customised survey given
to participants at the end of each level. These help the
art therapist refine clinical practice, provide evidence
on art therapy to other healthcare providers and
ensure quality care. The findings were summarised in
collaboration with a University partner (co-authors on
this paper). Figure 12 summarises patient perceptions
of the contributions of art therapy to changes in clinical
symptoms.
As can be seen from Figure 12, art therapy was found
to be most impactful for a range of symptoms. It is
notable that the identity integration experiences
reduced flashbacks and nightmares, helped participants
to focus on aspects of self that are deeply impacted by
PTSD and TBI, and positively impacted SMs in their self-
reported ability to experience positive emotions,
improve their sense of self, and find meaning in life.
Discussion and implications
This paper presents an art therapy clinical practice pro-
tocol implemented within integrative treatment pro-
grammes for active duty SMs with PTSD and TBI in
the USA. Treating PTSD, TBI, and co-occurring mood
disorders in active duty SMs poses challenges. The pro-
grammes presented here point to the value of art
therapy as a component of an integrative treatment
model that aids in non-verbal discoveries for SMs
along the themes of physical and psychological inju-
ries, relational support and losses, military identity,
community identity, existential reflections, questions,
transitions, and resolving a conflicted sense of self
(Walker et al., 2017).
Art therapy can offer insights into the lived experi-
ences of SMs struggling with PTSD, TBI, and co-
Figure 8. Level 3 open studio artwork. A soldier drew this image (in progress) of a road with a hole that shows fragments of mul-
tiple combat experiences, his efforts to emerge from the hole, to travel down the road with holes that become smaller as the road
moves forward to a more hopeful area in the distance.
10 J. P. JONES ET AL.
Downloaded by [173.75.253.233] at 02:47 01 November 2017

occurring mood disorders. Since much of the current
literature on PTSD and combat trauma focuses on
veterans, the authors’aim is to illuminate what is
being done in these innovative and structured treat-
ment programmes. The art therapy programmes
described here have grown and adapted in accordance
with ongoing participant surveys, in addition to the
most current theory and best practices for treating
PTSD and TBI. The evaluations served to provide aggre-
gate data on SMs’perceptions of the value and contri-
butions of art therapy in their overall treatment
experience. At each site, the programme evaluations
were helpful in documenting patient experiences and
communicating the perceived impact of art therapy
to staff and other healthcare professionals. This is a
valuable practice that should be integrated into art
therapy programming whenever possible. It is also
helpful to seek out partnerships with researchers and/
or local universities to assist with data analysis and
then use the findings to both improve clinical practice
and to advocate for art therapy programming. Present-
ing the treatment programme examples in this paper
also highlights the importance of providing art
therapy literature that describes the intersection
between research, theoretical frameworks, programme
evaluation, and current art therapy practices.
As can be seen from the treatment plans and
descriptions, there are important differences between
group and individual art therapy for service members
with PTSD and TBI. The goals of group art therapy are
reducing isolation, building relationships, and increas-
ing communication through the shared process of
creating and talking about their artwork together. Indi-
vidual art therapy helps patients focus on their own
Figure 9. Assemblage made in individual sessions. A soldier created this assemblage entitled ‘The Evidence of True Faith and Alle-
giance’which provides a glimpse of what can be seen on the floor of any forward medical station. The artwork depicts the essence
of the oath soldiers take, and following through with the oath to whatever trauma may occur or whatever end may come.
INTERNATIONAL JOURNAL OF ART THERAPY 11
Downloaded by [173.75.253.233] at 02:47 01 November 2017

specific challenges of personal grief, loss, and trauma
processing that they might feel uncomfortable
sharing in a group format. Most patients begin in the
structured group setting and gradually proceed to indi-
vidual and open studio projects. The transition is from
therapist led directives to patient led projects in order
to facilitate independent functioning and psychosocial
development from the symptoms.
Transition from military to civilian life happens in an
interpersonal context (DeLucia, 2016). One of the main
goals of programmes such as the NICoE and ISO is to
assist SMs in reintegration into their respective
communities, and art has been one way to help
bridge that gap. Whether it is through the display of
their masks throughout the treatment facilities or
through partnerships with local art studios that offer
classes to SMs, a visual community is being created
that lays out a context for healing. It is of note that
the art therapy programmes discussed in this article
have received extensive media attention, and it
appears that, through partnerships such as with the
National Endowment for the Arts (NEA), more attention
is being given to the value of art therapy as a treatment
modality for people with PTSD and TBI. The art
Figure 10. Mixed media artwork. A marine created this mixed media battlefield cross sculpture to memorialise a best friend and
comrade who was killed in action. Creating the memorial allowed him to feel he paid his respects.
12 J. P. JONES ET AL.
Downloaded by [173.75.253.233] at 02:47 01 November 2017

products, especially the masks, have helped visualise
the patients’challenges and struggles including their
invisible wounds (Lobban, 2014; Walker, 2017). This
media attention has helped bring art therapy to the
forefront as a potential treatment modality for SMs,
helping in particular to integrate their experiences,
externalise long standing symptoms, communicate
with family and caregivers, and address deep-seated
grief and loss.
Historically, successful treatment of PTSD and TBI
has been difficult for SMs due to a myriad of co-occur-
ring issues with psychosocial health and well-being
post deployment. Within the programmes presented
here, there are a variety of factors involved at a
number of levels driving change in treatment for SMs
with PTSD and TBI. The art therapy programmes were
created to actively engage SMs in treatment and
offer them forms of self-expression that are not
limited to verbal language alone. The placement of
these programmes within interdisciplinary treatment
centres and through partnerships with other agencies
such as the NEA and university research programmes
provide an example of interdisciplinary collaboration
and a model of integrative care for SMs struggling
with clinical symptoms. The role of ongoing pro-
gramme evaluation helps art therapists step away
from their own heartfelt assumptions of what
happens in treatment, and allows for the SMs to have
an active voice in advocacy, quality of care and the
development of new programmes that serve their
needs. The increased awareness of the role of arts in
healing and the physical examples of art created by
SMs have created a space for a new visual culture to
emerge within this community which works to de-
mystify the practice of art therapy.
It is importantto note that, while evaluating the value
of art therapy within the context of interdisciplinary
clinics, art therapy treatment emerges as a significant
agent of change that occurs within an SM’srecovery.
The art therapy tasks described throughout this paper
provide SMs with an opportunity to take a deep look
into a reflection of themselves in an attempt to integrate
fragmented parts of their emotions, memories, and lived
experiences. Processing the art products allows them to
discover what may have been hidden beneath the more
easily identified symptoms or issues that caused them to
seek treatment in the first place. Change occurs in art
therapy through disruption, specifically through
engagement with media that can be manipulated,
destroyed, and transformed, e.g. the blank surface of
the mask becomes disrupted the moment paint is
applied or found objects are attached. Many SMs
describe art therapy as having the precision of a
scalpel- that it is only through the art therapy process
that they are able to ‘cut through the clutter’of their
lives and get at the heart of the content they are
attempting to understand and overcome. Art therapy
accesses the underlying core of their physical symp-
toms, interpersonal issues, emotions, and behaviours,
which many refer to as their ‘personal enemy’.
Figure 11. Tile collage artwork. A marine created this mixed
media artwork to work through complicated grief of over 60
comrades he knew who were killed in action or died since
returning home (Note: This photo has been blurred to
protect the confidentiality of the fallen). The creation of the
memorial tiles allowed him to process the death and reflect
on the life of each individual, and the matting and framing
of the tiles with the American flag motif, seeming as if a flag
is draped over a casket, allowed him to move from focusing
on the traumatic nature of the deaths to honourably laying
each person to rest. His artwork evolved to capture ‘honour’
and he was able to release negative pent up energy as result
of the process.
INTERNATIONAL JOURNAL OF ART THERAPY 13
Downloaded by [173.75.253.233] at 02:47 01 November 2017

SMs describe their art therapy journey as one that
enables them to develop strategies to combat these
‘personal enemies’, leading to an experience of
control over their symptoms and experiences. The
interpersonal nature of art therapy allows for a sense
of reintegration and recovery to occur, and gives a tan-
gible form to their core issues. The artworks produced
become evocative tools that act as a visual voice,
improving communication and relationships with
themselves and others. Within the evaluation SMs
report finding hope for the future and a significant
increase in their ability to experience positive
emotions, with the creation of artwork playing a signifi-
cant role as an agent of change to SMs’sense of self.
The creation of an art product under the guidance of
a trained art therapist lays the groundwork for SMs to
use creativity to express their ongoing, and often
internal, dialectical dialogues.
Conclusion
This paper provides an overview of art therapy
approaches for military SMs facing post-traumatic
stress, traumatic brain injury, and psychological
health conditions in the USA. The session descrip-
tions for short term and long term care provide gui-
dance to art therapists working with this population.
Art therapy sessions in both of these settings were
conducted in the context of an integrative medical
care setting by credentialed art therapists. In
addition to clinical approaches, the paper also high-
lights the value of programme evaluation to
document perceptions, outcomes and data to advo-
cate for art therapy services. These approaches point
to a need for clinicians to balance evidence-based
treatment modalities that focus on symptom
reduction as well as the cultivation of a deeper
understanding of self in order to work to resolve
internal conflicts so often experienced by SMs. The
art therapy journey serves as an agent of change,
during which SMs establish a new sense of self as
creator rather than destroyer, as productive and effi-
cacious instead of broken, as connected to others as
opposed to isolated, and in control of their future,
not controlled by their past.
Disclosure statement
No potential conflict of interest was reported by the authors.
The views express in this manuscript are those of the authors
and do not reflect the official policy of the Department of the
Army/Navy/Air Force, Department of Defense, or US
Government.
Funding
This work was supported by National Endowment for the
Arts.
Notes on contributors
Jacqueline P. Jones, MEd, MA, ATR, is a Creative Arts Thera-
pist at the Intrepid Spirit Center at Fort Belvoir Community
Hospital, where she provides art therapy services to active
duty service members recovering from traumatic brain
injury and psychological health conditions. With support
Figure 12. Programme evaluation feedback on symptom alleviation through art therapy.
14 J. P. JONES ET AL.
Downloaded by [173.75.253.233] at 02:47 01 November 2017

from the National Endowment for the Arts, she established
the Creative Arts Therapies programme at the Intrepid Spirit
Center at Fort Belvoir after interning at the National Intrepid
Center of Excellence. She is an art therapist within Creative
Forces: The NEA/Military Healing Arts Network, and she has
focused on providing art therapy, program development
and expansion, and on exploring and identifying the
unique value of art therapy in interdisciplinary rehabilitation
settings for service members recovering from invisible
wounds of war. Prior to pursuing a career in art therapy,
Jackie was an art educator in Fairfax County Public Schools.
She earned her Master’s degree in Art Therapy from the
George Washington University, and her Master’s and Bache-
lor’s degrees in Art Education from the University of Mary-
land. She is a practicing visual artist.
Melissa S. Walker, MA ATR, moved to the National Capital
Region in 2008 to work for the Department of Defense after
earning a Master’s in Art Therapy from NYU. Ms. Walker devel-
oped and implemented the NICoE Healing Arts Program at
Walter Reed Bethesda, MD, US, to explore the integration
and research of the creative arts therapies for service
members with traumatic brain injury and psychological
health concerns. Ms. Walker currently serves as the pro-
gramme’s coordinator and also acts as lead art therapist for
Creative Forces: the NEA/Military Healing Arts Network - a col-
laboration aimed to expand clinical and community arts
access for the military population.
Jessica Masino Drass, MA, ATR-BC, is currently a research
fellow at Drexel University in the Creative Arts Therapy PhD
programme working under Dr. Girija Kaimal. Jessica specializes
in the treatment of complex trauma and dissociation, and has
published articles on Treating Borderline Personality from a
Dialectical Behavior Therapy framework and Punk Rock Art
Therapy. She is a graduate of Drexel University’sarttherapy
program, and also has an MA in School Psychology from
Rowan University, and BA in Fine Art from Rutgers University.
Jessica also co-founded Wise Mind Creations, LLC, a commu-
nity art studio specialising in mindfulness training.
Dr. Girija Kaimal is an Assistant Professor in the Department
of Creative Arts Therapies at Drexel University. Her research
examines physiological and psychological outcomes of crea-
tive visual self-expression. Girija currently leads two federally
funded studies examining arts-based approaches to health
among caregivers and military service members. She has
led longitudinal evaluation research studies examining arts-
based approaches to leadership development and teacher
incentives and won national awards for her research. Girija
is the Chair of the Research Committee for the American
Art Therapy Association, Assessment Fellow for Drexel Univer-
sity, and, is a practicing visual artist. Dr. Kaimal has a Docto-
rate in Education from Harvard University, a Master’s in Art
Therapy from Drexel University, and a Bachelor’s in design
from the National Institute of Design in India.
ORCID
Jacqueline P. Jones http://orcid.org/0000-0002-8484-2891
Melissa S. Walker http://orcid.org/0000-0001-9375-567X
Jessica Masino Drass http://orcid.org/0000-0001-9867-4019
Girija Kaimal http://orcid.org/0000-0002-7316-0473
References
Adams, Kathleen. (1990). Journal to the self. New York, NY:
Grand Central Publishing.
Bahraini, N. H., Breshears, R. E., Hernández, T. D., Schneider, A.
L., Forster, J. E., & Brenner, L. A. (2014). Traumatic brain
injury and posttraumatic stress disorder. Psychiatric Clinics
of North America,37(1), 55–75.
Barker, V. L., & Brunk, B. (1991). The role of a creative arts
group in the treatment of traumatic brain injury. Music
Therapy Perspectives,9(1), 26–31.
Blakeley, K., & Jansen, D. J. (2013). Post-traumatic stress dis-
order and other mental health problems in the military:
Oversight issues for congress. Library of congress,
Washington DC: Congressional Research Service.
Carr, S. (2014). Revisioning self-identity: The role of portraits,
neuroscience and the art therapist’s‘third hand’.
International Journal of Art Therapy, 19(2), 54–70.
Carr, S. (2017). Portrait therapy: Resolving self-identity disrup-
tion in clients with life-threatening and chronic illnesses.
London: Jessica Kingsley.
Chilton, G., Gerber, N., Bechtel, A., Councill, T., Dreyer, M., &
Yingling, E. (2015). The art of positive emotions:
Expressing positive emotions within the intersubjective
art making process. Canadian Art Therapy Association
Journal,28(1), 12–25.
Collie, K., Backos, A., Malchiodi, C., & Spiegel, D. (2006). Art
therapy for combat-related PTSD: Recommendations for
research and practice. Art Therapy: Journal of the
American Art Therapy Association,23(4), 157–164.
Csikszentmihalyi, M. (1990). Flow: The psychology of optimal
experience. New York: Harper and Row.
Defense and Veterans Brain Injury Center. (2017). DoD
Worldwide numbers for TBI [PDF file]. Retrieved from
http://dvbic.dcoe.mil/files/tbi-numbers/DoD-TBI-Worldwide-
Totals_2000-2016_Feb-17-2017_v1.0_2017-04-06.pdf
DeLucia, J. M. (2016). Art therapy services to support veterans’
transition to civilian life: The studio and the gallery. Art
Therapy: Journal of the American Art Therapy Association,
33(1), 4–12.
Dodd, F. G. (1975). Art therapy with a brain-injured man.
American Journal of Art Therapy,14(3), 83–89.
Doka, K. (2002). Disenfranchised grief: New directions, chal-
lenges, and strategies for practice. Champaign: Research
Press.
Drass, J. (2015). Art therapy for individuals with borderline
personality: Using a dialectical behavior therapy frame-
work. Art Therapy: Journal of the American Art Therapy
Association,32(4), 168–176.
Gantt, L., & Tinnin, L. (2007). Intensive trauma therapy of PTSD
and dissociation: An outcome study. The Arts in
Psychotherapy,34,69–80. doi:10.1016/j.aip.2006.09.007
Gantt, L., & Tinnin, L. (2009). Support for a neurobiological
view of trauma with implications for art therapy. The
Arts in Psychotherapy,36, 148–153. doi:10.1016/j.aip.2008.
12.005
Herman, J. L. (1992a). Complex PTSD: A syndrome in survivors
of prolonged and repeated trauma. Journal of Traumatic
Stress,5(3), 377–391.
Herman, J. L. (1992b). Trauma and recovery: The aftermath of
violence- from domestic abuse to political terror. New York,
NY: Basic Books.
Jain, S., McMahon, G. F., Hasen, P., Kozub, M. P., Porter, V., King,
R., & Guarneri, E. M. (2012). Healing touch with guided
imagery for PTSD in returning active duty military: A
randomized controlled trial. Military Medicine,177(9),
1015–1021.
Jones, J. (2017). Complicated grief: Considerations for treat-
ment of military populations. In P. Howie (Ed.), Art
therapy with military populations: History, innovation, and
applications (pp. 98–110). London: Routledge.
INTERNATIONAL JOURNAL OF ART THERAPY 15
Downloaded by [173.75.253.233] at 02:47 01 November 2017

Kaimal, G., & Blank, C. L. (2015). Program evaluation: A
doorway to research in the creative arts therapies. Art
Therapy: The Journal of the American Art Therapy
Association,32(2), 89–92.
Kaiser, D. H. (2015). What should be published in Art Therapy?
What should art therapists write about? Art Therapy: The
Journal of the American Art Therapy Association,32(4),
156–157.
Kimport, E. R., & Robbins, S. J. (2012). Efficacy of creative clay
work for reducing negative mood: A randomized con-
trolled trial. Art Therapy: Journal of the American Art
Therapy Association,29(2), 74–79.
Kline, T. (2016). Art therapy for individuals with traumatic
brain injury: A comprehensive neurorehabilitation-
informed approach to treatment. Art Therapy: The Journal
of the American Art Therapy Association,33(2), 67–73.
Kroch, R. (2009). Living with military-related posttraumatic
stress disorder (PTSD)-a hermeneutic phenomenological
study (Doctoral dissertation). University of Calgary.
Lazarus-Leff, B. (1998). Art therapy and the aesthetic environ-
ment as agents for change. Journal of the American Art
Therapy Association,15(2), 120–126.
Lobban, J. (2014). The invisible wound: Veterans’art therapy.
International Journal of Art Therapy: Formerly Inscape,19(1),
3–18.
Lobban, J. (2016). Factors that influence engagement in an
inpatient art therapy group for veterans with post trau-
matic stress disorder. International Journal of Art Therapy:
Formerly Inscape,21(1), 15–22. doi:10.1080/17454832.
2015.1124899
Mims, R. & Jones, J. (in press). Art therapy to address disen-
franchised grief in military service members. In R.
Jacobson & M. Wood (Eds.), Art therapy in hospice and
bereavement care. London: Routledge.
Shay, J. (1994). Achilles in Vietnam: Combat trauma and the
undoing of character. New York: Scribner.
Shear, M. K. (2015). Complicated grief. New England
Journal of Medicine, 372(2), 153–160. doi:10.1056/NEJM
cp1315618
Smyth, J. M., Hockemeyer, J. R., & Tulloch, H. (2008). Expressive
writing and post-traumatic stress disorder: Effects on
trauma symptoms, mood states, and cortisol reactivity.
British Journal of Health Psychology,13(1), 85–93. doi:10.
1348/135910707X250866
Tanielian, T., & Jaycox, L. (2008). Invisible wounds of war:
Psychological and cognitive injuries, their consequences,
and services to assist recovery. Pittsburgh, PA: RAND
Corporation.
Tedeschi, R. G., & Calhoun, L. G. (2004). Posttraumatic growth:
Conceptual foundations and empirical evidence.
Psychological Inquiry,15(1), 1–18.
Thompson, G. (2009). Artistic sensibility in the studio and
gallery model: Revisiting process and product. Art
Therapy: Journal of the American Art Therapy Association,
26(4), 159–166. doi:10.1080/07421656.2009.10129609
U.S. Government Accountability Office. (2011). VA mental
health: Number of veterans receiving care, barriers
faced, and efforts to increase access (GAO-12-12) [PDF file].
Retrieved from http://www.gao.gov/assets/590/585743
Walker, M. (2017). Art therapy approaches within the National
Intrepid Center of Excellence at Walter Reed National
Military Medical Center. In P. Howie (Ed.), Art therapy with
military populations: History, innovation, and applications
(pp. 111–123). London: Routledge.
Walker, M. S., Kaimal, G., Gonzaga, A., Myers-Coffman, K., &
DeGraba, T. (2017). Active duty military service
members’visual representations of PTSD and TBI in
masks. International Journal of Qualitative Studies on
Health and Well-Being.doi:10.1080/17482631.2016.126
7317
Walker, M. S., 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,49,10–18.
Wall, P. L. (2012). Posttraumatic stress disorder and traumatic
brain injury in current military populations a critical analy-
sis. Journal of the American Psychiatric Nurses Association,
18(5), 278–298.
16 J. P. JONES ET AL.
Downloaded by [173.75.253.233] at 02:47 01 November 2017