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Art Therapy for Military Service Members with Post-Traumatic Stress and Traumatic Brain Injury: Three Case Reports Highlighting Trajectories of Treatment and Recovery

May 2019
The Arts in Psychotherapy 63

DOI:10.1016/j.aip.2019.04.004

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CC BY-NC-ND 4.0

Authors:

Jessica Drass

University of the Arts

Girija Kaimal

Drexel University

Advances in both military and medical technology have led to decreased mortality rates among military service personnel in the United States, yet have led to an increase in occurrences of traumatic brain injuries and post-traumatic stress disorder in military service personnel, often resulting in prolonged unresolved symptoms. The purpose of this article is to illustrate the implementation and effects of an art therapy program on military service personnel attending an outpatient military treatment facility. To this end, we present case reports of three military service personnel diagnosed with comorbid traumatic brain injury and post-traumatic stress and describe their participation in the art therapy program at Intrepid Spirit One, the National Intrepid Center of Excellence satellite site at Fort Belvoir Community Hospital. Through discussion of the therapist's subjective observations, as well as the patients’ visual art productions and their personal verbal and written reflections on their experiences in art therapy and, eventually, on community art programs, this article highlights how art therapy was used to treat military trauma as part of a comprehensive integrative treatment program. The cases highlight how participation in a long-term, stage-based, structured art therapy program (through both group and individual sessions), enabled military service personnel to identify and articulate the complexity of their lingering trauma symptoms, fostering improvement in their communication with other treatment providers and loved ones, which, in turn, led to improvements in their overall quality of life.

Art therapy program structure at Intrepid Spirit One with integration of program evaluation.

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Clinical case examples. Note: DDS: Diagnostic Drawing Series; GN: graphic narrative; ISO: Intrepid Spirit One; ITT: Intensive Trauma Therapy; L1: level 1; L2: level 2; L3: level 3; TBI: traumatic brain injury; WRNMMC: Walter Reed National Military Medical Center; Signature Strengths Test. *This paper presents descriptions of this case summary until February 2018 when art therapy was terminated with author 1 due to the therapist relocating to work at another clinic. The military service person chose to continue to attend art therapy sessions at the ISO.

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Depiction of a location of an especially bad firefight.

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The Marine's depiction of the first explosion he survived.

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The Marine's drawing based on one of his favorite moments from deployment.

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Figures - uploaded by Girija Kaimal

Content may be subject to copyright.

Content uploaded by Girija Kaimal

Content may be subject to copyright.

Contents lists available at ScienceDirect

The Arts in Psychotherapy

journal homepage: www.elsevier.com/locate/artspsycho

Research Article

Art therapy for military service members with post-traumatic stress and

traumatic brain injury: Three case reports highlighting trajectories of

treatment and recovery

Jacqueline P. Jones

a,b,⁎

, Jessica M. Drass

, Girija Kaimal

Intrepid Spirit Center, Fort Belvoir Community Hospital, Fort Belvoir, VA, USA

Invisible Wounds Center, Eglin Air Force Base, FL, USA

Drexel University College of Nursing and Health Professions, Philadelphia, PA, USA

ARTICLE INFO

Keywords:

Post-traumatic stress

Art therapy

Traumatic brain injury

Case reports

Long term

Military

ABSTRACT

Advances in both military and medical technology have led to decreased mortality rates among military service

personnel in the United States, yet have led to an increase in occurrences of traumatic brain injuries and post-

traumatic stress disorder in military service personnel, often resulting in prolonged unresolved symptoms. The

purpose of this article is to illustrate the implementation and eﬀects of an art therapy program on military

service personnel attending an outpatient military treatment facility. To this end, we present case reports of

three military service personnel diagnosed with comorbid traumatic brain injury and post-traumatic stress and

describe their participation in the art therapy program at Intrepid Spirit One, the National Intrepid Center of

Excellence satellite site at Fort Belvoir Community Hospital. Through discussion of the therapist’s subjective

observations, as well as the patients’visual art productions and their personal verbal and written reﬂections on

their experiences in art therapy and, eventually, on community art programs, this article highlights how art

therapy was used to treat military trauma as part of a comprehensive integrative treatment program. The cases

highlight how participation in a long-term, stage-based, structured art therapy program (through both group and

individual sessions), enabled military service personnel to identify and articulate the complexity of their lin-

gering trauma symptoms, fostering improvement in their communication with other treatment providers and

loved ones, which, in turn, led to improvements in their overall quality of life.

Introduction

Advances in both military and medical technology have led to de-

creased mortality rates among military service personnel in the United

States, whereas there has been an increase in occurrences of traumatic

brain injuries (TBI) and post-traumatic stress disorder (PTSD) in mili-

tary service personnel (Lindquist, Love, & Elbogen, 2017;Wall, 2012).

Living with these modern wounds of war, both visible and invisible, is

diﬃcult and multifaceted for injured military service personnel (2016,

Lobban, 2014;Walker, Kaimal, Koﬀman, & Degraba, 2016). Conse-

quently, there has been a rise in interdisciplinary treatment programs

and research studies in order to meet the complex clinical needs of

individuals with comorbid TBI, post-traumatic stress (PTS) symptoms,

and related psychological health conditions (Bahraini et al., 2014;

Banducci, Bonn-Miller, Timko, & Rosen, 2018;Blakeley & Jansen,

2013) including using art therapy =(Campbell, Decker, Kruk, &

Deaver, 2016;Decker, Deaver, Abbey, Campbell, & Turpin, 2019;

Jones, Walker, Drass, & Kaimal, 2017;Walker et al., 2016). Further

complicating the clinical picture is the overlap in somatic, cognitive,

and psychological symptoms that are present in both conditions, such

as sleep disturbances, fatigue, avoidance behaviors, hyperarousal, dif-

ﬁculty with memory and concentration, and mood disturbances such as

anger, irritability, anxiety, and depression (Blakeley & Jansen, 2013;

Stein & McAllister, 2009). Evidence has shown that military service

personnel with comorbid TBI and PTSD also suﬀer from an overall

“clinical picture that is heightened in its severity than either condition

in isolation”(Wall, 2012). This article presents an in-depth look at the

cases of three military service personnel diagnosed with both TBI and

PTS and describes how art therapy was used as part of a comprehensive

treatment program to decrease symptoms of psychological trauma and

TBI in order to improve their quality of everyday life and assist in post-

combat transitions.

https://doi.org/10.1016/j.aip.2019.04.004

Received 8 August 2018; Received in revised form 29 December 2018; Accepted 28 April 2019

⁎

Corresponding author at: 96MDG/AMDS SGPF, Invisible Wounds Center, 307 Boatner Road, Eglin AFB, FL 32542, USA.

E-mail address: Jacqueline.P.Jones4.civ@mail.mil (J.P. Jones).

The Arts in Psychotherapy 63 (2019) 18–30

Available online 02 May 2019

0197-4556/ Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).

The experience of trauma in everyday life

For military service personnel, the experience of physical and psy-

chological trauma extends far beyond the battleﬁeld. PTS is experi-

enced through symptoms in four main categories: reexperiencing,

avoidance, numbing, and changes in arousal (Curran, 2010), which can

lead to trouble balancing the tasks of everyday living. In addition, the

emotional parts that were activated during the initial traumatic event

are stuck in modes of defense or hypervigilance and, in circumstances

of everyday life, can come to the surface through seemingly benign

stimuli many times with little or no awareness on the part of the in-

dividual. “Trauma survivors may experience sudden transitions from

states of normal consciousness to hypo- or hyperarousal, which can

engender abrupt changes in behavior, aﬀect, sensitivity to pain, and

awareness of self and environment”(Howell & Blizard, 2009, p. 497).

Traumatic experiences in the military, both physical and psychological,

can lead to intrusive memories and troubling physiological symptoms,

which can impede the development of an integrated postmilitary

identity, especially as military service personnel transition from combat

environments back to civilian life (Bowes, Ferreira, & Henderson, 2018;

DeLucia, 2016). Clark and Mackay (2015) highlight that intrusive

memories such as those related to trauma can create the reexperiencing

of feelings that can exacerbate emotional and cognitive dysregulation

that are already prevalent in the daily lives of the military service

members.

Treatments for traumatic brain injury and post-traumatic stress in the

military

Over the course of the last decade, there has been a focus within the

VA on training providers in two evidence-based psychotherapy

programs—Prolonged Exposure (PE) therapy (Foa, 2011) and Cognitive

Processing Therapy (CPT) (Resick, Monson, & Chard, 2014) for the

treatment of PTSD in military veterans (Hundt et al., 2018). The goal of

PE is to mainly promote emotional processing in patients through de-

liberate systematic confrontation with trauma-related stimuli (Foa,

2011), through both in vivo (real-life) and imaginal exposures to

traumatic stimuli (Foa, 2011). CPT is grounded in social cognitive

theory of PTSD that focuses on how the traumatic event is construed

and coped with by a person who is trying to regain a sense of mastery

and control in his/her life”(Aronson et al., 2018;Resick et al., 2014).

Although VA policy states that these two treatment methods should be

accessible to all veterans who meet the criteria for PTSD, evidence has

shown that as few as 6%–13% actually receive these services (Hundt

et al., 2018) and that, even when receiving these treatments, veterans

have poorer outcomes than civilians and many “continue to struggle

with and seek treatment for PTSD”(Banducci et al., 2018). This ﬁnding

is due to a number of factors, such as practical barriers of distance and

scheduling, in addition to fears concerning the need or ability to di-

rectly confront or speak about traumatic memories (Hundt et al., 2018).

Art therapy treatments for traumatic brain injury and post-traumatic stress

Studies have shown that traumatic memories are encoded non-

verbally, many times in images rather than in words (Clark & Mackay,

2015;Gantt & Tripp, 2016;van der Kolk, 2014). Clark and Mackay

(2015) delineated the connection between mental imagery and emo-

tional and physical responses in the body. Their research shows that

viewing images of an object or an event in one’s mind has an impact on

heart rate, breathing, and skin sensations (Clark & Mackay, 2015). This

result points to the value of using a nonverbal treatment such as art

therapy as part of an integrated model for treating military trauma

(Jones et al., 2017;Walker et al., 2016;Walker, Kaimal, Myers-

Coﬀman, Gonzaga, & DeGraba, 2017). The creation of art within the

context of art therapy can allow for access to nonverbal memories in a

novel, nonthreatening way (Gantt & Tripp, 2016) through the use of

materials, metaphors, and symbols, “which may facilitate consolidation

of experiences by converting an artistic form, representative of emo-

tions and reactions to trauma, into verbal communication”(Campbell

et al., 2016). From this perspective, art therapy may provide a way for

trauma victims to access memories from a safe distance (Johnson,

1987) rather than speak directly about their experiences (Talwar, 2007;

Tripp, 2007). Creative arts therapies have been used to reduce anxiety,

allow for creativity, and establish a sense of safety to help process

complex, frightening emotions that cognitive treatments alone (such as

PE or CPT) do not provide (Campbell et al., 2016).

Decker et al. (2019) performed a randomized controlled trial study

which compared an experiment group of veterans with combat-related

PTSD who received art therapy in conjunction with CPT with a control

group who received CPT and supportive psychotherapy and no art

therapy. A statistically signiﬁcant greater reduction in PTSD Checklist-

Military (PCL-M) scores and Beck Depression Inventory-II (BDI-II)

scores, as well as increased perceived beneﬁt of treatment were found

in those who received art therapy in addition to CPT. Gantt and Tripp

(2016) posited that the use of art therapy with trauma patients not only

can bypass defenses but can also build a pathway to nonverbal parts of

the brain that did not exist before. The authors describe their theory of

the Instinctual Trauma Response and how to utilize the graphic nar-

rative and the externalized dialogue techniques to treat preverbal

trauma within the context of art therapy.

Evidence is emerging that further supports the connection between

art making and changes in the brain that has relevance for the use for

art therapy in the treatment of military service personnel with co-

morbid TBI and PTS. In a study by King et al. (2017), using electro-

encephalographic tests, it was found that artmaking was associated

with improved brainwave activity. Kaimal et al. (2017) found that

artmaking activated the reward pathways of the brain indicating po-

tential for evoking positive emotion through creative expression. To

further bridge the connections between neuroscience and art therapy,

Kline (2016) highlighted the need for ﬂexibility within treatment pro-

tocols for TBI and states that the practice of art therapy provides an

opportunity for comprehensive treatment, most notably, safe space for

expression that includes an environment with minimal distractions,

adaptability to varying levels of ability and functioning as well as

sensitivity of challenges of identity and individuality.

Healing arts in the military

In 2012 the National Endowment for the Arts (NEA) formed a un-

ique partnership with the U. S. Department of Defense through which

creative arts therapies are oﬀered to active-duty military service per-

sonnel to better meet the complex needs of injured service members

with TBI and PTSD. An initiative of the National Endowment for the

Arts, Creative Forces

: NEA Military Healing Arts Network (https://

www.arts.gov/partnerships/creative-forces) is a partnership with the

U.S. Departments of Defense and Veterans Aﬀairs and the state and

local arts agencies with administrative support provided by Americans

for the Arts. We present case descriptions of the participation of three

military service personnel coping with comorbid TBI and PTS from the

art therapy program at Intrepid Spirit One, the National Intrepid Center

of Excellence satellite at Fort Belvoir Community Hospital, which pro-

vided services to active-duty military service personnel presenting with

TBI and psychological health conditions and retired military service

personnel and their families from the local region. The Intrepid Spirit

One clinic provided a holistic model of care while also supporting

cutting edge research in order to provide optimal clinical care to mili-

tary service personnel and their families. Art therapy was oﬀered at

Intrepid Spirit One as part of a range of therapies and aimed to help

service members express themselves and process traumatic experiences

from their past (Jones et al., 2017).

Based on the wide variety of articles that suggest a stage-based,

task-oriented model for trauma treatment (Campbell et al., 2016;

J.P. Jones, et al. The Arts in Psychotherapy 63 (2019) 18–30

Herman, 1992;Walker et al., 2016), the art therapy program at Intrepid

Spirit One was structured into levels, with participant and program

evaluation built in (Fig. 1). Three levels of art therapy were oﬀered at

Intrepid Spirit One including group and individual art therapy sessions

which have been described in detail in a previous manuscript (Jones

et al., 2017). The three levels include (1) Three weeks of introductory

group art therapy with speciﬁc directives for mask making, writing and

montage painting; (2) 6 weeks of group art therapy with speciﬁc di-

rectives to allow for deeper exploration and processing of issues of

identity, emotional regulation, insight, trauma and grief and loss pro-

cessing, transitions; and individual art therapy for deeper, more in-

dividualized externalization and processing of these themes; and (3)

Individual based or open studio based settings with patient driven di-

rections for projects, including participation in community arts projects

and community-based art as therapy settings.

In accordance with best practices for trauma treatment, the art

therapist at Intrepid Spirit One (author 1) designed the stage-based art

therapy protocol to work sequentially (Fig. 1). Level 1 focused on es-

tablishing safety and introduces military service personnel to the

practice of art therapy as a way to gain personal insight and as an outlet

for self-expression. Once safety was established, level 2 focused on

furthering self-awareness, building coping skills, and laying a founda-

tion for remembrance, processing trauma memories, and complex grief

work to come, as well as the in-depth processing. Level 3 focused on

continued in-depth processing of trauma memories, reconnection, and

reintegration with the self and others through independent art projects

and an open studio (Jones et al., 2017). Therapeutic writing was used

throughout the program to assist in communication during transitions

and traumatic processing (Jones et al., 2017). The rationale behind this

approach was discussed in greater detail in Jones et al. (2017). The

goals of the sessions were to provide each individual with new tools to

facilitate self-expression, access positive emotions, process and contain

traumatic experiences, and address issues related to TBI and PTS in-

cluding cognitive, sensory, and emotional integration.

Each military service person that enters art therapy treatment cre-

ates a mask as his or her ﬁrst project (Walker et al., 2016). The creation

of these masks acts as a rite of passage for military service personnel

entering the art therapy program. Masks have been used historically to

protect the vulnerability of the wearer (Lobban, 2014), especially in

times of war (Kaimal, Walker, Herres, French, & Degraba, 2018;Walker

et al., 2017). The masks themselves have become part of the visual

culture of military healing; they hang in the art therapy studios on site

and have been widely circulated through various media outlets as a way

to communicate the physical and psychological wounds of war (Jones

et al., 2017;Walker et al., 2016), while simultaneously giving permis-

sion to new military service personnel entering art therapy to use these

materials to express what was previously perceived as forbidden or

inexpressible. Through the creation of this project, military service

personnel are able to explore various and, many times, conﬂicting as-

pects of their evolving identities.

Fig. 2 outlines each military service person’s demographic in-

formation, diagnoses, presenting symptoms, as well as an overview of

the art therapy treatments each military service person experienced

during their engagement with art therapy at Intrepid Spirit One. Each

military service person is represented by his initial mask project. In this

article, each military service person’s story is presented in a narrative

format, using much of the person’s own words. These case summaries

were constructed from clinical notes maintained by the art therapist

and artwork generated by the military service person over the course of

treatment, from descriptions of their artwork, from patient feedback

evaluations (conducted at various treatment levels), and from reﬂec-

tions on treatment shared by the military service personnel themselves.

The cases illustrate how the practice of art therapy is informed by un-

derlying trauma theories and accepted clinical practices. Additionally,

the cases demonstrate how the art therapist created a therapeutic space

individualized for each military service person through psycho-educa-

tion, art-based assessments, connection to outside art communities, and

engagement with a variety of neurological techniques through verbal

and nonverbal media and methods. Each military service person was

given a pseudonym. Information about these military service personnel

was shared as part of a data-sharing agreement between the authors’

institutions. Case studies and program evaluation studies are exempt

from Insitutional Research Board approval at the site. Instead these

have been reviewed by clinic and hospital leadership, security man-

agement oﬃce, and the public aﬀairs oﬃce; who approved this paper

for public release at the ﬁrst author’s site at the time of publication. The

lead author also shared the case summaries with each of the three

military service personnel described and received their written consent

to proceed with publication.

Art therapy with patients with post-traumatic stress can impact

clinicians deeply (Gibson, 2018). Included therefore in the discussion

section are the lead author’sreﬂections on art therapist’s responses,

countertransference and experiences of secondary and vicarious

trauma.

Clinical case summaries

To highlight how military service personnel used the art therapy

program at Intrepid Spirit One to manage their symptoms associated

with TBI and PTS, three cases are presented. In this paper, case reports

and case summaries are used interchangeably. The art therapy provided

to the three military service personnel was similar in that they each

Fig. 1. Art therapy program structure at Intrepid Spirit One with integration of program evaluation.

J.P. Jones, et al. The Arts in Psychotherapy 63 (2019) 18–30

worked with the same art therapist, and each were undergoing inter-

disciplinary treatment on an outpatient basis in the same clinic. Art

therapy group sessions provided at the clinic were two hours, and in-

dividual appointments were generally one hour each. Open studio

pottery classes held in the community were two and a half hours long

with an option to arrive early. The frequency of appointments varied

depending on what other medical, work, and family life commitments

the military service personnel were juggling, and the length of time that

each person remained in treatment varied and was aﬀected by when

they each initially were referred to the clinic, were referred to begin

receiving art therapy, the date of medical retirement, and moving away

from the area.

Case #1, Jay: Art therapy increased communication ability and engagement

with other disciplines

Jay, a Marine mortarman, was referred to the Intrepid Spirit One

clinic for diﬃculties with memory, possibly related to TBI. He had been

deployed twice to Afghanistan and had blast exposure twice during his

ﬁrst deployment. The ﬁrst event occurred when he was walking with

his gunmen. The next thing he remembered was a big explosion and

walking back. He was not evaluated at the time and immediately

resumed normal duties, but he felt he’d had hearing loss. The second

event occurred when he was walking on a patrol. He was attacked

unexpectedly and sustained blast injuries when an improvised explosive

device (IED) was detonated. He immediately resumed duties and did

not remember post event details very well. When Jay reﬂected on his

blast exposures, he perceived that although the medical personnel at-

tached to his unit were generally proﬁcient, they did not seem to have

the training needed to accurately assess for non-physical injuries. This

lack of awareness of TBI signs and symptoms contributed to Jay con-

tinuing to remain deployed while his invisible injuries worsened, con-

tributing to an increasing disconnection between his physical and

psychological states and symptoms that would eventually become

chronic.

When he was initially referred to the TBI clinic, Jay was forgetting

daily items and, at times, he would forget where he was, despite re-

minders from his wife. He demonstrated a mind-body disconnect—for

example, he could not identify feelings of stress in his body, and, on a

couple of occasions, he wound up in the emergency room with an

elevated heart rate. He had minimal ability for verbal communication

and had poor insight into his stress-related symptoms, which led to poor

compliance with appointments. Overall, he was reluctant to receive

treatment because he did not wish to talk about his traumatic

Fig. 2. Clinical case examples.

Note: DDS: Diagnostic Drawing Series; GN: graphic narrative; ISO: Intrepid Spirit One; ITT: Intensive Trauma Therapy; L1: level 1; L2: level 2; L3: level 3; TBI:

traumatic brain injury; WRNMMC: Walter Reed National Military Medical Center; Signature Strengths Test.

*This paper presents descriptions of this case summary until February 2018 when art therapy was terminated with author 1 due to the therapist relocating to work at

another clinic. The military service person chose to continue to attend art therapy sessions at the ISO.

J.P. Jones, et al. The Arts in Psychotherapy 63 (2019) 18–30

experiences and was unable to articulate his everyday symptoms.

When Jay was referred to art therapy, his verbal communication

was minimal. For Jay, the option of communicating his current ex-

periences with visual instead of verbal expression appeared to enable

him to feel able to engage in treatment almost immediately. This was

evidenced by his ability to engage in the art making task and verbally

describe what he had visually expressed during the ﬁrst art therapy

session. Jay’s mask appeared to look like an old man with a question

mark across the face, symbolizing how “it gets old”to constantly forget

what people say to him and to not get answers to certain questions he

had about his health (Fig. 2). During individual art therapy sessions,

Jay began to identify internal signs and symptoms of a heightened

stress response. In the second session, an individual art therapy session,

he completed body map drawings, body scan meditations, and feelings

drawings and was able to begin to connect going from “0-60 ﬂat”

around people he did not trust in deployment settings to reacting in the

same way around strangers in public places while at home (Fig. 3).

Whereas he had previously been unable to acknowledge stress and

PTSD and triggers for hyperarousal, he was making these connections in

the second session of art therapy. During the second session of level 1

group, he wrote about an instance in which he stepped on a pressure

plate that luckily did not cause an explosion because a battery source

had died. During the third group session he created a painting of “the

last thing [he] saw before the IED exploded”that caused his injuries.

Jay shared that group art therapy provided him opportunities to con-

nect to others and decrease his feelings of disconnection and under-

stand how his prior combat experiences, including blast exposure, im-

pacted his symptoms. Within the ﬁrst month of art therapy he was

externalizing and processing events that almost took his life as well as

beginning to identify elements in the environment that triggered feel-

ings of fear rooted in his deployment experiences.

During individualized work following work in the level 1 art

therapy groups, Jay delved deeper into trauma work and continued

utilizing bilateral processing in his trauma-focused treatment by using

both writing and art making. He engaged in intensive trauma therapy

and was guided by the art therapist through the creation of a graphic

narrative and was educated about the various stages of the instinctual

trauma response (Gantt & Tripp, 2016). In order to process the ﬁrst time

he was shot at and almost killed and the string of subsequent combat

trauma events that ensued, Jay created drawings for each of these ac-

tions (graphic narrative), including a signiﬁcant day in which he was

involved in three diﬀerent ﬁreﬁghts and another in which his friend

was shot (Fig. 4). Based on Jay’s feedback to the art therapist, these

projects allowed him to gain greater insight and self-awareness of the

physiological responses to triggers in his environment, which led to him

gaining emotional and physical regulation and allowed for bilateral

stimulation of cognitive processes while creating art. This cognitive

sense led to better emotional regulation and reduction in symptoms for

Jay. Furthermore, it allowed him to realize his avoidant behavior to-

wards memories of trauma, which had led to cognitive dysfunction.

Through art therapy sessions, Jay reported that he gained an un-

derstanding of his combat-related stress, understood what triggers were

causing stress that impeded his cognitive abilities, what memories had

been inaccessible due to coping with trauma versus which memories

were not being stored due to his inability to focus on the present (and

not be disturbed by anxiety). Once this was achieved, he was able to

reengage with other disciplines and was able to make gains in proces-

sing and utilizing strategies that improved his cognitive abilities and the

quality of his daily life. He was able to control when he wanted to

communicate verbally (by talking) or nonverbally (by making art).

During this phase of his treatment in the clinic, he began to utilize the

art therapy open studio group, connecting with others and building a

sense of community while taking the reins of his artistic expression and

using art to convey his feelings about certain deployment-related cir-

cumstances. Jay continued to learn techniques to gain skill in using a

variety of art media in order to best capture details of events that

profoundly impacted him. Jay then began to create self-directed art-

works, such as a drawing of the ﬁrst dead child he saw on deployment,

a depiction of a demon that represents his concept of PTSD (Fig. 5), a

painting of a poppy ﬁeld that wound up being the setting for an espe-

cially bad ﬁreﬁght (Fig. 6), and a drawing of the ﬁrst explosion he

survived (Fig. 7).

After processing through negative memories, he began to focus on

creating artwork to capture positive memories and experiences from

deployment, such as creating a drawing based on a photograph of

himself with an Afghan local, which he described as one of his favorite

moments (Fig. 8). He began attending open studio ceramics sessions at

a local community pottery studio where he created ﬁsh sculptures and

otherwise captured that which makes him happy. He became much

more verbally expressive and would converse with this therapist,

Fig. 3. Drawings created by the Marine to gain insight into his unique triggers

for hyperarousal.

Fig. 4. Drawings created by the Marine as part of a complete graphic narrative

of a series of a prolonged combat trauma event.

Fig. 5. The Marine’s depiction of a demon who represents his concept of PTSD.

J.P. Jones, et al. The Arts in Psychotherapy 63 (2019) 18–30

processing his feelings related to being medically retired from the

United States Marine Corps and then about emotions and plans re-

garding his transition into the civilian sector. He continued to gain

insight into how his previous experiences aﬀected his current beha-

viors, and he began to show artwork to his wife to improve their

communication. When Jay was reengaged with other disciplines at this

point, the providers, such as his speech therapist and social worker,

commented on how he was more communicative and better able to

integrate and implement strategies he was learning in their sessions.

During his last day in art therapy, Jay completed a portfolio review

and stated that he felt that the signiﬁcance of his experience in art

therapy was that it enabled him to become more expressive and aware

of the connections between his mind and body. He reported being much

happier than when he had entered the clinic. He created a mask during

his last session, which he stated represented how he’s“still stuck in a

warrior phase but I know my issues, I know me, and I am happy.”It is

worth noting the contrast between this ﬁnal project and the mask he

created on his ﬁrst day of art therapy in which he expressed not un-

derstanding his presenting symptoms. In an art therapy evaluation

questionnaire, the patient identiﬁed addressing the following through

level 1 group art therapy: identity, self-expression, trauma processing,

personal insight. He cited self-expression as the area he addressed most

and stated “I think that for people like myself that can’t express or like

the normal sit and talk, this allows you to speak in a diﬀerent way.”

When surveyed about individual art therapy he identiﬁed addressing

the following: relaxation, self-expression, frustration tolerance, emo-

tional regulation, personal insight, cognitive skills, resiliency, and

trauma processing. According to the patient, he felt he addressed

trauma processing the most and stated “I never knew how aﬀected I

really am, till art therapy.”When asked whether art therapy helped him

diﬀerently than other treatments he has received, he stated, “Yes, be-

cause I never thought or would have thought I would be able to express

myself. I hold a lot that brings you down and tired. But this therapy is

allowing me to get through that.”He shared that feeling the support of

and connection with his art therapist kept him committed to art therapy

even when it was diﬃcult to face his internal demons and that the

support he felt from the interdisciplinary team kept him committed to

treatment even when a switch of command made this challenging.

After completing his treatment at Intrepid Spirit One, Jay medically

retired from the United States Marine Corps, and went to school where

he earned his bachelor’s degree and eventually pursued a nursing de-

gree. He shared that this treatment allowed him to communicate at

levels he feels would not have been possible without engagement in art

therapy. He reported being a happier person because he was better able

to communicate with people he encountered in his daily life as well as

with his family members. Although he did not continue to draw after

leaving art therapy, Jay reported that he often looks back at the work

he created on days he ﬁnds himself triggered to remember traumatic

events of the past. In doing so, he reported revisiting processing

through the events in therapy and being reminded of the importance of

being present and living his life to the fullest.

Case #2, Matt: Engaging in art therapy improved personal insight and

communication with others

Matt, an Explosive Ordnance Disposal (EOD) Airman, had three

deployments to Iraq and Afghanistan over the course of ﬁve years and

reported several blast exposures, involving many (on his third deploy-

ment, he encountered 54 improvised explosive devices in the ﬁrst

month alone) on dismounted patrols. While on foot, he endured several

improvised explosive device blasts at close range that left him feeling

punched, nauseous, and with migraines. During one ﬁreﬁght he lost

consciousness from being knocked back by a rocket-propelled grenade

blast. He was referred to the TBI clinic, presenting with chronic neu-

rological symptoms such as diﬃculty ﬁnding words, forgetfulness, in-

ability to complete tasks, and increased irritability. A few years after his

deployment, Matt disclosed to a medical provider that he noticed that it

would take him longer to formulate his thoughts into verbal expression,

that he experienced diﬃculty ﬁnding words, that he felt as though he

could no longer engage in public speaking or teaching due to the

communication issues that developed as a result of the blast exposures,

and that he felt self-conscious when responding to others.

When Matt entered the level 1 art therapy group sessions, he was

experiencing a lot of frustration due to issues with forgetfulness that

interfered with his ability to carry out daily life tasks. His mask, painted

with a camouﬂage motif that he smudged with red paint to represent

blood, had the words “The Air Force Doesn’t Do That”written across

the forehead (Fig. 2). Matt used this phrase to express that, despite his

experiences as an Explosive Ordnance Disposal technician on several

combat deployments, he felt that others constantly negated all of his

experiences by saying “The Air Force doesn’t do that,”(implying

Airmen are not exposed to combat or bloodshed within close range)

which was a signiﬁcant source of his anger. He also felt initially de-

tached from the group because he was conditioned to expect that others

would hold this preconception of him. His expressive writing focused

on narrating his personal story of wanting to join the military, the

process of joining, his experiences throughout his career, and the im-

pact of his service on his health and on his family. His montage painting

(Fig. 9) included many collaged elements such as a riﬂe, a tombstone

(of a comrade whom he thinks about every day), a badge of his

(showing his focus for the last 12 years), and statements that resonated

with him (such as “Fix yourself before you try and outrun yourself”).

This painting represented past experiences that shaped him as well as

how he desired to be in the future.

During his evaluation session following the level 1 groups, he re-

ported that the common experiences of the group members helped him

Fig. 6. Depiction of a location of an especially bad ﬁreﬁght.

Fig. 7. The Marine’s depiction of the ﬁrst explosion he survived.

Fig. 8. The Marine’s drawing based on one of his favorite moments from de-

ployment.

J.P. Jones, et al. The Arts in Psychotherapy 63 (2019) 18–30

gain comfort in sharing and that the expressive writing in particular

helped him communicate his thoughts more eﬀectively than verbally.

He set his primary goal for art therapy as improving communication

and continued on to level 2 group sessions. For the ﬁrst task, he de-

picted his greatest fear, that of dying too early and his greatest comfort

as ﬁnally feeling as though he was “coming home to something”for the

ﬁrst time (Fig. 10). During the dialogue writing session, he wrote out a

conversation that he would have with his daughter 20–30 years in the

future in which he expressed and worked through the feelings of fear he

had regarding their relationship; that she would blame him for not

being present enough because he was going through a divorce and she

would be living primarily with her mother.

It is important to note that around this time he became open and

honest with the Air Force about his health issues, and his long-term goal

changed to transitioning out of the military through a medical retire-

ment process. When depicting his soul (Fig. 11), he created an image

that expressed how both positive and negative emotions were mixed

around for him and “you never know which will show up.”His depic-

tion of what his soul needed to be nourished to a state of greater well-

being was depicted as feeling at his “best:”out on a lake, ﬁshing, on a

sunny day. Upon later reﬂection, he shared that this art therapy task

had a signiﬁcant impact on how he viewed art therapy and its role in

helping him communicate. For Matt, it was the ﬁrst time he did not

hesitate to depict how he felt and communicated it to the group. This

project helped him realize that “things do get bad, but they never get so

bad that you cannot come back.”By his own description, this project

was the ﬁrst one for which he used a full color palette. He carried these

realizations forward as he approached his future art therapy projects.

Although Matt initially felt withdrawn from the other participants in

the level 1 group because he was the only Airman, as the level 2 groups

progressed, he gained more comfort and greater willingness to connect

with group peers. At the same time, his artistic expression became in-

creasingly more expressive including new visual themes, such a moving

away from structured media and concrete imagery to utilizing more

ﬂuid media and depicting emotions through the use of symbolic colors

and shapes.

Matt spent a month and a half working on the ﬁnal art task of level

2, the celebration/commemoration box (Fig. 12). He intricately painted

the exterior of the box with ﬂags representing the states in which he

was stationed or the countries to which he was deployed, documenting

the chronology of his career. He placed Explosive Ordnance Disposal

lapel pins on the lid of the box to honor his career and utilized the

inside of the box to acknowledge, honor, and process traumas from war.

He included a photograph of the explosion that signiﬁcantly injured

him, a photograph of the EOD Memorial, a Killed in Action bracelet,

and memorial pamphlets. He was able to continue to express the anger

he felt when people dismissed Airmen as not having combat experience,

to process feelings associated with his own near-death experiences and

resulting injuries, and to create a memorial ground that he could per-

sonally visit to honor the deaths of his Explosive Ordnance Disposal

comrades.

Following his participation in the level 2 group sessions, Matt

elected to continue in individual art therapy. He performed the

Diagnostic Drawing Series (Cohen, Hammer & Singer, 1988), which was

processed to reveal that Matt was feeling generally frustrated and ir-

ritable. Underlying this was the fact that his life was full (with work and

being a supportive partner) but that he did not integrate doing activities

for himself that he would ﬁnd personally recharging. To represent this,

Matt drew a depiction of his ﬁgurative battery and included what drains

it and what recharges it. This process supported Matt in identifying

ways in which he could integrate self-care into his routine. He com-

pleted the Signature Strengths Test (McGrath, 2017) and began to

consciously engage in activities that would allow him to cultivate his

strengths and ﬁnd meaning, and he wrote about and illustrated a time

Fig. 9. Montage painting created by the Airman at the end of level 1 art therapy

group.

Fig. 10. Pair of drawings that captured the Airman’s greatest fear and greatest

comfort at the time these were drawn as part of level 2 art therapy groups.

Fig. 11. Pair of drawings created by the Airman to explore visualizing his soul

and what his soul needs for nourishment as part of level 2 art therapy groups.

Fig. 12. Celebration/commemoration box created by the Airman at the end of

level 2 art therapy groups.

J.P. Jones, et al. The Arts in Psychotherapy 63 (2019) 18–30

in which he demonstrated his primary strengths.

Next, Matt began a series of process paintings as a way to enter into

a deeper level of insight. He was instructed to begin with a blank canvas

and to create whatever he felt, with an invitation to further develop or

change or create over when he revisited the canvas each session. He

created an image of a dark grey silhouette in the midst of a background

chaotically painted with a variety of colors (Fig. 13). He described the

image as himself standing, blank, with noise and chaos happening all

around him. The next session he further developed the painting by

using six strands of yarn, each dipped in a diﬀerent paint color, and

then printed within the silhouette to create a chaotic mess of distin-

guishable colors (Fig. 14). He then described the painting as expressing

how he has so much going on inside that he is confused and, when

becoming emotionally triggered, “ﬁnds it hard to quite pick out what’s

wrong.”

After this painting was complete, Matt created an image on canvas

to depict how he felt when triggered by something in the environment

that causes him to become emotionally reactive without insight into

which ﬁgurative button was pushed. The image, a silhouette ﬁlled with

many shapes and colors, became the bottom layer of a layered series of

transparency sheet drawings (Fig. 15). At each session from that point

forward, Matt would create a drawing on a transparency sheet, fol-

lowing the same silhouette of the ﬁgure, each one being his visual ex-

ternalization of one particular stressor in his life (Fig. 16). He spent

each session focused on externalizing, processing, and becoming more

aware of the speciﬁc physical and emotional impact of memory issues,

physical pain, sleep issues, time pressures, involvement with the court

regarding his divorce, and challenging and supportive family members.

In a side project, he depicted feeling isolated. A few sessions into

working on the layered transparency project, Matt reported that he

found it was helping him get more attuned with himself and his triggers

and he found an increased ability to summarize and communicate the

insight he was gaining through art therapy, which was improving his

relationship with his new spouse.

At the end of level 3, Matt participated in a portfolio review and

reﬂected on his series of artworks as well as on his journey in art

therapy. He shared that he saw improvements in all aspects of com-

munication in his life as result of art therapy. Matt believed the process

of art therapy served to help him identify problems that he was not

consciously aware of and to understand the signiﬁcance of past ex-

periences for his current interpersonal situations. Through self-directed

art making, Matt built concrete representations of his emergent post

military identity, which created a sense of personal history that allowed

him to gain insight into his core sense of self. In this respect, the art

functioned as a “window”to the past and served as pieces of a con-

tinuously evolving self-portrait wherein he continued to gain insight

into an evolving personal identity.

This self-awareness allowed for improved communication with his

other providers and eventually led to more direct and targeted therapy,

greatly improving his overall treatment outcome. He shared that his

communication improved with his family, going from not telling them

anything about his deployment experiences and feeling that he was

viewed as an unstable person, to using the art therapy sessions to open

lines of communication with his wife and parents about what was

discussed and processed in art therapy. At work, he became able to

communicate what he had been through and what he was addressing in

therapy to younger Airmen and to Air Force leadership. After art

therapy treatment, Matt reported that he felt he would not be in the

improved position he was in his life without art therapy. He shared that

he was married to a wonderful woman with whom he shared a happy,

healthy relationship. He reported to feel supported by her every step of

the way and knew this was possible because he developed the ability to

communicate what he is going through.

Case #3, Dane: engaging in art therapy helped deﬁne a new purpose beyond

active-duty military service

Dane, a Psychological Operations soldier, sustained career-ending

injuries on deployment when a rocket detonated on a water tower near

him while he was exiting a trailer. He had several shrapnel injuries in

various locations on his face and body and there was documentation of

an altered state of consciousness. Dane was medevacked from the scene

to Walter Reed National Military Medical Center, where he spent ap-

proximately seven months undergoing surgery, rehabilitation, and re-

covery. Afterwards, he was sent home to engage in local rehabilitation

treatment, which he found frustrating because he was not able to secure

consistent appointments. Dane was referred to the Intrepid Spirit One to

receive intensive outpatient treatment, and he quickly became engaged

with each discipline within the clinic.

During Dane’s art therapy evaluation session, he speciﬁed that he

wanted to address the following goals through art therapy treatment:

self-expression, communication, emotional regulation, frustration tol-

erance, relaxation, processing of grief and loss, and processing of

trauma-based issues. He engaged in level 1 groups, where his mask

depicted a split sense of self, with one side representing himself as a

healthy operator, hiding aspects of himself due to the secretive nature

Fig. 13. Initial layer of process painting.

Fig. 14. Further development of process painting.

Fig. 15. Abstract concept of self; base layer for layered transparency drawings.

Fig. 16. Examples of drawings created on transparency sheets, each one en-

abling the Airman to dissect his triggers and gain better understanding of what

exactly underlies his symptoms.

J.P. Jones, et al. The Arts in Psychotherapy 63 (2019) 18–30

of his job, and the other side representing his injuries and his habit of

keeping aspects of his condition secret without intending to do so

(Fig. 2). He created a second mask, to be attached to the back of the ﬁrst

mask in a way that allowed the two parts to open like a locket. The

second mask, also split down the middle, depicts his physical pain on

one side and the façade he puts on when interacting with others, re-

presented by the look of metal. Through this project, he was ﬁnally able

to acknowledge his issues, which translated to more open commu-

nication with providers across disciplines. Through the remainder of

the level 1 groups, he wrote and created a mixed media artwork to

express and process feelings of grief and loss (Fig. 17).

After learning how to use art making for insight and self-discovery

in level 1, Dane continued with individual art therapy sessions to begin

to address grief and loss and to work on improving his communications

skills. He developed a novel technique for coping with his intrusive

memories and symptoms at night. When he had trouble sleeping, in-

stead of ﬁghting himself and becoming frustrated with his sleep issues,

he began to create paintings of the scenes that were keeping him awake

instead of actively avoiding them. He found that this helped him pro-

cess the imagery and the events of his intrusive memories. He would

bring the paintings into his individual art therapy sessions to process

the content of the imagery, much of which depicted scenes from combat

deployments.

Dane created a piece of work at home that he brought into therapy

with two goals: to test his art therapist (author 1) and, since she

“passed”as trustworthy, nonjudgmental, and non-skittish, to process

the work with her. He created a relief sculpture mounted in a shadow

box frame that was a realistic recreation of a piece of the ground in

Afghanistan, including details of the composition of the ground itself,

with added features such as a magazine, a piece of cord, shell casings, a

boot print, and (an artistic recreation of) blood (Fig. 18). Because he

reminisced about his job and role in Afghanistan and was mourning the

fact that he could never go back, he was able to “bring the ground

home,”in his artwork. This was signiﬁcant because many military

service personnel struggle with the fact they cannot “just go visit the

place where their buddies died.”

Once he had established a strong sense of safety and trust within art

therapy and with his art therapist, Dane continued to utilize art therapy

to delve into processing traumatic events from his military career.

Feeling challenged by the opportunity to express and expose the events

that were signiﬁcant sources of pain, he decided to fully test art

therapy, fully test himself, and throw himself into the process by a

“tearing oﬀthe Band-Aid”approach and depicting that which he could

identify as sources of his symptoms. Like Dane, many military service

personnel struggle with the opportunity to expose and process through

the sources of their pain and anger. Dane described this in his own

words:

It’s a constant battle in our mind because sometimes you want to

hold onto the pain and anger so hard because you can feel those

things and you want the anger. The anger kept you alive for so long.

You think you can’t live without it. If you’re honest with yourself,

you’ll admit that you like the pain a little bit. The pain is the most

direct link between you now and the you, you used to be. In the end,

though, you have to make a choice between moving on in life with

those moments or staying stuck in them. If you want a life after war,

you have to face those moments and take back control of your mind.

With this mindset, Dane created an artwork representing the faces

of two enemy individuals who were signiﬁcant in that Dane’s sub-

stantial injuries were tied to missions to capture these two men. Shortly

after this, Dane began to attend pottery sessions in an open studio

community arts engagement setting and utilized the space to create

emotionally expressive sculptures of ﬁgures in combat settings. Back in

art therapy, he created many extremely intricately detailed mixed

media artworks that enabled him to slow down his thoughts, shift his

locus of control, and process events at a controlled and manageable

pace, stepping away when needed. In one series (Fig. 19), a triptych, he

represented three types of losses he often encountered: deaths of in-

nocent civilians, represented through a depiction of a mass grave he

uncovered; deaths of comrades, represented by two combat cross

memorials; and deaths of enemy combatants, represented by an image

of a dead suicide bomber after an attack. Dane continued to attend

weekly pottery sessions, although his work shifted to creating func-

tional objects to promote peace and relaxation, such as fountains for the

garden and pots for plants. He found that he enjoyed taking an art-as-

therapy approach with pottery to balance the trauma-focused clinical

work he was doing in art therapy.

Over the course of four years, Dane attended the weekly open studio

group at the clinic and utilized consistent individual art therapy ses-

sions to create an expansive portfolio of three-dimensional and two-

dimensional mixed-media artworks to capture nostalgic, typical, or

traumatic scenes from his deployment history that conveyed feelings

that are prominent in the experience of service members medically

retiring from their military service. These works included the following

examples: “Discontinued,”a rusty-looking painting of a soldier that

represented “the feeling of not being useful anymore, like a tool that has

been replaced by something new and is left to rust and decay”(Fig. 20);

“Hole in the Wall,”a painting with relief elements of a hole in a wall

that represented how each hole “presents a plethora of dangers that

many people will never experience but are commonplace to the ground

assault solider;”“The Evidence of True Faith and Allegiance,”a sculp-

ture that included his combat boots and cloth fragments in a bloody

pile, that represented the ﬂoor of the medical station where he initially

received treatment when he suﬀered career-ending injuries and also

depicted “the essence of the oath we take;”“The Death of Innocents,”a

sculpture that illustrated the “truly horriﬁc reality of how even the most

innocent are aﬀected by war”as it depicted the skulls of children who

were used as leverage and ultimately murdered; “Join or Die,”a

Fig. 17. Montage painting created by the Soldier expressing and processing

feelings of grief and loss.

Fig. 18. The Soldier’s mixed-media recreation of a piece of the ground in

Afghanistan.

J.P. Jones, et al. The Arts in Psychotherapy 63 (2019) 18–30

painting with mixed-media elements, which used early American ima-

gery paired with Dane’s own words “to express how the American war

ﬁghter, past, present, and future, is essentially connected”(Fig. 21).

At this point it became important for Dane to show his work pub-

licly in order to bridge the gap of understanding between military and

civilian populations in an attempt to decrease the isolation that many

service members feel upon returning home and transitioning into a

civilian world (DeLucia, 2016;Lobban, 2014;Walker et al., 2016). As

someone whose purpose had been deﬁned by his service as a psycho-

logical operations soldier, Dane struggled with the fact that he could no

longer follow that path. Through art therapy, Dane found that he was

able to ﬁnd new purpose by using his role as an exhibiting artist to

communicate the warrior experience as a way to work toward creating

an America where returning service members feel less isolated, thus

ultimately combating disconnection and risk of suicide. Author 1 had

been seeking opportunities for Dane to share his work and found that a

national museum was extremely interested in exhibiting work created

by service members in art therapy.

Dane had his ﬁrst artwork shown at a national museum in the

summer of 2017 in an exhibit, as one of several artists from the Intrepid

Spirit One who displayed their artwork. A few months later, Dane was

invited to have a solo exhibition of his work at the museum. This show

included a lecture open to the public where author 1 provided the

context for understanding how art therapy is used to heal wounded

warriors while Dane presented signiﬁcant pieces of artwork he created

to illustrate the progress he made throughout his art therapy journey.

As result of this show, Dane was approached by a graphic designer who

oﬀered to set up a Web page for Dane to support him in establishing an

art business, which he planned to use to create and sell thought-pro-

voking artwork with a message.

In reﬂecting on how art therapy supported him as he transitioned

from being an active duty service member to a working artist, Dane

stated that he would not be where he was without art therapy. Through

art making, he was able to focus his mind, slow down, and approach

each step one at a time. For Dane, this translated to life outside therapy

by trying not to worry as much about the world outside and to focus on

one issue at a time. Engaging in art therapy also gave him skills and

strategies to cope with trauma and anxiety. He found that meeting and

surpassing challenges in making new and more elaborate artworks, he

could translate these processes into healthier thinking patterns. He felt

that, before art therapy, when his thought patterns became unstable, his

emotions would be unstable, leading to unhealthy actions. With the

addition of art therapy, when his thoughts became unhealthy, he would

engage in a project in order to address those unhealthy thoughts,

leading to emotional regulation, and healthier actions. After art

therapy, he continued to use art for self-discovery and to feel connected

to the millions of veterans who have served our nation.

Discussion

Through a discussion of visual art productions and the personal

reﬂections of three military service personnel on their experiences in art

therapy and community art programs, this article highlights how art

therapy was used to provide treatment for military trauma on an out-

patient basis as part of a comprehensive rehabilitative treatment pro-

gram within a military treatment facility. The environment of the art

therapy space, the therapeutic rapport developed, the trust established

with the art therapist, variety of art media, and the connections built

with peers fostered a safe therapeutic space for the military service

personnel to express, confront, and process that which was taking a toll

on them and underlying the symptoms they struggled most to manage.

Then, the skills that the military service personnel learned in the art

room, the art products themselves, and the associated processes, pro-

vided a further sense of safety and containment, enabling them to begin

to gain control over their symptoms, while also serving as bridges for

communication and connection between the military service personnel

and civilians. These cases point to the value of using nonverbal treat-

ments such as art therapy in addition to (or prior to) engaging in the

evidence and exposure-based psychotherapeutic treatment programs

such as PE or CPT.

We presented three cases to illustrate how art therapy can address

the clinical needs of military service personnel with TBI and PTS.

Participation in a long-term (1–4 years), stage-based, structured art

therapy program, through both group and individual sessions, enabled

military service personnel like the case examples mentioned here to

Fig. 19. A triptych representing three types of losses the Soldier often encountered throughout his time in service.

Fig. 20. Mixed-media artwork the Soldier created and entitled “Discontinued.”.

Fig. 21. Mixed-media artwork the Soldier created and entitled “Join or Die.”.

J.P. Jones, et al. The Arts in Psychotherapy 63 (2019) 18–30

identify and articulate the complexity of their lingering trauma symp-

toms, which led to improvement in communication with other treat-

ment providers and loved ones, and, in turn, led to improvements in

their overall quality of life. The externalized imagery created through

the art therapy program led to improvements in the ability of each

military service person to record his intrusive memories, identify

symptoms he was currently experiencing, and to have more eﬀective

interpersonal relationships in a variety of contexts—medical, personal,

and vocational. After establishing a foundation of safety and comfort in

the art therapy room through levels 1 and 2, the patients engaged in

individualized art tasks that focused on more complex traumatic con-

tent. As their art therapy journeys progressed, they found strength and

resilience and found that work in art therapy fostered improved com-

munication and connection with others.

Notable changes in the lives of these military service personnel

came through the task-oriented approach presented here. The layout of

the art therapy program described in the case summaries, grounded in

research, clinical theory, and an understanding of the military culture

in the United States, provides both structure and freedom for the

military service personnel. All three military service personnel stated

that the program increased the sense of control they felt in their lives

while also fostering a sense of competency and self-reliance as they

began to navigate their post military identities.

Role of the art therapist

It is important to note the role of the therapeutic space and the

therapeutic alliance created by the art therapist and the treatment team

at Intrepid Spirit One. An important aspect of treatment was the re-

lationship between the therapist and the patient, grounded in the es-

tablishment of trust, and that this was done through the therapist’s

honesty and faith in the patients. This can be seen through the in-

novative and individualized treatment provided by author 1, especially

through the community connections with local art studios and galleries

(Jones et al., 2017;Walker et al., 2016). Throughout the program, the

art therapist guided the patients to look for their own messages in their

art while also providing structured opportunities for feedback and re-

ﬂexivity through program evaluation surveys (Kaimal & Blank, 2015),

art-based assessments, and portfolio reviews. These structured feedback

methods provided visual and verbal evidence of the path of their

trauma treatment journey, usually a nonlinear one, while also helping

the military service personnel and their treatment providers to remain

aware of their clinical progress.

Gibson (2018) highlighted the need for art therapists working with

trauma to be sensitive to the impact on their own health and well-being.

The lead author who was also the art therapist used several self-care

strategies including her own artmaking and yoga practice to oﬀset high

demands of attention and nurturance needed to serve her patients.

Focus on clinician well-being is especially salient to ensure the well-

being of the patients. Art therapists might consider active strategies to

care for their own well-being including supervision, artistic practice as

well as identiﬁed activities that help process and replenish them.

As noted in Gibson (2018), therapists who treat trauma are at risk of

developing symptoms of vicarious trauma, experiences that “result from

a cumulative and empathetic engagement with another’s traumatic

experiences that can lead to long-term changes in an individual’s way of

experiencing themselves, others, and the world”(McCann & Pearlman,

1990, p. 132), and secondary trauma,“a form of trauma experienced by

the trauma worker where symptoms similar to those seen in people

with posttraumatic stress disorder (PTSD) can be seen”(Pearlman &

Saakvitne, 1995, p. 22). Author 1 was highly motivated to use art

therapy to foster increased insight, self-expression, trauma processing,

moral injury processing, and identiﬁcation of and subsequent control

over what was underlying symptomatology in the military service

personnel with whom she worked. She empathized deeply with her

clients and was extremely dedicated to ﬁnding ways to promote their

greater health and wellbeing. In addition to the face-to-face time spent

with clients she would read books to better understand psychological

eﬀects of combat or on other related topics such as grief or compassion.

She would also exercise after work every day and was involved in en-

durance athletics to process cases and to think of what approaches to

take the next session she would have with each individual. She would

constantly seek out new places to hike in constant search of more evi-

dence of beauty in the world to counteract all of the negative aspects

that she focused on for many hours each day. She also actively utilized

supervision as well as consistently maintained a visual journal to ex-

ternalize, process, or ground and center.

Self-care was always a priority, but as signs of vicarious trauma and

secondary trauma became evident, she searched for new strategies to

manage the eﬀects of the work. In addition to supervision and personal

art making, she integrated regular visits for acupuncture and Eye

Movement Desensitization and Reprocessing (EMDR) Therapy (Shapiro,

2018), and decreased endurance activities (which she found to be more

depleting) and deepened her yoga practice (which she found more re-

plenishing). She also arranged her schedule at work to create balance,

i.e. community art-as-therapy pottery would occur mid-week to break

up the heavy clinical work, and open studio group (which developed a

lighter-hearted, humor focused environment) was held at the end of

each week. Furthermore, her work to create public exposure opportu-

nities for military service personnel who wanted to publicly share their

work encouraged her to ﬁnd time to further foster her own artistic

identity through public exposure for her own art as well.

Mechanisms of change

Based on the clinical experiences and the case summaries, we pro-

pose that art therapy helps alleviate symptoms of military service per-

sonnel with TBI and PTS through the following processes: (a) improved

self-awareness (through creating and reﬂecting on the artwork); (b)

improved ability to safely express a range of emotions (positive and

negative) and integrate traumatic experiences through art making; (c)

improved interpersonal communication with others (through the crea-

tion and processing of artwork and modeling verbalization in the

therapeutic relationship); (d) improved self-regulation and cognition

(through focusing on and reﬂecting through the artistic process); and

(e) improved ability to manage stressors (by integrating novel problem-

solving approaches inherent in expressive art making and applying

these to reactions in daily life). Through these sequential expressive

tasks, the military service personnel became aware of their own vul-

nerabilities and used that information to guide future decisions, which

helped them develop coping strategies (such as painting intrusive

memories at night) and self-protective behaviors (ability to control

verbalizations and treatment methods) and led to diminished feelings of

traumatization. Empowerment became an important factor for the

military service personnel. The support received from the treatment

team, their fellow group members, and eventually their community led

to feelings of hope and empowerment as they worked toward over-

coming social stigma and isolation related to military trauma, re-

construction of identity, and communication of the invisible wounds of

war that are necessary for recovery.

These case studies demonstrate several mechanisms of change found

to be involved in trauma informed art therapy. In a literature review,

Smith (2016) identiﬁed the following therapeutic mechanisms of

change involved with art therapy treatment for veterans with PTSD:

“the group process”(promoting connection and decreasing sense of

isolation); “externalizing the image and symbolic expression”(the

problem becomes separate from oneself and the development of one’s

narrative is fostered); “from non-verbal to verbal processes”(memory

moves from non-verbal to verbal expression allowing for a recreation of

memory); “integration and processing of memory”(facilitating move-

ment in processing and the construction of a narrative); “containment”

(such as by therapist, environment, or artwork); and “artistic pleasure

J.P. Jones, et al. The Arts in Psychotherapy 63 (2019) 18–30

and mastery”(increasing in intensity by being in groups for therapy).

All of these factors were present in the case studies presented in this

paper. Another mechanism of change found to increase the eﬃcacy of

art therapy in the treatment of PTSD is the therapeutic relationship/

ongoing involvement of the therapist as opposed to when there is little

to no involvement of the therapist (Baker, Metcalf, Varker, & O’Donnell,

2018). As shown in the case studies, the therapist was consistently in-

volved throughout the art therapy treatment and it would have been

valuable to assess therapeutic alliance.

Another area currently being explored in the ﬁeld is the link be-

tween experiences with trauma, creativity, and posttraumatic growth.

Orkibi and Ram-Vlasov (2018), for instance, “found that emotional

creativity followed by CSE [creative self-eﬃcacy] (as two sequential

mediators) statistically mediated a positive association between ex-

posure [to trauma] and PTG [posttraumatic growth] as well as a ne-

gative association between exposure and mental health symptoms”(p.

9). How creative self-eﬃcacy is linked to a person’s posttraumatic

growth and improvement of health in general should be explored fur-

ther, as should speciﬁc elements of art therapy that facilitate action in

this domain.

Implications for the future

The case studies presented in this paper describe a trauma-informed

clinical art therapy approach to treating military service personnel

dealing with symptoms of traumatic brain injury and post-traumatic

stress in an outpatient multidisciplinary rehabilitative setting.

Embedded in the case studies are illustrations of numerous potential

mechanisms of change that should be identiﬁed and explored deeper.

For instance, it would be valuable to further explore which aspects of

art therapy treatment cause an increase in patient engagement in other

aspects of interdisciplinary treatment; or to further explore the link

between creativity and posttraumatic growth. Or, perhaps, to further

explore how long after art therapy treatment ends, patients are con-

tinuing to utilize the skills they gained through the art therapy process,

such as with emotional regulation, improved communication, or crea-

tive problem solving in daily life. Additionally, it may be valuable to

study the role of the art therapist in the eﬃcacy of the therapy, or the

signiﬁcance of engagement in community programs as a bridge to fa-

cilitate transition from clinic to community involvement. Further in-

vestigation into the speciﬁc mechanisms of change inherent in trauma

informed art therapy treating military service personnel healing from

TBI and PTSD should be considered.

Declaration of interests

None.

Funding

This project was funded by a graduate research fellowship from

Drexel University to Ms. Jessica Drass and by Creative Forces

: NEA

Military Healing Arts Network which is an initiative of the National

Endowment for the Arts (NEA) in partnership with the U.S.

Departments of Defense and Veterans Aﬀairs and the state and local arts

agencies. The Creative Forces

: NEA Military Healing Arts Network

initiative serves the special needs of military patients and veterans with

traumatic brain injury and psychological health conditions, as well as

their families and caregivers. Administrative support for the initiative is

provided by Americans for the Arts.

Disclaimer

The identiﬁcation of speciﬁc products, scientiﬁc instrumentation, or

organization is considered an integral part of the scientiﬁc endeavor

and does not constitute endorsement or implied endorsement on the

part of the author, DoD, or any component agency. The views expressed

in this study are those of the authors and do not reﬂect the oﬃcial

policy of the Department of Army/Navy/Air Force, Department of

Defense, or U.S. Government.

Acknowledgments

National Endowment for the Arts Creative Forces

Initiative.

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Full-text available

Dec 2017

Objective: There is a growing body of literature supporting the use of creative arts therapies; however, the efficacy of creative arts therapies in the treatment of posttraumatic stress disorder (PTSD) has not been systematically evaluated. The aim of this systematic review was to examine the efficacy of creative arts therapy including music therapy, art therapy, dance/movement therapy, and drama therapy, in the treatment of PTSD. Method: Ten databases were searched for peer-reviewed literature published from inception to December 2016. Studies were included in the review if they used a randomized controlled trial (RCT), a pseudo RCT, or a controlled study design; tested the efficacy of one of the creative arts therapies described above; and reported changes to PTSD diagnosis or symptomatology. Results: From an initial yield of 1,918 records, 1,653 records were screened on title and abstract and 125 were screened at full-text. Seven studies met the inclusion criteria for review, with four studies investigating art therapy, two studies investigating music therapy, and a final study investigating drama therapy. Individual studies were initially rated on a standardized quality and bias checklist, and then GRADE was used to rate the overall evidence for each intervention. The evidence for music therapy, art therapy, and drama therapy was ranked as low to very low, with no studies found for dance/movement therapy. Generally, the quality of the trials was very poor. Future directions for this field of research are to improve the scientific quality of the research trials in this area. (PsycINFO Database Record

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

Article

Full-text available

Nov 2017

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

Quantitatively Improved Treatment Outcomes for Combat-Associated PTSD With Adjunctive Art Therapy: Randomized Controlled Trial

Article

Jan 2019

This article describes a randomized, controlled trial (N = 38) that compared art therapy in conjunction with cognitive processing therapy (CPT) to CPT alone for veterans with combat-related posttraumatic stress disorder. Participants were randomized to either the experimental condition of 8 sessions of CPT and 8 sessions of individual art therapy or to the control condition of 8 sessions of CPT and 8 individual sessions of supportive psychotherapy. Outcome measures included the Beck Depression Inventory–II (BDI–II), PTSD Checklist–Military (PCL–M), and self-ratings of perceived treatment benefits. Experimental group participants had statistically significantly greater reduction in PCL–M and BDI–II scores compared to the control group and the perceived benefit of treatment was greater for art therapy as compared to CPT.

A Visual Conversation With Trauma: Visual Journaling in Art Therapy to Combat Vicarious Trauma

Article

Aug 2018

Diana Gibson

Art therapists working with trauma populations are continually exposed to traumatic stories and experiences from their clients. The negative effects of such exposure can begin to cause the therapists to become oversaturated with trauma and decrease their resiliency and balance in their lives. This viewpoint explores the effectiveness of using a visual journal as a processing tool in response to the lived experience of a therapist working with a trauma population of clients in a pediatric hospital setting. Through stories and images, the therapist explores the possibilities of a visual journal to be an effective tool for resiliency, processing, and ethical boundaries between work and home.

The influence of psychosocial factors in veteran adjustment to civilian life

Article

Mar 2018

https://onlinelibrary.wiley.com/doi/abs/10.1002/cpp.2182 Aim: Although most veterans have a successful transition to civilian life when they leave the military, some struggle to cope and adjust to the demands and challenges of civilian life. This study explores how a variety of psychosocial factors influence veteran adjustment to civilian life in Scotland, UK, and which of these factors predict a poor adjustment. Methods: One hundred and fifty‐four veterans across Scotland completed a set of questionnaires that measured veteran adjustment difficulty, quality of life, mental health, stigma, self‐stigma, attitude towards help‐seeking, likelihood of help‐seeking, experiential avoidance, reappraisal and suppression. Results: Veteran adjustment difficulty and quality of life were significantly correlated to a number of psychosocial factors. Mental health, experiential avoidance and cognitive reappraisal were found to be predictors of veteran adjustment difficulty, and experiential avoidance and cognitive reappraisal partially mediated the relationship between mental health and veteran adjustment, with experiential avoidance being the stronger mediator. Discussion: Our findings suggest that early assessment of experiential avoidance and cognitive reappraisal and the provision of relevant emotion regulation skills training could potentially reduce the veteran's need for more complex (and costly) psychological interventions in the future. Implications for veterans, as well as the services and professionals involved with veteran transition and health care are discussed.

Art Therapy for Military Service Members with Post-Traumatic Stress and Traumatic Brain Injury: Three Case Reports Highlighting Trajectories of Treatment and Recovery

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