Melissa S. Walker’s research while affiliated with Walter Reed National Military Medical Center and other places

Art therapy has traditionally been used as a treatment approach but it can also be applied successfully as a clinical behavioral health assessment tool in the care of military service members suffering from the effects of traumatic brain injury (TBI) and operational stressors. This observational study examined patterns of associations between visual imagery (mask and montage paintings) and clinical symptoms among 240 active-duty military service members with TBI, and associated psychological health conditions to include posttraumatic stress disorder (PTSD). The service members had participated in a 4-week intensive outpatient assessment and treatment program at the Walter Reed National Military Medical Center in the United States. Themes seen in the visual imagery were examined in correlation with standardized measures of PTSD (Posttraumatic Stress Disorder Checklist: Military Version) and depressive symptoms (Patient Health Questionnaire-9). The analysis showed that certain themes, like the use of color symbolism to depict psychological states, were associated with greater PTSD and depressive symptoms at the beginning of the program. In addition, patients who depicted themes like physical injury, psychological injury, and memories of deployment in Week 1 of the program were more likely to continue to represent them in Week 4. Depiction of themes like color metaphors and duality was associated with lower depressive symptoms at the end of the program. The findings indicate the potential clinical and prognostic value of tracking the content of visual imagery created by military service members with TBI and associated psychological health conditions. Clinical applications include the recognition that certain visual themes could indicate higher or lower levels of distress and may help guide targeted care.

Recent conflicts of war have resulted in what are being referred to as the “invisible wounds of war.” Complex, comorbid conditions in military service members (SMs) and veterans, including TBI and PTSD, have prompted clinicians and researchers to explore treatments which address this population’s unique needs, including personalized care in which the SM can meaningfully engage. Since 2010, the National Intrepid Center of Excellence (NICoE) has designed and implemented an interdisciplinary care model which incorporates the creative art therapies for SMs with TBI/PTSD and other associated psychological health conditions. Art therapy programming and research outcomes were presented at the 2017 International Conference on Mobile-Brain Body Imaging and the Neuroscience of Art, Innovation, and Creativity conference held in Valencia, Spain. Key findings when examining art therapy for SMs with TBI/PTSD include the need for individualized care for this unique population, including treatment which allows for safe expression of traumatic and emotional content, the fostering of a sense of belonging within community, as well as the use of art therapy as an assessment tool. Future need for prospective, controlled, multi-site research in art therapy has been implicated and is outlined in the Creative Forces®: NEA Military Healing Arts Network’s Clinical Research: A Strategic Framework and Five-Year Agenda (2018–2022).

Background: Therapeutic writing has been shown to improve both physical health and emotional well-being. This paper examines the usefulness of clinical notes as a data source, and presents two different analyses of individual clinical notes of therapeutic writing group sessions: analysis performed by a person and analysis by a computer-based program (Pennebaker et al., 2015). The therapeutic writing sessions were offered during the second week of treatment at the National Intrepid Center of Excellence (NICoE) as part of an integrative care model for service members (SMs) with traumatic brain injury and underlying psychological conditions to include post-traumatic stress disorder (PTSD). Method: Therapeutic writing sessions were facilitated in the art therapy studio at the NICoE. The sessions were documented in the military healthcare system’s patient record application by the art therapist and art therapy interns at the NICoE. Clinical notes were informed by SM self-report surveys and clinician observations. Notes from May 2012 to 2015 and were pulled and coded manually for emerging themes, then separately analyzed by a computer software text content analysis program (Pennebaker et al., 2015). Results: Overall, SMs reported more positive than negative, neutral, or mixed emotions during and after the therapeutic writing experience. Some reported a change from negative to positive emotions through the writing process, and many described experiencing relief during and after sessions. SMs wrote on a wide range of topics. Most SMs kept their writing pieces, although some destroyed them or shared them with others, and a few SMs gifted the pieces. Computerized-based analysis (Pennebaker et al., 2015) indicated that work and social were the most prominent content theme areas. It also showed that positive emotions were more evident than negative emotions in the clinical notes and that the focus of the writing pieces was primarily on the present rather than on the past or the future. Implications: Many SMs perceived the therapeutic writing experience as therapeutic, a relevant coping skill, and enjoyable. Some, however, preferred to work on art therapy projects they had begun in previous sessions (such as mask-making) during the writing sessions. The computer-based analysis of the clinical notes took much less time than the human analysis, but it did not produce results of comparable richness or nuance. Computer-based analysis of the actual therapeutic writing pieces may provide deeper insights into the content and themes that emerged during this therapeutic intervention.

This study involved a thematic analysis of montage paintings and of related clinical records of 240 active-duty military service members collected during their art therapy treatment for traumatic brain injury and underlying psychological health concerns, including post-traumatic stress, at the National Intrepid Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland, USA. Congruent with other research findings, the qualitative analyses of this study suggest that the group art therapy experiences fostered improvement in interpersonal relatedness, hopefulness and gratification for the service members in treatment, aiding in externalisation, progressive exposure and construction of a trauma narrative imperative for recovery. The mixed media nature of the montage painting supported the expression of a range of postcombat symptoms. Results from this study highlighted the complexity of military culture, necessitating a broader scope of analyses for how art therapy helps service members express and communicate their challenges to care providers, peers and family as well as regulate emotion in the short and long term.

TBI and PTSD are global issues and are often referred to as signature wounds of the Iraq and Afghanistan wars. Art therapy can provide unique insights into military service members’ injuries and states of mind via externalisation within an art product; however, interpretation of results is complex and subjective. Advance neuroimaging tools such as resting state fMRI can be employed to demonstrate objective measures of brain structure and activity. This case series highlights two distinct patient profiles, suggesting a relationship between resting state connectivity maps and dynamic thalamic connectivity (as well as PCL-C and NSI scores and brain scars) and the corresponding visual elements of masks made during art therapy treatment. Ultimately, this study indicates a need for future research examining potential neurological changes pre- and post-art therapy treatment.

Objectives The study aimed tocompare recurring themes in the artistic expression of military service members (SMs) with post-traumatic stress disorder (PTSD), traumatic brain injury and psychological health (PH) conditions with measurable psychiatric diagnoses. Affective symptoms and struggles related to verbally expressing information can limit communication in individuals with symptoms of PTSD and deployment-related health conditions. Visual self-expression through art therapy is an alternative way for SMs with PTSD and other PH conditions to communicate their lived experiences. This study offers the first systematic examination of the associations between visual self-expression and standardised clinical self-report measures. Design Observational study of correlations between clinical symptoms of post-traumatic stress, depression and anxiety and visual themes in mask imagery. Setting The National Intrepid Center of Excellence at the Walter Reed National Military Medical Center, Bethesda, Maryland, USA. Participants Active-duty military SMs (n=370) with a history of traumatic brain injury, post-traumatic stress symptoms and related PH conditions. Intervention The masks used for analysis were created by the SMs during art therapy sessions in week 1 of a 4-week integrative treatment programme. Primary outcomes Associations between scores on the PTSD Checklist–Military, Patient Health Questionnaire-9 and Generalized Anxiety Disorder 7-item scale on visual themes in depictions of aspects of individual identity (psychological injury, military symbols, military identity and visual metaphors). Results Visual and clinical data comparisons indicate that SMs who depicted psychological injury had higher scores for post-traumatic stress and depression. The depiction of military unit identity, nature metaphors, sociocultural metaphors, and cultural and historical characters was associated with lower post-traumatic stress, depression and anxiety scores. Colour-related symbolism and fragmented military symbols were associated with higher anxiety, depression and post-traumatic stress scores. Conclusions Emergent patterns of resilience and risk embedded in the use of images created by the participants could provide valuable information for patients, clinicians and caregivers.

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

Active-duty military service members have a significant risk of sustaining physical and psychological trauma resulting in traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). Within an interdisciplinary treatment approach at the National Intrepid Center of Excellence, service members participated in mask making during art therapy sessions. This study presents an analysis of the mask-making experiences of service members (n = 370) with persistent symptoms from combat- and mission-related TBI, PTSD, and other concurrent mood issues. Data sources included mask images and therapist notes collected over a five-year period. The data were coded and analyzed using grounded theory methods. Findings indicated that mask making offered visual representations of the self related to individual personhood, relationships, community, and society. Imagery themes referenced the injury, relational supports/losses, identity transitions/questions, cultural metaphors, existential reflections, and conflicted sense of self. These visual insights provided an increased understanding of the experiences of service members, facilitating their recovery.