Active-duty military service members' visual representations of PTSD and TBI in masks

A conceptual framework for a neurophysiological basis of art therapy for PTSD

Post-traumatic stress disorder (PTSD) is a heterogeneous condition that affects many civilians and military service members. Lack of engagement, high dropout rate, and variable response to psychotherapy necessitates more compelling and accessible treatment options that are based on sound neuroscientific evidence-informed decision-making. Art therapy incorporates elements proven to be effective in psychotherapy, such as exposure, making it a potentially valuable treatment option. This conceptual paper aims to inform the neurophysiological rationale for the use of art therapy as a therapeutic approach for individuals with PTSD. A narrative synthesis was conducted using literature review of empirical research on the neurophysiological effects of art therapy, with supporting literature on neuroaesthetics and psychotherapies to identify art therapy factors most pertinent for PTSD. Findings were synthesized through a proposed framework based on the triple network model considering the network-based dysfunctions due to PTSD. Art therapy's active components, such as concretization and metaphor, active art engagement, emotion processing and regulation, perspective taking and reframing, and therapeutic alliance, may improve symptoms of PTSD and prompt adaptive brain functioning. Given the scarcity of rigorous studies on art therapy's effectiveness and mechanisms of alleviating PTSD symptoms, the suggested framework offers a neurophysiological rationale and a future research agenda to investigate the impact of art therapy as a therapeutic approach for individuals with PTSD.

Art therapy masks reflect emotional changes in military personnel with PTSS

Among disabling post-traumatic stress symptoms (PTSS) are irritability, aggressive behavior, distressing memories and general impaired cognition and negative mood. Art therapy interventions, including mask-making, can potentially alleviate these symptoms. We tested the hypothesis that art conveys emotions and predicted that blinded viewers would be able to perceive changes in theoretically derived emotional profiles expressed in art made by military personnel with PTSS from the onset to the end of therapy. Five service members and veterans exhibiting PTSS were enrolled in an 8-session art therapy protocol, during which they artistically transformed papier-mâché masks at the beginning and end of the protocol. We found that blinded viewers without knowledge of the masks' creation stage (onset or end of therapy) read initial masks as conveying more negative emotions (e.g., angry, upset, and challenged) and later masks as conveying more positive emotions (calm and pleasure). Based on the assessments from the blinded evaluators, we infer the emotional transition experienced by the participants was expressed in the masks. In an exploratory arm of the study, we also found that viewers were better able to empathize with the negative emotions experienced by participants with PTSS when asked to explicitly take their perspective.

Creative Forces programming with military families: Art therapy, dance/movement therapy, and music therapy brief vignettes

LAY SUMMARY

Creative arts therapists (art therapists, dance/movement therapists, and music therapists) administer assessments and interventions that support the holistic well-being of military families affected by traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). Through participation in the Creative Forces: United States National Endowment for the Arts Military Healing Arts Network, military families discovered strengths, inspired connections, and improved understanding of their relationships. Creative arts therapies (CATs) motivated engagement, which ultimately boosted family resilience. CATs are an integral part of interdisciplinary care to address behavioural and rehabilitative conditions of military families impacted by TBI and PTSD. Future research should examine the efficacy of creative arts therapies in improving resilience in military families.

Collage-based graphic elicitation method for capturing the lived experiences of veterans with Gulf War illness

AIMS

Graphic elicitation is an emergent data gathering approach in qualitative research. An overview of the development and application of a collage based graphic elicitation method in gaining greater understanding about the experience of Gulf War Illness (GWI) is presented in this paper. The unique contributions of this method are also discussed.

MAIN METHODS

Fourteen veterans with GWI were interviewed and then invited to represent their experiences in a visual format through a collage graphic elicitation task. Interviews and collage artworks were coded and compared to both verbal and art responses during the graphic elicitation process.

KEY FINDINGS

Comparison of the content in the interview responses and collage artwork indicates that the graphic elicitation process resulted in three distinct responses: (1) Synthesis and confirmation of content articulated in the interviews, (2) focus on salient aspects of living with GWI, and (3) revealing previously unarticulated experiences.

SIGNIFICANCE

This work demonstrates the unique contributions of collage graphic elicitation, including allowing for spontaneity, metaphorical thinking, enriching verbal explication, and uncovering lived experiences and new affective responses. The sample size was too small to make any generalizations, and more research is needed to further validate these initial findings.

Creative Arts Therapy as a Potential Intervention to Prevent Burnout and Build Resilience in Health Care Professionals

The delivery of health care is undergoing a rapid evolution that is dramatically changing the way health care professionals perform their job responsibilities. In this increasingly stressful work environment, professionals are experiencing alarming rates of burnout. Recent efforts to enhance wellness have been directed toward organizations. However, because of the nature of the work performed in intensive care units, interventions to develop individual resilience are also needed. Currently, medical centers are environments in which the emotional impact of work-related trauma is often minimized and rarely processed. Some individuals may struggle to describe or express the impact of those traumas. Through nonverbal interventions, creative arts therapy can help people access, explore, and share authentic emotion in visual, musical, physical, or written form. By reconstructing meaning through transformative methods, participants may confront, reflect, and better cope with traumatic experiences while catalyzing social support networks and deepening relational bonds in the workplace.

Arts activity and well-being for visually impaired military veterans: a narrative discussion of current knowledge

OBJECTIVES

The objective of this study was to offer an overview of literature relating to the topic of arts as activity within the context of military and veteran health and to consider the implications of current knowledge on future research with visually impaired veterans.

STUDY DESIGN

A search for literature addressing the topic of visual art activities with visually impaired veterans was undertaken. No research addressing this topic was identified. A review of literature on the related topics of mental health and well-being in military veterans, visual impairment and mental health and well-being, and art therapy for veteran populations was carried out to offer an overview of current knowledge.

RESULTS

While there is growing evidence of the benefits of arts engagement among both general and military populations, the role of the visual arts in the everyday lives of broader veteran samples, and the impact of these activities on holistic well-being, remains underexplored. The current article highlights the need for art as activity to be differentiated from art as therapy and argues that the former might offer a tool to positively impact the holistic well-being of visually impaired veterans.

CONCLUSIONS

Future research relating to the use of visual art activities in the context of veteran health and well-being should endeavour to explore the potential impacts of engagement on holistic well-being. Research is needed to build on anecdotal evidence of the positive impact of arts engagement on visually impaired veterans by systematically exploring if, and how, holistic well-being in this population may be impacted by engagement with visual art activities.

Efficacy of an Interdisciplinary Intensive Outpatient Program in Treating Combat-Related Traumatic Brain Injury and Psychological Health Conditions

Background: Since 2000, over 413,000 US service members (SM) experienced at least one traumatic brain injury (TBI), and 40% of those with in-theater TBIs later screened positive for comorbid psychological health (PH) conditions, including post-traumatic stress disorder (PTSD), depression, and anxiety. Many SMs with these persistent symptoms fail to achieve a recovery that results in a desirable quality of life or return to full duty. Limited information exists though to guide treatment for SMs with a history of mild TBI (mTBI) and comorbid PH conditions. This report presents the methods and outcomes of an interdisciplinary intensive outpatient program (IOP) in the treatment of SMs with combat-related mTBI and PH comorbidities. The IOP combines conventional rehabilitation therapies and integrative medicine techniques with the goal of reducing morbidity in multiple neurological and behavioral health domains and enhancing military readiness.

Methods: SMs (n = 1,456) with residual symptoms from mTBI and comorbid PH conditions were treated in a 4-week IOP at the National Intrepid Center of Excellence (NICoE) at Walter Reed National Military Medical Center (WRNMMC). The IOP uses an interdisciplinary, holistic, and patient-centric rehabilitative care model. Interdisciplinary teams provide a diagnostic workup of neurological, psychiatric, and existential injuries, and from these assessments, individualized care plans are developed. Treatment response was assessed using the Neurobehavioral Symptom Inventory (NSI), PTSD Checklist—Military Version (PCL-M), Satisfaction With Life Scale (SWLS), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Epworth Sleepiness Scale (ESS), and Headache Impact Test-6 (HIT-6) and administered at admission, discharge, and at 1, 3, and 6 months post-discharge.

Findings: Following treatment in the IOP, the symptomatic patients had statistically significant and clinically meaningful improvements across all outcome measures. The largest effect size was seen with GAD-7 (r = 0.59), followed by PHQ-8 (r = 0.56), NSI (r = 0.55), PCL-M (r = 0.52), ESS (r = 0.50), SWLS (r = 0.49), and HIT-6 (r = 0.42). In cross-sectional follow ups, the significant improvements were sustained at 1, 3, and 6 months post-discharge.

Interpretation: This report demonstrates that an interdisciplinary IOP achieves significant and sustainable symptom recovery in SMs with combat-related mTBI and comorbid PH conditions and supports the further study of this model of care in complex medical conditions.

A case analysis of service-member trauma processing related to art therapy within a military-intensive outpatient program

Objectives

Art therapy has been widely used in clinical settings and has shown preliminary success in military trauma. This case study describes a mask‐making art therapy directive facilitated by a board‐certified art therapist as an adjunct to group posttraumatic stress disorder (PTSD) treatment in a military‐intensive outpatient program.

Methods

Described are clinical outcome measures, linguistic analysis of a personal journal, evaluation of this service‐member's artwork, and experiences in the program.

Results

Mask‐making, as a trauma‐focused group‐art therapy directive, expanded the understanding of treatment progress reflected in journal notes, mask imagery, and by a change in linguistic indices of trauma processing, despite an overall increase in PTSD symptoms as he confronted his traumatic experiences. He reported improvement in coping and successfully returned to full military duty following treatment.

Conclusions

This case study suggests that art therapy and written narrative, combined with standardized self‐report assessments, may more accurately indicate improvement in overall PTSD treatment.

'Master My Demons': art therapy montage paintings by active-duty military service members with traumatic brain injury and post-traumatic stress

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.

Neurobehavioral Management of the Polytrauma Veteran

Since the inception of the Afghanistan and Iraq wars, an increasing number of veterans have sought treatment from the Department of Veterans Affairs for combat-related injuries. Many veterans experience postconcussive symptoms, traumatic stress, chronic pain, sensory deficits, and/or headaches. The goal of this article was to highlight some of the challenges treatment providers may face, while providing rehabilitation specialists with important evaluation and treatment considerations in working with this population to maximize outcomes for these veterans.

Medical Students' Efforts to Integrate and/or Reclaim Authentic Identity: Insights from a Mask-Making Exercise

Medical students' mask-making can provide valuable insights into personal and professional identity formation and wellness. A subset of first- and second-year medical students attending a medical school wellness retreat participated in a mask-making workshop. Faculty-student teams examined student masks and explanatory narratives using visual and textual analysis techniques. A quantitative survey assessed student perceptions of the experience. We identified an overarching theme: "Reconciliation/reclamation of authentic identity." The combination of nonverbal mask-making and narrative offers rich insights into medical students' experience and thinking. This activity promoted reflection and self-care, while providing insight regarding personal and professional development.

Observational study of associations between visual imagery and measures of depression, anxiety and post-traumatic stress among active-duty military service members with traumatic brain injury at the Walter Reed National Military Medical Center

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.