Melissa Walker

A fit, uniformed Marine sat before me, focusing intently on the task at hand. He had been working on creating a mask now for almost two hours. He had never in his life engaged in anything like this before.

This Marine had recently arrived anxious, confused and angry. After 23 years of service to his country, he felt broken and hopeless. Multiple blast injuries had upset his cognitive abilities and caused daily headaches. Traumatic memories were constantly clouding his thoughts. He worried for the safety of his family. He was overwhelmed.

Suddenly, the Marine looked up at me. “I’m finished,” he declared. He stared at the mask, which was covered in symbolism only he could understand. I wouldn’t even begin to try and interpret his intentions, but I wouldn’t have to. He hesitated, then began pointing out each area of the mask and explaining its significance.

Afterwards, the Marine stared at me, shocked. “I can’t believe I just told you all of that. I’ve never been able to explain what was bothering me before. And now here it is… all in one place.”

A Marine who felt broken had for the first time found a way to put all of the pieces together. He would later describe the art therapy process as the key to his healing. “It released the block,” he explained, “and then my treatment just soared. For the first time in 23 years I could actually talk openly to anyone, because it unlocked it.”

Art Therapy at the NICoE
Art therapy is a psychotherapeutic process during which a trained therapist utilizes art-making as a symbolic vehicle for communication with the patient (click here to read a lengthier definition of art therapy as well as view practice requirements via the American Art Therapy Association). At the National Intrepid Center of Excellence (NICoE), service members coping with mild traumatic brain injury (mTBI) and psychological health concerns are assessed and treated over a four-week integrated care program. According to the National Center for PTSD, Mild traumatic brain injury (mTBI) is often referred to as the “signature injury” of the conflicts in Iraq and Afghanistan, and service members who have experienced mTBI are at increased risk of depression and underlying psychological health (PH) conditions to include post traumatic stress disorder (PTSD) (Summerall, 2007).

Art therapy, as well as music therapy and therapeutic writing, is the standard of care at the NICoE. Service members are introduced to creative arts therapy as a way to express themselves and process their identities, stressors, transition, and traumatic memories. The following list includes treatment goals and improvements observed at NICoE, with guidance from Collie, Backos, Malchiodi, & Spiegal (2006):

• Traumatic Brain Injury (TBI): Increased stamina and frustration tolerance, increased dexterity and hand-eye coordination, improved initiation of sequential activities, increased on-task duration, task completion improvement
• Post-traumatic Stress Disorder (PTSD): Reduction of arousal/hypervigilance, reconsolidation of memories, increased exposure to/processing of traumatic memories, reactivation of positive emotion
• TBI and PTSD: Decrease in anxiety, reduction of agitation/anger, increased self esteem, reconnection with/repair of sense of self/identity, increased sense of control and self efficacy

Also observed during group art therapy at NICoE are Sell and Murrey’s (2006) assertions that “social growth encouraged by the art therapist balances the nonverbal representations with verbal elicited communication,” and “interaction with the art therapist and other group participants promotes social skills and ultimately self-understanding for the client with TBI.”

For many service members, art therapy is a safe and validating way to share their feelings and emotions, and as it turns out – there is a scientific and biological explanation as to why art therapy is a beneficial modality for this population.

Art Therapy, Research, and the Brain
In a healthy brain, the left and right hemispheres are constantly communicating. According to Bessel van der Kolk (2003), neuroimaging scans suggest that when an individual attempts to recall a traumatic event, the left frontal cortex of the brain shuts down. This includes the Broca’s area of the brain, which is the center of expressive speech and language. In contrast, the areas of the brain that are activated during trauma light up. These include areas in the right hemisphere of the brain that control emotional and autonomic arousal, and detect threat (Crenshaw, 2006). According to Klorer (2005) art-making activates the same parts of the brain as trauma… indicating that art therapy has the ability to bypass the left frontal cortex and stimulate the area of the brain responsible for encoding the traumatic memory. When an individual then processes the meaning behind their artwork with the therapist, they are reactivating the frozen speech area of the brain, and therefore reintegrating the two hemispheres.

NICoE hopes to one day glean more information into the neuroscience of art therapy via research, and studies for the exploration of the benefits of the creative arts therapies are currently being developed with cautious sensitivity not to disrupt the delicate balance of clinical care VS assessment. A ground-breaking partnership with the National Endowment for the Arts aims to measure the effectiveness of the creative arts therapies for service members and their families, and a formal therapeutic writing protocol for a mixed methodology study is in the IRB submission process.

A Path to Wellness & Healing
While art therapy cannot be recreated without the therapist present, service members are encouraged to continue art-making autonomously after discharge. Quite often service members share that they have continued exploring the creative arts since leaving the NICoE, and many send photos of their recent work. One service member has set up his own studio and is selling his work and donating the profits to wounded warrior charities. Another has written a screenplay and was awarded a full scholarship to Vassar College, where he plans to double major – with his second major focusing on the expressive arts and therapy.

During the recent National Summit:  Arts, Health and Well-being across the Military Continuum at Walter Reed National Military Medical Center, it was encouraging to see how many community programs and organizations have been created to assist in the continuity and reintegration of our service members. And while creative arts therapists will continue to push for an increase in formal positions across the continuum of care, the existence of arts engagement opportunity outside of and as an adjunct to treatment is crucial. It is my hope that we continue to work together and network so that we may streamline efforts and help to ensure service members and their families are aware of the opportunities available to them. 

References
1. Summerall, E.L. (2007). Traumatic Brain Injury and PTSD. Retrieved from http://www.ptsd.va.gov/professional/pages/traumatic-brain-injury-ptsd.asp.
2. Collie, K., Backos, A., Malchiodi, C., & Spiegal, D. (2006). Art Therapy for Combat Related PTSD: Recommendations for Research and Practice.  Art Therapy: Journal of the American Art Therapy Association, 23(4), 157-164.
3. Sell, M., & Murrey, G. (2006). Alternative Therapies in the Treatment of Brain Injury & Neurobehavioral Disorders: A Practical Guide, (pp.29-39 . Routledge.
4.  van der Kolk, B.A. (2003) “The frontiers of trauma.” Presentation at the Psychotherapy Networker Symposium. Washington, DC.
5. Crenshaw, D. (2006). Neuroscience and Trauma Treatment. In Carey, L. (Ed.), Expressive and Creative Arts Methods for Trauma Survivors, (pp. 21-38).Philadelphia, PA: Jessica Kingsley Publishers.
6.  Klorer, G.P. (2005). Expressive therapy with severely maltreated children: Neuroscience contributions.  Art Therapy: Journal of the American Art Therapy Association, 22(4), 213-220.

For more art therapy research references, please also visit the “Art Therapy Outcomes Bibliography,” via the American Art Therapy Association Research Committee.