Approximately 2.6 million United States service members were deployed to serve in the military from 2001 to 2011, during the period of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF). And research suggests that 10–18% of veterans from those operations return home with Post-Traumatic Stress Disorder (PTSD). Intense and debilitating fear, depression, negative moods, and nightmares interrupt their daily lives.
Among the various clinical techniques and tools used to treat service members with PTSD, art therapy is a strong option. A 2012–14 survey at the National Intrepid Center of Excellence (NICoE, the outpatient clinic dedicated to treatment of Traumatic Brain Injuries at Walter Reed Military Medical Center in Bethesda, Maryland) ranked art therapy among the top five most helpful techniques used to treat veterans.
NICoE is one of 11 sites across the U.S. that hosts Creative Forces, the creative arts therapy initiative launched by the National Endowment for the Arts and Department of Defense, which employs art therapy, music therapy, and dance therapy to treat psychological disorders related to post-traumatic stress and traumatic brain injuries (TBIs). In addition to these clinical sites across the country, and one telehealth program to help service members living outside of those communities, the initiative also funds research in the field.
A new article published in the International Journal of Art Therapy by researchers and art therapists of Creative Forces reports fresh evidence pointing to the positive effects of art therapy on U.S. military service members with TBIs and PTSD. “The art therapy journey serves as an agent of change,” the authors write, “during which [service members] establish a new sense of self as creator rather than destroyer, as productive and efficacious instead of broken, as connected to others as opposed to isolated, and in control of their future, not controlled by their past.” The program officially launched in 2011, but its efforts can be traced back to 2004, when the NEA partnered with the Department of Defense to create an expressive writing program called Operation Homecoming: Writing the Wartime Experience. That successful initiative became part of formal medical protocol, among other therapeutic activities for troops returning from active duty, and it paved the way for the Creative Forces pilot program at NICoE. The second outpost of Creative Forces followed soon after at the Intrepid Spirit Center at Fort Belvoir Community Hospital in Virginia. The success of those programs led to a significant funding and expansion in 2016; the NEA received $1.92 million from congress for Creative Forces that year, in addition to the initiative’s existing annual appropriation. The total budget for the fiscal year that recently finished was $2.6 million. That funding covers the salaries of creative arts therapists as well as equipment and supplies at the clinical sites, the telehealth program, research, and the creation of a digital toolkit for community sites. The NEA projects that beginning in 2018 creative art therapists of Creative Forces will deliver an estimated 1,000 treatment sessions per year, and will enroll around 200 new patients per year. Advertisement
Service members living near or being treated at Fort Belvoir work with art therapist Jacqueline Jones, who has been working with Creative Forces since 2013. There, Jones runs a fully-stocked art studio where she conducts three levels of programs, ranging from a three-week-long introductory course of “instinctive, spontaneous, process-oriented artmaking” to an open studio setting, where patients work side by side on their own long-term, self-directed projects.
Artmaking in the introductory course includes decorating a blank mask and other activities meant to surface underlying stressors. “You go with the flow and let the art lead you,” Jones explains, “then when you finish, you take a step back and we process it together. We delve into the symbolism of the colors and images used, and look at the orientation of everything on the canvas or page, and see what it reveals.”
She points to these artworks as particularly important when treating “invisible injuries,” a way to access “something concrete and tangible to explain and express their experience with a traumatic brain injury and post-traumatic stress—things that other people can’t see or understand.”
Most patients continue on to the second level: a six-week program of group and individual sessions, where patients work on a series of drawing and expressive writing tasks, and the creation of a box meant to celebrate or commemorate something. “We use art in different ways to process specific traumatic events, to grieve specific losses, or to work through moral injury or identity issues,” Jones says.
The third tier of therapy is an open studio program that allows vets to “continue to bond and develop camaraderie and community, while also allowing them to develop their own personal artistic identities,” Jones notes. One patient who has progressed through this level, Mike Goodrich, will have his first solo show this month at the National Museum of Health and Medicine in Maryland.
Different patients have different needs. “It really matters how long they’re seen in our clinic and what their goals for treatment and recovery are,” Jones says. For example, a service member who is having angry outbursts in public might enter the clinic looking to gain emotional regulation. “He knows that that’s a behavior he wants to stop but he doesn’t know how,” Jones explains. “Through art therapy we can do things to work towards that goal, such as figuring out what someone’s particular triggers are or really uncovering what is underlying the anger.” Once the patient is able to identify those triggers, they’re better prepared to process whatever is inciting the anger and to recognize in the moment that they’re experiencing that trigger. “They can emotionally regulate and calm themselves down before having a reaction that they don’t want to have,” she explains. Other patients with symptoms of post-traumatic stress might be looking to lessen nightmares and improve their quality of sleep. “In that case we may be using art to process specific traumatic events to a place where they come to resolution,” Jones says, “so that they may move to a place where they might dream about those things, but it becomes more like they’re watching a movie instead of actively being in the middle of the event occurring over and over.” Communication is a common treatment goal, especially in regard to communicating with family members. “A lot of the art they create is a really good externalization of what they’re going through and it helps them gain insight into what’s really underlying their issues, symptoms, and behaviors and so it first and foremost gives them great insight into self.” Jones recalls helping a specific patient at Fort Belvoir work through a traumatic event and the associated negative emotions. “At a certain point he just looked up at me and he said, ‘I like myself now,” Jones recalls. While many patients who meet their treatment goals stop engaging in art therapy, some continue on an ongoing basis. “Artmaking is their primary method of processing things that happened in the past but also processing the present,” Jones explains. “It’s their way of maintaining well-being.” Jones also collects data from her patients in order to determine how valuable art therapy is to them. “What has come back so far is that the majority of patients attribute or credit art therapy with increasing their ability to experience positive emotions and their self-concept,” she attests. Recently, Creative Forces has begun to organize summits that bring together creative arts therapists, researchers, and military personnel to discuss and assess this research, and to determine what future studies should address.
Sgt. Robert Fox painted this mask at the National Center of Excellence for the Intrepid's satellite office at Fort Belvoir, Virginia. Photo by Elizabeth M. Collins. Courtesy of the Department of Defense.
Dr. Girija Kaimal, an art therapy researcher at Drexel University (one of the few schools with art therapy Ph.D. programs) has been working with Creative Forces since 2013. Her scholarship, undertaken in partnership with Jones and fellow art therapists Melissa S. Walker and Jessica Masino Drass, has been based upon the artwork and clinical notes coming out of Fort Belvoir and NICoE. One major project set out to analyze 370 artist-made masks created at the two sites. The clinicians had noticed certain recurrences over time, Kaimal explains, so they devised a way to analyze the masks systematically, looking for patterns among the ways that service members with TBIs and PTSD had represented themselves. In the mask’s imagery, researchers found representations of people who had died, as well as allusions to damaged relationships, a sense of belonging and community, pop culture figures, an overall injured sense of self, and broad existential concerns. They were able to take this visual data and compare it with clinical data. “This is where we’re being very innovative,” Kaimal explains. “There’s very little done on how visual representations might relate to people’s psychological health and wellbeing.” “What we are finding is that when people represent a whole image or an image that is integrated, that’s usually indicative of better psychological health,” she continues, “whereas images that are very fragmented tend to be associated with worse outcomes.” Kaimal notes that future research based on artworks will look at a patient’s artistic output over time, through the course of the clinical program; and they will also collect, analyze, and compare data collected from the various Creative Forces sites. Creative Forces is playing an important role not just for service members, Kaimal emphasizes, but for the art therapy profession at large. “One of the challenges in our field is that because it’s been mainly clinical and there are only a handful of Ph.D.s, so we haven’t had enough capacity for research,” Kaimal explains. “What Creative Forces offers is funding for research, which is quite scarce for creative art therapy. And we are able to do larger-scale studies—things at a scale that we’ve never been able to do before.”