Therapy

Art Therapy: Treating Combat-Related PTSD

First, let’s be clear—it’s complicated.

Posted Oct 23, 2016

Combat Veteran's art therapy response to PTSD; from collection of C. Malchiodi, PhD, ©2016, reprinted with permission.
Source: Combat Veteran's art therapy response to PTSD; from collection of C. Malchiodi, PhD, ©2016, reprinted with permission.

Much of art therapy’s value as a form of trauma intervention is predicated on two principles. First, based on recent developments in neurobiology and posttraumatic stress, art therapy is often defined as a form of “sensory-based” intervention (Malchiodi, 2003; 2008; Steele & Malchiodi, 2012); that is, it provides purposeful psychotherapeutic experiences that capitalize on the body’s senses in ways that verbal psychotherapy does not. In other words, by tapping the senses (in this case, through the visual, tactile and kinesthetic aspects of art making), traumatic memories can be retrieved and with further psychotherapeutic interactions, restructured and repaired. Second, there is some evidence that art therapy may help to reconnect feeling (implicit memories) with thinking (explicit memories), a process that may reduce posttraumatic stress reactions (Malchiodi, 2003; Steele & Raider, 2001). This notion is based on much of what trauma specialists such as Rothschild (2000) and others have observed—that posttraumatic stress reactions may occur when sensory memories of a traumatic event become disconnected from declarative memories; the reconnection of these two forms of memory may be an important piece in the puzzle of trauma integration.

There is wide agreement that art therapy is in need of more research, particularly in the area of trauma resolution. A recently published study set out to do just that though examining the impact of cognitive processing therapy (CPT) and CPT provided in conjunction with art therapy on military in treatment for combat-related posttraumatic stress disorder (PTSD) (Campbell, Decker, Kruk, & Deaver, 2016). In brief, six participants completed a CPT treatment protocol (control group) and five participants completed a protocol combining art therapy with CPT (experimental group). The control group engaged in a manualized CPT treatment for PTSD, consisting of eight sessions including written homework between sessions with the goal of reframing negative thoughts and challenging distorted beliefs. The experimental group participated in eight sessions that included art-based assessment, psychoeducational information about PTSD, and a series of familiar art therapy approaches: drawing trauma narratives, mask-making, mind mapping, papermaking and review of art created during treatment (for a slightly more detailed description of the art therapy components, please see the actual article at the end of this article). The rationale for the application and sequence of these art therapy directives was left unexplained, but they may have been included because these approaches have been used by art therapists with reference to trauma resolution in other settings.

In brief, the study concludes that both groups demonstrated significance when it came to changes in PTSD symptoms according to standard measures; improvement with treatment is also significant for both groups. However, the important take-away in this study emerged in other ways that I have noted in previous posts on art therapy research. First, content analysis of the commentaries of participants pre- and post-treatment may more clearly identify just what the role of art therapy may be within trauma intervention in general. As in other studies, art therapy is often cited by participants as a positive form of communication, especially in the expression of emotional content that often defies verbal communication. Also, while significance was demonstrated in both control and experimental groups, future revised studies of this nature may help to identify if the addition of art therapy to standard treatments such as CPT are “valued-added” when it comes to efficacy. In my experience, many individuals find protocols such as CPT or cognitive-behavioral therapy on the dry side and compliance over time is difficult. I predict that with more carefully constructed studies we may indeed find that art therapy is the necessary “value-added” component to not only improve outcomes, but also increase all-important compliance in treatment, especially for those challenged by posttraumatic stress reactions.

In sum, this particular study has a variety of challenges, including the small N of 11 participants; in fact, to identify it as a “randomized controlled trial” is a little bit of a stretch by some standards. It was also not clearly explained how art therapy methods were integrated within a CPT protocol for implementation as described within the abstract of this study. A section called “Artwork” seemed like an afterthought and did not clarify exactly how the art products were formally evaluated or if the descriptions were simply clinical observations. Art therapy as a field is in the midst of its own growing pains in terms of research and investigators are still sorting out what are a difficult and complex maze of research methodologies and how to address the key questions that confront the field’s credibility as a viable treatment option. My hope is that future studies of art therapy within the context of trauma intervention begin to clarify the value of the “art psychotherapeutic relationship” as well as addition to the evaluation of art processes and products during treatment. Until then, I encourage you to read more about this current study at http://www.tandfonline.com/doi/full/10.1080/07421656.2016.1226643 (available for a limited time as free access).

Be well,

Cathy Malchiodi, PhD

©2016 Cathy Malchiodi

References

Campbell, M., Decker, K, Kruk, K., & Deaver, S. (2016). Art therapy and cognitive processing therapy for combat-related PTSD: A randomized controlled trial. Art Therapy, 33(4), 1-9. http://www.tandfonline.com/doi/full/10.1080/07421656.2016.1226643 (available for a limited time as free access).

**Malchiodi, C. A. (2003). Art therapy and the brain. In C. Malchiodi (Ed.), Handbook of Art Therapy (1st ed) (pp. 16-24). New York: Guilford Publications.

**Malchiodi, C. A. (2008). Creative interventions and childhood trauma. In C. Malchiodi (Ed.), Creative Interventions with Traumatized Children (1st ed.) (pp. 3-21). New York: Guilford Publications.

Rothschild, B. (2000). The body remembers. New York: Norton.

Steele, W., & Malchiodi, C. A. (2012). Trauma-informed practices with children and adolescents. New York: Taylor & Frances.

Steele, W., & Raider, M. (2001). Structured sensory intervention for children, adolescents and parents: Strategies to alleviate trauma. Lewiston, NY: Edwin Mellen Press.

**Second editions of these volumes are in print, but the first editions are cited to underscore the historical development of key principles involved in art therapy and trauma intervention.