Art therapy in the treatment of PTSD

Art Therapy and PTSD

Art Therapy Utilized in Cases of Post Traumatic Stress Disorder (PTSD)

Art has always played a major role in human life and development. Some of our knowledge of our earliest ancestors comes from the drawings and sculptures they left behind. Art is an essential part of what it is to be human, and can be utilized for a variety of purposes including communication, expression, and even therapy. Art therapy is known to have beneficial results for individuals suffering with a variety of cognitive disorders, such as that of Post Traumatic Stress Disorder (PTSD). PTSD is an anxiety disorder which plagues patients after the event or multiple events of trauma which instill painful memories and later manifests itself as a wide variety of behavioral and physical symptoms depending on the individual. Young children exposed to trauma and war veterans who have witnessed the horrors of battle are particularly vulnerable to developing PTSD. Recent research has utilized art therapy as a methodology to help alleviate the stress associated with PTSD and remove some of the emotional pain experienced by sufferers through catharsis. Through utilizing the various assessment models available to the practice of art therapy, PTSD can be diagnosed and treated through non-verbal expression which proves less complicated than traditional therapies which rely on interviews. Art therapy can prove successful in relieving the symptoms f PTSD, especially in those most vulnerable to its development.

One disorder in particular which has been known to use art therapy for a wide variety of reasons is that of Post Traumatic Stress Disorder (PTSD). This proves to be an anxiety disorder which occurs after the individual patient has had to deal with a traumatic event of some sort (Riley 2004). As a traumatic experience unfolds, human nature responds to a primitive form of survival; flight or fight. When a person becomes overwhelmed in a traumatic experience, that individual's verbal consciousness fails. It then enters the nonverbal mind. This creates a dangerous situation which can result in PTSD. This stress can then manifest itself in a variety of ways and symptoms, which can affect the sufferer for short or long periods of time, depending on the nature of the trauma.

In many cases, individuals have higher risk factors of developing PTSD if they have been exposed to earlier traumatic experiences, a bad familial environment, alcohol or drug abuse, and a lack of social support to recover from their traumatic experience (Riley 2004). Most cases of PTSD prove to have symptoms which manifest themselves as three different categories; the first of which deals with the individual re-living the traumatic experience through dreams, nightmares, flashbacks while awake, heightened anxiety, and even hallucinations in the most extreme cases. These symptoms plague patients and can create real disturbances in the otherwise normal life of an adult or child. Another category of symptoms includes that known as avoidance symptoms. These symptoms manifest themselves as avoidance from strong emotional contact in fear of anxieties surfacing, avoiding people and locations which trigger reminders of the traumatic event, loss of memory, and an overall feeling of numbness and detachment from the external world (Riley 2004). With the exhibition of such symptoms, the patient finds themselves increasing cut off intentionally from the external world around them which had initially fostered the trauma that created such stress. The final category is the most noticeable to external viewers and is known as arousal symptoms, which mainly include issues with change in behavior and routines. These symptoms include insomnia, extreme and noticeable anger and irritability, lack of concentration, and nervousness (Riley 2004). Along with the psychological ramifications of PTSD, some patients are also plagued with physical symptoms such digestive problems, chest pain, head aches, and dizziness.

In many cases, symptoms differ from individual to individual based on the acuteness of occurrence and how long those symptoms last or lasted. Acute PTSD occurs directly after the event for a short duration of time (Riley 2004). Acute PTSD normally lasts from around one to three months of exhibiting symptoms, followed by a relief of such stress for various reasons. Chronic symptoms last much longer, over three months after the occurrence of the traumatic event, while delayed onset symptoms can appear months after the event. Children and veterans deal mainly with chronic and delayed onset PTSD due to the extreme nature of their trauma and complete helplessness during the event or multiple events which created the trauma. This anxiety disorder has been plaguing Americans for generations, and is said to have no absolute cure, only a variety of methods used to help individuals cope with their fears and anxieties created out of a single traumatic event or a series of painful events.

Particular demographics prove much more vulnerable to developing TSD after cases of both physical and mental trauma. In many cases, war veterans prove particularly vulnerable to an onset of PTSD, thus creating colloquial names for PTSD such as "shell shock" or "battle fatigue" (Riley 2004). Cases linked to war can be traced back almost as long as war has been examined as a factor in psychological health. More recently, the Vietnam war produced thousands of soldiers returning home with symptoms of PTSD, and many more were coupled with heavy drug addiction as a way to cope with the horrors of such a vicious jungle way. Today, as the war in Iraq and Afghanistan rages on, more and more soldiers are returning home with stress related to PTSD. In fact, one 2004 study (Hoge et al.) conducted early on in the war found an astonishing 12-20% of soldiers and Marines returning from Iraq to have symptoms of PTSD. That is a relatively large amount, especially to return to a society which expects its soldiers to be able to deal with the psychological ramifications of modern warfare. Yet, around 6-11% of soldiers coming out of Afghanistan were also exhibiting signs of PTSD related to their combat experiences, (Hogue et al. 2004). These war veterans were dealing with the stress of seeing dead bodies, killing, and having people close to them killed. As a result, this stress can quickly turn into the anxiety driven PTSD. After a traumatic event, the individual suffering from PTSD has intensified fears, anxieties, and feelings of helplessness which then have negative ramifications on that individual's daily and long-term life.

Other than war, typical experiences leading to PTSD include rape, assault, severe natural disasters, car accidents, and abuse (Riley 2004). Children have a heightened vulnerability to PTSD in cases of physical or sexual abuse and other traumatic events which might otherwise be dealt with properly in an adult mind. Due to the fact that children have very little control over the trauma, many are prone to developing PTSD as a result of particularly painful experiences. This is then only further complicated with their lack of mastery of language, which can make traditional therapy difficult in exploring and relieving emotional stress from a particular event. Thus, even with treatment, PTSD in many children can go unchecked and relatively unrelieved based on a lack of ability to explore the trauma through traditional therapeutic practices which rely on the construct of language as an important element to relieving harmful stress associated with PTSD. When stress occurs, most children are unprepared to deal with it properly, and then severely react which only increases their vulnerability to developing PTSD (Perry 1999). Children exhibit a wide variety of PTSD related symptoms including impulsivity, distractibility, dysphoria, numbing, social avoidance, dissociation, insomnia, aggressive play often re-enacting out their lived traumatic experiences, poor school performance, and delayed development (Perry 1999). These unique symptoms exhibited by children dealing with PTSD make diagnosis and proper treatment difficult for practitioners, especially as the diagnosis is left unchecked for years after the trauma. The true source of the problem continues to be buried deep within the child's mind and is masked by a variety of symptoms which can look like other disorders such as Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD). Yet despite such increased risk and potential damage of PTSD in children, relatively little research has been conducted devoted strictly to managing PTSD in young kids.

There are a variety of ways currently used to treat and diagnose PTSD, including that of art therapy. Typically, cognitive behavior therapy is used to help teach PTSD patients to manage their stress and anxieties in order to further distance themselves from the traumatic event (Riley 2004). Unfortunately, many war veterans suffering from PTSD fail to get proper treatment based on the image of a negative stigma, resulting in potential psychological harm and years of dealing with the stress and anxieties of PTSD (Hoge et al. 2004).

Yet, for those individuals dealing with PTSD, whether from war experiences or other traumatic events, who do seek treatment find a wide variety of options available.

Unfortunately, in today's modern world, many children are being exposed to traumatic events (Wethington et al. 2008). These events then lead to the potential of later developing symptoms of Post Traumatic Stress Disorder which can haunt the individual for an entire lifetime. Children need special attention when dealing with traumas they might not fully understand. Thus art therapy has been proven to benefit the increasing number of children dealing with PTSD and other trauma related disorders creating fear and anxiety within the innocent child. Another major benefit of art therapy is that of the informal nature of the expression. Unlike language which is complicated through strict grammatical rules, artistic expression has the freedom to express complexities outside of language (Malchiodi 2006). In children, who do not yet have a full grasp and understanding of the complexities of language, art therapy allows certain emotions to come out which would have otherwise been unable to be expressed using a limited word bank and language ability, "Children do not have extensive vocabularies for describing their feelings and experiences, but they are generally comfortable with art as a natural way to communicate," (Malchiodi 2006:13). And so, art therapy provides a necessary alternative which allows children dealing with PTSD to cope with their stress and experience treatment rather than simply discussing it. Art therapy has been proven to benefit many cases of children dealing with acute PTSD, yet more research is needed to fully explore its impact of children suffering from long-term chronic PTSD. This lack of knowledge concerning strictly chronic PTSD sufferers proves that the true benefits of art therapy have not been fully developed or explored to produce real and reliable findings on how it can be utilized as a practice to help alleviate the stress of PTSD in young children.

Yet, despite a lack of research in some areas of art therapy, it still has proved a popular alternative for a wide variety of mental and anxiety disorders. Throughout history, art has been harness by individuals to rely religious and emotional meaning. Generations upon generations have witnessed the expression of art as both a communicator as well as individual relief. Since the 1930s, art therapy has been used in a variety of settings in order to help relieve mental stress. Many cases have seen art to empower the artist in his or her pure emotional expression, "Art therapy has grown from this concept that art images can help us to understand who we are, to express feelings and ideas that words cannot, and to enhance life through self-expression," (Malchiodi 2006:2). The art involved in such therapeutic methods is vast, and incorporates a variety of media in its intervention practices. Painting, drawing, sculpture, and other forms of artistic expression have been utilized within a variety of therapy models aimed at reducing stress and diagnosing depression and Post Traumatic Stress Disorder (PTSD).

These visual therapeutic methods have been known to noticeably lift the moods of patients suffering from PTSD (National Standard 2008).

Art has always been known to help express emotions and elevate the mindset of the artist. Now, there is physical evidence which shows the serotonin levels increase while the individual creates, "the actual process of art making can also alleviate emotional stress and anxiety by creating a physiological response of relaxation or by altering mood," (Malchiodi 2006:13). This elevator can help remove the previous tortured patient from their anxious fears and worries, at least for a period of time while the art is being created.

This form of therapy can be a huge release of negative and harmful emotions. Understood as catharsis within the context of psychology, art therapy can cleanse or purge negative emotions from an individual's mind through the medium of art, "Catharsis literally means cleansing or purging; in therapy it refers to the expression and discharge of strong emotions for relief. Making a drawing, painting, sculpture, or other art form can be cathartic in that is may provide relief from painful or troubling feelings," (Malchiodi 2006:13). Art therapy has proven to be very effective in cases which patients are otherwise unable to express emotions verbally, "art therapy enables the expression of inner thoughts or feelings when verbalization is difficult or not possible," (Natural Standard 2008). It proves to be a release of emotional stress without the complications of verbose explanations and the anxieties which come with it.

Art therapy empowers an otherwise powerless individual and allows him or her to visually express what has haunted them in the past, thus giving the patient a sense of self-control when such feelings were potentially lost due to PTSD. Like other cognitive-behavior therapies, it can be adapted to suit a multitude of different environments when needed (Wethington 2008). Each individual patient can have various art therapy activities tailored to his or her needs and the demands of the disorder that plague them. The creation process involved with art therapy also has a huge impact on the minds of those suffering from PTSD and other disorders. This creation allows for personal fulfillment in "the creation of a tangible reward [which] can build confidence and nurture feelings of self-worth. Personal fulfillment comes from both the creative and the analytical components of this process," (Krapp & ). Art therapy has been used as a type of intervention in order to curb various disorders from doing more harm to the minds of both children and adults.

Art therapy is currently used in a variety of practices dealing with assessment and treatment of PTSD. Studies have shown that PTSD sometimes is stored within the minds of patients as representative images, "researchers have discovered that traumatic experiences often become encoded in the mind in the form of images. That is, when we experience traumatic events such as violent acts or catastrophes, our minds may take them in just like a camera taking a photograph," (Malchiodi 2006:10). And so, visual images produced through various models of art therapy can help express those images without complicating the traumatic photograph with extra vocabulary. When trauma proves too painful for words, artistic expression can be a valuable tool in understand trauma and progressing forward to a life unaffected by such events. Previous research has shown the usefulness of art therapy as a gauged to detect depression and other symptoms of PTSD (Wallace et al., 2004). With this detection and potential early diagnosis, a greater breadth of treatment can be made available to those suffering from PTSD. In a 2004 study (Wallace et al.) investigated depression in children and young adults who had recently had renal transplants aimed at measuring the prevalence of depression along with assessing how useful the Formal Elements of Art Therapy Scale (FEATS) proved to be in such a young demographic. This scale requires the use of black, brown, yellow, orange, red, purple, magenta, hot pink, turquoise, blue, green, and dark green watercolor markers on a 12x18" white paper (Malchiodi 2002). The children were then asked to draw a person picking an apple off a tree. These drawings were later analyzed based on such categories as prominence of color, color fit, implied energy, space, integration, logic, realism, problem solving, developmental level, details, line quality, person, rotation, and preservation (Malchiodi 2002). This particular assessment models allows for easy group comparison and application of methods on both children and adults. FEATS is also based on established global art elements, which then helps eliminates artistic bias against particular works. The FEATS scale was used in the 2004 Wallace et al. study to gauge depression and signs of PTSD in young adults and children recently having been through renal transplants through analysis of the global arts elements and the use and expression of color within the individual drawings. Assessments of the product of the visual art produced through FEATS showed that art therapy revealed more signs of PTSD and depression than a more formalized self-report measures (Wallace et al., 2004). Yet, the focus of this study lies directly in recognition of PTSD and not the treatment, despite its valuable information regarding more intimate ways of diagnosing and spotting PTSD in patients dealing with various forms of trauma.

Yet more research has uncovered benefits of art therapy in PTSD patients -- "especially in children. A 2001 study (Chapman et al.) used another art therapy research model in order to explore how art therapy helped depress various symptoms of PTSD in children. Set in an urban trauma center, the study was originally designed to reduce symptoms within child and young teen patients using the Chapman Art Therapy Intervention model (CAATI). The CAATI model was designed and planned for "incident-specific, medical trauma t provide an opportunity for the child to sequentially relate and cognitively comprehend the traumatic event, transport to the hospital, emergency care, hospitalization and treatment regimen, and posthopsital care and adjustment," (Chapman et al. 2001). Initial analysis at first showed no statistically significant difference between other intentionally reducing therapies within the same age range of PTSD patients (Chapman et al. 2001). Yet, later analysis found that the CAATI model did have an effect of reducing acute stress symptoms within many of the young participants who took part in the art intervention. The CAATI model was designed for acute PTSD cases only, and so misses a vast amount of information regarding children with more chronic or delayed onset cases of PTSD. However, the findings of this study does still attest to the concept that art therapy does help relieve elements of stress which are common with the diagnoses of certain cases of PTSD in patients, both young and old.

Alongside with the vulnerable demographic of children, art therapy does prove to have benefits within war veterans dealing with the symptoms of PTSD. Many traditional therapies, including drug based therapies, are aimed at relieving the stress and anxiety associated with PTSD. However, art therapy aims at actually helping remove the emotional pain which causes that stress and anxiety (Casura 2008). The catharsis experienced in art therapy can help release deep battle wounds within the scarred minds of veterans suffering from PTSD. In fact, a 1997 study of Vietnam veterans dealing with PTSD in an in-house setting saw that art therapy significantly helped reduce PTSD symptoms within the most severe cases (Casura 2008). Several veterans known for their cases of PTSD caused by the Vietnam war have attested to the powerful experience of art, and how it can be harnessed to let go of painful experiences. Haunting memories of war can be transposed onto actual art pieces, which can then carry the weight rather than the individual who was initially forced to suffer them. Art therapy not only provides a distraction for the intense symptoms suffered by former soldiers, but it also provides a sense of relief through release of inner stress in a casual and comfortable manner.

Art therapy is most effective when used in combination with other cognitive stimulating therapies. Several studies have incorporated art therapy with a variety of other cognitive therapies intended to work best on children and adolescents who have been forced to experience trauma (Freeman 2006). Because of the success of cognitive behavior treatments, such as art therapy treatments, it has been suggested to use combinations including cognitive behavioral techniques along with eye movement desensitization and reprocessing (EMDR), psychotherapy, and drug treatment (Freeman 2006). Other therapies which integrate nicely with art therapy include such treatments as play therapy, psychodynamic therapy, and pharmacologic therapy (Wethington 2008). These therapies in combination with more traditional therapies for disorders such as PTSD have been seen to have the most effective results. Such therapies have been known to help decrease psychological stress and potential future harm of harboring such stress within children and young adults both in individualized sessions and in group sessions (Wethington 2008).

Art therapy as a practice varies depending on the individual and/or group which are being exposed to it. It can be practiced in both individual and group settings, depending on the nature of the patients. In many cases, art therapy is very similar to a regular art class; yet, the goals prove very different, "in most art therapy sessions, the focus is on your inner experience -- "your feelings, perceptions, and imagination," (Malchiodi 2006:4). The art expressed within the realms of art therapy is not that of a rendering of the outside world, but that of the internal being of an individual. This type of therapeutic process also helps incorporate the individual patient in with the healing process. Because art carries much different meanings when observed from various people, utilizing the patient to help analyze what the art means places them in a seat of agency, where they actually have a large part in developing their meaning through art (Malchiodi 2006).