Combat Trauma Art Therapy Scale

This study correlated an art therapy descriptive technique originally applied to adolescent burn victims with adult combat-related victims in an effort to identify art themes and graphic elements associated with post-traumatic stress disorder. The designed rating instrument, referred to as the Combat Trauma Art Therapy Scale (CTATS), consisted of 62 items aimed to detect common themes associated with war time experiences. Using the CTAS, raters examined 158 pictures, with depictions of women, violence, and combat interwoven, suggesting an ongoing struggle to cope with the emotional aftermath of recent traumatic experiences. Published by Elsevier Inc. The United States is involved in two large military operations, one in Afghanistan referred to as Operation Enduring Freedom (OEF), which started in October 2001, and Operation Iraqi Freedom (OIF), which followed in March 2003. Soon after the launch of OIF, researchers conducted a comprehensive assessment of the war’s emotional impact (Hoge et al., 2004). Using the DSM-IV TR’s definition of post-traumatic stress disorder (PTSD), these investigators reported 12.9% of Army Service Members deployed in support of OIF and 12.2% of Marine Corps personnel supporting OIF met the criteria for PTSD. Roughly half that number, 6.2%, of Army personnel engaged in combat operations supporting OEF met the criteria for PTSD. A later analysis of the war’s impact, published 4 years after OIF started, concluded that clinicians now were identifying 20.3% of Active and 42.4% of Reserve Component soldiers in need of mental health treatment for PTSD, depression, and alcohol use disorders (Milliken, Auchterlonie, &Hoge, 2007). The collectiveweight of these clinical investigations points to enduring emotional consequences for a sizeable group of combat veterans. Identification and treatment of combat veterans suffering emotional problems from their war experiences requires the sustained vigilance of a multidisciplinary group of clinicians. Based on the authors’ clinical observations in the military population, service members, like many individuals copingwith a traumatic experience,may fear verbalizing their story. In some cases that is a conscious decision to spare both themselves and the listener the graphic, highly emotional details. This approach may cause friction among friends and ∗ Corresponding author at:Walter ReedArmyMedical Center, Department of Psychiatry, 6900 Georgia Avenue NW, Washington DC 20307, United States. Tel.: +1 202 782 1553. E-mail address: [email protected] (R.G. Lande). family members who, desperately seeking to help the troubled service member, feel rebuffed in their supportive efforts. In other cases, the highly charged traumatic event cannot, as a consequence of various psychological defenses such as repression, dissociation, and denial, be verbally recreated. Dissociation may play a key role. A traumatic event may create a sudden blast of emotion, surprise, and powerlessness and when coupled with dissociation as a psychological coping mechanism, interferes with a person’s ability to integratememories ina readily retrievablemanner (Nemiah, 1998). On theonehand, thisdefensiveprocessprotects the individual from re-experiencing the original trauma and its associated emotion, but it also hinders recovery efforts in PTSD treatments. Art therapy can overcome the obstacles imposed through dissociation by tapping into the person’s nonverbal world. This can be a less emotionally threatening way to unite the fragmented trauma memories. The use of various art materials provides a number of advantages such as allowing the trauma victim to tell their story with the emotional distance achieved through a pictorial depiction (Avrahani, 2005). In addition, artwork typically relies on various symbols, many ofwhich are personal, to express thoughts and feelings. Artwork can be viewed from a safe psychological distance offering opportunities to rework images and in the process gaining a sense of reassuring mastery. Clinicians can identify specific therapeutic interventions that appear helpful in reducing the PTSD triad of avoidance, hyperarousal, and intrusiveness (Collie, Backos, Malchiodi, & Spiegel, 2006). Based on clinical experience, art therapists recognize the therapeutic value of consolidating memories, progressive exposure, externalization, arousal reduction, and emotional selfefficacy. The consolidation of memories is a key component art therapists hope to achieve which ideally leads to an integrated trauma story. Avoidance is a core feature of PTSD and art ther0197-4556/$ – see front matter. Published by Elsevier Inc. doi:10.1016/j.aip.2009.09.007 R.G. Lande et al. / The Arts in Psychotherapy 37 (2010) 42–45 43 apy helps overcome this dysfunctional stalemate by creating a less threatening symbolic exposure to the original trauma. Artwork creates a physical representation of the trauma story, one that the individual can literally externalize and hold safely at distancewhile they process the emotional content. Externalization contributes to a safety zone that reduces anxiety and lessens the hyper-arousal associatedwith the emotionally charged subject. The ultimate consequence of safely expressing a traumatic event is a renewed sense of emotional self-efficacy. In their clinical practice, art therapists may choose among several theoretical approaches, such as cognitive, psychodynamic, humanistic, and eclectic. These different clinical approaches differ inmany respects including the degree of structure the therapist brings to the interaction. In a military treatment facility, a more structured approach may resonate better with the service member’s training thereby promoting therapeutic engagement. A task orientated approach increases the military participant’s sense of control by reducing unpredictable expectations, a necessary predicate to engage in the expressive narration andmemory integration necessary to achieve symptom relief with PTSD (Rankin & Taucher, 2003). In a similar fashion, a customized rating questionnaire permits similarities among PTSD patients’ artwork to emerge. This study used a systematic approach with service members’ artwork in an effort to identify common themes and graphic elements. Previously published studies adopted a similar strategy. In one clinical study, the investigators reported use of a descriptive assessment for psychiatric art (Hacking, Foreman, & Belcher, 1999). The authors rated artwork based on color, line quality, and space. In a study examining the artwork created by patients at a forensic hospital, a standardized art assessment tool known as the Formal Elements Art Therapy Scale (FEATS) identified a statistical correlation between a past criminal history and the scale’s activity score (Lande, Howie, & Chang, 1997). The FEATS is an example of an art therapy rating instrument that attempts to standardize the analysis of a patient’s artwork (Gantt & Tabone, 1998). Another instrument, The Person Picking anApple fromaTree (PPAT) Assessment, requires both a standardized task and standardized rating using the FEATS (Gantt & Tabone, 1997). This study sought to show similarities in themes that were tracked and assessed by Appleton in her work with adolescent burn victims (Appelton, 2001). Adolescent burn victims share certain similarities with combat veterans where changes in physical appearance, a life-threatening event, and a loss of invincibility can seriously impede a return to a normal emotional life. According to this view, trauma resolution includes four stages: (1) impact; (2) retreat; (3) acknowledgment; and (4) reconstruction. Each stage has accompanying themes and graphic elements that can be identified in theperson’s artwork. Reconstruction, for example, couldbe identified by themes involving home or work images and graphic elements such as fully completed pictures.