'Principal My Demons': art therapy montage paintings by active-duty military service members with traumatic brain injury and post-traumatic stress

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  1. http://orcid.org/0000-0001-6642-3426Marygrace Berberian1,two,
  2. http://orcid.org/0000-0001-9375-567XMelissa S Walker3,
  3. http://orcid.org/0000-0002-7316-0473Girija Kaimal1
  1. i Creative Arts Therapies, Drexel University College of Nursing and Wellness Professions, Philadelphia, Pennsylvania, USA
  2. 2 Fine art & Arts Professions, New York University, Steinhardt, New York, New York, U.s.a.
  3. 3 National Intrepid Middle of Excellence (NICoE), Walter Reed National Military Medical Center, Bethesda, Maryland, United states of america
  1. Correspondence to Professor Girija Kaimal, Drexel University College of Nursing and Health Professions, Philadelphia, PA 19034, USA; gk27{at}drexel.edu

Abstract

This written report involved a thematic analysis of montage paintings and of related clinical records of 240 active-duty armed services service members collected during their art therapy handling for traumatic encephalon injury and underlying psychological wellness concerns, including post-traumatic stress, at the National Intrepid Middle of Excellence, Walter Reed National Military Medical Eye, Bethesda, Maryland, Us. Congruent with other research findings, the qualitative analyses of this study propose that the group art therapy experiences fostered comeback in interpersonal relatedness, hopefulness and gratification for the service members in treatment, aiding in externalisation, progressive exposure and construction of a trauma narrative imperative for recovery. The mixed media nature of the montage painting supported the expression of a range of postcombat symptoms. Results from this report highlighted the complication of armed services civilization, necessitating a broader scope of analyses for how art therapy helps service members express and communicate their challenges to care providers, peers and family besides as regulate emotion in the short and long term.

  • art therapy
  • mental health care
  • metaphor

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  • art therapy
  • mental wellness care
  • metaphor

Introduction

More than ii.6 million US military service members have been deployed since 2001 in our post 9/11 earth.1 Unlike other armed services service periods in history, recent conflicts accept led the all-volunteer armed forces to participate in multiple deployments that are often long and that severely restrict the time at dwelling betwixt deployments, thereby adding meaning stress to their situations.two 3 Additionally, the newly adaptive body armour developed to protect them confronting explosive devices in combat has enabled service members to endure greater hazard and thereby increased the number of service members returning abode with 'polytrauma.'iv Polytrauma has been defined as the bear upon of multiple injuries that may be life-threatening and issue in impairments in cognitive, psychological, psychosocial and physical functioning.iv–6 Consequently, 375 230 military service members have been diagnosed as having suffered a traumatic brain injury (TBI) since 2000.vii Farther, in a survey administered past the Veterans Administration from 2006 to 2010, an estimated 480 748 service members were found to exist struggling with post-traumatic stress disorder (PTSD).1

The number of veterans who received mental healthcare increased from 4% in 2006 to 12% in 2010.one However, many veterans suffering with mental health bug do not seek aid and others diminish the severity of their issues.8 Verbally expressing symptoms is a challenging limitation for those who accept been traumatised.9 10 As an alternative intervention, the visual expression afforded by art therapy is increasingly gaining acceptance as a treatment for service members with PTSD and TBI.11–14

Art therapy for military service members with TBI and PTSD

Art therapy relies on art making and artistic processes within a psychotherapeutic relationship to improve or restore functioning and/or a sense of well-being.xv The need for self-expression past service members has been identified as important for recovery and reintegration into civilian and family life.16 17 Art therapy addresses the effects of deployment and combat as well as the emotional impact associated with TBI, PTSD and/or comorbid psychological disorders sustained every bit a result of being a witness, victim or agent of combat or related events.11 13 14 17 18

Inside integrative military medical care settings, art therapy has gained recognition as a form of complementary care.11 18 19 Art therapy provides visual expression for the unspeakable symptoms caused by gainsay appointment.11 14 17 As an overwhelming psychic experience, trauma can ofttimes exist somatically stored.x 20 Symptoms such as expressive and emotional numbing, along with other ailments, are ameliorated through the art therapy processes, which form images for the internal wounds of combat.fourteen 17 21 For trauma survivors, the retelling and reformulation of the terrorising memories through pictorial, non-verbal iteration can mostly be less threatening than verbal disclosure because much is mitigated through the visual symbolism.22–24

Current research has identified therapeutic elements implicit in art therapy that could address symptoms of combat-related post-traumatic stress (PTS): (ane) progressive exposure, (ii) externalisation for processing, (3) reactivation of pleasure, (4) promotion of self-efficacy through mastery and (5) conception of a reconsolidated narrative.12 22 25–28 Gantt and Tinnin26 recommended that art therapists develop approaches for trauma recovery that integrate fragmented traumatic experiences into a coherent narrative and reduce dissociation by externalising the dialogue between exact and non-exact states. The goal is to remember rather than relive the experiences of terror.29 The emotional burden of the trauma often destabilises the survivor, creating hopelessness and helplessness, leading to what van der Kolk terms 'speechless terror'.10 thirty For trauma survivors, there is often a suppression of emotional expression and an disability to principal cognitive awareness and engage in verbal processing.31

The internal ache that underlies retention and emotion may be uncovered and managed through art making, which provides opportunities for mastery and command not otherwise available in more traditional modes of therapeutic intervention.17 Emotional altitude can exist gained when the art processes summon the assertion of power and mastery by externalising those fragmented somatic and conscious memories.32 Because art making is an iterative procedure to reformulate new narratives through the doing/undoing process, newer integrations of memories are rehearsed at one's ain pace and suspension rigid thought patterns.28 This process is particularly helpful considering TBI and PTSD symptoms tin impair cognitive processing for injured service members.33 34

Because art making is oft a gratifying, emotionally rewarding experience, survivors will often experience a reactivation of pleasure in art therapy.22 27 Enhanced self-efficacy has long been linked to motivation-seeking behaviours.35 Collage is one method of fine art making that has been plant to reduce stress and decreases feet.36 The juxtaposition of disconnected visual forms brings new meanings and awareness in this new configuration that joins text to paradigm.37 38 This multilayered process, when combined with painting, was described equally 'montage painting' shut to fifty years agone past Andre Verlon39 during some other period of international military conflict. Verlon advocated for this innovative approach to art making as a social response of the fourth dimension. He wrote:

My intention is not only to bring out the quintessence of the polarity of the issues of modern reality: structure-destruction, security-fear, civilization-boorishness, homo-motorcar, motion-blockage, etc.; but besides to probe the fundamental interplay beneath the conflicting forces of technology, turn a profit, fright, violence and man'southward hope for a better world. (39, p. 383)

Clinical observations indicate that grouping art therapy is highly effective with service members because it allows the strengths of the community-based military civilisation to benefit the private participant.40 Information technology is the strength of the unit of measurement's cohesion that shields the adversity of combat, the development of PTSD and possibly suicidality.41 Herman notes,

Those who take survived learn that their sense of self, of worth, of humanity, depends upon a feeling of connectedness to others. The solidarity of a group provides the strongest protection confronting terror and despair, and the strongest antidote to the traumatic experience. Trauma isolates; the group re-creates a sense of belonging. Trauma shames and stigmatizes; the group bears witness and affirms. Trauma degrades the victim; the group exalts her. Trauma dehumanizes the victim, the group restores her humanity. (42, p. 214)

At the National Intrepid Center of Excellence (NICoE) Intensive Outpatient Programme at the Walter Reed National Military Medical Center in Bethesda, Maryland, USA, art therapy has been effective in the rehabilitation of injured service members coping with comorbid TBI and psychological health weather.thirteen xiv 43 44

Setting

Fine art therapy in the integrative setting of NICoE finer ameliorated symptoms for injured service members managing TBI and co-occurring mood disorders since 2010.13 43 44 This intensive outpatient program is an integrative care model with an outlined handling protocol over the class of 4 weeks. In fine art therapy, service members are assessed in both group and individual sessions. In the outset calendar week of treatment, service members create three-dimensional masks in group fine art therapy sessions. Mask making in fine art therapy has become an integral part of the handling at NICoE. Even earlier the first art therapy session is held, the visible displays of the masks proudly exhibited in public areas coupled with the extensive media coverage of these works have implicitly congenital trust in the fine art-making process. The masks help the processing of traumatic memories related to TBI and combat through a more symbolic externalised representation.13 14 43 44 In45 the group context, the masks help to organise overwhelming responses to combat injuries, channelling verbalisations that had been internally silenced. Service members oftentimes continue working on their masks while they receive other integrative services such as music therapy, beast-assisted therapy, medical and nursing care, physical therapy, family therapy and individual counselling.

In week iv, the final week of treatment, service members are prompted to create montage paintings. This directive, designed by Walker, merges past and present experiences every bit a multilayered, multimedia art course.44 45 Presented with an 8'×10' sheet, service members are invited as follows:

Some people choose to but paint and then they might use collage to embellish sure things, or they may collage and and so paint to embellish certain things or they may go back and forth. You tin document or process something from the past, or focus on where you lot are currently, or on hopes, goals, or concerns for the future. There are 2 different ways to arroyo this, you tin can either accept an idea in your mind of exactly what yous want it to look like and y'all can spend the session actualizing that epitome, or you can take no idea of what yous desire it to look similar, no idea what you want it to be nearly and just spend some time going through magazines, cutting out any words or images that resonate with you for whatever reason. Information technology can exist a really insightful process to then organize what you lot've collected on to your sail. (43, p. 3)

Service members are able to cull from a generous assortment of fine art materials including paints, printed images and clay.

Analyses of the montage paintings created past service members are described in this paper. The study design was a qualitative thematic analysis46 of images created in the montage paintings and the descriptions provided by participants.

Methods

Study participants

Demographic information were available for 208 out of 240 study participants. Service members from all branches of the Armed Services were included in this study. These participants were managing comorbid symptoms of combat-related TBI and psychological health conditions. Participants (n=208) ranged in age from 21 to 59 years (mean=35.75, SD=vii.43) and predominantly identified as men (97.i%, n=202). The racial and ethnic distribution was every bit follows: White, 88.five%; Hispanic, 5.8%; Black, 2.ix% and Asian/Pacific Islander, 2.nine%. Although service members were affiliated with all five branches of armed forces service, the Navy was the well-nigh represented (44.seven%, northward=93). The bulk of service members were enlisted (83.2%). The remaining participants were officers, many of whom were special operations. The fourth dimension of service ranged from 1.5 to 33 years (hateful=14.68, SD=7.11).

Data sources

Information sources for the study included (1) photographs of montage painting artwork created past service members and (2) documented clinical notes. Data collected from the mask analyses were likewise used for comparing.xiv Participants' exact descriptions of the symbolism embedded in the artwork and their resulting experiences were captured in clinical notes. These notes, about 50–100 words, and photographs of the artwork were uploaded as part of electronic medical record documentation into a common military patient charting and medical information database. Additional demographic information was as well available on participants' age, gender and armed services rank. More than 800 paintings have been made over the past 6 years. Data including consent for assay, photographs of the montage paintings and concurrent notes were available for 240 participants. Demographic information was available for 208 participants.

Data analysis

An iterative process informed by thematic assay was used to analyse the data.46 47 Photographs of the montage paintings were first extracted from the data files and reviewed collectively to identify visual themes for open coding. These themes were compared with the start information prepare collected from the masks. Pictorial and symbolic representations, as well as visual elements such as color, media and composition, were noted. The list of codes was reviewed for consensus and cantankerous-referenced with the study sample for axial coding. An exhaustive total of 174 codes were ultimately generated to capture the frequencies of observations such equally verbal descriptions of memories of deployment or the creative option to use text in the montage paintings. Clinical notes from the grouping art therapy sessions and the culminating artwork were coded qualitatively through a Web application for mixed methods research applicable for the social sciences.48 One coder reviewed the sample. Another coder reviewed the data set, and each coding discrepancy was discussed to reach consensus. Verbal, behavioural and visual elements of the clinical meet were comprehensively examined. These findings were then compared with the results analysed for the information set of the masks. Because the same codes were used, comparisons could be fatigued from the two time points: week 1 (masks) and calendar week four (montage paintings). The changes in frequencies noted between these two information sets are substantial and place areas for future examination.

Results

The information analysed included clinical documentation and artwork of injured service members (n=240) who participated in group fine art therapy. Code occurrences were computed for frequency. Table 1 shows the codes yielding the highest frequencies in the data analyses.1

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Table 1

Notable occurrences in montage data fix thematic analyses

Art-making experience: Pleasance, socialisation and openness elicited

Data collected from the montage paintings indicated that group art therapy was beneficial. Participants specifically commented about their enjoyment (41.3%, n=99), were able to share artwork with peers and clinicians (30.4%, n=73) and voiced concerns and feelings about experiences related to their injuries (35.4%, northward=85).

Artwork: Use of text

Near half of the works (43.8%) used preprinted or originally formed text in the compositions of the montage paintings. These words were more often than not cut out of magazines; a few were written in with pigment. Text included phrases or words exemplifying the service members' thoughts including famous quotes or fragments from songs and poems. This reliance on text suggests a greater need for mastery of the expressed content. Whereas some theorists come across the use of words in expression as a form of intellectualisation, information technology is also regarded as an adaptive defence to manage the intensity of what is existence processed.49 fifty The transition from not-verbal to verbal processing through creative processes, a notable observation from other enquiry, is also axiomatic in this study.11 Additionally, the utilise of words relates to cognitive rather than visceral reactions, which allows for emotional distancing and mastery. The utilise of text in the montage paintings is exemplified in figure 1A,B. In effigy 1A, preprinted text is adhered to a painted background. Selected text includes 'BOOM', 'Finding My Place', 'The Eyes Say It All', 'Return to Reality' and 'What about the survivors?' Effigy 1B depicts the painted words 'Putting pen to newspaper to write something profound is simpler than putting bullets to flesh'. The inclusion of either preprinted text or text inscribed past hand was coded independently. Although the processes and resulting montage paintings vary, each expresses personal postcombat reflections.

Figure 1

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Figure 1

(A,B) Service members used both preprinted text and painted words to share their expressions in more literal terms. (C,D) Service members rely on the richness of nature metaphors to capture the psychological impact of combat.

Artwork: Nature as metaphor

The utilise of metaphor is widely used in artistic arts therapies equally a change agent to challenge sometime thinking and nascence new opportunities.51 Nature was the most frequent metaphor depicted in the montage paintings (35%, northward=84). Service members seemingly related to nature as a safe realm for expressing conflicted material. Nature, ofttimes symbolic of dynamism, served to showcase the themes of aggressor/victim, fragility/grandeur, unpredictability and stability. Attempting to mitigate these dualities, service members examined their own internal conflicts through the nature-inspired art they created. Internal struggles were projected onto the more universal, external surround. figure 1C,D reflects the montage paintings thematically coded for use of nature every bit a metaphor. In effigy 1C, an isolated volcano spews matter off the boundary of the canvas while preprinted text, 'Master Your Demons' is anchored at the bottom. In effigy 1D, an open-mouthed shark lurks in the water with other fish. The inclusion of the word 'Allurement' speaks to the vulnerability of this predatory encounter.

Artwork: Life story

Early attempts to integrate the combat trauma into a more holistic biographical narrative in recovery are evident in figure 2A,B. The externalisation of autobiographical details aids memory processing by formulating a reconsolidation of memories through a newly synthetic narrative.12 22 28 The composition is visually divided in figure 2A because at that place is a clear delineation between gainsay and postcombat life. A flaming 'TBI' lurks in the altitude amid the headstones of those who were killed in combat. The brusque, coloured lines show the meticulous efforts taken to include the details in a methodical style. With the American flag centred on the folio, each side of the barracks suggests divergent scenes. In figure 2B, the montage painting reflects the service member seeking salvation, equally he inscribed 'God Deliver Me From Evil'. He regretted the burden his war machine experiences had perceivably imposed on his family. The execution of the paint cloth appears less controlled in this paradigm and the brown colour both camouflages and conceals the words. Reddish colour is used for the word 'Evil' which is too splattered cantankerous the stick figures higher up the word 'Family.'

Figure 2

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Figure two

(A) Artwork exemplifies the service member'south life story. The service fellow member described that he wished to depict 'being in the trenches' (describing his deployment and injury), and so the claiming of climbing out (reflecting his treatment at the National Intrepid Center of Excellence) to a brighter, better identify. The service fellow member reflected that 1 solar day life will terminate; he depicted this with a bright lite and ii shadows overlooking the fallen. (B) While struggling with head pain, the service member shared this work, explaining it represents how he has 'tainted' his family due to everything he has been through in the military. He shared his hopes, 'God evangelize me from evil'. (C) The service member covered his canvas board in cover-up printed cloth. He printed and glued pictures related to his military career while sharing his desires to return to combat. He listened to his peers who suggested he has accomplished much in his life and volition take the opportunity to accomplish more outside of the war machine.

Memories of deployment

In comparison to the mask information, at that place was a 13.5% increase in service members' expression of deployment memories, rising from eight.2% in week ane% to 21.7% in week 4. After iv weeks of treatment, rubber established through trust in the treatment seemingly encouraged more than difficult memories to be more readily activated. Progressive exposure to gainsay memories aids trauma recovery and aligns with previously accounted inquiry findings.22 26 32 Figure 2C is a montage painting coded for memories of deployment. Covered get-go in camouflaged textile, the montage painting included images of badges, weapons and service members in combat. Images of the service member's own military machine division are too included. His verbalisations during the grouping process described his yearning to return to combat. The montage serves equally a non-linear way to capture the gainsay experiences concretely for integration into the personal narrative.43 Service members were able to 'remember' without 'reliving' the experience.29

Artwork: References to serenity/interests

Time to come goals were as well described in the montage paintings. Service members relied on cocky-efficacy to outline personal goals post discharge. These images were largely hopeful and relate to the reactivation of positive emotion noted in existing inquiry.11 22 28 Effigy 3A,B shows examples of montage paintings coded for references to serenity and interests. Effigy 3A reflects a barren mountain of solitude described as 'My Happy Place' from individually cut messages. Effigy 3B depicts a man form in water. The service member explained the xanthous and red paint strokes to be 'thoughts seeping in' from floating in warm water. While both images were described as serene associations, each holds a sense of isolation.

Figure 3

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Figure 3

(A) After first painting his groundwork landscape, the service member fabricated an image of a cluster of trees and cutting out messages to read 'My happy place'. (B) The service fellow member depicted a person floating in h2o and used yellow and red pigment strokes to illustrate one'southward thoughts seeping in. (C) The service fellow member suggests the yellowish footsteps he stood on when he was a new Marine recruit. He stated that the footprints represent where it all started likewise as the side by side steps he volition need to accept in his life as he anticipates retirement. (D) He then chose to add together positive phrases on the dorsum of his montage painting equally motivation for moving forrad. (Eastward) The service member used adhesive notes on a cork-covered lath to outline his future tasks.

Hopefulness was likewise improved (eleven.one%) over the form of four weeks in the data samples. Figure 3C,D is representative of montage paintings coded for hopefulness. Clinical notes draw, 'Pt stated the footprints correspond where it all started, as well as the next steps he will need to take in his life (retirement)'. The footprints relate to the yellow painted footprints recruits stand up on their start entry, symbolic of the structure established to stand in formation and recount all those who have served in the past. The drill instructor ritualistically recites, 'you have just taken the first step toward becoming a fellow member of the world's finest fighting force, the U.s. Marine Corps'. This service member opted to include photographs with quotes in the back of his sheet frame to aid him in his transition to noncombatant life. The ii quotes read, 'A journey of a thousand miles begins with a single pace' and 'When I allow get of what I am, I go what I might exist'.

Effigy 3E is also a montage painting coded for increased hopefulness. The service member used cork to encompass the surface. Tasks are outlined on adhesive notes under the title 'Things To Do'. Selected notes read: 'Find God or faith or at to the lowest degree requite it a effort?', 'Talk the wife into not leaving', 'Be more friendly to people', 'Stop swearing at the kids, at the dog, at the neighbour, at myself', 'mow the backyard', 'drink less' and 'Go to the dinner party and act like you are having fun'. Evidence of self-efficacy as described in other research can be seen in this chore-oriented, organised montage painting that outlined both short term and long-term personal goals.22 25 27

Other notable changes

The montage painting data set up from week 4 was compared with that from the masks created during week 1. Other notable differential changes betwixt the masks and montage paintings are as follows: (1) increased cocky-sensation and socialisation (26.9%), (2) increased patriotism (xi.eight%), (3) increased pleasure from fine art making (10.five%), (four) greater awareness of psychological distress (5.3%) and (5) decreased reporting of depression and anxiety (4.3%).

Figure 4A,B shows montage paintings coded for increased self-sensation. In figure 4A, a service member depicts his experience of PTSD equally beingness non-human, pictorially illustrated as 'The Blob' character. The preprinted words 'getting to know you' align with his exact statements almost trying to connect with the 'who' he is within. The centralised text, 'Tin can you accolade the power inside you' parallels the intentional efforts to fit the images together tightly in a puzzle-similar composition and so each is visually held by the other. Figure 4B incorporates a three-dimensional switch in its visually divided composition. The service fellow member depicted his two (although unequally divided) sides: a peppery, aggressive facet labelled as a 'monster' and a more compliant side, embellished with packaged sweetener flanked by words 'refreshing' and 'relief'. Patriotism, commitment to service and courage are evident in figure 4C. The montage includes two popular mottos in military culture, 'People slumber peacefully in their beds at night knowing that rough men stand ready to exercise violence on their behalf' and 'May the skulls of my enemies exist piled as trophies at my feet'.

Figure 4

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Figure four

(A) The service member worked with focused intention to reflect his experience with PTSD. He relied on images of the Hulk character to explicate how he struggles to contain his anger and come to grips with the 'who' he is inside. (B) The service fellow member mounted an electrical switch to his board to illustrate the 'switch' he feels inside. The upper one-half was described as the fiery, ambitious side and the lower one-half with the words 'refreshing' and 'relief' alongside a bundle of artificial sweetener correspond his nice side. (C) This service member used gold to write popular quotes nigh patriotism and courage beside his military insignia. PTSD, post-traumatic stress disorder.

Discussion

Nosotros conducted a qualitative analysis of montage paintings (n=240) made past active-duty military service members with traumatic encephalon injuries and related psychological health conditions. The findings of this written report are congruent with results from recent art therapy research that has presented therapeutic elements beneficial for service members: (1) progressive exposure, (ii) externalisation for processing, (3) reactivation of pleasure, (4) promotion of cocky-efficacy and (5) conception of a reconsolidated narrative.12 22 25–28 The montage paintings created by the service members reflected relevant themes described literally through the utilise of text and/or pictorially through the use of visual metaphors.

Service members at the NICoE accept used art therapy in an integrative setting to manage symptoms of TBI and underlying psychological health weather. Group art therapy was institute to exist a positive feel for participants in this report. The data sample indicated that 41.three% of participants spontaneously and specifically described the fine art making experience to be enjoyable; 30.four% were able to share their artwork with clinicians and 35.four% engaged socially in the group, sharing concerns. Pregnant changes to identities are experienced equally service members shift from active to non-active military service.52 In grouping art therapy, anxieties tin be effectively contained in the grouping, with the therapist and through the created art production.53 Simply existence present with others who hold similar experiences reduces isolation and forges connectedness.42 The gratification gained by the service members from the art therapy feel resulted in increased pleasure, increased socialisation and greater openness about the recovery processes.

Derailing gainsay injuries and the accompanying psychological anguish disrupt the strong sense of identity held past service members and strip them of their abilities to actively participate in the experiences that had once held them rubber in solidarity.52 Group handling with service members can reveal vulnerability and psychological fragility that are foreign and contradictory to the solidarity and leadership of the collectivist military machine civilisation.xl 52

The montage painting, created at the week iv time point, is sequential to the mask created during week 1 of treatment at the NICoE. The montage painting, an aggregation of preprinted images, text and more traditional art materials, enables progressive exposure and externalisation for processing. The viii'×10' canvas provides a sturdy surface on which to integrate the more fragmented aspects of self, treatment and hereafter equally a civilian. Because it is a small composition, the service members gain a sense of mastery to select the most pertinent aspects of their recovery process. Service members cull whether to work abstractly or figuratively. Some use personal images and writing. The process promotes self-efficacy.

A central tenet of fine art therapy theory postulates that all artists, regardless of skill level, project underlying conflicts in art making.54 The rich content of the montage paintings reflects the circuitous recovery experiences of service members. The nigh frequent codes were the apply of nature metaphors (35%), reflection of a life story (28.8%), memories of deployment (21.7%) and references to serenity (17.v%). Findings also notation increases in patriotism (11.8%) and hopefulness (11.1%). The noted increase in self-awareness tin point to the conception of a reconsolidated trauma narrative equally elements of past experiences are integrated into the adaptive coping in the nowadays.12 22 26 28

In art therapy group sessions, wounded service members bring together together to make meaning from the discrepancies of existing beliefs and current realities.55 The shared experience of the grouping allows service members to be psychologically held in the space while newer identities are being rehearsed. The use of montage painting with the military machine population enables service members to 'discover the layers of his or her experiences and revisit their story as a therapeutic means of creating, understanding and gaining a sense of mastery'.(17, p. 45) The inherent properties of collage and montage painting help to reconcile cognitive and emotional racket for trauma-related symptoms.

By externalising underlying feelings in the montage paintings, processing is more than easily tolerated. Pleased with their finished products, service members frequently souvenir their paintings to loved ones with pride. Art therapy aids the larger rehabilitative goals of increasing stabilisation, establishing condom and increasing sensation of symptoms.43 The communal experience of grouping art making fostered increased social connectedness by diminishing feelings of shame and isolation commonly felt by service members managing combat injuries.

Results from this study highlight the complexity of the military culture, necessitating the broader scope of analysis afforded by qualitative inquiry. The dialectic being of aggressor/victim, honour/shame and vulnerability/invincibility tin be best captured through qualitative research methods. More qualitative inquiry is needed to capture the breadth of military service members in postcombat recovery.

The study has many limitations that warrant attending. The data are secondary and our analysis and interpretation are based on photographs and brief clinical notes. This limits the extent of meaning and attributions nosotros tin make for the imagery created by the service members. In addition, the artwork was created in the context of a 4 week intensive outpatient integrative medical intendance plan facilitated in the safety of group setting by a Masters level art psychotherapist. Every bit such, artmaking that invites exploration of challenging clinical symptoms cannot be replicated in other contexts that do not provide these structures of psychological and physical safety.

In that location are, however, several areas for further study. Art therapists might interact with colleagues in humanities, medical and social sciences to further examine how fine art therapy helps service members limited and communicate their challenges to intendance providers, peers and family as well as regulate emotion in the short and long term. Further written report might also examine if certain types of imagery relate to specific clinical trajectories of recovery every bit well as if specific types of injuries might exist particularly sensitive to artistic arts therapies interventions.

Conclusion

The montage paintings serve equally visual reflections of the military service members' experiences of TBI and underlying psychological health conditions, and the integrative handling received at the NICoE medical centre. The paintings helped service members consolidate their experiences into one epitome and also served as a reminder that treatment for the symptoms is circuitous and multifaceted. To the best of our knowledge, this is the first article to highlight how paintings created through art therapy support the mental health needs of service members, but further research is needed to ameliorate understand how visual self-expression helps with short-term and long-term outcomes. Imagery provides a rich loonshit for clinicians to engage patients in describing concrete and psychological symptoms related to military experiences. Healthcare providers, clinicians and practitioners working with injured service members could benefit from collaborating with art therapists to provide integrative care that honours visual communication for traumatic experiences that cannot be communicated through verbal means alone.

References

  1. ↵

    U.Southward. Regime Accountability Role. VA mental health: Number of veterans receiving care, barriers faced, and efforts to increase admission (GAO-12-12) [PDF file]. 2011 https://www.gao.gov/products/GAO-12-12 ().

  2. ↵

    Institute of Medicine. Returning home from Iraq and Afghanistan: Assessment of readjustment needs of veterans, service members, and their families. Washington, DC: National Academies Printing, 2013.

  3. ↵
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