A literature review of the therapeutic mechanisms of art therapy for veterans with post-traumatic stress disorder

ABSTRACT

Post-traumatic stress disorder in combat veterans is often managed with the use of psychological intervention such as Cognitive Behavioural Therapy (CBT) and Eye Movement Desensitisation and Reprocessing (EMDR). There is a body of evidence that suggests that some individuals do not respond as well as others to such interventions. Other strategies in use to support veterans in recovery include art-based therapies and anecdotal evidence suggests that these have therapeutic impact for veteran groups that do not benefit from the aforementioned psychological therapies. This article describes a review of the literature associated with art therapy with combat veterans, aiming to ascertain what the therapeutic mechanisms are for veterans in using art therapy to manage post-traumatic stress disorder symptoms. Themes became evident within the literature review that are discussed and analysed, with resultant ideas for future research possibilities identified.

KEYWORDS:

• Veterans
• post-traumatic stress disorder
• art therapy
• therapeutic mechanisms

Introduction

United Kingdom military service personnel have been involved in the conflict arena in a multitude of settings for varying periods of time and with differing levels of intensity for hundreds of years. Most recently, there has been engagement in Cyprus, Northern Ireland, the Falkland Islands, the Balkans, Iraq and Afghanistan (Murrison, 2010).

Veterans returning to the UK from military conflict experience a slightly elevated incidence of specific mental health problems compared to that of the general adult population (Murrison, 2010). Such mental health problems predominantly consist of anxiety and depression (Murrison, 2010), but there is an increasing recognition of the incidence and diagnosis of Post-Traumatic Stress Disorder (PTSD).

Additional challenges for veteran groups include social adjustment to the civilian environment, housing and employment concerns and family relationship problems. It is of particular note that alcohol and substance use are statistically problematic for returning veterans (Murrison, 2010), and veterans who have experienced combat are more likely to be sentenced to prison for violent offences (MacManus et al., 2013). Veterans have utilised coping strategies in order to manage their symptoms, for example excessive use of alcohol or illegal substances. Such coping strategies can be particularly problematic, requiring interventions from a multitude of health and social support services.

Combat Stress, a UK-based military mental health charity concerned with mental health problems within the veteran groups, reports an increase in the number of self-referrals and referrals from other agencies (http://www.combatstress.org.uk, 2013). Interestingly, these referrals have typically spanned decades of military engagement, including in some instances conflict from the 1940s and 1950s. This is largely due to the late recognition by the veterans and those around them that symptoms observed and reported are of PTSD (Shepherd, 2000). Typically, veterans experience symptoms associated with trauma for 15 years before seeking help. The pressure of the social stigma associated with the experience of mental health problems is exacerbated by historical cultural attitudes to mental illness within the Forces population (Forbes & Creamer, 2003). In addition, veterans often experience the stigmatising nature of mental health problems in the UK civilian population (Murrison, 2010).

One area of intervention identified for PTSD is trauma-based therapy as recommended by the National Institute for Health and Clinical Excellence (NICE) (https://www.nice.org.uk/guidance, 2011). Cognitive Behaviour Therapy (CBT) is one such therapeutic intervention and NICE outlines the evidence base for CBT and also Eye Movement Desensitisation and Reprocessing (EMDR) (Shapiro & Forrest, 1997). However, despite the supporting evidence identified by NICE, there is also evidence that CBT is not necessarily effective with all groups, with studies suggesting successful outcomes as low as 50% (Kar, 2011), specifically for some groups with a complex range of other social and health features. It seems timely that alternative psychological interventions are examined in greater detail.

In addition to psychological and pharmacological therapies, other interventions are frequently used to treat PTSD, including creative and arts-based therapies. This is a treatment option that has been used either as an individual therapy or as part of group therapy for a wide range of service user groups including children, veterans and survivors of sexual and physical abuse, all of whom have had a diagnosis of PTSD (Chapman, Morabito, Ladakakos, Schreier, & Knudson, 2001; Slayton, Archer, & Kaplan, 2010; Speigal, Malchiodi, Backos, & Collie, 2006).

Veteran groups have adopted the avenues afforded by creative arts expression not only to try and provide a conduit for exploration of the trauma itself, but also as a way of exploring in depth the narrative related to the traumatic incidents that have led to the PTSD (https://www.va.gov; https://www.mentalhealth.va.gov). Veterans in the UK have described their experience of using art therapy (Lobban, 2012), and the resulting data suggest great benefit for this particular group. The challenge in understanding the beneficial outcomes for veterans in using art therapies is the paucity of empirical research in this area (Lobban, 2012; Speigal et al., 2006).

Evidence from individual case studies is suggestive of beneficial outcomes (Hines-Martin & Ising, 1993; Morrisey, 2013). In addition, current revelations about creativity and the functions of the human brain from the neuroscientific community (Van der Kolk & Fisler, 1996) suggest that further exploration of the beneficial qualities of engaging in art therapies for trauma would be apt (Hass–Cohen & Carr, 2008).

Literature review

Methods

This review of the relevant literature is narrative in nature, and is therefore broad in scope (Aveyard, 2014). It seeks to examine the use of art therapy interventions with veterans of combat who have a diagnosis of PTSD, and thereby identify the treatment mechanisms through critical appraisal of the retrieved literature (Greenhalgh, 2006). Please see Appendix A for further detail of the search processes.

Inclusion and exclusion criteria

Articles examined for the purposes of the review included studies that addressed the use of all art therapies with veteran groups. Art therapy interventions were included when PTSD was not evident as a clinical diagnosis but the recipients of the therapy included veterans, as the experience of veterans as a specific cultural group was hypothesised to include PTSD.

Due to the breadth of literature relating to the use of art therapies with children and young people, articles addressing this group were included. In addition, articles related to children and young people with a clinical diagnosis of PTSD and art therapies were included. A further inclusion was art therapies with non-veteran groups.

Literature results from 1980 allowed for the inclusion of literature associated with the art-making groups and experiences of Vietnam veterans, included due to the extensive work that has been carried out with this particular veteran group. Additional inclusion criteria were for articles using all methodologies and that of published and peer reviewed literature.

Exclusion criteria for the review search included mental health problems that were not clearly described as PTSD related, for example palliative care, HIV care and treatment for trauma related to the diagnosis of HIV, brain injury as a result of conflict or accident, trauma due to stillbirth, racism, or for individual symptoms of trauma rather than the diagnosis of PTSD.

In addition, studies were excluded that explored help-seeking families with a family member with PTSD, and those describing concerns related to co-morbidity for the individual with PTSD such as alcohol or substance use problems.

Art therapies have also been used extensively in working with women with trauma symptoms and those who have reached adulthood while still continuing to experience the trauma of childhood sexual abuse. However, such studies do not specifically address the use of art therapy with PTSD symptoms and as such were excluded from inclusion for the purposes of the project.

Studies that were not written in English were not included. It is possible that by using these exclusion criteria, important research was missed, but the likelihood of possible misinterpretation of the literature would be increased if they were to be included.

Search results

Final papers selected for review numbered 11. The studies were varied in nature and construct; professionals in the field of mental health wrote all of the articles. The literature was largely drawn from work led by professionals with an interest in, and positive view of, art therapies. It is important to bear in mind the potential for bias in interpretation of results for these papers as the likelihood is that the topic is being approached from a particular psychotherapeutic stance (Parahoo, 2006). It may be that there is an existing positive view of the therapeutic possibilities of creative therapies.

The majority of the papers were original research of a qualitative design (Avrahami, 2005; Lobban, 2012; Pifalo, 2002; Speigal et al., 2006); three were quantitative (Chapman et al., 2001; Johnson, Lubin, Miller, & Hale, 1997; Lyshak-Stelzer, Singer, St. John, & Chemtob, 2007), two mixed methods (Kopytin & Lebedev, 2013; Rademaker, Vermetten, & Kleber, 2009) and two were reviews of literature with personal comment (Gantt & Tinnin, 2009; Nanda Upali, Gaydos, Hathorn, & Watkins, 2010).

Settings for the studies included paediatric units (Chapman et al., 2001; Pifalo, 2002) and clinical services that were designed specifically for working with veterans with PTSD (Kopytin & Lebedev, 2013; Rademaker et al., 2009). One study was undertaken as the result of a film being made of the art therapy process for combat veterans (Lobban, 2012). The studies were from international sources in addition to the United Kingdom, predominantly from the United States. This is unsurprising in the light of the large body of research that has been undertaken into the experience of Vietnam veterans (https://www.va.gov).

The resulting papers were read systematically, and as the appraisal process unfolded it was evident that themes were emerging. Thematic analysis (Braun & Clarke, 2006) allowed for themes to be systematically identified and coded. From the analysis six clear themes were identified.

Thematic analysis of the literature

The group process

The impact of the sharing of trauma and experiences in the group setting is referred to in eight of the selected papers. Rademaker et al. (2009) suggest that the group processes inherent in art therapy groups support symptomatic recovery from PTSD. However, it is of note that the multimodal nature of the art therapies offered means it is not possible to discern which aspects of group therapy were beneficial, and within which group the beneficial effect occurred. The study refers to Van der Kolk and Fisler (1996) who saw the group context as having the possibility to create a safe re-experiencing of the trauma. The study notes that as with the work of Schnurr, Friedman and Green (1996), the group setting offers a safe place for the participants to explore their traumas and re-experience them vicariously as part of the group discussion.

Lobban (2012) describes the group process as having a significant impact on PTSD symptomology, particularly dissociation. It is suggested that the clearly defined structure and culture of the Armed Forces per se provides a ready-made cohesive peer group and Lobban (2012) identifies that the group art process facilitates a reconnection to this supportive experience while providing a perceived ‘safe’ environment in which to explore challenging emotions and memories. The assertion is that the containing nature of a charity and institution that deals wholly with this group also facilitates the sense of being able to share, rather than the nature of the group art process in isolation.

As with Rademaker et al. (2009), Pifalo (2002) observed with traumatised adolescents that there was a significant reduction of symptoms associated with trauma when group processes were utilised. Pifalo (2002) understands the group process as creating a container for the feelings of the group, being large enough to withstand the combined experiences of trauma for each member through the process of safely sharing experiences. The capacity of the group to allow discussion and sharing and more importantly being believed by others led Pifalo to describe the ‘Circle of Believers’, a concept echoed by Lobban (2012) who talks of the ‘Band of Brothers’ experience of the group.

It is important to note that the impact of a group process on children and young people across a range of ages would have differing outcomes to a veteran group related to age and experience. However, it is apparent that there is a component of this process that has had a positive impact upon specific symptoms. Both studies appear to be describing a specific facet of the therapeutic process occurring in art therapy groups, related to shared understanding and experiences. It is interesting to note that despite the difference in participants in both these studies, this facet is seen as part of the therapeutic mechanism.

Kopytin and Lebedev (2013) discuss how the formation of the groups helped break down traditionally held views about masculinity and strength in the military groups and facilitated conversations about trauma, aided by humour. This differs somewhat from the experience of Lobban (2012), where the hierarchy of the Forces already in existence appeared to provide a structure before group work commenced and contributed to the ‘Band of Brothers’ concept already mentioned. It may be that this difference is a cultural difference related to the differing therapeutic environments and countries in which the studies were carried out. While the focus of Kopytin and Lebedev (2013) was on the development and use of humour in groups, it is noted that the groups themselves appear to have offered a format for shared recalling of trauma and a reduction of previously held unhelpful ideas about how to manage such experiences in isolation.

Pifalo (2002) agrees with Lobban (2012) and Kopytin and Lebedev (2013), despite considering a different participant group of young people. Pifalo (2002) notes the importance of the group identity for the group and that the naming of the group was most important in helping this supportive environment. Johnson et al. (1997) observed that the art group had showed greater improvement in PTSD symptoms than the other areas that were measured and regarded this as due to the group process itself.

Lyshak-Stelzer et al. (2007), in a study of adolescents who had experienced trauma, noted that the function and thereby process of the group had a significant impact on participants. All talked of feeling safe within the groups and able to share. Chapman et al. (2001) argue that this is due to the art process itself, rather than to the inherent nature of the groups.

Speigal et al. (2006) aimed to establish a conceptual framework for the best use of art therapies for PTSD, and identified group treatment in three stages following a systematic review of the literature. The study notes that the group members identified that through the group process self-esteem can be enhanced, and that emotional and challenging memories or experiences can be shared and witnessed in a non-judgemental manner by group members who may be experiencing similar emotions. Again, this seems to resonate with the ideas suggested by Lobban (2012) and Kopytin and Lebedev (2013).

Group work is cited as ‘best practice’ in the study, suggesting that the process allows for the sharing of traumatic material in a trusting environment where the experience of hearing others share allows for the individual to gain confidence in sharing their own experiences, and reduces feelings of isolation (Speigal et al., 2006).

In triangulating this research, the study asked art therapists for their opinion. The study lacks detail in considering the responses of the therapists on what the effective therapeutic mechanisms were, although responses contribute to the overall proposed treatment regime that concludes the study. The therapist participants identified the containing quality of the groups and concurred with other studies in considering the safety of expression of trauma as key in supporting the participants.

Externalising the image and symbolic expression

This theme was mentioned in all the papers. The concept of externalising and development of a narrative related to the experience of the participants is seen as key in the studies. Externalising is a psychological treatment construct that suggests that the problem, symptom or challenge is considered as a separate entity to the individual. This allows the participant freedom from the constraints of the problem, symptom or challenge as it alters the position that the individual has in relation to the problem, potentially allowing for mastery over the problem that has been externalised (White & Epston, 1990).

Lobban (2012) describes how the veteran group at Combat Stress described the ‘flow of the image making’, an idea that the non-directed approach to their image making and the psychological freedom of working without prior planning freed them from the constraints of preconceived ideas. Lobban (2012) describes the power for the group of creating a tangible image, which the veteran can then step back from and observe, linking this to externalised symbols of trauma being able to stand alone, thus giving the observer the power to walk away from the image, if they choose.

Kopytin and Lebedev (2013) concur with this view, seeing the image formation as important in telling the story of trauma for the group of veterans when they were looking at humour in groups. As with Lobban (2012), they perceived the externalising of the images as key. The process of having the image externalised and observable on paper or in three-dimensional form, for example in sculpture, allowed the participants to choose to engage in narratives about the image or not to; it gave the participants the opportunity to observe the problem from another perspective, an image that the participants felt they now had mastery over.

The symbolic nature of the image was assessed as part of one study when considering the use of humour, and it was noted that the images tended to be of the participants themselves, which veterans reported as helpful. Symbols deemed by the veterans to represent unpleasant phenomena included snakes, dinosaurs and cats and the use of these images served to identify and externalise fearful people and events (Kopytin & Lebedev, 2013).

As mentioned earlier in relation to the previous theme, Speigal et al. (2006) found that the generation and externalising of the image is a significant factor and include it in the proposed model of working using art therapy with combat veterans with PTSD. The authors describe the importance of the ability of the observer to view the image from a chosen emotional distance and to assert some power over the image. It is suggested that the emotional distance afforded through this process allows for the creation of a newly constructed and coherent narrative related to the trauma, concurring with both Lobban (2012) and Kopytin and Lebedev (2013).

Nanda Upali et al. (2010) explore the power of war memorials in allowing veterans and their families to externalise memory and emotion by projection onto the memorial, and propose that the same is possible through the use of art images in the clinical environment. The study proposes that images that are situated in clinical areas and accessed by veterans should not be of a nature that can remind veterans of their traumatic experiences. This is because the images are not within the emotional control of the veteran and may cause distress and unhelpful remembering of trauma. It is suggested that close attention is paid to the experiences of veterans in informing which images may be symbolic of traumatic events or memories and that the symbolism may not be apparent to the observer.

It is suggested that symbolic imagery may play a part in the restorative care and recovery period for combat veterans, including recovery from physical injury (Nanda Upali et al., 2010). This would be most pertinent in physical recovery environments where veterans may be recovering in the same setting for some time due to the nature of their physical injuries (https://www.combatstress.org, 2013). They would therefore experience exposure to visual imagery for long periods of time and the study suggests that the nature of the image may have an impact on recovery. Although this study is not concerned directly with the therapeutic mechanisms of art therapy as a participative activity, it considers how the external image and projection of feelings and emotions onto the image appears to be beneficial in recovery as it seeks to address symptoms through the uses of restorative art activity (Avrahami, 2005).

Avrahami (2005) notes that the symbolism of the images used in two case studies with veterans is important in assisting the veterans to understand and express the trauma and events that followed the trauma. This study suggests that symbolisation is a key facet of the art therapy intervention, positing that metaphors in the art images produced can be used to help the veterans in developing an understanding of their experiences.

Speigal et al. (2006) identify symbolic expression as allowing a gradual revelation of the expressed memory or trauma at a rate that is within the young person’s control. This process in turn allows for the young person to overcome any possible avoidance and for therapy to progress. This would appear to support Lobban (2012) and Kopytin and Lebedev (2013), in that the image being external to the participant and under their control has an impact on how the image is viewed. In addition, Nanda Upali et al. (2010) identify that the visual impact of the image has relevance for recovery processes.

Pifalo (2002) describes the value of the symbolic art product for the group of young people taking part in the study, and as with the other studies alluded to here, the externalising of the image as an object that is symbolic of their trauma. The study also talks of the emotional distance created from the image for the young people, and of that distance acting as a buffer or barrier between themselves and the symbolic image. This would appear to resonate with the theme of externalising the image discussed in studies earlier (Kopytin & Lebedev, 2013; Lobban, 2012; Nanda Upali et al., 2010). Despite the differences in the groups described in the studies, the process of externalising the image and the symbolic content as understood by the participants is significant.

From non-verbal to verbal processes

In the study of adolescents with PTSD symptoms and the use of a trauma-focused art therapy treatment (TF-ART), Lyshak-Stelzer et al. (2007) identified that the representations and art products generated by the young could be used as the basis for verbalising experiences, often when verbalising had not been possible. This was within the safety and structure of the group process, as noted in an earlier theme. It is interesting to note that this study was concerned with adolescents and that verbal expression was reported to be a particular challenge for the groups, who also had additional mental health problems, and a significantly lower measurement of IQ than the general adolescent population.

Similarly, Speigal et al. (2006) identified in the review of studies into the efficacy of art therapies that the process of non-verbal expression through art assists in the process of developing verbal processes of expression. Speigal et al. (2006) see the art therapy process as facilitating a reconsolidation of memories for combat-related PTSD veterans. Arts therapists responding to their study identified that the art making could provide non-verbal processing through externalising of the image and mastery over the image and their interpretation of it. This interpretation fits with Lobban (2012), who notes that the symbolic expression through the production of the image facilitates a narrative of the trauma or feelings associated with the trauma.

Gantt and Tinnin (2009) carried out a review of research studies supporting a neurobiological view of trauma in which trauma is framed as essentially a non-verbal problem. They describe this as having implications for art therapy. The study posits that current neurobiological models regard the labelling and identification of emotional states as problematic. In addition, art therapy can offer the individual or group the opportunity to ‘reassociate’ (Van der Kolk & Fisler, 1996) words and experiences by focusing on the construction and making of art images about the trauma itself. The review identifies that the opportunity to verbalise trauma allows for a recreation of order in memory storage.

Chapman et al. (2001) concur with this view, identifying that the art therapy processes allowed for the shift from a non-verbal representation of the trauma to a discursive representation, which was then explored as part of the group process. The neurobiological view that the two hemispheres of the brain are predominantly either verbal (left hemisphere) or visual (right hemisphere) is championed here, as in Gantt and Tinnin (2009). Both studies suggest that art creation and therapy can allow integration of the neural pathways to facilitate transition of memory from non-verbal to verbal expression.

It is important to acknowledge that not all studies into the processing and integration of memories hypothesis are solely applicable to veterans’ experiences of PTSD (Van der Kolk & Fisler, 1996). Studies into memory processing in PTSD have included work on general trauma rather than diagnosed PTSD. However, current neurobiological ideas about integration and processing in trauma offer an understanding of how art therapies may be helpful (Hass–Cohen & Carr, 2008; Panksepp, 2012).

Integration and processing of memory

Lobban (2012) writes of the cerebral storage of traumatic memories for the veteran art therapy group at Combat Stress. Drawing on the work of Van der Kolk and Fisler (1996), she describes how memory in PTSD remains unprocessed (McNamee, 2004) and therefore prone to manifest itself as physical symptoms for the veterans.

Lobban proposes that veterans with PTSD experience disorder of their capacity to store, process and retrieve information. It is noted in this study that recent neuroscientific studies (Hass–Cohen & Carr, 2008; McNamee, 2004; Panksepp, 2012) have shown that the left hemisphere of the brain shows decreased activity, and right hemisphere activity is increased in trauma, although not all studies are specific to the experiences of veterans with PTSD, but include participants from a range of clinical backgrounds, all of whom had experienced trauma and symptoms associated with PTSD (McNamee, 2004; Rauch et al., 1996; Van der Kolk & Fisler, 1996. The studies referred to have been carried out with individuals who have symptoms of PTSD, including victims of rape, assault and veterans of conflict. It is proposed that this has an impact on an individual’s ability to process memory and translate experiences into speech; in the case of veterans it is noted (Van der Kolk & Fisler, 1996) that dissociation is a key feature and that therefore the integration of memories allows for focus on the image and thus verbalising of the experience.

Lobban (2012) describes the process of creating art through therapy as potentially integrating these two areas of the brain, through the recreation of narrative experience and the processing of this being finally stored in the areas of the brain as narrative memory. This in turn constructs a narrative in the process. Lobban (2012) noted this in her group work, as members gradually moved from creating images to higher order thinking and then verbal discourse relating to the traumatic events and their aftermath. Speigal et al. (2006) also note that the process can allow the development of a coherent narrative for the individual, suggesting that this also assists in the integration of memory, from the non-verbal to the verbal processing areas of the brain. Gantt and Tinnin (2009) describe the processing of ‘fragments’ of memory that can be integrated through the art process and the restoration of ‘temporal order’. Avrahami (2005) agrees, identifying the process of integrating memory as a key theme in the case studies, suggesting that the visual representation facilitates processing in both hemispheres of the brain, allowing for reintegration of memory through verbal discourse about the trauma.

Containment

Avrahami (2005) focuses on the psychological concept of containment as being therapeutic in art therapy for veterans engaged in individual therapeutic work. Containment is described as a fundamental aspect of the therapeutic engagement, whereby the therapist works to ‘contain’ the emotions expressed both verbally and non-verbally, through the process of engagement with the patient and the image. The therapist is seen as able to ‘hold’ the immensely powerful feelings that emerge as a result of the therapeutic process. Avrahami suggests that the holding process is a therapeutic mechanism in itself. It is essential to remember that the professional stance that Avrahami adopts is that of an arts psychotherapist and as such the concepts of ‘holding’ and ‘containment’ would be implicit in that role.

Speigal et al. (2006) echo this understanding of containment as a concept, but describe the container as being the image or the made object as opposed to the therapist working as the container. The image then contains the trauma, allowing the growth of a sense of control over the traumatic material. Conversely, Lobban (2012), Lyshak-Stelzer et al. (2007) and Pifalo (2002) see the group process and the participants as containing the trauma. This difference is interesting but it can lead to differing understandings of what containment means in each therapeutic setting and therefore differing understandings of the outcomes and whether the suggested containment is part of the efficacy of the art intervention.

There is no clear explanation of the understanding of any participant groups about what might be understood by containment in the psychological sense, thus, despite the concept being described across the papers, it was impossible to ascertain exactly what is being referred to as each paper seems to have a different conceptual understanding.

Artistic pleasure and mastery

All the studies identify the pleasure of the art-making experience, which is perceived as increased in intensity by the experience of being in the groups for therapy in three studies (Kopytin & Lebedev, 2013; Lobban, 2012; Pifalo, 2002). Lobban (2012) notes the sense of achievement afforded by making something that is admired by the self and others, particularly of note in a group of veterans amongst whom art creativity may not have been explored in the past.

Kopytin and Lebedev (2013) focus on the process of the creative endeavour and challenge for the veteran group in the process of making art. The study identified that the process of creating an object or painting was pleasurable in itself; the distraction and focus afforded a break from symptomology, as the challenge was to make the art. In addition, for this study humour was identified as a key component in the veteran group and this may have had an impact on the pleasure of the process.

Speigal et al. (2006) note that mastery also includes mastery over trauma symptomology and identify this aspect as key. The veteran can still experience enjoyment and pleasure, gaining mastery over their troubling symptoms of PTSD. It is also noted that the pleasure is beneficial, that the creation of an art image or object is important in its own right in raising self-esteem and reducing numbness caused by dissociation, a symptom of PTSD. The study also notes that the relaxation afforded by the art-making process reduces physical symptoms of hyper arousal caused by PTSD, without needing to undertake a more concrete relaxation intervention. Avrahami (2005) notes that the creation of the form that the art image takes allows the veteran to have complete control, and to make changes when and how he wishes. This control increases self-esteem as the veteran has the experience of regaining mastery over a process as well as experiencing pleasure in art making.

Limitations of the review

The predominance of art therapy-specific authors and journals in the retrieved literature was one limitation of the search (Aveyard, 2014). It is clear in the review literature that there is a growing body of interest in developing an understanding of how art therapy is therapeutic in veterans with PTSD, and in all trauma groups across ages. However, there are limited studies that identify art therapy treatment mechanisms in isolation from other treatment modalities. There are also limited studies that offer an understanding of the experience of the combat veteran and in establishing what it is that works from their perspective.

A further challenge was that the themes identified within the literature interchanged with each other frequently, particularly when the studies were considering memory integration and processing. This theme frequently became blurred into the theme related to verbal and non-verbal processing

The studies are undertaken from a particular therapeutic stance that tends to be of a psychodynamic perspective. Hence, an understanding of concepts such as containment and projection is taken as read and understood. In addition, there are two studies that inform the reader from the beginning that it is known that art therapy ‘works’ (Rademaker et al., 2009; Speigal et al., 2006). Such a perspective should be seen as having a strong potential for bias in the review of literature.

It is notable that the studies rely on the support of evidence from specific neuroscientific studies and the recent understanding of neurological functioning (Panksepp, 2012). This is a new and rapidly changing field that has a bearing on the outcomes in trying to understand the therapeutic mechanisms of art therapy for combat veterans with PTSD.

It can be argued that any literature search would be inherently biased due to the focus of interest of the researcher. For this reason the author has attempted to be as explicit as possible in describing process of search, appraisal and thematic analysis. In addition, the author is not from the art therapy field and as such can offer a differing perspective on the appraisal of the literature.

Conclusion

There is a consensus across six of the studies that the group and the group experience have a significant impact on the therapeutic mechanisms of recovering from trauma and PTSD. In addition, all the papers describe the impact of externalising the art image in order to facilitate processing of memories. Also, there is an emphasis in the papers on the transition from non-verbal expression to verbal processing of trauma through the use of art, and this again leads to a change in the nature of memory storage. It is clear that all the authors support further exploration of the therapeutic mechanisms for all groups experiencing trauma and PTSD and a drive to begin to develop a robust evidence base to support art therapy interventions.

The review of the literature suggests a need for continued research into the therapeutic mechanisms of art therapy for veterans with PTSD from an alternative perspective in addition to the evidence already gathered by art psychotherapists. It also suggests that there is a need for understanding art therapy treatment mechanisms for the combat veteran group as a treatment process in isolation from other available multimodal treatment strategies. This presents an interesting challenge as multimodal treatment regimes are the norm for veteran groups who access support services. It is clear that direct engagement with veterans to develop an understanding of the processes inherent in art therapy would be beneficial in establishing therapeutic mechanisms. It is to be hoped that this review adds to the burgeoning body of research evidence for the use of art therapies with veteran groups.

Acknowledgements

I would like to thank Janice Lobban, Senior Art Psychotherapist at Combat Stress, Leatherhead, Surrey, for her support and advice in relation to art psychotherapy with veterans and for her generosity in sharing her experiences and answering so many of my questions.

Notes on contributors

Alison Smith is Field Lead for Mental Health and Teaching Fellow at the School of Health Sciences, University of Surrey. Following completion of a Fine Art degree and then her Mental Health Nurse qualification, Alison worked extensively with young people and their families. Her interest in military mental health came as a result of working clinically with veteran fathers and their families. Her clinical work often involved utilising creative therapeutic techniques, working at the South London and Maudsley (Bethlem) Adolescent Unit, St. Bartholomew’s and Sussex Partnership NHS Trust. She most recently completed an Advanced Diploma in Therapeutic and Educational Application of the Arts as a precursor to beginning MA Art Psychotherapy studies.

Alison teaches across all the Health Science programmes in addition to leading the mental health team and aims to integrate creativity, education and professional therapeutic practice. She also continues to hold a small clinical caseload in a community Child and Adolescent Mental Health Service.

Her research interests include art therapies across clinical practice, ethics in mental healthcare and child, adolescent and family mental health. Email: [email protected]

ORCID

Alison Smith http://orcid.org/0000-0002-7499-7136

Appendix A

Search Strategy

A comprehensive electronic search of relevant databases was carried out, including that of CINAHL (Comprehensive Nursing and Allied Professionals). This provides an advanced search of up to 3070 journals, and helped to develop an initial search focus. Medline was also used, providing a substantial database of over 400 UK-based journals and PROQUEST which was searched as it supports PILOTS (Published Literature on Traumatic Stress), which allowed access to specific trauma-focused literature.