A Community Building Approach to PTSD Using the Arts in a Military Hospital Setting

PTSD Feels Like, Mixed Media Sculpture by Cpt Rina Shah (USA, ret) exhibited at Lorton Workhouse Arts Center in Lorton, Virginia, 2011.

Social support plays an integral role in the management of the negative impact of stress upon health and recovery from trauma [1]. Sufferers of combat-induced posttraumatic stress disorder (PTSD) frequently complain of feelings of isolation , loss of identity, and a decreased ability to connect with and empathize with others, including loved ones. The stigma of mental illness, internal and external pressure to uphold the dominant narrative of the invulnerable hero, and the complexity of emotions toward the combat experience are among the barriers to honest communication and reintegration into civilian society [2]. But trauma and the resultant fragmentation of memory provides an opportunity for patients to rebuild identity and meaning through the regular construction of narratives—not once, but on a regular basis, as circumstances evolve [3]. Encouraging individuals to independently and interdependently engage in the arts as an occupation [4, 5] through which to actively reevaluate relationships with themselves, their memories, and their loved ones empowers them to become active participants in their treatment, and can improve outcomes across the continuum of care.

21.1 History and Overview

In 2011, during Base Realignment and Closure (BRAC) the arts program operating out of the Morale, Welfare, and Recreation (MWR) Arts and Crafts Center at Forest Glen, a satellite facility of Walter Reed Army Medical Center, became a program of the Department of Rehabilitation at Walter Reed National Military Medical Center (WRNMMC) in Bethesda, Maryland. Since then, the program has expanded, offering 17 weekly recurring programs for patients and families (not including bedside visits and one-on-one co-treatment sessions) at both WRNMMC and Fort Belvoir Community Hospital (FBCH) in Virginia. More than 600 patients and family members participate in recreational arts activities through the program each month.

The WRNMMC Department of Rehabilitation’s Occupational Therapy Service provides recreational arts activities, facilitated by artists, through multiple departments, including psychiatric partial hospitalization, inpatient psychiatry, pediatrics, oncology, and others. These programs are offered as: (1) treatment directed sessions, (2) voluntary/self-selecting sessions, and (3) weeklong workshops, which include a mixture of in-treatment and self-selecting participants. In all of these sessions, the focus is on engagement in art-making as an occupation which aids transitions through phases of treatment (i.e. inpatient to outpatient, active duty to civilian), increasing patient/participant responsibility for care, creating opportunities for healthy socialization, and providing tools and practice for effective communication. Participants are introduced to a wide range of art forms including writing, visual arts, music, and performing arts.

Further explanation of the primary components of the arts activities is given below:

In-treatment sessions are held in collaboration with partial-hospitalization/intensive outpatient programs, as well as some inpatient programs primarily in group settings. In addition to physical injuries, these individuals may be in treatment for mental illness, trauma-related stress, substance dependency, or a combination. Attendance in recreational arts activities is mandatory, often in spite of initial trepidation, and participation is documented by or under the supervision of a licensed clinician.

Open sessions, held on the hospital campus, are by and large, not treatment-directed, though many participants were initially referred or made aware of the sessions from occupational therapists and behavioral health providers. Participants choose to attend and work on projects of their choice. At one table, people explore self-portraits, soapstone carving, knitting, painting, and more. The atmosphere is social conversation, laughter, coffee drinking, coming and going. A flattened hierarchy is maintained in these groups—all first names, regardless of rank. The sessions take place at set times and locations, and last for 2 h or more. Participants are not required to arrive on time or stay for the entire session. This accommodates busy schedules and makes it easy for individuals to remember and return to the sessions after an absence. These sessions include patients from all over the hospital, inpatients, and family members.

Weeklong workshops are art, writing, film, music, or combination workshops culminating in a performance that is open to the public. The daily sessions are held at the USO Warrior and Family Centers at Bethesda and Ft Belvoir, and are facilitated in collaboration with contemporary, professional civilian, and veteran artists. As a group, participants work through the week to plan and complete their portion of an exhibit or performance. Each individual is completing a personal work of art, but is simultaneously working as an interdependent group, supporting and propelling one another forward. Participants leave with a completed “product”—a piece of writing, a short film, a piece of artwork, or a recorded track of music and the culminating performance. This product represents successful participation and an opportunity to step out and claim their narratives.

It is important to note that these arts activities are presented as an occupational therapy modality rather than art therapy—meaning that occupation in these activities is considered both process and product [4]. Through the process of creating art within the group context, participants both directly and indirectly address the issues of isolation, stigma, and loss of identity as they connect with people with shared experiences rather than in individual doctor’s offices or isolated behind closed doors at home. Participants learn to make sense of their emotions, history, experiences, and stories, understand and empathize with those around them, and consider ways of connecting with civilians, family members, and fellow service members. Many of these participants have experienced a significant life changing event due to service-related injuries and, as a result, often an unplanned and challenging transition from military to civilian life. They must manage these obstacles in addition to coping with the avoidance, re-experiencing, alterations to mood and thoughts, heightened arousal and reactivity, and often co-occurring family and social discord that come with PTSD. By engaging in the creation of art, which provides in the most basic sense a chance to use coping skills and practice effective communication, participants are also empowered to build new skills and identities during their treatment and recovery.

There is much overlap in the benefits and approach of these activities with more traditional therapies; however, these sessions differ from traditional clinical arts therapy or psychotherapy support groups in these key ways:

Inclusivity: Mixed groups of participants may include combat- or noncombat- deployed service members, veterans from various eras, physically or mentally ill patients, traditional military dependents and nonmedical attendees.
Participant led: While project ideas or writing prompts are available, participants are not required to respond to a specific topic or directive, but instead are encouraged to direct themselves based on individual interests.
Emphasis on independence/community reintegration: Participants begin tasks that are unlikely to be completed in the course of one session and are encouraged and enabled (through availability of materials and access to community resources) to continue to pursue these interests outside of sessions, on their own or with peers.
Nondiagnostic: The artwork produced is not assigned meaning by a therapist; instead the process is used by the participant to construct his or her own subjective meaning, and given the opportunity to explain that meaning in a social setting.
Active facilitator engagement: Participants and facilitators are engaging in the art-making process simultaneously in an environment of flattened hierarchy.
Duration and frequency of participation are not pre-determined, but have organic ebb and flow dictated by individual needs—participants may suffer setbacks such as re-hospitalization or difficulties within personal relationships and find a need to attend more frequently or conversely, may gain employment or leave the military health system, but may choose to attend public events and openings. This is key, as participants need continued support as they move through the system and reintegrate back into their chosen communities.
Continuity of facilitators—participants are able to build and maintain rapport with facilitators as they move through phases of treatment, creating a relational bridge that helps individuals who struggle with change and mistrust to push themselves creatively while feeling a sense of social support.

The cases presented below are composite case histories based on the hundreds of participants in the arts programs. Care has been taken to protect the identities of participants while demonstrating realistic treatment courses based on common symptom profiles and outcomes.

21.2 Case 1

21.2.1 History/Presentation

Susan is a 28-year-old African–American female army combat medic, married with children, with two combat deployments. Susan endured childhood trauma, including abandonment, sexual trauma, the loss of a sibling, and a suicide attempt. Susan first sought treatment in March 2012 after being assigned to work at WRNMMC and noticing difficulty functioning in her personal and professional lives. Susan began with weekly therapy appointments in the outpatient behavioral health clinic, and was prescribed medication for anxiety, depression, and panic. After 2 months, Susan received a referral to the Psychiatry Continuity Service (PCS), an intensive outpatient psychiatric program.

Initially referred for her childhood experiences, it was soon determined that due to significant combat trauma during her first 15 month deployment (including responding to mass casualties, treating gunshot wounds on Iraqi children, and recovering severed body parts), Susan would benefit from taking part in the trauma recovery program, the track for individuals suffering from combat related PTSD. She described “panic attacks,” feeling as though she could not breathe, crying, and an overwhelming need to leave the situation triggered by crowded spaces and loud noises. Each attack was followed by a sense of shame and fear that she would never recover or be able to function as she did before her deployments, leading to further isolation and decreased interest in activities she had previously enjoyed.

21.2.2 Intervention

21.2.2.1 May 2012

Susan attended weekly writing groups with the recreational arts program during her stay in the partial hospitalization program. Susan was quiet at first, very obviously skeptical of the process, but during her third session, she shared a piece of writing that was honest and clear, acknowledging struggling with feelings of inadequacy as a mother. She wove together multiple narratives—the neglected child, the witness to the horrors of war, the parent who missed so many of her children’s birthdays. Sharing it was obviously difficult, and Susan had to pause multiple times during the reading to collect herself, but she completed reading and began to share her writing regularly thereafter.

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