Assessing trauma through art: The signs of inner struggle

Active duty military members who experienced traumatic brain injury often also have to manage post-traumatic stress disorder, depression, or anxiety. Can the art they make help specialists to identify the severity of their inner struggles?

"Traumatic brain injury" (TBI) refers to sudden head trauma that causes harm to a person's brain.

One context in which TBI might occur is military service, in which a person is always exposed to danger and physical injury.

Those who have experienced TBI might also be diagnosed with a psychiatric condition, usually: post-traumatic stress disorder (PTSD), major depression, or generalized anxiety disorder.

To find a more effective way of supporting military service members to cope with the psychological trauma that often accompanies TBI, therapist Melissa Walker — of the Walter Reed National Military Medical Center's National Intrepid Center of Excellence in Bethesda, MD — started an art therapy program in 2010.

Walker's approach is to provide the participants with generic masks of human faces, which they are then encouraged to personalize in any way that they see fit or find helpful.

A new study that was led by Girija Kaimal, from Drexel University in Philadelphia, PA — conducted in collaboration with Walker and colleagues from other institutions — looked at the masks created by 370 active duty military members with TBI, searching for patterns that might correlate with different levels of psychological injury.

Their findings, reported in the journal BMJ Open, indicate that certain types of imagery are telling of ongoing psychological distress, while others point to a state of inner resilience.

"Few studies in art therapy," explains Kaimal, "have linked visual symbols with existing standardized clinical measures. This helps us see if there are patterns of visual representations that relate to psychological states"

Metaphors of belonging suggest resilience

The masks analyzed for the purpose of this study were created by participants over the course of a 4-week art therapy program.

A mask featuring imagery of distress (left), and one featuring symbols of belonging (right).
Image credit: BMJ Open

The participants all received a blank mask that they were able to modify in any way they liked, with the purpose of expressing how they felt.

The researchers then categorized the masks according to recurrent themes that they identified.

The scienists linked recurring themes with data from questionnaires assessing the participants' state of depression, stress, anxiety, or PTSD.

Kaimal and colleagues observed that participants who used imagery that suggested states of inner unrest also had more acute forms of PTSD than peers who employed metaphors of belonging, such as symbols of their respective military units, or the flag of the United States.

Over a quarter of all the masks included symbols of psychological distress, and approximately a third exhibited various metaphors, which were linked to lower anxiety symptoms. Around 10 percent of the masks featured symbols of belonging.

"We were surprised by how strongly references to a sense of belonging were associated with positive health outcomes," notes Kaimal.

Subtle exceptions

However, even when it comes to apparent emblems of belonging, there is a caveat: not all such instances indicated a sense of psychological resilience.

Some such depictions of "home" were used in distorted ways — fragmented flags, for example — suggesting the opposite: a state of alienation and distress.

"Fragmented representations of military symbols" were present in about 10 percent of the masks, and they corresponded to increased levels of anxiety.

"There is a subtle difference here between identification with military branch and the use of fragmented imagery associated with the military symbols," says Kaimal.

"It might be that an integrated sense of belonging and identity are associated with resilience while use of fragmented images are associated with some ongoing struggles."

Girija Kaimal

The scientists caution that these associations may not hold true for just any person facing mental health issues.

This study, the investigators emphasize, dealt specifically with active military members who had to deal with particular traumatic contexts.

Also, the participants who provided masks and data for the new study were predominantly male, meaning that the researchers have not had an opportunity to verify whether the links would present significant differences in the case of women.

'Patterns of strengths and struggles'

Still, the authors note that establishing correlations between patterns emerging in therapy art and the mental states of participants could help healthcare providers to provide better support to their patients.

"The main takeaway," says Kaimal, "is that visual representations embed patterns of strengths and struggles that can help clinicians and researchers better serve this population in coping with their injuries and the psychological symptoms that accompany them."

In the future, she aims to investigate even more closely the links between the imagery created in art for therapeutic purposes and clinical symptoms.

Specifically, Kaimal would like to verify whether such art can provide clues as to whether a patient is seeing any improvements in their mental state as a result of therapy.

"[D]o certain types of imagery correlate with improved outcomes over time?" asks Kaimal, adding, "We hope to publish those findings in the next few months."