PTSD Intensive Treatment Programme: An Adaptive Model of Art Therapy

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Art therapy has been offered at Combat Stress since 2001.  Combat Stress is the UK's leading veterans' mental health charity, providing free specialist multidisciplinary clinical treatment and welfare support to veterans across the UK. Community as well as residential interventions are provided. Three residential treatment centres within the UK in Ayrshire, Shropshire and Surrey deliver a variety of residential programmes.  There is currently no other dedicated art therapy provision offered to military veterans in the UK.

Weekly art therapy groups are a core component of a specialist six week residential Post-Traumatic Stress Disorder (PTSD) Intensive Treatment Programme (ITP) that has been running since 2011.
The ITP is tailored to the needs of veterans who have been severely traumatised by their military service. Participants suffer severe PTSD which is present with complex co-morbid disorders such as depression and alcohol disorders.  The ITP comprises psycho-educational and skills-based training groups, 15-18 sessions of individual trauma-focused cognitive behavioural therapy, and art therapy. Combat Stress has invested in expanding art therapy provision throughout all three treatment centres since 2013. Over the course of a year, an average of 300 veterans access the ITP.  The ITP is funded through NHS National Specialised Commissioning and is subject to regular external benchmarking.

Description of the arts activity

An adaptive, integrated form of art therapy has been developed in response to the specific needs of traumatised veterans. Informed by neuroscience, this model is mindful of military culture and shaped by the framework of short-stay admission. Traumatic memories are not stored in a coherent narrative format; rather they become dysfunctionally stored deep in the central nervous system, and are triggered automatically by sensory, trauma-related cues. Art therapy is an insight-orientated psychological treatment that accesses non-verbal areas of the brain associated with emotions, visual imagery and bodily sensations. Consequently, art therapy supports veterans participating in the ITP who may respond more effectively to a non-verbal approach, by connecting with the particular qualities that are inherent in art making, such as symbolic and sensory expression. In this way, veterans are able to connect with and express emotions that they may find hard to put into words. The art therapy groups are 75 minutes long and comprise free art making time in response to a relevant theme and subsequent discussion. Post-session group reflection on what has been created promotes insight, incorporates adaptive information and aids development of a meaningful narrative to the trauma experiences.

Details of the project participants

Veterans’ ages range between 18 and 97 currently. This broad demographic includes the full spectrum of military ranks, geographical spread, ethnicity and gender; 3% are female.

Typically veterans will have served in more than one conflict zone. On average the duration it takes for a veteran to seek support from Combat Stress is 12 years after exiting the military. Chronicity complicates clinical presentation, with co morbid illness such as depression and substance misuse disorders impacting on veterans’ family relationships. This can lead to social exclusion and homelessness. The numbers of veterans accessing Combat Stress is increasing, with a 26% rise between 2014/2015 to a total of 2,328 referrals that year.  Veterans most commonly self-refer, less frequently they are referred by the NHS, either by their GP, Community Mental Health Teams or psychology service.  Art therapy is accessible to all veterans.

Project management

The art therapists at Combat Stress are experienced in working with complex trauma and group work, and provide the sessions supported by a co-facilitator. Time is set for the group process to be discussed between co-facilitators post-session, and individual clinical notes are recorded for each group participant. The art therapists participate in regular clinical supervision in line with regulatory guidelines . All veterans participating in the ITP art therapy groups are provided with information about the treatment aims and objectives of the art therapy groups prior to commencing sessions. Specific art therapy goals are identified collaboratively and reviewed regularly during treatment. Evaluation forms containing quantitative and qualitative questions are used after the final art therapy session to anonymously gather veterans’ views on the art therapy groups.

Evaluation methods and findings

87% of veterans who completed the ITP between 2012 and 2014 saw a reduction in their PTSD symptoms, and co-morbid anxiety and depression, anger, alcohol use with improvement in function, which was maintained at their six month follow up.  A recent study conducted at Combat Stress, looking at the acceptability of art therapy as a treatment modality to veterans, found that there was a high level of immediate and on-going acceptability of the contribution art therapy made to the veterans’ treatment experience.  Thematic analysis indicated that art therapy facilitated communication and bonding; and the ability to unlock feelings otherwise difficult to connect with, supporting the belief that art therapy offers a non-verbal form of processing of traumatic memory. Veterans reported the positive impact of the soothing environment of the groups and the physical and sensory qualities of the diverse art materials used.  Another study, investigated veterans’ engagement in art therapy groups on the ITP . This demonstrated benefits from seeing a different side to their peers and hearing others’ interpretations of group themes. It stimulated new ways of thinking, helping veterans recognise they were not suffering alone thereby reducing isolation.

Supported using public funding by the Arts Council England