Bridging psychological barriers between the child and the father after his returning from the war – Could group art therapy help ?

Introduction. War veterans with chronic post-traumatic stress disorder (PTSD) have poorer family and parenting functioning, but little research has focused on these impairments. Case report. This paper presented how the series of drawings and the group art therapy process enhanced bridging the psychological barriers of a 33-year-old male PTSD war veteran to engagement with the child. After two years of deployment he returned home and suffered mostly from PTSD numbness and avoidance symptoms. The veteran had the family readjustment difficulties and felt guilty for being detached from his 3-year-old son. He underwent integrative treatment in the Day Unit Program. The drawings series were made by free associations. Clinical observations and group discussions were recorded in the group art therapy protocols. The presented patient got gratifications and support from the group members for his illustration of popular cartoon heroes, and decided to draw Mickey Mouse at home. On the next session he shared his satisfaction for bridging the gap between him and his son, having done the same drawings with his son at home. Beck's depression inventory (BDI) was used for self-rating of depression and a reduction of BDI score from 18 to 6 during the treatment course was recorded. Conclusions. Series of drawings illustrated shift from war related past toward current family life of the war veteran. Group art therapy gave him gratification and support with hope and a sense of belonging, thus facilitated his parenting readjustment.


Introduction
There are evidences that post-traumatic stress disorder (PTSD) can impair psychosocial and occupational functioning and overall well-being of veterans 1 .After war deploy-ment PTSD is more prevalent in military veterans and higher rates of family reintegration problems were reported 2,3 .In the frame of affected family cohesion and communications, military veterans often have reduction of attachment and parental satisfaction 4 .PTSD symptoms of emotional numbing and anger are particularly related to family relationships among military veterans and to providing the best treatment approaches interpersonal skills and family support are recommended 5 .Among the symptoms of combat-related PTSD emotional numbing, which consists of lack of experience feelings, detachment from others and lowering previously activities, together with avoidance present the hard-to-treat symptoms 6 .
The findings suggest that family and social support play important role in the development, maintenance and recovery of PTSD 7 .Some researches support an integrative approach to intervention in which dealing with daily stressors and family problems give chance for treatment improvement 8 .Art therapy studies reported improvement with the various patients groups 9 .In war veterans, art therapy has been recognized as beneficial, effective and promising care, besides trauma-focused and other psychotherapy approaches 10 .
The art group therapy in the frame of intergrative program in the Day Hospital of the Clinic for Psychiatry, Military Medical Academy, Belgrade, was described in this paper.This integrative treatment consisted of dynamically oriented open, heterogeneous group psychotherapy for neuroticand stress-related disorders three times a week, recreational and occupational activities and individual counseling.The art group therapy had been applied once a week.The group was open, heterogenous with both geneder, civilian and military patients who were currently treated in the Day Hospital due to various mental disorders.This activity consisted of drawing by free association and free choice of coulored pencils and crayons on the same size of paper.In the same day the group session with exhibition, voting for the most interesting drawing and discussion of all drawings was performed for 90 minutes.After completion of the sessions the therapist conducted qualitative analysis of the drawings content, the form and the content of the group protocols.
This paper illustrated how the therapeutic effects of the group art therapy process can bridge the psychological barriers of veteran to engagement with his child and to gain perspective on their past and present life situations after war returning.Qualitative analysis of drawings and the issues from the group protocols that arise from group dynamics also performed through using art-based activities and discussion.

Case report
A 33-year-old married male military war veteran had returned from war in former Yugoslavia three months before his admission to non-specialize day unit treatment.He was referred after out-patient treatment of PTSD diagnosed according the DSM-IV criteria with dominant symptoms of reexperience and avoidance 11 .The history of other DSM-IV Axis I mental disorders was excluded.He was treated by counseling and pharmacotherapy and after four weeks of outpatient treatment the symptoms were decreased.He continued to take medications and returned to his job.However, next month his mental condition worsened and he was referred to day unit integrative treatment.On admission the patient gave written inform consent for participation in treatment, and ethic approval for drawing use was also obtained.The latest release of the Helsinki Declaration and principles of good clinical practice were applied.
The main complaints of the patient were decreased mood and guilt feelings due to avoidance his family members and the experienced detachment especially from his little son.During the two years of his participation in the war, he was separated from his family all the time, and only few times visited them shortly.But, now, after the war, at home, he yearned for rebuilding the lost connections with his family.Instead of that, in the afternoons he was sitting alone in the silence, staring only at TV, without saying anything to his wife and little son.He could not find the way to become closer to his 3-year-old son who was a 6-month-old baby when he was deployed.He was overwhelmed with grief because his son could not recognized him when he returned from the war.
On his first drawing the patient drew his flashback related to battlefield trauma (Figure 1).He named it as "Fear and silence before battle" and described his terrified experience with anticipation of death, horror, helplessness and grief for his killed friends.Next week he drew his military uni-Fig. 1 -"Fear and silence before battle".
form which he took off after returning home (Figure 2).He felt emptiness after war and ambivalence with a question what to do and how to continue and named the drawing "How to go ahead?"For these two drawings he got a few votes from other members.The next session brought him most voices for his drawing and was voted as most interesting (Figure 3).He was surprised because he thought his drawing childless and felt ashamed.He had no idea what to draw at the beginning of the session, than he recalled that he liked to draw popular heroes of cartoons, and spontaneously, according his childhood memories drew Mickey Mouse.The members who voted for his drawing told that he made them very chilly and turned them to their happy childhood.They stressed that his drawings were made by great skills.He was very glad and next sessions he continued to draw other cartoon hero (Figure 4) and got many voices from the others and reported that he had already gotten most gratification from his son.He started drawing Mickey Mouse and other cartoon heroes at home.His son liked to watch him during drawing and tried to make drawing by himself.The father helped him and they drew together cartoon heroes on the walls of his bedroom.The patient became satisfied as parent and felt attached to his child and family.These feelings he shared with the group members on the verbal group sessions too.
The global functional assessment (GAF) scale was applied to measures psychological, social and occupational functioning 12 .Clinical assessment was performed and GAF score showed moderate symptoms on admission and mild on discharge (56 vs 68, respectively).The Beck's Depression Inventory (BDI) was used for self-rating depression and the reduction of the BDI score from 18 to 6 during the treatment course was recorded 13 .

Discussion
This case report presented with a series of drawings illustrated a course of positive change in the war veteran readjustment to family, especially to his little child.Qualitative analysis of the drawing content showed a shift from orientation from the war-related past toward the current family life.War veterans readjustment family problems such are feeling like a guest (40.7%), ambivalent about their family role (37.2%) and experience that their children were afraid of and detached from them (25.0%) were explored 6 .The series of these presented drawings illustrated crossover from war themes in the drawings to "here and now" problems of paternal impairments after a long war combat deployment.Military deployment is stressful not only for parents but also for their children 7 .A long deployment is related to challenges the parent and child distress 14 .There are a few clinical studies of impact of military deployment on young children 15 .The interrelation of family cohesion and PTSD symptoms was reported, however emotional sharing may moderate the PTSD effects on parental functioning [16][17][18] .
Chronic post-deployment PTSD is often comorbid with depression and other mental disorders linked with prominent family readjustment problems 2 .In this case, the veteran had moderate impaired global functioning and mild depression on admission.On discharge his functioning was at the mild level impairment, and depression remitted.Other authors reported on the assessment war veterans by the GAF as a simple and useful tool 19 .There was reporting that PTSD veterans could overcome their treatment resistance and improve self-esteem and communication skills through group interaction in the creative atmosphere of art therapy 20 .
Through artwork by free associations and regression the presented patient spontaneously recalled his favorite cartoon heroes from his happy childhood.A personal feeling of emotional numbing and social isolation which are commonly seen in patients with PTSD, were also reported in the presented case.The parenting role and communication with his only child, a little, 3year-old son, became the focus of his day living.The group protocols from sessions contented the veteran's statement of feelings of emotional numbing and failure in parenting role.However, after the group session when members openly gave gratifications and supported him to continue drawing of chilly and favorite cartoon heroes, which he drawn by free associations, he got idea to do it at home.Very soon the gap between the father and his son was bridged.The veteran has been deployed for more than two years.His son was a baby when he went, and a 3year-old boy when returned, home.In this age verbal communication has physiological and psychological limitations and drawing may enhance their self-expression.
The presented patient received a combined pharmacotherapy and integrative psychotherapy during participation to day treatment, so we cannot separately consider art therapy efficacy in PTSD treatment.However, this case was an illustrative example for a war veteran who suffered of chronic PTSD and improved his skills to cope with readjustment problems and to replace them from therapeutic setting to his family milieu.

Conclusion
The art group therapy could help war veterans to identify problematic interpersonal functioning and illustrate treatment response for each person through series of drawings.This treatment for war veterans PTSD may help to overcome avoidance and emotional numbing, especially related to parenting and reintegration into family.