Posttraumatic stress disorder and art group therapy : self-expression of traumatic inner world of war veterans

Background/Aim. Art therapy and drawings may serve as alternative means of expression and release from trauma among veterans diagnosed with posttraumatic stress disorder (PTSD). Methods. The retrospective clinical study of drawings of war veterans was performed. A total of 89 war veterans met the Diagnostics and Statistical Manual of Mental Disorders (DSM-IV) PTSD criteria and were consecutively admitted to the Day Hospital during 5 years. Art group therapy as part of integrative treatment was performed once a week. The group was open and heterogeneous. Qualitative analysis of drawings content and group protocols were obtained. The drawings were made by free associations. War related themes were explored and descriptive statistics were applied. Results. The most frequent type of common themes of combat stress presented battle and witnessing wounded and killed combatants. Less frequent were themes of graves, destroyed cities and broken trees. The veterans preferred black and red colors with association to death, blood, wounds and destroyed objects. Conclusion. Drawing could provide a unique, complex, visual illustration of war traumatic experiences and memories of posttraumatic stress disorder veterans. Art group discussion might enhance war veterans’ verbal expression due to group support in safe setting. As adjuvant psychotherapy, art group therapy could enrich awareness and the ability of clinicians to treat hard posttraumatic stress disorder symptoms related to uncovered war trauma.


Introduction
Posttraumatic stress disorder (PTSD) related to combat exposure has been associated with severe psychosocial dysfunction.War PTSD was over three times more prevalent among deployed veterans than non-deployed veterans even ten years later 1 .There were reports that approximately 7.6% to 20% of the troops deployed to Iraq and Afghanistan may require PTSD treatment 2,3 .
Post-deployment early interventions may reduce risk for PTSD development, and there is a recommendation that Correspondence to: Gordana Mandić-Gajić, Clinic for Psychyatry, Military Medical Academy, Crnotravska 17, Belgrade, Serbia.E-mail: mandig468@yahoo.comall PTSD veterans receive evidence-based cognitivebehavioral therapy 3,4 .The most recommended kinds of psychotherapy are prolonged exposure and cognitive processing therapy among cognitive behavioral therapy, then eye movement desensitization and reprocessing (EMDR) and psychodynamic psychotherapy for PTSD treatment 5 .
Empirical evidences of good results for trauma treatment by art group therapy in clinical practice have been reported, but the systematic review of its effectiveness has not been established 6 .Art therapy provides an alternative means of expression and release from trauma.It may be a more profound and long-lasting procedure than standard treatment forms, so there is an urgent need for further research on art therapy and trauma 5,6 .Treating war PTSD veterans challenges the clinicians faced with these patients, especially due to the fact that they are not fond of verbal expression of trauma events.A better inside into the inner world of veterans related to war trauma is essential for treatment tailoring and improvement.
The aim of this study was to present clinical observations of group art therapy as part of integrative treatment of war veterans with PTSD in the Day Unit and qualitative analyse of the drawing content.

Methods
The retrospective clinical descriptive study of the drawings of PTSD diagnosed combat veterans who returned from war deployment in former Yugoslavia was performed.The veterans were consecutively admitted to the Day Unit, Clinic of Psychiatry, Military Medical Academy, Belgrade, between 1992 and 1996.They were male patients who met the PTSD criteria according to DSM-IV 7 and were treated in the Day Unit for two months.The presence of co-morbid major depression, psychotic disorders and alcohol or substance harmful use or dependence were exclusion criteria.PTSD veterans with more than three months and less than two years after returning from the war were studied.

The procedure
The form and content of drawings' series and group protocols from art group therapy sessions were qualitatively analyzed.The frequency of different types of presented war trauma were analyzed.The data from medical records were obtained.

Interventions
The integrative day treatment program was applied.The general goal was not only to reduce the clients' symptoms, but to enable personality social integration, as well.The staff of the Day Unit included psychiatrists, psychotherapists, clinical psychologists, and nurses.All the patients received combined pharmacotherapy, occupational therapy, counseling, individual and group verbal therapy and group art therapy.PTSD veterans underwent homogenous group psychodynamic therapy for anxiety and stress related disorders three times a week.As adjuvant therapy art group therapy for the patients currently treated in the Day Unit was performed once a week.The group consisted from both gender, civilian and military adult participants with various mental disorder.In the first part of session the patients were drawing by free association and free choice of colors.Second part lasted 90 minutes when the patients exhibited drawings by themselves and discussed them in the setting of group analysis of drawings with therapists.The structural sessions started with giving the drawing title and discussing the feelings related to each drawing.The group was open and heterogeneous.The sessions usually consisted of 12 to 18 patients and among them 1-4 were PTSD combat veterans.The course of integrative treatment lasted two months and included on the average 7 art therapy sessions.Basic art materials, such as crayons and pastels, colored pencils, gouache paints and white paper of the same sizes, 210 × 297 mm were available.
The participants gave signed informed consent on admission and the latest release of the Helsinki Declaration was applied.Ethic approval for drawing use were obtained.

Participant characteristics
There were 89 male PTSD war veterans: 72 (80.9%) active military personnel and 17 (19.1%)reserve, middle age of 35.6 years.The most were married (82%) and had on the average, 12.6 years of school.

Analysis of the drawings with war related themes
There were 553 drawings collected from PTSD war veterans (average 6.2 for each subject).After qualitative analysis of the drawings content and form, the war related themes were detected among 82.8% (n = 458) drawings, and were classified into five mainstream types according to the common theme.Each type of the theme was presented by some examples of PTSD veterans drawings.The each participant gave the title and described events and feeling related to the drawing during group sessions.Only 17.2% (n = 95) drawings illustrated other, war-non related themes.
The most frequent type of war-related themes among participants was illustrated as horrifying war zone traumatic events with threatened death or injury and witnessing wounded and killed combatants in 48.3% drawings (n = 267) (Figures 1-3).
The next series of drawings illustrated broken trees, stripped of leaves, with no branches, often without roots and pulled out of the ground at 4.3% drawings (n = 24 ) (Figures 13-15).

The analysis of drawings form
Qualitative, observational analysis of the most preferred chosen colors showed that the PTSD veterans in the drawings preferred black and red colors.Black was reserved for death and fear and red for illustrating blood and wounds.Lines were sharp and quick, showing extreme tension and emotional charge.

Self-reported feelings, associations and behavior expressed during sessions
From the group protocols self-reported associations and self-descriptions of feelings related to illustrated themes expressed during sessions were obtained and analyzed.During discussion the participants verbally expressed horror, helplessness, grief, anger, guilt, loneliness and the need for forgetting anything related to exhibited drawings.They stated that they felt unpleasant when evoking memories.The patients' behavior in the group analysis was similar to their social functioning at the time: silence, negative attitude, doubting the possibility to be cured, repeating themes, and feeling that they have a "job" to do it.However, after a few sessions the most of the veterans changed their attitude, and became more interested in discussing drawings of civilian members with everyday life themes.

Discussion
The structure of the symptoms of PTSD in deployed war veterans is not known enough, but the separate four factors of re-experiencing, avoidance, dysphoria, and hyperarousal symptoms have been identified 7,8 .In this study the veterans most frequently drew the horrifying combat traumatic events with threatened death or injury, witnessing wounded and killed combatants and nightmares as themes, which is in concordance with another reports 9 .Some new approaches to PTSD treatment refer to the interpersonal view of PTSD, and considers, estrangement feelings, guilt and protective factors, such as forgiveness and social support 10 .
The themes of illustrated graves and destroyed cities and trees in war zone after combats were less frequent.Other authors reported that war deployment was associated with PTSD in terms of significantly more frequent exposure to wounded and killed and to the feeling in great danger of being killed during deployment in 20.8% vs 18.9% cases, respectively 11 .
Psychodynamic processes became visible through "inner pictures" of the creative process of drawing that some authors suggested may be the main focus for group psychotherapy 12 .But in this paper, drawing and art group therapy did not take the central part of integrative therapy.The decision to make heterogeneous art group therapy was the result of practical reasons as it was only the adjuvant kind of therapy.The PTSD veterans were submitted to integrative treatment with the focus on homogeneous psychodynamic group psychotherapy for anxiety and stress related disorders three times a week.The veterans also could go on further discussing about traumatic themes from their drawing in homogenous group psychotherapy.Sometimes it was less painful for them to talk about trauma the next day on the verbal therapy group session.
War veterans are often socially isolated based on negative experiences they had with civilians, so participating in the group analysis of drawings was a chance to correct that experiences in a controlled and protected environment.Negative attitude was presented at starting art therapy, but after a few sessions it used to be resolved and the most of the veterans accepted this program that made them possible to experience the group support and gratification.
Our clinical experience confirmed the recommendations of another authors that art therapy interventions may uncover unknown and traumatic material while enhancing relaxation and improving communication skills through group interaction 5 .
Positive effects of art therapy associated with patients with different clinical profiles as an acceptable and costeffective treatment have been reported 6 .There is no need for expensive equipments, and drawings could help in diagnostic and therapeutic evaluation processes 13 .In the frame of multidimensional treatment of posttraumatic stress disorder visual art therapy is a unique approach and enables working on traumatic memories and integration 14 .Most of the veterans avoided talking about their traumatic experiences in front of other persons without war experiences 14 .But visual expressing and facing their drawing directly is a chance to observe it from another perspective after war 15 .The therapist and the other members of the group then helped them to synthesize the differences between war and peace time reality.There was the evidences that nontrauma focused psychotherapies less reduced PTSD symptoms compared to trauma-focused treatments with greater drop-out in treatment groups 16,17 .Some efforts were done to promote the evidence-based psychotherapies for PTSD in mental health settings, but additional studies are needed to understand implementation of evidence-based therapy 18 .The researchers reported positive effect of art group war veteran therapy with the defined themes for each session the same for all participants according to the therapy program 19 .We preferred free associations for expression of inner world of the participants.Our findings suggest that art group therapy warm up veterans for enhancing psychodynamic group psychotherapy and other activities in the Day Unit.
The treatment goals are: reduction of anxiety, lessening of passivity, increasing of self-confidence, providing communication in positive atmosphere.During the course of day integrative treatment, these war veterans draw themes of nightmares and reminiscing war scenes with all the previously shown negative feelings.Influenced by the whole therapeutic process in the Day Unit it was observed that they gradually switched from war themes to the current social context and reality, focusing more on the "here and now" problems.They also started showing feelings of hope, with increased selfconfidence in positive communication atmosphere provided.
The second part of sessions further may clarify the drawings content with the patients verbal expression of drawings during group discussion.It might enlarge the therapeutic response, trust, confidence and the group support for the participants.The important role of group psychotherapy in improving interpersonal trust in veterans with PTSD was reported 20 .
The limitation of this study is that it was the retrospective descriptive analysis with clinical observations of only war-and trauma-related themes of drawings of war veterans.The heterogeneity of patients population with civilian and military persons with various mental disorders suggests the need for caution in interpreting the results of this paper.The therapists must be careful and aware of how countertransference affects their interpretation of the drawings, even when symbolization is simple and obvious.The art group of veterans might give a unique contribution to treatment, but here it was framed into integrative day treatment and could not be evaluated and extracted from the other procedures.In this paper the focus was on the clinical experience and practice, but further studies and analyses of art therapy versus other treatments are needed to provide the evidence of its efficacy.

Conclusion
The findings of this study suggest that drawing could provide a unique and complex insight into visual presentation of uncovered war trauma experiences and memories of PTSD veterans.Group discussion might enhance selfconfidence and verbal expression of each war veteran followed by group facilitation and support.As adjuvant psychotherapy the art group therapy could enrich awareness and ability of clinicians to treat hard PTSD symptoms in war veterans.

Fig. 1 -
Fig. 1 -The Combat (A veteran who drew it described fear, horror hopelessness, death which he expirienced during the battle).

Fig. 2 -Fig. 3 -Fig. 4 -
Fig. 2 -The Ultimate Combat (A scene to the combat in which all of the companions have died, while the author of the drawing has also fought and his suffered a life-threatening injury.Feelings of life endangerment, fear, sorrow because of the companions who have died, but also a will to survive and the feeling of vengeance).

Fig. 5 -
Fig. 5 -An Ambush, a deadluck (A dream followed by the feeling of complete helplessness and horror of the combatant in the war, after which he wakes up drenched in sweat, terrified).

Fig. 6 -
Fig. 6 -The whirpool of death (A desperate scream for help, horror, his attempt to save himself, while he sinks in the whirpool of death).

Fig. 7 -Fig. 8 -Fig. 9 -Fig. 10 -
Fig. 7 -The field of the nameless graves (Instead of wood of treas, the field of the nameless cross tombstones.The sad memory of a great number of the companions who succumbed to their injuries).

Fig. 11 -
Fig. 11 -The demolished church (The description of a burned and ruined church which was seen by a retern at the battle-field, after the withdrawal of the enemy.Feelings of sorrow and rebellion against the enemy because of the profanation of a religions sanctuary).

Fig. 12 -
Fig. 12 -A little girl in the whirpool of the war (A memory of the village after the redemption.From a burning and ruined house only the girl has managed to escape.Feelings of devastation and sadness for the orphan, whose family and happy childhood were gone forever because of the war).