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RЕSSIVЕ АRTS ТHЕRАРY IS АN ЕFFЕСTIVЕ FОRM ОF HЕАLING THЕRАРY FОR WОMЕN WITH РТSD RЕTURNING FRОM THЕ WАR Name Institution Date Introduction In their lifetime, people experience trauma as an essential part of their lives. Throughout history, people adapt to traumatizing life events with creativity and flexibility. Others extensively become fixated with these stressing life events and end up leading traumatized lives and traumatizing existences. People who have experienced traumatizing events in their lives have a tendency of following roughly similar patterns of adaptation and disintegration. Many survivors from war zones have managed to temporarily overcome their experiences as well as harness their pain in acts of sublimated creation (Van Der Kolk, 2014). However, these people eventually succumb to the despair of war memories in the end. According to Paulson & Krippner (2012), certain roles and responsibilities within cultures are gender-specific. The breadwinner and the warrior were prevailing American models of maleness just a few decades ago. Likewise, being a homemaker, stable and family-oriented, was a traditional American female role. Recently, there is blurring of male and female roles and responsibilities over the past several decades, as both men and women step into each other’s stereotypical arenas. This has led to the erosion of male superiority. While not yet achieving complete equality, more and more women are increasingly claiming the right to choose their roles, independent of males. Today, women are increasingly challenging men in most professions, and now, hardly any endeavor is purely a male one. Although many women serving in various military capacities have been killed, U.S. infantry troops are still primarily men. Even so, after their successful and impressive combat participation in both the Gulf War and Operation Iraqi Freedom, frontline U.S. combatants of the future are sure to include women. By year 2006, approximately 70 female soldiers had lost their lives in Iraq (Paulson & Krippner, 2012). This number is more than the total from the Vietnam, Korean, and Gulf wars in combination. Women have been very excellent in military service in countries such as Israel and have been key elements in various militant, paramilitary, and insurgent groups. Background of the Study Art therapy is considered to be the type of treatment that explores a person’s feelings, reconciling emotional conflicts, fostering self-awareness, improving reality orientation, as well as reducing anxiety and increasing self-esteem (Ramirez, 2014). The most dominant method of treatment over time has been the Cognitive Behavioral Therapy (CBT). However, this method has been found to treat only a few symptoms that are characteristic of PTSD. Specifically, CBT has been found to be ineffective in the treatment of emotional numbing and avoidance. People suffering from PSTD are unable to express the traumatic events that they encountered (Van Der Kolk, 2014). Therefore, there is no better approach to addressing this problem than art therapy because it allows these individuals to express themselves without any difficulty. The most effective approach is applying art therapy in group setting because it offers an opportunity to give a feedback to people who are experiencing the same problem. The main role of art therapy is to help people suffering from PTSD bridge their memories of past traumatic events. This approach helps individuals understand and communicate their traumatic experiences. Various art activities are included in art therapy, including painting, drawing, and photography. In art therapy sessions, participants share their experiences in a healing environment, ultimately helping them improve upon their behavioral and metal health. The next section is dedicated to investigating PTSD, expressive art therapy activities and sessions, and best practices. Trauma from Combat Military members who are involved in combat operations and other hostile military activities, including peace-keeping missions in the country as well as outside, disaster relief, and foreign diplomatic facilities become vulnerable to various forms of danger. Some of these dangers include dangers posed by suicide bombers, improvised explosive devices, small fire arms, and rocket propelled grenades. When military members encounter such experiences, they suffer trauma from the encounter with such experiences (Price et al., 2015). This form of trauma is mostly experienced by male military members leading to the development of PTSD among these military members (Van Der Kolk, 2014). Other problems experienced and leading to trauma while in these combat missions include, lack of sleep and food, lack of social support systems, and excessive physical exertion which eventually lead to poor health status as well as quality of life. Military Sexual Trauma Military female are always at a disadvantage when it comes to military combat missions because, in addition to the experiences mentioned in the above section, they are also exposed to sexual harassment. According to Ramirez (2014), military sexual trauma (MST) is highly prevalent among women in armed forces. The term MST was adopted in 1990s by the Department of Veterans Affairs and it represents sexually assaulting women in the military. Just like experiences in combat exposures lead to the development of PTSD, sexual harassment of women in military also leads to the development of PTSD. Despite there being more males in the military than females, females are the ones that experience MST the highest. According to the study by Ramirez (2014), the total number of men serving in military in 2010 was 1,249,475 whereas the number of females in the military was 209,222. The difference between the women and men receiving treatment for MST is very wide with 22 percent of females receiving treatment compared to 1 percent males. This means that women are 20 times likely than men to receive treatment for MST. The number of reported cases of MST among the military members is rising. Ramirez (2014) observes that the number of MST cases reported in 2012 was 3,300 which were relatively higher than the 2,374 cases reported in 2005. This shows that there is greater need to focus more attention in this area. Statement of the Problem According to Ramirez (2014), around 22 veterans, including other military service members such as one active duty service member, reservist, or national guardsman commit suicide. This study found out that this rate has been rising since 2008 when a total of 197 cases of suicide among this group were reported. In 2009, these cases rose to 238, in 2010 to 301, in 2011 to 283, and in 2012 to 325. The government has focused most of its efforts to fighting terrorism while leaving the war veterans to fight the war of post-traumatic stress disorder symptoms on their own. However, most researchers are dedicating much effort in investigating treatment methods that can help address PTSD symptoms (Price et al., 2015). Many treatments have been researched overtime; however, only minimal research has been focused on the area of treatment via expressive arts therapy. Literature Review Soldiers’ Experiences during Combat Missions Many U.S. soldiers have become disillusioned about their involvement in different wars and this leaves them no goal except duty and survival (Price et al., 2015). Upon returning from war, many women try to eliminate these experiences out of their minds. If the history of the United States has taught the world about anything, it is that all too often, veterans are unable to let go of their war experiences – instead, denying, suppressing, or displacing their trauma. The experiences faced by these women and their relevance must be kept continuously in mind, because the families of combat veterans with PTSD face challenges along with those faced by the women veterans themselves. Many women veterans cannot sustain their marriages, especially after returning from war. Other women veterans commit acts of violence against their family members, including murdering their husbands and/or children (Herman, 1997). In such cases, incarceration has become the most popular treatment only insofar as it protects others. It is rare that these women veterans receive any direct continuing help resolving their issues. In addition, little research has been directed in this area. Often, the experiences soldiers had had in the war influenced how well or how poorly they functioned upon their return to civilian life (Price et al., 2015). Of the nearly three million men and women who served in Southeast Asia, approximately 870,000 were involved in combat. The others served in rear echelon assignments, and they did not engage in combat. Combat veterans generally had more difficulty readjusting to civilian life than did the much more numerous rear echelon types. The degree of support returning veterans received from family, friends, church members, workplaces, and government agencies often shaped how a veteran came to terms with his war experiences and reintegrated into civilian society. Post-Traumatic Stress Disorder It soon became obvious that large numbers veterans suffered from higher levels of stress than did their civilian counterparts. These symptoms, which often fail surface until years after the veterans return from the war, are labeled “post-war syndrome” (Engel, 2004). In 1980, these symptoms were given a new label by the American Psychological Association (APA) - Post Traumatic Stress Disorder (PTSD). According to the APA findings, people experienced the traumatic event through recurring dreams or memories, or by seeming to experience it as if it were happening in the present. There are different motivators of PTSD among men and women. However, motivators among different gender seem to vary. Combat exposure is predominantly associated with PTSD in men while military sexual trauma (MST) is predominantly associated with PTSD in women (Ramirez, 2014). Despite the type of motivator, expressive art therapy has proved to be one of the most effective forms of treatment among military members with PTSD. The main objective of this study is to investigate the effectiveness of expressive arts therapy in treating PTSD in military members coming out of war zones. Female war veterans afflicted with PTSD experienced various psychological dysfunctions which were attributed to the traumatic experiences they had encountered during the war. Most of them resulted to abusing alcohol and drugs, experiencing recurring nightmares due to wartime experiences, psychic numbing, and chronic depression. Others included guilt feelings as a result of their war actions or having witnessed their fellow soldiers getting killed without help, Lack of intimate feelings, and outbursts of anger and aggressive behavior. Recognition of PTSD as a Psychological Disorder In addition to the large numbers of Vietnam veterans afflicted with psychological disorders, soon after the war ended former soldiers claimed that they suffered from a wide range of serious illnesses deriving from their exposure to chemical defoliants. Thousands of U.S. military personnel were exposed to chemical defoliants that were sprayed by the U.S. Air Force over the jungle of Vietnam to kill foliage that being used by the VietCong and NVA forces as cover (Beckham, Feldman, & Kirby, 1998). Initially, the government dismissed all claims and the companies that manufactured the chemicals insisted they were not dangerous. In 1979, two veterans groups filed class action lawsuits on against the companies that had manufactured this chemical, including Monsanto Corporation and Dow Chemical Company. After six years of litigation the case was settled out of court. The chemical companies agreed to pay $180 million into a fund for veterans and their children. There was an acknowledgement by the Veterans Administration that PTSD should be classified as a psychological disorder afflicting many veterans, including female veterans, that were coming out of Vietnam. This realization made the Veterans Administration open 137 centers across the United States to treat, counsel, and support veterans with PTSD. It was difficult to identify the number of veterans who were suffering from PSTD. Varying data were given by different surveys. The estimates provided by the veteran’s group were that more than 1.5 million veterans, including women, were suffering from PSTD. In a study by the Centers for Disease Control indicated that approximately 2 percent of the total veterans who had come out of Vietnam alive were suffering from PSTD. The severity of symptoms accompanied the severity of illnesses. Methodology Research Design This is a qualitative study involving investigating one client participant suffering from PTSD. The data for the present study was collected via an interview with the client, discussion with her, observations, and content analysis of this participant’s personal journal. Via a heuristic model, this study examined how the participant with PTSD views the recovery process, and whether art therapy has contributed to the experience of recovery. In order to gain a holistic understanding of the goals, motivations, and challenges encountered by military women within the recovery process, grounded theory was used to form a theory. The participant was seen for four sessions of art therapy interventions. Each of these sessions took two hours long. During the first hour, the participant was engaged in an interview. During the second hour, the participant was engaged in an art activity and was required to complete an art piece of her choice. The two-hour sessions were conducted once a week for four weeks. During the therapy sessions, the participant discussed with the researcher about her personal goals and challenges during the recovery process. The participant was also engaged in therapeutic activities with art materials to allow her room to express herself. The researcher requested the participant to maintain a diary that enabled her to organize her thoughts. The researcher analyzed the participant’s personal memoir for content, including their fear and anxiety associated with the experiences during war, coping skills, feedback on the reliability of art materials, and identification of situations that evoked negative emotions. The researcher recorded observations, personal reactions, and feedback to each session in his own personal journal. A content analysis of researcher’s personal journal correlated with the participant’s daily chronicle. During the final triangulation of the interview, observations, and content analysis of the written material showed the perspective of women in active, recurring recovery from PTSD. Data Gathering Methods Description of the Participant This study incorporated only one female war veteran as the study’s participant. The female participant was requested to participate in the research study and voluntarily agreed to attend the one month program. The woman was targeted because she had tried recovery through other methods of treatment, including the cognitive behavioral therapy, which is the most commonly used type of treatment. There are several reasons that motivated the female war veteran to participate in this study. She chose to participate in this study out of the concern she has for those who come out of the war with trauma. The researcher first obtained a written consent from the participant. Interview The researcher engaged the participant in an initial interview to inquire about the participant’s prior rehabilitation attempts, possible reason for the failure of treatment, and thoughts about their condition. For the present study, the researcher obtained consent in during the first session with the participant. During each of the four sessions, the researcher engaged the participant in covering different topics related to PTSD therapy. Some of these topics include relapse prevention, personal motivation, and coping skills among other topics. The identified topics may have changed according to the needs of the participant during the study. In each of these sessions, the researcher requested the participant to create art from a large selection of materials. Before each art session, the researcher engaged the participant in an interview. During these informal interviews, the researcher asked the participant certain semi-structured questions related to specific topics. For example, one of the question asked is, “What are your coping strategies when a triggering event occurs?” The researcher encouraged the participant to discuss her previous experiences in recovery. These discussions were more focused on events that possibly trigger the trauma. Before each discussion session, the mood of the participant was rated on a scale of range one to five. Before, the primary interview, the researcher asked the participant to discuss her thoughts on why previous attempts of treatment have failed, and whether she believes that art can play a role in her recovery process. In each of the other three sessions, the researcher began by engaging the participant in a mood check, followed by a short review of the last session. The researcher introduced the topic of discussion and offered the participant an opportunity to add additional thoughts on the previously discussed subject matter. The researcher used the grounded theory approach in which the proposed topic can always be changed in accordance with the needs of the study. Expressive Art Therapy Process According to the study by Artra (2013), art therapy can help the participant towards meaning-making. This fact motivated the researcher to integrate the use of art therapy in the present study. For each of the four sessions, the researcher recorded the interview using a tape-recorder. After the interview, the participant was given an opportunity to use art materials to create artworks of their desire. The participant could either engage the researcher in the art-making process or make the artworks on her own. The reason for using artworks in the sessions was to inspire the participant to fully engage in the art process. The art materials used in the art process included markers, acrylic paints, plain and decorated papers, oil and chalk pastels, colored pencils, collage materials, and magazines. The participant was encouraged to utilize different materials in a way that will reflect their idea to explore or their emotional state. The researcher was aware that the art materials may make the participant uncomfortable, so, he encouraged the participant to start by exploring the art materials. In each session, the second hour was dedicated towards giving the participant an opportunity to participate in the therapeutic use of art to express her emotions and thoughts surrounding recovery. The participant used the art materials as she deemed fit. During this session, the researcher offered a non-structured art directive. Whenever the participant was found to struggle with the art process, the researcher intervened and gave optional structured directives depending on the participant’s needs. Some of these directives include cost-benefits collage, barriers to recovery, self-portraiture, recovery bridge drawing, depicting herself a year from now, and drawing with eyes closed among other directives. During the discussions that followed these directives, the participant evaluated her artwork while describing how it felt to create the artwork, the thoughts that came to her mind during and after creating the artwork. Other descriptions that the participant was required to provide are about the lessons she learned about herself creating the piece of artwork, what she would like other people to learn from her artwork, and whether the artwork reminds her of anything. The role of these questions was to give the participant an opportunity to engage in an inward process of self-evaluation. The researcher directed the participant to record these responses in her diary. During the final session in the fourth week, all the artworks were summarized and discussed. The discussion was intended to help clarify the beneficial properties of art therapy process. Through these art works, the researcher was able to identify the role of expressive art therapy. The researcher encouraged the participant to identify personal themes or interrelated content within the artwork. Results This section is dedicated towards reviewing the data collected during the present qualitative study. For confidentiality purpose, the researcher used a pseudonym instead of participant’s actual name. The transcribed interviews, observations, and content analysis of the participant’s diaries and the researcher’s personal journal were used as research data. The woman involved in the present study volunteered her time and honesty to help both the researcher and herself understand the recovery process via expressive art therapy. The participant was selected based on her level of response to the art therapy process. Participant: Debra Debra (pseudonym) is an African American woman, 42 years old, divorced, with two children. Debra was born in 1975 in Waterbury, Connecticut. Debra completed her high school diploma in 1987 and immediately joined the military for training. After being in the military for 3 years, Debra was sent to a combat mission in October 1990 at the Gulf. She had been working in the military for 3 years prior to being sent to participate in the Gulf War in 1990. After returning to the U.S., Debra continued working in the military for 2 years after which she was unable to sustain her work due to regular traumatic attacks. For the time she has been working, she has been able to cater for her two children. As indicated in this section, since she came back to the U.S., she has been suffering from post-traumatic stress disorder which has significantly affected her life preventing her to engage in constructive work. Debra said, “During some of these traumatic attacks, “My children have had to live with my parents and they are advanced in age.” She seemed pessimistic whether she will ever recover from this situation. Previously, Debra has been engaged in several cognitive behavioral therapies (CBT) without much significant healing. After all these therapies, Debra has experienced a relapse short period after the end of the therapy. Debra said, “I consider myself a responsible mother.” However, she observes that her condition has significantly affected her relationship with her children. She indicates, “My situation is worse such that I am even experience these traumatic attacks in the presence of my children.” During the first interview, Debra seemed uncomfortable – she severally shifted her chair and sipped her coffee repeatedly during the interview. However, in the sessions that followed, Debra became more comfortable. When asked about the use of expressive art therapy within the recovery from PTSD, Debra said that “I think your expressive art therapy is helpful for the veterans suffering from PTSD.” Initially, Debra was resistant of the art process but later complied with the researcher’s request provided it would not consume much of her time. The first artwork that Debra wanted to create was a recovery collage influenced by items that reminded her of positive memories. Throughout this collage work, Debra struggled a lot. She requested the researcher to allow her to complete the art work outside of the session. The participant did not make any art work during the session; however, Debra completed the collage art work by the time of the second session. The artwork that was completed during the second session was a large mandala with oil pastels. When she was making this art work, Debra spoke about the need for her medication and the role it will play in helping her improve the relationship with her children. Her eyes remained focused on the page and only stopped while she was changing colors. During the other two sessions, Debra completed a large collage work (18” x 24” frame). She completed this collage work using magazine cutouts. Some of the pictures included in this collage work included shells and flowers among other pictures. Words such as higher purpose, fun, magic, and journey stuck out from among many words and phrases used. These words were significant for the positive meaning they portrayed. Throughout her art works, Debra seemed to avoid using red color. The color represented blood which brought bad memories from the combat mission in the Gulf region. Discussion As discussed by Van Der Kolk (2014) in his book, the most effective solution to healing is to find ways of altering the inner sensory landscape of the client’s body. Debra reviewed her various triggers, experiences in previous treatment strategies, and previous relapse situations. The inability to cope with intense emotional experiences and to cope with life events represents some of the main factors for relapse after previous therapeutic sessions. Crawford (2010) argues that psychotherapy helps people in therapy to put experiences into words and narrative forms of expression. However, she further observes that people who have experienced serious traumatic events often do not have a coherent memory that can help them understand about their trauma. Crawford has provided great insights into how the memory, consciousness, and body-mind can be integrated during the therapy. Debra seems to be one of such clients who lack a coherent memory. Debra had specific need for recovery, including working on issues such as trauma. The participant was selected for her extended experience in seeking recovery and her interest in the art therapy. Emotional triggers are the leading cause of recurrent PTSD attacks (Herman, 1997). These triggers include fear, hurt, sadness, anger, and loneliness. However, expressive art therapy helped the participant overcome the challenges experienced in the previous treatments. The participant became personally aware of the problem-solving skills and practiced them while making the artworks. Creating artworks was found to alleviate negative emotions and feelings thus increasing her self-confidence through completion of each session. The participant was provided with a safe environment where personal issues were brought to clarity. In addition, self-disclosure was encouraged as the participant expressed herself in an acceptable form. Art therapy allowed the visual expression such that the participant was able to externalize her emotions. Through this approach, the participant was able to process her feelings externally through art works. The participant indicated that the art process was relaxing, fun, and ‘beautiful’. The participant also indicated that the art allowed her to identify deeper personal insights. Therefore, art served as a form of expression for confronting and exploring personal insight. References Artra, I. P. (2014). Transparent Assessment: Discovering Authentic Meanings Made by Combat Veterans. Journal of Constructivist Psychology, 27(3), 211-235. Beckham, J. C., Feldman, M. E., & Kirby, A. C. (1998). Atrocities exposure in Vietnam combat veterans with chronic posttraumatic stress disorder: Relationship to combat exposure, symptom severity, guilt, and interpersonal violence. Journal of traumatic stress, 11(4), 777-785. Crawford, A. (2010). If ‘the body keeps the score’: Mapping the dissociated body in trauma narrative, intervention, and theory. University of Toronto Quarterly, 79(2), 702-719. Engel Jr, C. C. (2004). Post-war syndromes: illustrating the impact of the social psyche on notions of risk, responsibility, reason, and remedy. Journal of the American Academy of Psychoanalysis and Dynamic Psychiatry, 32(2), 321-334. Herman, J. L. (1997). Trauma and recovery (Vol. 551). Basic books. Krippner, S. and Pitchford, D. B. (2012). Post-traumatic stress disorder. ABC-CLIO. Price, M., Maples, J. L., Jovanovic, T., Norrholm, S. D., Heekin, M., & Rothbaum, B. O. (2015). An investigation of outcome expectancies as a predictor of treatment response for combat veterans with PTSD: Comparison of clinician, self‐report, and biological measures. Depression and anxiety, 32(6), 392-399. Ramirez, J., Erlyana, E. and Guilliaum, M., 2016. A review of art therapy among military service members and veterans with post-traumatic stress disorder. Journal of Military and Veterans Health, 24(2), p.40. Van Der Kolk, B. (2014). The body keeps the score. New York, NY: Viking. Read More