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Art Therapy for PTSD in Traumatized Patients after Disasters

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 Asia-pacific Journal of Multimedia Services Convergent with Art, Humanities, and Sociology
Vol.8, No.12, December (2018), pp. 615-625
http://dx.doi.org/10.21742/AJMAHS.2018.12.57

Art Therapy for PTSD in Traumatized Patients after Disasters

Mi-Sun Lee1)
Abstract
The aim of this study was to examine the effectiveness of art therapy as a psychosocial intervention for
traumatized patients exposed to disasters. Psychological symptoms related to trauma can be caused by an
overwhelmingly negative event such as a disaster. Patients who have been abused or traumatized might be
encouraged to use art therapy as a mental health intervention. Art therapy combines the creative process
and psychotherapy, facilitating growth through self-exploration and understanding. Specifically, art therapy
provides activities for expressing emotions and thoughts to facilitate recovery from post-traumatic stress
symptoms. Art therapy provides an opportunity for a patient to visually express their experience of
emotions, thoughts, and traumatic memories. Although art therapy offers benefits, the effectiveness of art
therapy on trauma intervention has not yet been established. This study suggests evidence of the effect of
art therapy for trauma and the need for more reliable research on art therapy in the Republic of Korea.
Future studies should delimit in greater detail the possibilities of art therapy after disasters in clinical
practice.
Keywords: Art therapy, PTSD, Trauma, Disaster

1. Introduction
Countries worldwide experience various types of disasters, including tornados, tsunamis,
hurricanes, earthquakes, war, fire, vessel accidents, terrorism, volcanic eruptions, and traffic
accidents.[1] In South Korea, the Motor Vessel Sewol was carrying 476 people on a voyage
from Incheon to Jeju in April 2014 when it capsized and sank. The disaster resulted in a total
of 304 deaths.[2] Disasters like this can result in physical and mental health problems for the
survivors or victims who experience these traumatic events. Traumatic experiences thus are an
important cause of psychiatric disorders. A national survey in the United States (US) reported
that more than 19% of men and 15% of women are exposed to disasters and traumatic events
during their lifetime.[3] Additionally, statistics show that 70% of adults in the US have
experienced some traumatic events in their lives and that up to 20% of this population will go
on to develop post-traumatic stress disorder (PTSD).[4]
Received(September 29, 2018), Review Result(October 19, 2018)
Accepted(November 9, 2018), Published(December 31, 2018)
1)(Professor, Corresponding Author) 18582 Department of Meditation Psychology, Nungin University,

Paltan-myeon, Hwaseong-si, Gyeonggi-do, Korea email: [email protected]

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Art Therapy for PTSD in Traumatized Patients after Disasters
PTSD is a type of psychopathology experienced after large-scale traumatic events. After the
terrorist attacks on the World Trade Center (WTC) on September 11, 2001 (9/11), research
found widespread post-traumatic stress symptoms in the US.[4] After 9/11, the period of
recovery was lengthy, lasting through June 2003. In addition, Disaster Psychiatry Outreach
(DPO) evaluated 848 patients affected by 9/11 in New York and provided appropriate
interventions. DPO psychiatrists determined that the patients had psychiatric illness and were
in need of psychotropic medication.[5]
Generally, people who suffer from PTSD, as well as those who have depression or anxiety,
can be provided psychological intervention such as art therapy. Art therapy has been widely
practiced in psychosocial therapy treatment for decades. Moreover, art therapy can be used to
help patients overcome the psychological symptoms and stress of their traumatic experiences. In
particular, psychological first aid (PFA) recommends providing art materials to encourage
children and youths to make use of immediately available sources of social support.[6]
Although art therapy has been used to intervene in helping patients cope with chronic illness,
it has not been specifically tested with patients exposed to a traumatic event.
Thus, the aims of the present study were to investigate the effectiveness of art therapy and
suggest a trauma-focused art therapy after a disaster.
2. PTSD and psychosocial intervention
A disaster is a sudden, calamitous event that seriously disrupts the functioning of a
community and causes human and environmental or economic losses.[7] A traumatic event
could be human-made, such as a car accident, street violence, family violence, etc. There are
also natural traumatic events, such as hurricanes, floods, tornados, fires, earthquakes, etc.
Disaster might impact people directly or indirectly. Both natural and human-generated disasters
often overwhelm one's normal coping capacity. Victims of traumatic events may experience
intense fear, hopelessness, and helplessness that exceed normal coping skills and have an
increased risk of developing post-traumatic stress symptoms (PTSS) or PTSD.[8]
PTSD symptoms include re-experiencing phenomena, avoidance of the traumatic event,
negative alterations in thoughts and mood, and hyperarousal symptoms.[9] Individuals might
respond to trauma in different ways. Patients who have experienced traumatic events may not
respond to the conversation as they normally would and could appear withdrawn. Anxiety
symptoms such as nightmares, irritability, poor concentration and mood swings could occur.
Furthermore, the emotional symptoms of trauma may include anger, sadness, denial, and

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emotional outbursts.[10]
Therefore, therapeutic interventions are needed and should be provided for patients
experiencing of these trauma-related symptoms.
Mental-health interventions for treating trauma range from PFA delivered at a disaster site to
clinical therapies delivered later in recovery.[11] Many forms of therapy continue to emerge to
treat those who have experienced traumatic events. The National Child Traumatic Stress
Network (NCTSN), established by the US Congress in 2000, provides the clinical treatments,
mental health interventions, and other trauma-informed service approaches for traumatized
youth. For the NCTSN, core components of interventions emphasize maintaining function and
adaptive routines.[12]
In addition, psychological interventions such as psychodynamic psychotherapy, psychological
debriefing, cognitive behavioral therapy (CBT), prolonged exposure (PE), and eye movement
desensitization and reprocessing (EMDR) have been proposed as therapies for PTSD.[13]
Psychological interventions might modify stressors that could trigger episodes, improve
treatment compliance and help patients address psychological illness.
In South Korea, recent research[1] has also recommended psychosocial interventions such as
trauma-focused CBT, psychoeducation, EMDR, play therapy and art therapy for children and
adolescents exposed to disasters. Most interventions include psychoeducation about trauma
symptom reactions, anxiety reduction strategies, stabilization, and relaxation. Nevertheless, more
detailed clinical evaluations and interventions might be indicated for patients who do not
appear to recover within a month or so after a disaster.[8] Based on this, disaster crisis
interventions and services protect existing social supports and foster resilience.
[Table 1] Psychological interventions related to PTSD
Psychological
interventions for Definition and core action of interventions
trauma
· A technique designed to reduce the occurrence of PTSD
· To provide contact and engagement, safety and comfort, stabilization,
Psychological First Aid information gathering regarding current needs and concerns, practical
assistance, connection with social supports, information on coping, and
linkage with collaborative services
· An evidence-based therapeutic intervention for patients and their loved
Psychoeducation ones that provides information and support to better understand and
cope with illness
Psychological · A formal version of providing emotional and psychological support

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Art Therapy for PTSD in Traumatized Patients after Disasters

Debriefing following a traumatic event

To prevent the development of PTSD and other negative sequelae
·

· An evidence-based psychotherapy or counseling that aims at addressing

Trauma-focused the needs of children and adults with PTSD and other difficulties
Cognitive Behavioral related to traumatic life events
Therapy · To provide the ability to identify and cope with emotions, thoughts, and
behaviors
Eye movement · A form of psychotherapy developed by Francine Shapiro which uses eye
desensitization and movements or other forms of bilateral stimulation to purportedly assist
reprocessing patients in processing distressing memories and beliefs
· A form of behavior therapy and cognitive behavioral therapy designed to
Prolonged exposure treat post-traumatic stress disorder, characterized by re-experiencing the
therapy traumatic event through remembering it and engaging with, rather than
avoiding, reminders of the trauma (triggers)
Play therapy and art · To provide play and art activities for them to express their experiences
therapy and feelings through a natural, self-guided, self-healing process

3. Art therapy for PTSD after the disaster

Art therapy is a creative form of intervention used as a therapeutic technique. It can be
effective because it provides an opportunity for alternative expression. Moreover, it is used in
many clinical and other community settings with diverse populations. Art therapy is a Health
and Care Professions Council (HCPC)-approved form of psychological therapy in the UK.[14]
The British Association of Art Therapists (BAAT) defines art therapy as "a form of
psychotherapy that uses art media as its primary mode of expression and communication."[15]
Art therapy includes and combines various approaches such as cognitive-behavioral,
person-centered narrative, and Gestalt therapy.
The American Art Therapy Association (AATA) describes art therapy as "a mental health
profession that uses the creative process of art making to improve and enhance the physical,
mental and emotional well-being of individuals."[16] The aims of art therapy include personal
growth, increasing creativity, fostering self-awareness, reconciling conflicts of emotion, recovery
of daily life, and improving self-awareness and self-fulfillment.[14] Art therapy provides
activities for expressing emotions and thoughts to facilitate recovery and growth from
psychological distress.[17]

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Using art to express emotion accesses visually stored memory and body memory. Through
the externalization of their narratives and by drawing pictures about their experiences, patients
can feel safe to access their physical and emotional experiences, and realize that here-and-now
is a safe place. It focuses on the creative art-making process, or on the analysis of expression.
Representing feelings and conflicts in a drawing, painting, clay work, or another form of
creative visual art allows patients to think about their problems in new ways. It is important
to have an awareness of the effective properties of different art materials to use them safely
with patients. Some materials could be triggering when used in the wrong context. Therefore,
each material is carefully selected to express unconscious thoughts, feelings, and memories.
Using imagery, color, and shape as a creative therapeutic process might allow for the
expression of feelings and thoughts that would otherwise be difficult to articulate. The art
therapist both interprets the patient's symbolic expression as communicated in the art and
elicits the patient’s interpretations of their own artwork.
In addition, artwork can be more reliable than verbal communication in some patients
because feelings might be better expressed through art therapy experiences.[18] Thus, art
therapy should be considered for people with posttraumatic symptoms, before supportive
psychological therapy and counseling, in conjunction with other modes of communication
within a therapeutic relationship in the clinical setting.[19] Hence, psychosocial and art-based
interventions could provide effective psychosocial support and rehabilitation services. In
particular, such interventions might be used in conjunction with other psychotherapy techniques
such as CBT. Art therapy is helpful to self-regulate and modulate the reactions to traumatic
experiences for eventual trauma integration and post-traumatic growth.[20]
Art therapy could be provided as a mental health service to preschoolers, children,
adolescents, and adults, whether as individuals, groups, or families. As the patient experiences
the process of creating therapeutic artworks, they could be coping with traumatic memory,
increasing neurosensory abilities and cognitive insights.
However, the visual and sensory activity using art materials might trigger some patients’
traumatic events and may aggravate their psychiatric symptoms. Therefore, above all, a
qualified art therapist should be trained and provide systematic education or consistent
supervision.
4. Discussions
In the face of trauma, artwork might help children and adolescents gain symbolic control

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Art Therapy for PTSD in Traumatized Patients after Disasters
over traumatic events that are confusing and frightening. Art therapy has been used in various
traumatic events, including crisis intervention and disaster relief.
The effective results of art therapy in the clinical setting have often been reported. Art
therapy can access trauma recollections by engaging the senses.[21] The results of the present
study are quite similar in that children who suffered PTSD and received the Chapman Art
Therapy Treatment Intervention (CATTI) did show a reduction in acute stress symptoms.[22]
Furthermore, after Hurricane Katrina in the US, the previous study described that drawing
activities and narratives were used to help children understand their experiences related to the
traumatic event.[23]
Drawing is a useful technique to identify patients’ emotions and possible problems, as well
as to gain information directly from themselves.[24] Based on the externalization of trauma and
emotions, artwork could act as an external reflection during treatment. In addition, the research
found that after utilizing art therapy for trauma treatment, 89% of participants either recovered
or met criteria for improvement. The Art Therapy Institute provides art programs for refugee
adolescents from Burma to decrease the traumatic symptoms.[25] This result suggests that art
based intervention is a useful treatment for PTSD.
Evidence for trauma-focused art therapy is based on the fact that art expression is effective
in reconnecting implicit (sensory) and explicit (declarative) memories of trauma and in the
intervention of PTSD.[24] Based on the above, this study discusses art therapy for patients
exposed to a traumatic event in the following four categories.[Table 2]
First, art therapy can be used to stabilize the body’s responses, to identify traumatic
memories through art activities and to make an image in order to externalize a problem. Image
making with art materials could be integrated with cognitive-behavioral therapy (CBT) to
improve the efficacy of the intervention. Steele and Raider[26] studied how drawing and
cognitive reframing skills help children recall and process traumatic events. In PFA, art
materials, building materials, or coloring books are provided to help children and adolescents
engage in soothing, familiar activities. For instance, group drawing, scrabble games, making a
paper doll chain or circle chain, folding ‘fortune tellers’, and making paper balls and tossing
them at wastebaskets.[27]
Second, the use of mental imagery helps patients to practice new emotional patterns and
reinforces a sense of safety. The patients could make images or representations of the negative
schema, negative self-talk, and anxiety-producing cognitions. They could make sense of and
process their experience, as well as use symbols and metaphor to gain a safe distance from
traumatic events. Additionally, with the goal of reframing negative thoughts and emotions and
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reducing the post-traumatic stress symptoms, Malchiodi[28] used a drawing technique to assist
children and adolescents in crisis to depict their experiences.
Third, interacting with an image can replace a verbal directive and promote re-connection
with positive self-soothing. The therapist could ask the patient to make an image representing
a problem that contributes to psychiatric symptoms and help to begin to identify and process.
Image making could serve to help the patients reframe or restructure traumatic experiences and
behaviors and visually develop strategies. Integrating image-making into the therapy may help
to address some issues, i.e., making an image of a ‘stressor’, ‘how I could prepare for a
stressor’, ‘step-by-step management’ and ‘stress reduction'.[20] Furthermore, art therapy could
provide more long-lasting healing and be more profound than other treatments by providing
an alternative means of expression and release from trauma.[21] Therefore, the image works
could produce powerful representations of the mind.
Fourth, artwork can be used to normalize and enhance resilience, and it can be completed at
home, helping a patient interpret their thoughts and feelings daily.[20] By exercising a negative
image through artistic expression, a patient who is exposed to traumatic events could develop
more positive assumptions. Additionally, art therapy could help patients to foster resilience
through exploring alternate outcomes in a safe environment. They could externalize inner
feelings and conflicts, allowing for discussion with the therapist.
Finally, according to these principles, patients exposed to traumatic events could enhance
their formation of a hopeful plan and rehabilitation from post-traumatic growth.
The results of the present study are consistent with a previous study where twenty-two
children with asthma participated in 60 minutes of active art therapy for seven weeks and
received benefits that included increased quality of life and decreased anxiety symptoms.[29]
Art therapy also appeared to be cost-effective compared with the wait-list group. Additionally,
in another previous study[30] on art therapy, traumatized adults who underwent art therapy
had shown a significant decrease in depression and traumatic symptoms.
Nevertheless, further studies and developmental guidelines will be needed to confirm this
finding and provide evidence to inform analyses of art therapy versus other treatments.[31]

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Art Therapy for PTSD in Traumatized Patients after Disasters
[Table 2] Suggestions of the categories of trauma-focused art therapy
Category Contents of suggestion
· To stabilize the body’s responses and therapeutic grounding
· To provide the relief from tension and anxiety
Stabilization and · To identify traumatic memories through art activities and to make an
promote calming image that externalizes a problem
· To establish a supportive therapeutic relationship

· To reduce over emotionality/engagement

· To experience self-soothing through art-making
Promote a sense of · To encourage patient's spontaneity through drawing
safety · To use mental imagery in order to practice new emotional patterns and
reinforce a sense of safety
· To help the patient reframe or restructure traumatic experiences and
behaviors and visually develop coping strategies
· To provide art materials that would assist the patient in recreating the
Image artworks traumatic event
· To increase coping skills and validate trauma · To provide ways for the
patient to review what occurred symbolically through artwork and to
problem-solve
· To use artwork to enhance resilience and complete activities that
represent the imagery of thoughts and feelings
Enhancing resilience · To promote a sense of self-efficacy and access to social support
· To provide a transformative and restorative experience of hope for
better times to come

5. Conclusions
The present study aimed to establish adequate criteria for art therapy to address disasters
and trauma. From the available evidence, the following conclusions can be drawn from this
review. In summary, art therapy showed significant positive effects for traumatized patients in
previous studies. The understanding of art therapy processes for patients after a disaster could
inform preparedness and crisis-planning efforts and facilitate social support. Trauma-focused art
therapy could help with normalizing feelings, increasing relaxation, increasing a sense of
stability, exercising coping skills, and establishing a social support network and community.
There are several limitations to this study. This study lacked specific information about
findings and thus may not represent a general justification. Nevertheless, confirmatory studies
should be conducted to confirm this finding, as there is currently no standard outcome

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measure for defining "successful" treatment through art therapy in clinical practice. Additionally,
further study could examine various aspects of the correlations between disaster and art
therapy. Recommendations for future research have suggested directions including more design
and implementation of treatment approaches, methods of screening and triage, and longitudinal
monitoring of the outcomes of the course of the intervention. Furthermore, we would need to
consider post-traumatic growth for traumatized patients.
In conclusion, image work through art therapy complements a trauma-focused CBT approach,
and therapists could provide an opportunity to capitalize on visual interaction and
communication to enhance trauma-focused therapy. These results might form the evidence base
for further research on trauma treatment and trauma-focused art therapy.

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