Monday, 26 August 2013

2009 - Art Therapy for the Malvinas War Veterans


- Eduardo C. Gerding  -

International Review of the Armed Forces Medical Services-December 2009-Vol 82/4

Art therapy provides ways to express feelings and experiences that are difficult to express verbally.  As a form of psychotherapy art therapy helps war veterans communicate and resolve traumatic memories, relieve stress, and reduce symptoms of trauma-related conditions. Art Therapy has made a unique contribution as well to victims of psychological trauma, like children, schizophrenics, brain-damaged, elderly, and the developmentally delayed (Johnson). Sexual abuse, domestic violence, school violence and homicide, war and terrorism and medical trauma(Collie) The encoding of traumatic memories may be via a ¨photographic¨ visual process so a visual media may offer a unique means by which these may come to consciousness. Though traumatic memories can also be generated by particular sounds or intense body exercise, these modalities may overwhelm the patient (Kolb, 1984). The art work, by being distanced from the body of the patient, seems to provide a safer media for expression of traumatic images (Golub, 1985)


Hans Prinzhorn (1886 -1933) was a German psychiatrist and art historian who studied art history and philosophy at the University of Vienna, receiving his doctorate in 1908. He then went to England to receive voice training, as he planned to become a professional singer. He later received training in medicine and psychiatrics, serving as an Army surgeon during World War I. In 1919 he became assistant to Karl Wilmanns at the psychiatric hospital of the University of Heidelberg. His task was to extend an earlier collection of art created by the mentally ill and started by Emil Kraepelin. When he left in 1921 the collection was extended to more than 5000 works by about 450 "cases". In 1922 he published his first and most influential book Bildnerei der Geisteskranken (Artistry of the Mentally Ill), richly illustrated with examples from the collection. While his colleagues were reserved in their reaction, the art scene was enthusiastic.
Jean Philippe Arthur Dubuffet (1901 - 1985) was one of the most famous French painters and sculptors of the second half of the 20th century. Influenced by Hans Prinzhorn's book Artistry of the Mentally Ill, Dubuffet coined the term Art Brut (outsider art) for art produced by nonprofessionals working outside aesthetic norms, such as art by mental patients, prisoners, and children. He amassed his own collection of such art, including artists such as Aloïse Corbaz and Adolf Wölfli. The collection is now housed at the Musée de l'Art Brut in Lausanne, Switzerland. Dubuffet sought to create an art as free from intellectual concerns as Art Brut, and his work often appears primitive and child-like. Many of Dubuffet's works are painted in oil paint using an impasto thickened by materials such as sand, tar and straw, giving the work an unusually textured surface. From 1962 he produced a series of works in which he limited himself to the
colours red, white, black, and blue.

In USA, Art therapy has been a valuable part of mental health services offered by Veteran´s Hospitals since 1945 when the Winter VA Hospital in Topeka, KS, offered art therapy as part of their psychiatric services to returning World War II veterans. By 1980 a job series was established to facilitate the hiring of art therapists nationwide the GS638 series for Creative Arts Therapists and Recreation Therapists. Today, art therapists are employed in VA hospitals and offer therapeutic services to military personnel and their families in hospitals such as Walter Reed in Washington DC. Many art therapists provide service to military personnel through TRICARE, managed health care, and other programs for military, reserve and retired service men and women. (Art Therapy, Postraumatic stress disorder, and veterans). Soldiers begin by creating art, using a medium of their own choosing, to reflect positive qualities of their war service, such as bravery and resiliency. From there the art therapist gradually tutors her patients to address more difficult subjects culminating with the traumatic experience that has triggered the PTSD (Vantage point) In 1990, Dissanayake stated that art comes from the wish to do something in response to problems and fears we face. We find emotional satisfaction and calm in the controlled behavior of shaping time and space, of putting these into comprehensive forms. (Appleton) 

In 1960 an International Exposition of Art in Psychopathology took place in Paris linked to the first World Congress of Psychiatry. There have been several Argentine and Latin American Congress on Art Therapy ; 1st (August 24, 25 and 26, 2005 ) ,2nd ( October 11, 12 and 13rd ,2006 ) , 3rd ( 5,6 and 7 September,2007) ,4th Congress ( September 10,11 and 12th 2008). The next congress will take place at the Centro Cultural Estación Mapocho of Santiago (Chile) on August 21,22 and 23rd.,2009.

Art Therapists
In USA Art Therapists hold a credential in the field of Art Therapy such as Registration (ATR)or Board Certification (ATR-BC). Many art therapists also hold an additional license in counseling, psychology, or marriage and family therapy. Art therapists are skilled in using drawing, painting, sculpture, and other media in assessment and treatment and the clinical application of methods of psychotherapy and counseling of methods of psychotherapy and counseling to achieve treatment goals and objectives. (Art Therapy, Postraumatic stress disorder, and veterans).

Art therapists encourage Veterans to reflect on the meaning of their artwork to assist their psychological recovery, promote insight, and improve functioning. Based on their knowledge of art materials, human development, and physical, mental, and emotional conditions, art therapists select specific drawing, painting, or sculpting activities to augment cognitive, psychological, and physical rehabilitation. (Art Therapy, Postraumatic stress disorder, and veterans).

In order to work in the UK as an art therapist in the NHS and Social Services, it is mandatory to possess the post-graduate Diploma in Art Therapy or Art Psychotherapy. Applicants for art therapy training should normally be graduates in art and design but qualified teachers, social workers, psychologists and other professionals with a commitment to the practice of the visual arts are also considered. All post-graduate courses in Art Therapy and Art Psychotherapy abide by standards set down by the Health Professions Council (HPC) and are approved by the council. Chile requires 143 credits and a minimum of 100 practice hours to obtain a degree of Art Therapist.

Art Therapy and PTSD
Approximately 30% of people who have been in war zones develop PTSD. The rates of PTSD for veterans of the wars in Afghanistan and Iraq are conservatively estimated to be 11% and 18% respectively with a higher rate for veterans of the war in Iraq because of greater combat exposure. PTSD increases in a linear manner with the number of fire-fights a soldier experience (Hoge et al 2004;Litz 2005). It is assumed that PTSD has been under-reported for veterans of both these wars to avoid stigmatization. Studies have found that 45% of Iraq war veterans accused mental health services in the year after returning home. 18,7% of the veterans of the US war in Viet Nam developed war-related PTSD during their lifetimes and 9,1% were stil suffering from PTSD 11 to 12 years after the war ((Dohrenwend et al,2006) (Collie)

According to the American Art Therapy Association, art therapy helps by:

  • Reducing anxiety and mood disorders common to military personnel with PTSD.
  • Reducing behaviors that interfere with emotional and cognitive functioning.
  • Externalizing, verbalizing, and resolving memories of traumatic events 
  • Reactivating positive emotions, self-worth, and self-esteem. (American Art)
Johnson and colleagues(1997) found that art therapy was the only component among 15 standard SIPU components, such as group therapy, drama therapy, community service, anger management, and journaling, that produced the greatest benefit for veterans with the most severe PTSD symptoms (The other 14 components were most effective for those with the least severe symptoms). They also found art therapy to be exceptional in that the veterans could tolerate war-zone content during art therapy and could no do so during other activities. (Collie)

Art Therapy for Veterans with PTSD: 
¨Best Practices¨
Treatments for PTSD need to reduce immediate symptoms and to address the underlying problems that perpetuate symptoms. A three-stage approach is recommended similar to the approach for treating complex PTSD outlined by Ford et al (2005). The goals of the first stage are to reduce arousal symptoms, to develop emotional self-efficacy, to reactivate positive emotions (reduce emotional numbness), and to create emotional safety and social bonds among veterans as a foundation for further therapeutic work. 

During the second stage.
The focus is on processing traumatic memories and emotions. Through nonverbal expression and progressive symbolic exposure, traumatic memories are recalled, expressed, and consolidated into a coherent trauma narrative (verbal or visual) that is owned and acknowledged by the person and seen as part of the person´s past. The goal of the third stage is to help group members incorporate new insights and understanding into their lives. (Collie)

This picture was made by a British War Veteran admitted in Audley Court
This picture was made by a British War Veteran admitted in Audley Court who fought
in the 1982 South Atlantic conflict. He received a shot which produced an unbearable
pain which is superbly depicted in his work.
(Kindly submitted by Commodore Toby Elliott OBE RN , Director-Stress Center, UK)

Art Therapy with Adolescents
Adolescence has been recognized as one of the most creative times of life. Symbols visually express developmental changes and experimentation with one´s self and role in society (e.g: graffiti, personal adornment, and body tattooing or piercing). Art provides a vehicle for adolescent self-expression that is constructive and reinforces experiences of mastery through expressive media, structured processes, responsive artmaking and brief therapy.(Appleton)

Pictures made by patients

Pictures made by patients kindly submitted by Professor Daniel Gerbiño of the Instituto
Municipal de Rehabilitación de Vicente López ¨ Dr Anselmo Marini ¨ ( Av Maipu 3075-CP: 1636 -Olivos ). An agreement was submitted by the autor to provide Art Therapy to the Argentine Malvinas War Veterans.

Art Therapy Trauma Intervention 
and Assessment Paradigm 
in an intensive care burn unit (Appleton)

From left to right: Master of Arts and Plastic Artist Daniel Gerbiño† and Eduardo C. Gerding
From left to right: Master of Arts and Plastic Artist Daniel Gerbiño† and the author. On
September 22nd, 2008 the Latin american Art Therapy Congress took place in Vicente
Lopez led by Pofessor Gerbiño, the Secretary of Health and Social Action Professor
María Cristina Mandich and the Director of the Local Council Rehabilitation Institute
¨Dr Anselmo Marini ¨ Dr Ernesto Matassa. Photograph: Dr EC Gerding.

  • Appleton, Valerie EdC, ATR, MFCC, NCC-Avenues of Hope: Art Therapy and the resolution of trauma. Eastern Washington University.
  • Art Therapy, Posttraumatic Stress Disorder, and Veterans from theAmerican Art Therapy Association (AATA)
  • Barmak L.Lic. and Bottini M. Prof. El error de uno es el error de todos-Hospital General de Agudos Juan A. Fernández-4to Congreso Latinoamericano de Arte & Rehabilitación, 10, 11 y 12 de septiembre de 2008, Buenos Aires.
  • Chapman, Linda MA, ATR-BC et al-The effectiveness of Art Therapy interventions in reducing Post Traumatic Stress Disorder (PTSD)Symptoms in Pediatric Trauma Patients. San Francisco Injury Center.
  • Collie, Kate et al. Art Therapy for Combat-related PTSD: Recommendations for research and practice. Art Therapy- Journal of the American Art Therapy Association, 23(4)pp 157-164, 2006
  • da Silveira, Nise y Mello, Lis Carlos-Imágenes del Inconsciente-Fundación Proa. Buenos Aires, 2004.
  • De los Ríos Möller, Carlos-Arte y Resiliencia-Red Psicoarte de Sociedad Atenea de Viña del Mar, Chile. 4to Congreso Latinoamericano de Arte & Rehabilitación, 10, 11 y 12 de septiembre de 2008, Buenos Aires
  • Fusté Padros, Marta Cristina-El Arte del Ave Fénix-Samanta y una propuesta para su reinserción social y laboral.-CeFAP-Centro de Formación y Atención Psicopedagógica-Posadas (Misiones),Argentina 4to Congreso Latinoamericano de Arte & Rehabilitación, 10, 11 y 12 de septiembre de 2008, Buenos Aires.
  • Giménez, Verónica and Ramos Matías-Aportes del Arte en la Construcción de la Resiliencia-Experiencias creativas con adultos mayores en el Hogar San José-4to Congreso Latinoamericano de Arte & Rehabilitación, 10, 11 y 12 de septiembre de 2008, Buenos Aires.
  • Gutierrez, Elvira-Trastornos de la personalidad y arteterapia- Revista Asociación Española de Terapia Gestalt A.E.T.G. nº 24,Mayo 2004: 52-57
  • Johnson, David Read PhD, RDT-The Role of the Treatment Arts Therapies in the diagnosis and treatment of psychological trauma. The Arts in Psychotherapy, Vol 14 pp. 7-13.
  • Maldonado, Ricardo. La vorágine, un taller para detener el torbellino. Asociación Sísifo, Cruces del Arte. 4to Congreso Latinoamericano de Arte & Rehabilitación, 10, 11 y 12 de septiembre de 2008, Buenos Aires.
  • Melgar, Maria Cristina and Lopez de Gomara, Eugenio-Imágenes de la locura-Ediciones Kargieman, Buenos Aires 1988
  • Mota, Joaquín-El Arte de ser Desigual...Aquello que no todos logramos entender. 4to Congreso Latinoamericano de Arte & Rehabilitación, 10, 11 y 12 de septiembre de 2008, Buenos Aires
  • Schneider, Judith Lic and Stecconi, Miriam Lic.-Los puentes de expresión-Escuela de Educación Especial Nº501-Servicio de Trastornos Emocionales Severos. 4to Congreso Latinoamericano de Arte & Rehabilitación, 10, 11 y 12 de septiembre de 2008, Buenos Aires
  • Valladares, Ana Claudia Afonso-El Arteterapia ayudando en el cuidado y en la rehabilitación de adictos. 4to Congreso Latinoamericano de Arte & Rehabilitación, 10, 11 y 12 de septiembre de 2008, Buenos Aires
  • Vantage Point-The Art of War: Feds may study art therapy´s effect on PTSD 

    • American Art Therapy Association (AATA) (USA)
    • Asociación Chilena de Arte Terapia (ACAT) (Chile)
    • Asociación Profesional Española de Arteterapeutas (ATe) (Spain)
    • Centro Argentino de Medios Alternativos de Comunicacion (CAMAC) (Argentina)
    • Elaine Elliott, Publications Administrador of The British Association of Art Therapists. (UK)
    • European Consortium of Art Therapy (Ecarte)
    • Janki Foundation for Global Healthcare, London (UK)
    • The Society for the Arts in Health Care (USA)