Using art therapy to overcome avoidance in veterans with chronic post-traumatic stress disorderJanice Lobban and Dominic Murphy

ABSTRACTAvoidance can be a significant barrier to engaging in trauma-focused treatment for post-traumatic stress disorder (PTSD), as well as being a mechanism that creates restrictions thatcan seriously impact functioning and wellbeing. Following an outpatient study with veteransthat indicated art therapy might assist the overcoming of avoidance, a group of veterans wasoffered an art therapy-focused, short-stay, inpatient admission at the veterans’ mental healthcharity Combat Stress to explore this potential outcome. Participants were able to use the arttherapy process to express and tolerate painful thoughts and emotions, and to consider theeffects of rigid perceptions. The group dynamic between the veterans created a strongcontainer for this process. Consequently, this study suggests that art therapy can beconstructively employed in assisting veterans to overcome avoidance PTSD symptoms and asa means of opening up new ways of perceiving, interpreting, and responding to situations. Itis proposed that the non-verbal operations of art therapy enable this process through theuse of imagination and creativity.

ARTICLE HISTORYReceived 21 September 2017Accepted 22 October 2017

KEYWORDSArt therapy; veterans;avoidance; chronic PTSD;perceptions; group dynamic;creativity

Introduction

Experiential avoidance, or ‘the unwillingness to remainin contact with private experiences such as painfulthoughts and emotions’ (Chawla & Ostafin, 2007,p. 871), is a factor common to a range of psychologicalconditions and can present a significant barrier toengaging in treatment. According to Monestès et al.,experiential avoidance spans nations and is trans-cul-tural. They put forward the case that it is ‘based on afundamental verbal/cognitive process: an overexten-sion of verbal problem solving into the world within’(Monestès et al., 2016, Abstract). Pineles et al. (2011)argue that overdependence on avoidance as acoping strategy can hamper the natural process ofrecovery after trauma. Indeed, there seems to begeneral agreement between schools of thought thatalthough avoidant coping might provide short-termrelief, it is maladaptive and perpetuates problems(Hayes, Wilson, Gifford, Follette, & Strosahl, 1996;Kashdan, Barrios, Forsyth, & Steger, 2006).

Avoidance is one of the four clusters of symptomsassociated with post-traumatic stress disorder (PTSD),as defined by the Diagnostic and Statistical Manual ofMental Disorders (DSM–5). It presents as ‘Persistentavoidance of stimuli associated with the traumaticevent(s)’, either through thoughts and feelings or exter-nal reminders such as people or places (American Psy-chiatric Association, 2013, p. 271). Avoidance can resultin limitations such as social withdrawal and psychicnumbing, which can seriously impact functioning andwellbeing.

Recent research has shown that although trauma-focused cognitive behavioural therapy (TF-CBT) is aneffective, evidence-based treatment for PTSD, there isa subset of clients with high levels of avoidance anddissociation who find it difficult to engage in thisform of treatment (Kaur, Murphy, & Smith, 2016). Fur-thermore, in their review of 55 studies, Schottenbauer,Glass, Arnkoff, Tendick, and Gray (2008) reveal thatsuccess rates for CBT as a single intervention for veter-ans with PTSD has been just 50 per cent in some cases(Smith & Lobban, 2017). Coupled with this, there are anincreasing number of veterans seeking help for mentalhealth problems (Murphy, Weijers, Palmer, & Busuttil,2015). This would seem to indicate a need to findalternative forms of treatment for those veterans withhighly avoidant or dissociative PTSD presentations,such as approaches that are less reliant on verbal/cog-nitive processes.

Emerging studies from both the UK and the USAsupport art therapy as a promising treatment for veter-ans with PTSD (Collie, Backos, Malchiodi, & Spiegel,2006; Lobban, 2016a; Palmer, Hill, Lobban, & Murphy,2017). It is proposed that art therapy is able to accessnon-verbal operations of the brain that do not commu-nicate in words and language but through emotions,sensations, and visual imagery (Hass-Cohen & Carr,2008). This non-verbal approach is thought to bypasscensoring cognitive mechanisms that restrict progressand thereby facilitate the expression of suppressed oravoided psychological material (Lobban, 2017a;Rubin, 1999). Once expressed, the material is availableto be worked with.

© 2017 British Association of Art Therapists

CONTACT Janice Lobban janice.lobban@combatstress.org.uk

INTERNATIONAL JOURNAL OF ART THERAPY2018, VOL. 23, NO. 3, 99–114https://doi.org/10.1080/17454832.2017.1397036

Since 2001, art therapy has been part of the treat-ment available at the veterans’ mental health charityCombat Stress, and that is the context for this study.Established in 1919 in the aftermath of the FirstWorld War, Combat Stress, as it is now known, hasbecome a national organisation dedicated to providingfree specialist clinical treatment and support to ex-ser-vicemen and women (Combat Stress, 2017).

Despite a long association between art therapy andmilitary trauma, little has been written about this areaof work (Hogan, 2001; Lobban, 2017b). More broadly,Smith conducted a review of art therapy literatureassociated with trauma, including studies of work withveterans. The review highlighted the importance ofthe group experience as a therapeutic mechanism intrauma recovery. The study also concluded that ‘thereis a need for understanding art therapy treatmentmech-anisms for the combat veteran group as a treatmentprocess in isolation from other available multimodaltreatment strategies’ (Smith, 2016, p. 72). Currently atCombat Stress, group art therapy is not usually offeredto veterans in isolation fromother treatmentmodalities.

In order to examine the particular therapeutic mech-anisms of art therapy for treating PTSD, Combat Stressprovided a two-week inpatient admission for a groupof veterans. The programme centred on art therapyclosed group work and individual sessions. Veteranscould work on their own creative projects in the occu-pational therapy activities room, but they could notattend the psycho-educational, CBT-focused groupsof the concurrent treatment programmes. In thatway, the main focus was on art therapy and art-making.

To try to address the current gap in literature, ashighlighted above, in this article four case studiesfrom the art therapy-focused admission at CombatStress are presented to explore how art therapymight help veterans to overcome, or to cope with,the limitations of avoidance related to PTSD.

Context of the study

Combat Stress has three treatment centres which,between them, cover referrals from the whole of theUK. The current study took place at the Surrey treat-ment centre, which covers a catchment area fromCornwall to Kent, and East Anglia to the south coastof England. The centres provide short-stay admissionsfor different treatment packages. Art therapy is avail-able as part of all of the programmes, at all three treat-ment centres. An adaptive art therapy model hasevolved at Combat Stress that is tailored to suit theshort-stay format. Mindful of military culture and theeffects of trauma, a phasic, theme-based approachhas been adopted to facilitate gradual, paced exposureto difficult material (Lobban, Mackay, Redgrave, & Raja-gopal, 2017). The use of themes which are shaped tosuit each particular group, at a particular time, provides

a focus and framework whilst encouraging individualapproaches.

Veteran feedback through group evaluation sheetsand research questionnaires at Combat Stress hasbeen used to try to understand the therapeuticmechanisms at play in art therapy (Lobban, 2016b;Palmer et al., 2017). This led to an art therapy outpa-tient study for individual veterans, which wasdesigned to observe the process when delivered sep-arately from the multimodal, inpatient packages.Veteran presentations were recorded at baselineand again during a review after 12 art therapy ses-sions. Results suggested that veterans were able touse the art therapy process as a way of overcomingavoidance (Lobban, 2017a). These findings led tothe current study, this time for veterans in a groupformat. As a pilot study, the admission wouldprovide information that could help to guide futureservice development.

In order to fulfil the criteria for participation in thepilot admission, veterans were required to have beenable to engage in the creative and reflective processesof art therapy during at least one previous inpatientadmission. Participants were also required to haveenduring, chronic PTSD with avoidance presentationsand to be not yet able or willing to take part in thesix-week, evidence-based, CBT-focused PTSD pro-gramme. Telephone contact was made by the leadart therapist with each veteran to discuss the admissionoption. In that way, any questions were answered toensure informed choice before participating in thisnew programme.

All the data for this study was collected by 20November 2016.

Case reports

The following section is an overview of each partici-pant, followed by an explanation of the admission psy-chometrics used in order to describe the presentationof participants.

Mr A is a married man in his 50s who served in thearmy for 23 years, with deployments in NorthernIreland and Bosnia. His symptoms included anxiety;hyper-vigilance; dissociation; flashbacks of pasttrauma; and avoidance, which manifested in social iso-lation. At one point he did not leave his home for threemonths.

Mr B is a married man in his 60s who served in thearmy for 15 years, with a number of deployments inNorthern Ireland. His PTSD symptoms included beinghighly anxious; socially isolated; having daily intrusivethoughts of past trauma; frequent night terrors;feeling detached from others; survivor guilt; hyper-arousal; and a very exaggerated startle response.

Mr C is a married man in his 50s who served for 10years in the RAF Regiment, which included deployment

100 J. LOBBAN AND D. MURPHY

in the Balkans and the Gulf. His PTSD symptomsincluded anger; guilt; hyper-vigilance; crowd avoid-ance; poor sleep; and rumination.

Mr D is a single man in his 60s who served in thearmy for 8 years, with deployments in NorthernIreland. His PTSD presentation included a past historyof alcohol dependency; anger, depression; avoidanceof thoughts, feelings, and activities; lack of motivation;and feeling cut off.

Psychometric measures

Patient Health Questionnaire (PHQ-9)This nine-item self-administered questionnairemeasures severity of depression. Each item is rated0–3, with a maximum score of 27. The higher scoresindicate greater severity of symptoms, with a score of10 or above indicating high levels of depression(Kroenke & Spitzer, 2002; Spitzer, Kroenke, & Williams,1999).

Generalised Anxiety Disorder (GAD-7)This seven-item self-administered questionnairemeasures severity of anxiety. Each item is rated 0–3,with a maximum score of 21. The higher scores indicategreater severity of symptoms, with scores of 5, 10, and15 used as cut-off points for mild, moderate, and severeanxiety (Swinson, 2006).

PTSD Checklist for DSM-5 (PCL-5)This is a 20-item self-report measure that assesses the20 DSM-5 symptoms of PTSD. A total symptom severityscore, with a maximum of 80, is obtained by adding thescores from each of the items. The suggested cut-offscore is 34 for PTSD screening (Murphy, Ross,Ashwick, Armour, & Busuttil, 2017; Weathers et al.,2013).

Warwick & Edinburgh Mental Wellbeing Scale(WEMWBS)WEMWBS is a self-report measure for mental wellbeingamong people aged 13–74 in the UK. It comprises 14positively worded statements with five response cat-egories from ‘none of the time’ to ‘all of the time’.The total score ranges between 14 and 70. An increasein the total score indicates an improvement in well-being (Tennant et al., 2007).

The psychometric measures (Table 1) revealed thatthree out of the four veterans were experiencing highlevels of depression and severe anxiety, and that theymet the criteria for PTSD. Mr C’s PTSD symptom levelwas particularly high and, probably as a consequenceof this, his wellbeing was low.

The art therapy images and poems that were pro-duced act as tangible ‘snapshots’ of participants’ pro-gression through the short programme. It is thesecreative expressions that are the focus of this study,

with particular attention paid towards how avoidancechanged for each individual.

Pilot art therapy admission

Over the two-week admission, there were six two-hourthemed groups which were in the mornings; four one-hour individual sessions in the afternoons; and twohalf-day gallery visits with workshops. Gallery visitswere to the Lightbox, Woking, approximately 30minutes’ drive from the treatment centre. The mainexhibition on display at the time was ‘The Story ofBritish Comics So Far: Cor! By Gum! Zarjaz’, and oneof the art therapy group themes was tailored aroundthe exhibition.

Another significant factor in the choice of themeswas that admission took place over Remembrance inNovember 2016. Although a particularly significanttime of year for veterans, this was not done at therequest of the art therapists. It happened to be atime when four bedrooms were available to accommo-date veterans on the pilot programme. This timing pre-sented advantages and disadvantages. Being anemotive time of year, there was potential to tap intosignificant material that would be closer to thesurface. Two of the participants, however, Mr B andMr C, had already made arrangements locally overRemembrance weekend, and so would need to takeleave from the treatment centre and miss theMonday morning group of week two. This meant abreak in treatment with the potential of losing momen-tum and effects on group bonding.

Three of the four participants, Messrs B, C, and D,had met before during past admissions at the treat-ment centre. The intention had been to balance theprofile of possible participants so that no one personfelt different from the others. Mr D was a creativewriter.A fifth veteran, however, who was an

Table 1. Psychometric measures to describethe presentation of participants.Veteran Admission

Mr APHQ 9 14GAD-7 15PCL-5 55WEMWBS 29

Mr BPHQ 9 20GAD-7 21PCL-5 65WEMWBS 35

Mr CPHQ 9 23GAD-7 19PCL-5 74WEMWBS 16

Mr DPHQ 9 0GAD-7 5PCL-5 24WEMWBS 37

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acquaintance of Mr A and a creative writer, was unableto participate in the admission at that time.

All the groups were facilitated by the lead art thera-pist, co-author of this article, with an art therapist col-league and an art therapist trainee co-facilitating ondifferent days. Individual sessions were with the leadart therapist in three cases, and with the art therapistcolleague for one veteran.

Group 1

After a time of discussion around the aims and formatof the admission, the setting of mutually agreedground rules, and distribution of sketchpads for per-sonal use as appropriate, the theme of ‘My Planet’was set as a baseline for the treatment intervention.Participants had an hour to make a creative response.They could take a break as desired, and make them-selves a drink to consume in the group space if theywished. Individuals gathered materials and focusedon the task in hand, working quietly but withoccasional verbal exchanges. After the hour, thegroup gathered together for an hour of reflective dis-cussion. Each participant presented their work in turn,using Blutack to display each image on the wall as afocus point, so that everyone could see it clearly. Thiswas the veterans’ idea and not a suggestion made bythe facilitators.

Mr C thought that he had ‘copped out’ of revealingthe truth and taken an easy option. His image andpoem were comments from a global perspectiveabout inhumanity and discord (Figure 1); however,the work captured the source of his trauma – witnes-sing evil – which affected his view of mankind and

subsequent functioning. He said that he should havecreated an image of himself trapped inside a cellbehind bars, as that would represent his reclusive life-style more accurately. Mr C was able to create suchan image later that day in his individual art therapysession.

He also introduced the idea of inaccurate percep-tions into the group, whereby assumptions might bemade about individuals or situations that are far fromthe truth. He used himself as an example, suggestingthat people might view him as confident andassured, or as someone to challenge to a fight. Inreality, he preferred to avoid people, crowed places,and confrontations.

Beside his name at the top of his image, Mr A wrote‘aged 6 ¾’ to signify the image’s self-perceived child-like quality (Figure 2). He described his world as ‘flat’and how he became tipped over the edge at the slight-est thing; also that he was hanging on by a thread. Mr Awould become tearful and stammer if he got too closeto emotional experiences, so preferred to steer clear ofthis whenever possible. He described himself as a ‘crybaby’, making light of the response that was beyondhis control but which caused him distress. The termalso conveyed a child-like association.

Mr D wrote a poem, ‘Our Planet Earth’, which heshared with the group. He took the full hour to craftthe work and as he read it aloud to the groupmembers, he winced at lines he perceived as ‘clunky’.Taking a more general view of the shared world welive in, he was not explicit about what life was like forhim from day to day. Any personal struggles hemight have had were buried beneath the words. Hepreferred to capture a sense of the fleeting nature of

Figure 1. My Planet by Mr C.

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life and the need to value and cherish what we have,mindful of the future generations that will follow.

Mr B had taken a while to begin image-making, thenrushed to try to finish within the hour. This was tobecome his pattern. He listened intently to what theother group members shared and took a great interestin their work. He asked questions and made obser-vations, in this way generating further discussion andeliciting deeper meaning. When it came to his turn toshare his image, he became anxious and could notarticulate the personal meaning so clearly. Othersoffered their ideas and this helped him to convey hissense of optimism for the admission. Also a recluse,Mr B felt that a window was opening for him, lettingin air and light (Figure 3).

Just as the psychometric measures completed at theoutset of the admission were designed to capturelevels of depression, anxiety, PTSD symptoms, and well-being, the art therapy theme provided an opportunityto describe such aspects symbolically. In this way, therewas also the potential to disguise, omit, or elaborate onmaterial, concentrating on what they felt comfortableto share within a group.

Although each veteran had individual art therapysessions, the main focus for this study is on the workcreated in the group format. Where particularly rel-evant, observations from individual sessions areincluded.

First gallery visit with workshop

The following day, the four veterans and two art thera-pists travelled to The Lightbox, Woking, in a minibus,escorted by the Combat Stress driver. The majority ofthe veterans were anxious about this journey to an

unfamiliar place, through heavy traffic. Reclusive andsocially-avoidant, visiting galleries was not somethingthe veterans usually did, but they were determined tosee it through. Mr C preferred to sit in the front seatnext to the driver so he had a clear view. Everybodychatted, which provided mutual contact and gave analternative focus to spotting potential dangers.

Once at the gallery, the party was met by twomembers of the Lightbox staff and introduced to themain exhibition of ‘The Story of British Comics SoFar’. The exhibition not only displayed copies of twen-tieth-century and contemporary comics, but alsoincluded work from a wider perspective, such as

Figure 2. My Planet by Mr A.

Figure 3. My Planet by Mr B.

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reproductions of William Hogarth’s satires andexamples of Egyptian hieroglyphics. The veteransshowed an interest in the work, which stimulatedresponses such as fascination, nostalgia, humour,memories from service years, and curiosity. The groupwas particularly intrigued by Grayson Perry’s etching‘Map of Nowhere’ (2008) and its use of symbolswithin a circular map depicting an inner self.

A coffee break in the gallery foyer became quite dis-tressing for some veterans due to the high level ofnoise; however, the Combat Stress group all sattogether and chatted. Hyper-vigilance and anxietywas observed in veteran participants, but distress toler-ance techniques were used to good effect.

Gallery staff then led a three-dimensional collageworkshop inspired by the comics’ exhibition, held ina quiet room. The art therapists were joint participantsin the art-viewing and image-making, but alwaysmindful of maintaining appropriate boundaries. Theirmain task was to facilitate a safe, cultural, creativeexperience outside of the usual therapy space that sub-sequently could be further explored back at the treat-ment centre.

Group 2

After reflecting on experiences of the gallery visit theprevious day, with general agreement that it hadbeen worthwhile, the theme for the group was set asGrayson Perry’s Map of Nowhere (2008), with no cleardirective. One or two of the veterans were familiarwith Grayson Perry, his alter ego, and reputation forcross-dressing, and mentioned this. This broughtfurther food for thought in connection with theconcept of social perceptions and different presenta-tions that had been raised in the first art therapy group.

After an hour of image/poetry making, the groupgathered together to share their work. Rich in symbo-lism, Mr A’s image depicts him within a circle ofbarbed wire, behind bars, and with a bricked-upmouth (Figure 4). He has waterfalls for eyes and a but-terfly in his stomach. He has green blood runningthrough his veins to represent his close connectionwith the army. Many of his symbols stimulated discus-sion within the group and a sense of identification withmeaning. Several of the veterans came from militaryfamilies, and the significance of this was explored.

Mr C created a collage of extremes on a black andwhite background (Figure 5). On the white background,his past self holds many positive qualities and experi-ences. On the black, current side he representshimself looking back. The viewer just sees the back ofhis head. On the border between the sides, he isshown as a soldier with downwards gaze.

Revealing more of himself through his poetry in thissession, Mr D reflected on the thought of being‘nowhere’. He incorporated the lines ‘As darkness

creeps in, I’m feeling despair’ and ‘My life is a struggle,I cannot deny’, seemingly opening a different perspec-tive from what he shared through the psychometricmeasures. His line ‘Achieve I must, always aim high’stimulated discussion about standards set in the mili-tary. Mr B seemed moved by the poem and said thathe wanted to clap in recognition of its value.

Mr B’s image depicts an opened can of beans(Figure 6). The contents are being removed a spoonfulat a time but they are not yet being transferred to thesuitable container and so are becoming spilt. Thisthought-provoking image prompted group discussionabout trauma treatment and opening up the innerworld of past experiences. The group members recog-nised that they were opening up to one another, buthow exposure to the trauma material needed to bepaced, a spoonful at a time. Concerns were expressedthat the six-week Intensive PTSD Treatment Programmeoffered by Combat Stress might be too short to be ableto open up and achieve a sense of closure within thetime restrictions, although the desire to come to termswith the past was conveyed. This stance seemed tohover on avoidance, whilst recognising personal limit-ations and capacity for trauma work at that point intheir lives. Living with avoidance comes at a cost.

Group 3

During the initial time to discuss thoughts from theprevious session, the veterans fed back that theythought the programme was going well. Some werepleased with their personal ability to go so deeplyand expose their feelings. The potentially challengingtheme of ‘Remembrance’ was then set as the focus as

Figure 4. Map of Nowhere by Mr A.

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it was the day prior to Armistice Day, and the last timethe full group would meet until the following Tuesday.

This session had further richness and depth, thetheme seeming to provide an opportunity for personaland group reflections on loss, grief, respect andhonour. Mr A again used the symbol of barbed wire,but this time the wire is cut, with the barbs transform-ing into birds flying into the distance to signify release(Figure 7). Although emotional when sharing themeaning of his image, Mr A said that he was notfeeling overwhelmed by his emotions, and so able toconvey the meaning in words.

Mr B drew an image of tears being absorbed into apoppy, the symbol of Armistice Day (Figure 8). Eachteardrop holding an echo of the window he createdin his image made in the first group. Participants recog-nised how the group itself had become a container forthe sharing and processing of emotions, whichincluded the full breadth of feelings from hope andoptimism to sadness and loss.

Initially, Mr C had been unsure how to respond tothe theme and had considered revisiting his childhood.Perhaps informed by his experience from the firstgroup, when he felt he had ‘copped out’ from revealingwhat he had really wanted to express, Mr C drew acomplex and extremely meaningful image of himselflooking back (Figure 9). Again the viewer is lookingover his shoulder, but this time we can see hissymbols of remembrance. He elaborated on themeaning of each symbol, which included reference tohis index trauma and how that affected his life fromthen on. All participants supported Mr C through hisexposure of this difficult emotional material. Mr B in

Figure 5. Map of Nowhere by Mr C.

Figure 6. Map of Nowhere by Mr B.

Figure 7. Remembrance by Mr A.

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particular gave him encouraging feedback, yet alsochallenged Mr C’s rigid, negative self-appraisals, offer-ing different perceptions of the factors in play.

Mr D regretted that he could not give the group ahappy ending but he could provide some hopethrough his poem. He acknowledged the debt ofhonour to the fallen, and also the sense of pride forhaving belonged to the military and having served hiscountry. Significantly, Mr D connected the wearing ofthe poppy with ‘Releasing those emotions we’ve heldinside’ and wearing his heart ‘on his sleeve’, the timeof year seeming to give personal licence for theexposure of the effects of loss. Later that day, he was

able to explore his military experiences in more depthin an individual art therapy session; the words of hispoems taking on further meaning. In the more intimatesetting of one-to-one sessions, Mr D was later to remarkhow he was surprised by the strength of feeling stirredthrough re-reading his poems.

Group 4

By the Monday morning of week two, Mr B and Mr Chad not yet returned from their separate experiencesof weekend leave, hundreds of miles away from thetreatment centre. Those present in the group reflectedon the first week of the programme, and RemembranceSunday in particular. Mr D and Mr A had found the pro-gramme hard but extremely worthwhile so far. Mr Ahad been using his sketchpad to record the imageshe had created in the group sessions. This repetitionseemed to assist processing and prompted furtherinsights, which he was able to explore in more depthin individual sessions.

To create a break from the intensity of the groupsessions so far, and to maintain progress at that pointuntil the other group members returned, the themeof ‘My finest hour’ was set. The intention was to encou-rage participants to revive pleasant memories thatmight act as a balance to the challenging materialexplored up to that point. Mr A created two imagesof personal achievements, one from the beginning ofhis military service and the other from more recently.They held a sense of personal pride and satisfaction,which served to reaffirm those positive qualities.

Mr D’s poem acknowledged that he had manyachievements to choose from, whilst recognising thathis journey had been ‘a long winding road, the

Figure 8. Remembrance by Mr B.

Figure 9. Remembrance by Mr C.

106 J. LOBBAN AND D. MURPHY

potholes, the ‘U’ turns, [and] the uneven load’.However, he chose ‘putting down the booze’ as hisfinest hour, outlining how ‘the man in the mirror I seein the morning [… ] likes me now’. This significantstep on his personal road to recovery was a recentdecision that had been a turning point.

Group 5

Now back to the full group number, Mr B and Mr Cshared how it had been for them leaving the pro-gramme and returning home for the RemembranceDay events. There had been challenges, including allthe travelling involved, which had been tiring, butexperiences from Group 3 had been held in mind.

The theme of ‘Ways of seeing’ was set to encourageparticipants to pick up thoughts that had been emer-ging in the earlier groups about perceptions. Mr Bwas the first to share his work, which was an imageof two crystal balls (Figure 10). They contained colour-ful reflections echoing the windows that had featuredin earlier work. He found it hard to understand its fullmeaning himself at that point, and to articulatemeaning to the group. It is not unusual for themeaning of art therapy images to emerge over time.Ideas were played around with between participants.

Mr D’s thoughtfully crafted poem explored theconcept of different points of view, as well as the per-spective of hindsight. He noticed that ‘one man’s blackis another man’s white’ and that ‘some see darkness,some see light’. Also that ‘a man shall see what hewants to see’ and that ‘a man’s view changed againsthis will, will have the same opinion still’, thereby under-lining the need for willingness to change. This

observation was particularly significant in terms ofovercoming avoidance.

Mr A described his avoidance of crowds, which theother participants could relate to, and shared the pro-gress he was making in that respect. His image con-trasted 20 people in the enclosed space of a bar withthe same people spread over a rugby stadium (Figure11). This reframing offered the group ideas to consider.

Mr C was reluctant to share his work at first due tohis concern that it might upset the other groupmembers, but participants demonstrated their willing-ness to see his work. He had drawn an image of havinghanged himself in response to a letter from the Ministryof Defence (MoD) (Figure 12). The letter lies opened onthe doormat with certain key words standing out: ‘yourpension’, ‘sorry’, and ‘will not’. In fact, when read as awhole, the letter is informing him of an increase inhis war pension. Mr C explained how he tends to antici-pate the worst, and then misread situations from thisnegative position, sometimes with catastrophic conse-quences. This stimulated much discussion within thegroup, as all the veterans could relate to this response.With PTSD, there is a heightened sense of threatperception.

Mr C had also written a poem, which he shared withthe group. It described how he thought other peopleviewed him by outward appearance; for example, ‘allsee a skinhead, all see a thug, it’s only a haircut, I’dlove a hug’. Although, within the group, participantswere able to get a sense of Mr C’s softer side, therehad been occasions when he had been discriminatedagainst because of his appearance.

Second gallery visit with workshop

As before, Mr C asked to sit in the front of the minibusalongside the driver for a clear view during the journeythere and back. Mr B sat behind him, drawing in hissketchpad. He captured observations such as roadsigns and buildings, as well as the back of Mr C’shead. Mr D looked for inspiration from nature for hispoetry, observing the autumnal colours of the leavesalong the way. Once at the gallery, the group brieflyrevisited the main exhibition before exploring thesmaller exhibitions and the museum. After a coffeebreak, gallery staff provided a mono-printing work-shop. During this time, Mr B reproduced some of hisobservations from the journey (Figure 13), addingsweat droplets emanating from Mr C’s head. Thesymbol of water droplets reflecting windows, andlooking over the shoulder of Mr C, echo imagescreated in the art therapy groups.

Group 6

This last group began with a discussion of the galleryvisits. The second gallery visit had seemed rushed,Figure 10. Ways of seeing by Mr B.

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and participants would have preferred more time tolook at the exhibitions rather than having the mono-printing workshop. This seemed to reflect growing con-fidence in the public space. The veterans had enjoyeddiscovering artwork in the galleries and had notneeded the tighter guidance of a workshop. In thefirst week, the quiet space away from the crowds hadbeen welcomed. The theme of ‘Voyage of discovery’was set, which seemed to resonate with elements ofthe discussion.

Looking through the images together, progress wasseen and acknowledged. Mr D was first to share his

work. It charted apprehensions about being involvedin the new type of admission, and also the benefits ofengagement. He thought back to his journey to thetreatment centre almost two weeks previously, touch-ing on his hopes of being able to express himself crea-tively. He reflected on how ‘Each day I’ve sat, my pen inhand, writing and hoping others will understand’. Thefirst gallery visit had ‘brought out a silent tear’. He feltthat the admission had helped him to unearth his trea-sure and ‘now some action’.

In Mr A’s work, he returned to the symbol of a flatworld, which he drew in the first session, ‘My Planet’.This time, instead of a waterfall streaming from theedge of the planet into nowhere, he charted hisjourney upwards, leading to a transformed planetwhich has become ‘The world of wonder’ (Figure 14).The journey of life had been along a ‘rocky road’through barbed wire to the ‘desert of doom’ and the‘motorway of maybe’, seemingly stuck in repeated pat-terns. The world of wonder is entered by the ‘beach ofbeauty’ and there are many modes of transport avail-able, including a ship across the ‘sea of tranquillity’.

Mr C’s work contrasted black andwhite backgroundsagain, but this time he drew an open door between thetwo sections, with the name of the treatment centre onit, to symbolise enlightenment (Figure 15). On the blacksection of the paper is a candle with matches ready tobring light into the dark tunnel. On the white paper,he drew the words ‘quality’ and ‘hope’ in large letters,along with a ship of life with a sail of peace breakingthrough the word ‘discovery’. At the bottom of theimage are further meaningful symbols, including foot-steps reaching a brick wall met by a signpost to movearound the wall in order to find freedom.

Mr B wanted to be the last to share work as hisimage was a tribute to the group. He used symbols

Figure 12. Ways of seeing by Mr C.

Figure 11. Ways of seeing by Mr A.

108 J. LOBBAN AND D. MURPHY

to represent each veteran, taken from their own work(Figure 16). At the top, the back of Mr C’s head;below that, a cannon and some rugby balls from MrA’s work. Both of the areas are laced together bybarbed wire with flying birds, a tribute to Mr A. Thebarbed wire leads to a pair of glasses to represent MrD, along with musical notes to convey the lyrical toneof Mr D’s voice as he read out his poems to thegroup. The notes are floating out of an open window,echoing the barbed wire birds and renewing Mr B’ssense of optimism. His own name is floating freelyalongside the musical notes. This image was deeply

meaningful for the whole group. They all signed it,photocopies were made for each participant, and theoriginal was left in the safekeeping of the facilitators.

The group shared their experiences of the two-weekadmission: the highs and lows; the support given andreceived; the adventures and the discoveries. There wasno expectation that the group would continue andtherewasacceptance that it hadbeenaone-off, althoughif there had been an opportunity to continue, that wouldhave been welcomed. Participants were pleased withtheir personal achievements. Individual future treatmentpathways were discussed in one-to-one sessions.

Figure 13. Mono-print of observations from the journey by Mr B.

Figure 14. Voyage of discovery by Mr A.

INTERNATIONAL JOURNAL OF ART THERAPY 109

Discussion

At the outset of the admission, there was already a levelof group bonding. The veterans knew the lead arttherapist, and three of the four veterans had alreadymet each other during previous admissions. All partici-pants had experienced multiple admissions to thetreatment centre, which included art therapy groupattendance on a trans-diagnostic two-week pro-gramme, although not all together in a closed groupformat. Usually, art therapy group attendance on the

trans-diagnostic programme varied from day to day,frequently incorporating first-timers. The lack of conti-nuity meant that participants did not reach a deeperlevel of self-expression that comes with familiarityand trust. Nevertheless, on all programmes at CombatStress, veterans regularly report the benefits of beingwith other veterans, where no pretence is necessaryand they can be their ‘true selves’. Other veteransunderstand the written and unstated rules of servingin the armed forces, and may have been exposed tosimilar traumatic experiences. The expectation thatothers will maintain the military code of coveringeach other’s back creates a supportive environment.Earlier experiences of attachment built during serviceyears are rekindled. The covered area for smokers inthe grounds of the Surrey treatment centre has beennamed ‘The Office’ by veterans on admission. It is inthat space that veterans, some non-smokers, gatherinformally to debrief after groups or one-to-one ses-sions, and to offer mutual support.

Yalom (1995) highlighted 11 therapeutic factors rel-evant to group therapy that have an influence either bytheir presence or absence. Of particular relevance inthe veteran context are the therapeutic factors of uni-versality, cohesion, guidance, interpersonal learning,and the instillation of hope. Mirroring familiar factorsassociated with military training and functioning, veter-ans are ready to listen to and learn from each other dueto previous cohesion experience. A sense of personalisolation is moderated by the knowledge that individ-uals are not alone in meeting life-changing symptoms,which then become normalised. Veterans are willing topass on knowledge gained to help fellow veterans,thereby fostering hope. The art therapy groups, like

Figure 15. Voyage of discovery by Mr C.

Figure 16. Voyage of discovery by Mr B.

110 J. LOBBAN AND D. MURPHY

all other groups at Combat Stress, are able to draw onthe strengths of these therapeutic factors.

The theme ‘My Planet’, in the first art therapy groupof this study, gave veterans an opportunity to reveal abit about themselves. Some participants were guardedin their creative responses and took a more objective,global view at first sight. During the subsequent discus-sion, Mr C acknowledged that he had avoided reveal-ing what life was actually like for him, althoughsignificant aspects were coded within his image. MrD’s poem did not reveal any personal struggles. Mr Bshared his optimism that he would be able to openup through the admission. It was Mr A’s image of aflat world hanging on by a thread that gave thegroup a tangible, symbolic example of psychologicaldifficulties to focus on. The concept of differing percep-tions emerged from the group discussion and wasdeveloped over the admission. This introduced thepossibility of changing viewpoints that might havebecome rigid and unhelpful.

The first gallery visit underlined the problems theveterans faced being in a busy, public place. Withheightened anxiety, hyper-vigilance, and hyper-arousal symptoms to contend with, the veteranswould not normally have placed themselves in such asituation. The exhibition contained familiar elements,such as comics from childhood, which provided a con-nection; however, rather than sticking with the familiar,participants were also interested in making new dis-coveries, the Grayson Perry image being an example.Thus, so far in the admission, the veterans had wit-nessed examples of each other’s creative work andlooked together at the work of others in a galleryspace, thereby introducing fresh ideas and viewpoints.

In Group 2 of the programme, all participantsrevealed more of themselves through their work inresponse to Grayson Perry’s ‘Map of Nowhere’, theunfamiliar image that had caught their attention atthe gallery. In Mr D’s poem he admits that his life is astruggle and in Group 3, ‘Remembrance’ provided theopportunity for him to wear his heart on his sleeve.Armistice time allowed for personal grief to becomeincorporated into the wider pool of shared grief. ByGroup 4, Mr D was able to reflect on the personal sig-nificance of having stopped using alcohol as a way ofescaping his problems. His poems became more expli-cit about the challenges he faced whilst recognisingthat he had unearthed personal treasure to help himcope with the challenges. He set himself the task oftaking action based on his discoveries.

Mr C included a symbol of himself in his image inGroup 2 which enables the viewer to look over hisshoulder. As yet the viewer cannot see what Mr C islooking at but, in Group 3, this is revealed. What isshown includes a symbol of his index trauma, whichwas an unexpected, emotional, yet welcomed releasefor Mr C. This would seem to indicate that he was

feeling safe enough within the group experience toallow the expression of vulnerabilities.

It has been proposed that the non-verbal mechan-isms of art therapy enable the expression of emotions,sensations, and visual imagery, bypassing verbal/cogni-tive restrictions (Hass-Cohen & Carr, 2008; Lusebrink,2004). The use of symbolism and metaphor, essentialingredients of art therapy, creates a safe distancefrom which to examine the creative expressions ofinner experience (Wise & Nash, 2013). McNameesuggests that art therapy captures non-verbal ‘rightbrain truths [… ] facilitated by the safety of metaphor’,circumventing verbal left brain limitations (McNamee,2004, p. 141). Art therapy has long been recognisedas a way of reaching unconscious material and bringingit into conscious awareness (Case & Dalley, 1992). Fur-thermore, trauma expert Bessel Van der Kolk (2014)proposes that the use of imagination and playfulnessare a vital part of recovery from trauma. Art therapyis able to provide a means through which imaginationcan be channelled and new possibilities conceived.

Mr B’s images created in Groups 2 and 3 are associ-ated with containment. The first image provides a con-tainer but the contents of the opened can of beans arenot yet reaching it, perhaps reflecting his anxiety aboutthe therapeutic process. Mr B had highlighted hisdesire to open up from the outset of the programme.His next work shows the poppy/container being ableto absorb the tears of grief, which seemed to reflectMr B’s experience of the art therapy group as beingcontaining at that point.

Mr A’s images continued to openly express hisstruggles with PTSD, with the symbol of barbed wiretaking on changing meaning as both restrictive andthen liberating, when transformed into birds. Hisability to articulate his feelings without stammeringor crying improved as his distress tolerance increased.The images Mr A created in Group 4 enabled reconnec-tion with his personal achievements. His image inGroup 5 in response to ‘Ways of seeing’ was more sol-ution-focused, offering a reframing of challenges faced.Although capturing the emotional intensity of hisexperience of crowded places, the image alsoseemed to shift away from avoidance towards takingaction to make crowds more bearable. This shift wasalso seen during the second gallery visit, whereby,now familiar with the gallery, participants seemed tobe gaining confidence in the space.

In Group 5, Mr C gave an example of his own mis-conceptions when fuelled by threat perception andexpecting the worst, and also his experience of howothers might view him detrimentally. The associatedgroup discussion around perceptions seemed toopen the possibility of change. In the final group, MrC’s ‘Voyage of discovery’ seems full of potential. Heconsidered that the admission had facilitated discov-eries and provided hope for an improved quality of

INTERNATIONAL JOURNAL OF ART THERAPY 111

life. From being guarded in his first image, Mr C allowedhimself to approach his most challenging psychologi-cal material during the admission. Surprised withhimself for having been able to speak about histrauma through the images he created, and to toleratethe distress caused, he was in a better position tochoose whether or not to pursue trauma-focused work.

Mr B’s final tribute to the group seemed to capturethe value of the shared experience. He had connectedwith the symbolism used in the work of the other par-ticipants, which had held meaning for him. He createdechoes of meaning in his own work, which was furtherdeveloped in individual sessions. Mr B was also able tomake in-roads into his traumatic experiences for thefirst time. For Mr A, Mr B, and Mr D, the admissionacted as a stepping stone to further in-depth work,which they had not felt prepared to engage in priorto the art therapy-focused admission.

In response to the group evaluation questionnaire,in which participants were asked what they hadfound most helpful/interesting, the feedback was:

‘The group, the lack of any overbearance, and freedomto express or not’; ‘For the first time ever I openly talkedof my trauma… it really opened me up’; ‘Being able toopen up and share thoughts and memories to others’;‘The use of art helps me to see things in a better lightand have a better outlook on life as a whole’; ‘Thewhole two weeks were extremely beneficial to mepersonally’.

Although the sample was restricted to only four par-ticipants, a reduction on scores for the avoidancecluster of PTSD symptoms was observed from a meanscore of 2.9 at admission to 2 at discharge (meansscores could range from 0–4). Given the brevity ofthe intervention, it was encouraging to see thesereductions.

Strengths and limitations

Despite the fact that avoidance was recognised as a keyfeature of the PTSD presentation of all attendees, allwere able to create work that expressed emotionalmaterial, and to tolerate the emotions shared withinthe group and one-to-one contexts. All participantsreported improved wellbeing at the end of theadmission.

As the admission occurred over Remembrance Day,it could be argued that issues were nearer to thesurface, and so more accessible than usual; however,the timing also presented the challenge of a break incontinuity, as two participants had prior engagementswhich meant absence from one group. The bondsformed in the group, however, seemed strongenough to absorb the break, and continuity wasmaintained.

This study includes psychometric results to demon-strate the presentation of each veteran at baseline. The

measures were repeated at the end of the admissionand significant progress was seen. The measureswere not repeated over time, however. This wasmainly because it was considered that the psycho-metric measures used were not capturing effects par-ticular to art therapy. An appropriate measure has yetto be found to assist research in this area. That said, itwould have been advantageous to have repeated thePCL-5 three months after discharge to explore theimpact on the avoidance cluster of PTSD symptoms.

As images have no single meaning, the interpret-ations offered here are the results of discussions withthe veterans at the time. This study is about the useof visual art therapy, but one of the participantschose to write poetry in creative response to thegroup themes. Although his images were portrayedin words, Mr D’s input remains crucial to this paper.

Conclusions

The art therapy admission provided an opportunity forthe veterans to work with PTSD-related avoidancesymptoms. Participants challenged safety behavioursnot only by expressing emotional material but also byexposure to the crowed gallery public space. Each indi-vidual demonstrated willingness to consider changethrough the creative exploration of perceptions.Whether or not participants chose to move on totrauma-focused work as part of individual recoverypathways, by the end of the art therapy programmethe veterans had the experience of remaining incontact with painful thoughts and emotions, therebyovercoming experiential avoidance (Chawla & Ostafin,2007).

Through art therapy, the veterans used symbolismto express distressing thoughts and emotions,thereby creating a safe distance from the material. Dis-playing the images on the wall for group considerationtook the focus away from each veteran-creator, provid-ing a shared point of dynamic contact as ideas wereplayed with and emotions felt. Participants discoveredthat this form of exposure was tolerable and not over-whelming. The group dynamic created a strong con-tainer for this process.

The results of this study suggest that art therapycould be constructively employed as a means of assist-ing veterans to overcome avoidance symptoms thatprevent them not only from engaging in trauma-focused work but also from defeating the restrictionsthat seriously impact functioning on a day-to-day basis.

The study also highlights the need to develop psy-chometric measures that are able to capture the mech-anisms of change at play through the art therapyprocess in a reliable and consistent way, as it isemployed as a treatment for overcoming avoidancein veterans with PTSD.

112 J. LOBBAN AND D. MURPHY

Ethical standards

Ethical approval for this paper was granted by theCombat Stress ethics committee and consent wasobtained from the four participants to be used as anon-ymised case studies.

Disclosure Statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Janice Lobban is Senior Art Psychotherapist at Combat Stress,the veterans’mental health charity, where she has worked for16 years. In 2016, she was awarded a Winston ChurchillResearch Fellowship, which allowed her to visit art therapistsacross the USA to study the art therapy provision there forveterans and serving military personnel. Recently, sheedited the book Art Therapy with Military Veterans: Traumaand the Image, which has brought together experienced con-tributors in this field, including veterans, to discuss the com-plexities of working in this context. She has lectured on arttherapy and military trauma in London, Stockholm, St Peters-burg, Amsterdam, and New York.

Dr Dominic Murphy is a senior clinical lecturer at CombatStress and King’s College London. He is a Clinical Psychologistand has also completed his PhD. Dominic has specialised inworking in the field of trauma. He has set up and runs aresearch department at Combat Stress and has an extensivepublication record of over 50 publications within the areaof military mental health. Dominic has lectured on militarymental health at a number of international conferencesaround the world, teaches at King’s College London, andhas supervised a number of doctoral projects.

ORCID

Dominic Murphy http://orcid.org/0000-0002-9530-2743

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