Bulletin

Bulletin vol. 34 no. 1 | 27 For over 10 years, art therapy has been incorporated into the interdisciplinary team model at the National Intrepid of Excellence (NICoE), Walter Reed National Military Medical Center, in Bethesda, MD – where I was the Marine's art therapist. The NICoE, which opened in 2010 to treat active military service members (SMs) with TBI and associated mental health difficulties, began as an intensive outpatient program (IOP) for SMs stationed across the nation/overseas and has since expanded to include a long-term outpatient (OP) treatment program. Conventional military medicine including clinical neuropsychology, along with complementary and integrative treatments, are utilized in both intensive and longitudinal outpatient programming in order to engage the SMs in holistic, immersive care which aims to instill hope, healing, discovery and learning. Art therapy, delivered by certified art therapists as a form of psychotherapy, is integrated as a standard of care within the NICoE's IOP programming. All SMs who are part of the IOP are automatically scheduled to receive art therapy. The benefit of having a set amount of time with the SMs during the IOP programming is the ability to integrate and standardize art therapy directives that are observed to be most impactful on this patient population. Early on in the development of the program's model, two group art therapy directives were designed to bookend individual, more personalized art therapy sessions. Mask-making group occurs in the first week of treatment and was chosen due to how the paper mache mask templates metaphorically encapsulate and represent the focus of the NICoE mission: the brain, and because it naturally leads SMs to contemplate their identities as they enter treatment (Jones et al., 2018; Walker, 2017; Walker et al., 2017). Montage painting group occurs in the final week, and allows for the layering of words and images, which often leads to representations of change that occur as well as hope for the future (Berberian et al., 2018; Walker, 2017; Walker et al., 2017). SMs have the option to take their artwork with them at discharge, or leave it behind. Work that is left behind is usually done so purposefully, either because the SM feels they have expressed what they needed to and would symbolically like to move on, or because the SM wants their piece(s) displayed in the studio to inspire others (Jones et al., 2018; Walker, 2017). Art therapists are uniquely trained to view products made in treatment with a critical and perceptive eye. Surrounded by the work and witnessing what the service members chose to create in art therapy, I began to notice common imagery depicted in the mask and montage themes, as well as a connection in the artworks' themes to the SMs who created them. Being immersed in a space dedicated to art therapy treatment that allowed for the creation of what I refer to as "visual community" enabled me to more deeply contemplate the patterns of this community, and to consider what story this body of work might tell us about this patient population. In 2011, the National Endowment for the Arts partnered with the NICoE and Walter Reed to bring creative writing under the NICoE Healing Arts Program umbrella. Eventually, the partnership expanded to include music therapy and dance/movement therapy, and the Arts Endowment also began placing creative arts therapists at additional Defense Health Agency's TBI Pathway of Care clinics. Today, this partnership is known as Creative Forces®: NEA Military Healing Arts Network, an initiative of the National Endowment for the Arts in partnership with the U.S. Departments of Defense and Veterans Affairs and state and local arts agencies. The Arts Endowment and its collaborators are invested in standardizing creative arts therapies delivery and understanding how creative arts therapies benefit patients' recovery, well-being, and overall quality of life. To help ensure future providers of art therapy, with funding support from the Arts Endowment, the NICoE Healing Arts Program and NICoE Research Department formed a research collaboration with Drexel University's College of Nursing and Health Professions, which includes a creative art therapies doctoral degree program. Research had already shown there is a shutdown in the Broca's, or speech language area, of the brain after an individual experiences trauma (Rauch et al., 1996; van der Kolk, 1996). These findings have also been observed in neuroimaging scans of the SMs coming through the NICoE program (Walker et al., 2016). Van der Kolk et al. (1996) described this effect as "speechless terror," and it seems sensory therapies, such as art therapy, give SMs an alternative way to express what are known as the invisible wounds of war (Gantt & Tinnin, 2009; Walker et al., 2016). If this is indeed the case, it is thought that the images the SMs create may serve as visual representations of the SMs' states of mind. That is, they provide the SMs with a visual voice for communication to the therapist, the treatment team, and their families and peers when words may be few (Jones et al., 2018; Walker, 2017). "Though he felt simultaneously worse and be er, the mask making process revealed a truth from which he could no longer hide, 'I knew I had a subconscious to deal with. I could manipulate therapists to get back out on deployment, but I couldn't lie about the results in front of me.'" (Worth Parker, 2020)

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