Introduction

Post-Traumatic Stress Disorder (PTSD) is a mental health condition estimated to affect 1 in 10 people in the UK during their lifetime.¹ PTSD occurs after a person has experienced or witnessed a traumatic event that caused acute and chronic changes in the neurochemistry and neural circuits of the brain.² Affected individuals may experience symptoms such as severe anxiety or flashbacks which can have a severe impact on their day-to-day lives. Art therapy can be used as a form of psychotherapy to help people with PTSD safely process or express the difficult emotions that they are experiencing.³ This article will provide an overview of PTSD and art therapy before discussing the potential impact that art therapy can have on individuals affected by PTSD.

Understanding PTSD

PTSD is a mental health condition that occurs after a person experiences or witnesses a traumatic event. Around 50% of people will experience trauma in their lifetime, but only 1 in 10 people will go on to experience PTSD.⁴ There are common misconceptions that people with PTSD are ‘dwelling too much on the past’ or ‘need to get over’ what has happened to them.⁵ However PTSD is not just a psychological condition, people with PTSD also experience changes in specific regions of the brain and its neurochemistry which contribute to the acute or chronic symptoms of PTSD.²

Causes and symptoms

PTSD can be caused by several traumatic events, it is not just a result of combat as it happens with veterans. PTSD UK states that “the defining characteristic of a traumatic event is its capacity to cause fear, helplessness, or horror as a response to the threat of injury or death”, meaning that PTSD can affect anyone.³ Below is a short and non-exhaustive list of traumatic events that could cause PTSD:

• Any form of abuse - including child, domestic and sexual abuse
• Bereavement
• Discrimination or violence faced by marginalised communities
• Military combat
• Refugee and asylum-seeking experiences
• Road Traffic Incidents

Experiencing or witnessing a traumatic event contributes to neurochemical and physical changes in the brains of those with PTSD. Brain imaging studies have shown people with PTSD have excessive activity in their amygdala- the brain region involved in triggering the ‘flight or fight’ response¹- and reduced activity and size in the hippocampus, a brain region involved in the formation and retrieval of memories⁶. The altered activity in these brain regions contributes to a ‘hypervigilant’ state that impairs an individual’s ability to discriminate between real threats and non-threats, altering their stress response. PTSD may cause an individual to experience the following symptoms:⁷

• Vivid flashbacks
• Intrusive thoughts or images
• Nightmares
• Physical sensations such as pain, sweating, trembling
• Becoming easily upset or angry 
• Hypervigilance
• Disturbed sleep or a lack of sleep
• Difficulty concentrating
• Feeling that they need to keep busy
• Avoiding anything that reminds them of the trauma
• Feeling emotionally numb or cut off from themselves

Impact on mental health

The physical and psychological symptoms of PTSD can be very distressing and have a significant impact on the day-to-day lives of individuals affected by the condition. Anxiety and depression are common comorbidities of PTSD, with major depressive disorder (MDD) suggested to be comorbid in 52% of PTSD patients in a 2013 study.⁸ The impact of PTSD on mental health differs between individuals and may be influenced by other factors, including pre-existing mental health conditions, previous traumatic experiences and the quality of an individual’s support network.⁹ 

Art therapy basics

What is Art therapy?

According to the British Association of Art Therapists, “ art therapy is an established form of psychotherapy, delivered by trained art therapists.”¹⁰ Art therapy aims to reduce distress and improve mental health by using art as a mode of expression for difficult emotions or memories that individuals affected by PTSD may be experiencing. This form of therapy is suitable for people of all ages and backgrounds and does not require individuals to have any artistic skill to be effective in managing PTSD symptoms.¹¹ In the UK, all art therapists must be registered with the Health and Care Professions Council (HCPC) by law to ensure they meet the appropriate standards of conduct, performance and ethics.

How it works

Art therapy is still undergoing research to demonstrate its effect in alleviating symptoms of mental illness but it has already shown its benefits as an integrative therapeutic option for PTSD.¹² Creative expression achieved during art therapy can reduce stress and anxiety whilst promoting feelings of relaxation.¹³ People with PTSD may find art therapy an effective way of processing and exploring difficult emotions or memories that they are unable to manage via other therapeutic methods. For example, patients who are unable to discuss distressing memories during trauma therapy may benefit from externalising what they are unable to communicate by producing artwork to reflect how their memories make them feel.¹⁴ Multiple studies have shown the effectiveness of art therapy in reducing primary PTSD symptoms such as avoidance coping mechanisms and hypervigilance.¹⁵ However, trauma-focused psychotherapy approaches such as Eye Movement and Desensitisation Reprocessing therapy (EMDR) are usually the primary form of treatment offered to PTSD patients.

Efficacy of art therapy for PTSD

Research Evidence

Studies have shown the efficacy of art therapy in reducing PTSD symptoms. For example, the 2007 study by Henderson et al. evaluated the effects of drawing therapy using mandalas on the symptoms of individuals with PTSD symptoms. At the one-month follow-up, there was a statistically significant difference in the prevalence of PTSD symptoms in the mandala drawing group but no significant difference in symptoms of anxiety or depression between this group and healthy controls.¹⁶ The literature evaluating the efficacy of art therapy for PTSD is limited, with studies often involving very small groups of around ten patients. Therefore, further research is required to understand the potential benefits of this form of psychotherapy.

Integrated Approach to Therapy

The National Health Service recommends that more people with PTSD should receive trauma-focused treatments such as CBT or EMDR therapy to reduce PTSD symptoms and improve well-being.¹⁷ However, more than 30% of PTSD patients do not benefit from these interventions. This includes patients with severe trauma and difficulties talking about their experiences.⁵ As such, an integrated therapeutic approach to the treatment of PTSD including both trauma-oriented psychotherapy and art therapy may be more effective in reducing PTSD symptoms in these patients. A 2016 study of eleven veterans with PTSD explored the efficacy of a combined approach using cognitive processing therapy (CPT) and art therapy.¹⁸ The study failed to show a statistically significant difference between reduced PTSD symptoms in veterans who received both therapies versus CPT alone, most likely due to its small sample size. However, the study demonstrated that participants receiving both treatments had a higher treatment adherence, with 40% of those receiving CPT alone leaving treatment prematurely. Consequently, this study infers that art therapy helps to reduce PTSD symptoms and may improve patients’ adherence to treatment.

Techniques and approaches

Various forms of art therapy

Art therapy can include any form of creative activity such as sculpture, painting, drawing or music. During art therapy, your therapist will encourage you to use one of these mediums to explore your feelings and will explain how the creative process can be beneficial.¹⁹

Examples include:

• Visual art therapy - drawing, painting, sculpture, etc
• Performing arts - acting, drama and dance
• Music therapy
• Literary art - poetry

FAQ’s

Where can I access art therapy?

You may be able to access art therapy provided by your local NHS community mental health team. This means you will first need to discuss what mental health services are available in your area with your GP. However, if this service is unavailable in your area you may wish to work with a private art therapist. You can find registered art therapists in the UK using the British Association of Art Therapists list to find professionals in your area.

What can I expect when starting art therapy?

Art therapy will take place in a private room or online using software such as Zoom. Art therapy can be provided for an individual or a group. Therefore, you may be joined by a group of other participants in addition to the art therapist.²⁰

What if I am not very good at art?

Art therapy does not require any previous experience or artistic skill to be effective in reducing PTSD symptoms and alleviating stress. The most important thing about art therapy is the process of making the artwork, as this is when you will be confronting memories or emotions that are arising based on the prompt given to you by your art therapist. Art therapy sessions are not art lessons, and your therapist will not be evaluating the quality of your artwork.