The Brain and Art Therapy for Post-Traumatic Stress Symptoms

Source: Anjan Chatterjee

In 1946, John Huston, the legendary filmmaker, made a documentary called Let There Be Light. The film was shot at a psychiatric facility, Mason General Hospital, and portrayed Army casualties who the narrator says “suffered psychoneurotic symptoms: a sense of impending disaster, hopelessness, fear, and isolation.” The documentary was banned by the Army and not released until the 1980s. Its print and sound quality was not restored until 2012.

As a nation, we have an uneasy relationship with our veterans who return from war as anything other than triumphant heroes. A counter to this unease, in 2008 the National Defence Authorization Act directed the Department of Defence (DOD) to establish a comprehensive plan to prevent, diagnose and treat service members (SMs) with post-traumatic stress symptoms (PTSS) and traumatic brain injury. In 2010 the DOD founded the National Intrepid Center of Excellence (NICoE), currently a directorate of Walter Reed Military Medical Center. Recently, we at the Penn Center for Neuroaesthetics (PCfN) collaborated with NICoE and Creative Forces®: NEA Military Healing Arts Network to investigate the effects of art therapy in ameliorating PTSS. This nascent collaboration is beginning to bear fruit.

Art therapy at NICoE

While anecdotes abound and substantial clinical experience attests to the usefulness of art therapy, hard evidence of efficacy is difficult to come by. Identifying associated neural biomarkers would help validate this approach to supporting people struggling to regulate their emotions and memories. At NICoE, SMs receive a four-week intensive outpatient program, which consists of individual and group art therapy sessions. As part of their sessions, SMs create a self-portrait on paper mâché masks to express their emotional experiences. They also have the opportunity to participate in a research study that obtains advanced magnetic resonance imaging.

We recently published a retrospective analysis of over 100 SM self-portrait masks and the brain correlates of their response to art therapy (Payano Sosa et al., 2023). Art therapists can interpret cognitive and affective themes expressed in the masks based on the image, their expertise, and the relevant clinical context. Art therapists in this protocol identified themes of psychological closure and healing in 36 of 105 masks. Using closure as an external marker of improvement in the mental distress experienced by these SMs, we asked if neurophysiological differences were present between these two groups.

Neural networks

As a general observation, different parts of our brain show correlated neuronal activity when people are at rest. These areas form coordinated networks—the assumption being that neural activity at distant locations (or nodes) that are correlated in time constitute a distributed functional unit. Several resting state networks have been identified in the brain and considered responsible for functions like deploying attention, determining the salience of objects, or shifting mental states inwardly (as in mind-wandering). One advantage of examining resting state connectivity patterns is that the method does not require participants to do anything other than lie still.

Our exploratory study probed for differences in neural network patterns in the group of SMs who showed psychological closure in their masks in response to art therapy from patterns in those who did not show such evidence of healing within their masks. SMs who depicted closure in their masks had increased connectivity between dorsal attention networks and areas important for memory (hippocampus) and for processing pain (insula, thalamus, post central gyrus). The important point is that, in a group of people who benefited from therapy, a difference could be identified by experts interpreting their masks and also in their neurophysiology.

Looking ahead

What do these neural differences mean? We can only guess, relying on what is called a reverse inference. That is, we guess at the meaning of these neural patterns based on what we think we know about the brain structures involved. In technical jargon, our results are called hypothesis generating rather than hypothesis confirming. The pattern we observed could mean that people who are better able to pay attention to their painful and traumatic memories are more likely to express beneficial effects of art therapy in their masks. Unanswered by these data is the causal direction between biomarker and therapy. Perhaps these neural biomarkers are already present in people who have a psychological predisposition to benefit from art therapy. Alternatively, the therapy itself produces beneficial psychological states that reorganizes neural connections.

Much work lies ahead. The alchemy of healing psychological trauma by expressing emotions though art in a safe therapeutic relationship begs further study. We owe this effort to our veterans.