• Girija Kaimal, Melissa S Walker, Joanna Herres, Louis M French, and Thomas J DeGraba.
• Creative Arts Therapies, Drexel University College of Nursing and Health Professions, Philadelphia, Pennsylvania, USA.
• BMJ Open. 2018 Jun 11; 8 (6): e021448.

ObjectivesThe study aimed tocompare recurring themes in the artistic expression of military service members (SMs) with post-traumatic stress disorder (PTSD), traumatic brain injury and psychological health (PH) conditions with measurable psychiatric diagnoses. Affective symptoms and struggles related to verbally expressing information can limit communication in individuals with symptoms of PTSD and deployment-related health conditions. Visual self-expression through art therapy is an alternative way for SMs with PTSD and other PH conditions to communicate their lived experiences. This study offers the first systematic examination of the associations between visual self-expression and standardised clinical self-report measures.DesignObservational study of correlations between clinical symptoms of post-traumatic stress, depression and anxiety and visual themes in mask imagery.SettingThe National Intrepid Center of Excellence at the Walter Reed National Military Medical Center, Bethesda, Maryland, USA.ParticipantsActive-duty military SMs (n=370) with a history of traumatic brain injury, post-traumatic stress symptoms and related PH conditions.InterventionThe masks used for analysis were created by the SMs during art therapy sessions in week 1 of a 4-week integrative treatment programme.Primary OutcomesAssociations between scores on the PTSD Checklist-Military, Patient Health Questionnaire-9 and Generalized Anxiety Disorder 7-item scale on visual themes in depictions of aspects of individual identity (psychological injury, military symbols, military identity and visual metaphors).ResultsVisual and clinical data comparisons indicate that SMs who depicted psychological injury had higher scores for post-traumatic stress and depression. The depiction of military unit identity, nature metaphors, sociocultural metaphors, and cultural and historical characters was associated with lower post-traumatic stress, depression and anxiety scores. Colour-related symbolism and fragmented military symbols were associated with higher anxiety, depression and post-traumatic stress scores.ConclusionsEmergent patterns of resilience and risk embedded in the use of images created by the participants could provide valuable information for patients, clinicians and caregivers.© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

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