Unlocking Healing: can art therapy enhance trauma-focussed cognitive behavioural therapies for PTSD?

December 17, 2024

While trauma-focussed cognitive behavioural therapies (TF-CBTs) are gold standard for treating PTSD, I'm really curious about the integration of art therapy with TF-CBTs. Particularly as a way to overcome the early and significant drop out from TF-CBTs.

Art therapy uses creative expression —drawing, painting, sculpting, or other forms of visual art—to support emotional healing, mental and physical wellbeing. For individuals with PTSD, art provides an alternative language to process emotions and memories that may be too overwhelming or unclear to verbalise. Art processes can help access these implicit memories in a less distressing way. Art therapy can reduce trauma-related symptoms, improve emotional regulation, and promote a sense of safety. Engaging in creative activities can activate the parasympathetic nervous system, reducing the fight-or-flight response active with hyperarousal symptoms. Creating art allows clients to reclaim agency over their narratives, fostering empowerment and resilience, building, or reconnecting, with a sense of safety and control.

TF-CBTs are structured, evidence based interventions designed to help individuals identify and challenge unhelpful thoughts and beliefs about the trauma. While the exact core components vary depending on which modality is being used (e.g., CBT or CPT), both involve exposure to trauma related triggers. While TF-CBTs are effective, some individuals may struggle with the verbal nature of these therapies, drop out rates remain high, and a sizeable proportion of people are unresponsive to these treatments. This is where integrating art based processes in therapy may help.

Psychoeducation with visual aids

Rather than explaining the impacts of trauma verbally, clients can use visual art to represent how they experience PTSD. For example, drawing what their “fight, flight, or freeze” response feels like can make abstract concepts more tangible.

Creative coping skills

Art therapy helps clients develop grounding techniques. Activities like creating a "safe place" painting or designing a personal stress-relief toolkit encourage self-regulation.

Trauma narrative through art

Not everyone is ready to write or talk about their trauma. Art therapy allows clients to create a visual trauma narrative, such as a series of images or abstract representations. This indirect approach can help clients process their experiences without becoming overwhelmed.

Cognitive processing with metaphors

Art can symbolise distorted beliefs. For instance, a client might draw chains to represent feelings of entrapment, which can then be explored and reframed during talk therapy sessions.

Gradual exposure with safe boundaries

Creating art about triggering situations in a controlled environment helps clients face their fears step-by-step. A client might first sketch a setting related to their trauma before progressing to more detailed depictions.

Healing from PTSD is a journey, and no single approach works for everyone. By combining the structured techniques of TF-CBTs with the experiential nature of art therapy, individuals can utilise multiple pathways to recovery. This integrated and complementary approach honours the complexity of trauma, provides tools for clients to process their experiences in ways that feel safe and empowering, which may increase compliance, and the efficacy of each intervention.

References

Campbell, M., Decker, K. P., Kruk, K., & Deaver, S. P. (2016). Art therapy and cognitive processing therapy for combat-related PTSD: A randomised controlled pilot study. Art Therapy, 33(4), 169-177. https://doi.org/10.1080/07421656.2016.1226643

Campbell, M., & Knoerl, R. (2021). Using art therapy to support veterans with PTSD: A review of clinical outcomes. Trauma-Informed Practice Journal, 8(1), 23-30.

Lewis, C., Roberts, N. P., Gibson, S., & Bisson, J. I. (2020). Dropout from psychological therapies for post-traumatic stress disorder (PTSD) in adults: Systematic review 44 and meta-analysis. European Journal of Psychotraumatology, 11(1). https://doi.org/10.1080/20008198.2019.1709709

Malchiodi, C. A. (2020). Trauma and expressive arts therapy: Brain, body, and imagination in the healing process. Guilford Publications.

Schouten, K. A., de Niet, G. J., Knipscheer, J. W., Kleber, R. J., & Hutschemaekers, G. J. M. (2018). The effectiveness of art therapy in the treatment of traumatised adults: A systematic review on art therapy and trauma. Trauma, Violence, & Abuse, 20(2), 220-232. https://doi.org/10.1177/1524838018755927

Schouten, K. A., van Hooren, S., Knipscheer, J. W., Kleber, R. J., & Hutschemaekers, G. J. (2019). Trauma-focused art therapy in the treatment of posttraumatic stress disorder: A pilot study. Journal of trauma & dissociation, 20(1), 114-130.

Woollett, N., Bandeira, M., & Hatcher, A. (2020). Trauma-informed art and play therapy: Pilot study outcomes for children and mothers in domestic violence shelters in the United States and South Africa. Child abuse & neglect, 107, 104564.

Michelle Saleeba Psychology
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Evidence-based therapy for adults seeking clarity, resilience, and renewal