Running head: DRAW YOUR FEELINGS

Draw Your Feelings

Intervention for Veterans with Combat-Related Post Traumatic Stress Disorder
Sami Walsh, Anna Godwin, and Skylar Wheeler
East Carolina University

Background
Running head: DRAW YOUR FEELINGS

I. Modality category: Emotional Control

II. Name of Intervention Activity: Draw Your Feelings

III. Materials Needed

Each participant will need:

● Paper (one sheet per participant)

● Markers/Colored Pencils/Pens (at least 5 color options per participant)

IV. Treatment Population/Diagnosis-

Veterans with Combat-Related Posttraumatic Stress Disorder

V. Description of Treatment Population/Diagnosis-

Post Traumatic stress disorder (PTSD) is a psychiatric disorder that can occur in individuals who
have experienced or witnessed a traumatic event(s). It is said to be the inability to cope, followed
by a sense of overwhelming stress (“DSM-5”, 2013). Symptoms fall into clusters based on the
five-factor model. These include reexperiencing, avoidance, numbness, dysphoric arousal, and
anxious arousal (American Psychiatric Association, 2013). In the United States, PTSD affects
approximately 3.5% of the adult population. It is estimated that one in eleven individuals will be
diagnosed in their lifetime. The numbers of veterans affected varies by the area of service. 11-
20% of veterans a part of Operations Iraqi Freedom and Enduring Freedom will develop PTSD
in a given year. Of those who served in the Gulf War, 12% have PTSD in a given year. In
addition, approximately 30% of those who served in the Vietnam War will have had PTSD in
their lifetime. Factors that influence the prevalence based on war include, what the veterans role
was in war, the politics around the war, where the war was fought, and the type of enemy faced.
(“US Department of Veterans Affairs”, 2018). When service members transition out of the
military, they face the challenge of transitioning to civilian life. Leaving the military service
requires establishing a new community and the ability to connect to that community. Factored
with PTSD, this is challen for veterans (Kintzle, et al., 2018). The therapeutic use of art is an
appropriate intervention for this population because the use of imagery has been proven to treat
trauma. By incorporating creative arts into a veterans treatment plan, the individual will have the
Running head: DRAW YOUR FEELINGS

ability to express positive feelings, externalize difficult emotions and gain insight into the
symptoms which they are experiencing. (Park West Gallery, 2017).

Physical Effects:

Pain, muscle tension, increased blood pressure, increased heart rate, headaches, easily
startled, negative impact on body systems,and difficulty with sleeping (Bhandari, 2020)

Psychological or Mental Effects:

Irritability, aggression, emotional numbness, anxiety, intense guilt, sadness, outbursts of

anger, intrusive memories or flashbacks, easily aroused, night terrors, dissociative
experiences, and some may experience hallucinations and delusions (Barnhill, 2018)

Social Effects:
Avoidance of people, places, activities or situations, detachment, isolation, negative
coping skills, and diminished interest in activities (Barnhill, 2018)

Cognitive Effects:
Negative alterations in memory, dissociative amnesia, difficulty concentrating, poor
problem solving skills, trouble with planning, and learning impairment (Barnhill, 2018)

VI. Recommended Group (Group & Size)

This intervention is better suited for veterans with combat-related PTSD. The therapeutic
sessions will consist of up to 8 individuals in the treatment group. The purpose of the
intervention is to improve the client's emotional control. The intervention was designed to focus
primarily on the appropriateness of emotional responses and engage clients in the therapeutic use
of art. Clients participating in this intervention must be able to follow directions and complete
multi-step tasks. Those with active psychosis, and delusional behaviors that can cause disruption
should be excluded. This intervention could also be adapted to other populations including but
not limited to pediatrics, adults or geriatrics, that have been exposed to trauma.

ICF Codes and Treatment Goals and Objectives

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VII. ICF Functional Outcome Area Classification

b1521 (Regulation of emotion): Mental functions that control the experience and display of
affect.

d2401 (Handling stress): Carrying out simple or complex and coordinated actions to cope with
pressure, emergencies or stress associated with task performance.

VIII. Treatment Goals and Objectives for Intervention

GOAL: Improve expression of feelings
OBJECTIVES:
1) Patients will identify 4 challenging feelings (ICF b1521) that are hard to express at the
conclusion of the 3rd treatment session.
2) Patients will identify 3 healthy outlets to channel emotions and feelings (ICF b1521) by
the end of the 4th treatment session.

GOAL: Improve Increase awareness of stress management strategies

OBJECTIVES:
1) Patients will identify 3 triggers (ICF d2401) that lead to maladaptive behaviors at the
conclusion of the 2nd treatment session.
2) Patients will identify 3 positive coping skills related to stress management strategies (ICF
d2401) by the end of the 4th treatment session.

Facilitation Process, Contraindications and/or Precautions, Variations and Processing

IX. Facilitation Process
Name of Activity: “Draw Your Feelings”
1. Facilitator should have paper and coloring supplies (markers, colored pencils, pens) ready for group
session before the participant arrives.
2. Facilitator will provide each participant with what they need (one sheet of paper, and at least 5
different colored markers).
3. Allot 10 minutes to frontload the session topic; feelings related to trauma.
4. Allocate 20-25 minutes to allow clients to draw/color through creating an image of what happened
during their trauma.
5. Once clients are complete with drawing allot 25-30 minutes for participants to show their peers their
art work and explain/discuss.
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Figure 1
Example of Completed Visual Trauma Narrative

(Decker, et. al, 2018)

X. Variations

1. This intervention could be individual, in pairs or in small group settings.

2. This intervention could be collaborative where each participant has a section of a large
wall mural rather than an individual sheet of paper.
3. This intervention could also be used in pediatric, adult, and geriatric populations who
have also experienced trauma.
4. This intervention can be used with other populations with similar needs (ex: individuals
with substance abuse issues)
5. The materials can vary from markers to colored pencils to paint to pastels.
6. The participants can create a drawing of the last moment they remember directly before the trauma.
7. The participants can create a drawing of a moment right after the trauma.
8. The participants can create a drawing from a time they felt safe from the threats of war.
9. The participants can create a drawing of a time when they tried to self-soothe.

XI. Contraindications and/or Precautions

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1. Those with active psychosis should not participate.

2. Those with delusional thoughts or other disruptive behaviors in groups should not
participate.
3. Those who are not able to follow instructions should not participate.
4. Those who can not wait their turn to speak should not participate.

XII. Processing Questions

1. What aspects of your drawings reflect your emotions? Color choice? Shapes? Overall
format?
2. In what ways did drawing allow you to release your emotions and feelings?
3. What are some of the triggers that arose from participating in this activity?
4. What are some other healthy ways you can release your feelings and emotions other than
art?

XIII. Evidence-Based Abstract

Kathleen P. Decker, Sarah P. Deaver, Vanessa Abbey, Melissa Campbell & Christa Turpin
(2018) Quantitatively Improved Treatment Outcomes for Combat-Associated PTSD With
Adjunctive Art Therapy: Randomized Controlled Trial, Art Therapy, 35:4, 184-194, DOI:
10.1080/07421656.2018.1540822

The therapeutic use of art is an intervention that is being conducted with individuals with
Post Traumatic Stress Disorder (PTSD). PTSD is a psychiatric disorder that can occur in
individuals who have experienced or witnessed a traumatic event(s). The art intervention uses
imagery to reactivate positive emotions, enhance self-efficacy and improve self esteem. It targets
both hemispheres of the brain; the right hemisphere to build the visual imagery, to then transform
the traumatic experiences formed in the left hemisphere. The purpose of this study was to see
how art therapy in concurrence with cognitive processing therapy (CPT) would lead to a greater
decline in symptoms for combat veterans rather than the use of CPT alone. 96 veterans were
screened for intervention eligibility and the final sample included 38 who were placed randomly
either in the experimental or control treatment. The study was implemented over 8 sessions of
individual art therapy each lasting an hour. The art sessions involved creating and processing the
Running head: DRAW YOUR FEELINGS

veterans’ visual trauma narrative, allowing the participants to express themselves. Six steps of
direction were provided by the therapist to construct the visual trauma narrative. The variables
were measured pre-treatment, midpoint and post-treatment. Instruments used were the PCL-M
to measure the severity of PTSD symptoms, the BDI-II to measure depression, and a 5-point
Likert scale used to allow participants to rate the benefit of art therapy in their treatment
sessions. The study found that the experimental group has a statistically greater rate of decline in
PTSD symptoms overall. The Reduction in PTSD symptoms correlated with the reduction in
depression symptoms. The Likert scale also found that participants in the experimental group
with the art intervention rated it a 4.8/5 on beneficial level. Therefore, the art intervention did in
fact, provide an intervention with significant positive results for veterans with PTSD. PTSD
symptoms were improved, and depressive symptoms decreased. The art intervention was
preferred by veterans rather than CPT alone. Recreational therapy can be used to address many
factors that are affiliated with improving emotional control in clients with PTSD. Specifically, in
this article, this study proves that recreational therapists can utilize aspects of an art intervention
and visual imagery. This provides clients with PTSD the opportunity to increase posttraumatic
growth. Enabling the ability to create a safe space, process traumatic memories and gain better
emotional control in their life through the reflective process of art. Recreational therapists’ can
also apply the therapeutic use of art with other populations who have similar needs to reach the
desired outcomes.

XIV. Reference List

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Barnhill. (2018, July). Posttraumatic Stress Disorder (PTSD) - Mental Health Disorders.
Retrieved from
https://www.merckmanuals.com/home/mental-health-disorders/anxiety-and-stress-
related-disorders/posttraumatic-stress-disorder-ptsd.
Bhandari, S. (2020, February 18). Posttraumatic Stress Disorder (PTSD): Symptoms, Diagnosis,
Treatment. Retrieved from https://www.webmd.com/mental-health/post-traumatic-stress-
disorder#1
Running head: DRAW YOUR FEELINGS

Kathleen P. Decker, Sarah P. Deaver, Vanessa Abbey, Melissa Campbell & Christa
Turpin (2018) Quantitatively Improved Treatment Outcomes for Combat-Associated
PTSD With Adjunctive Art Therapy: Randomized Controlled Trial, Art Therapy, 35:4,
184-194, DOI: 10.1080/07421656.2018.1540822

Kintzle, S., Barr, N., Corletto, G., & Castro, C. A. (2018, August 22). PTSD in U.S. Veterans:
The Role of Social Connectedness, Combat Experience and Discharge. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6164108/

Park West Gallery. (2017, November 10). How Art Therapy Helps Veterans. Retrieved
from https://www.parkwestgallery.com/how-art-therapy-helps-veterans/

Veterans Affairs. (2018, July 24). Retrieved from

https://www.ptsd.va.gov/understand/common/common_veterans.asp

XV. Name of Student(s)

Submitted by: Sami Walsh, Anna Godwin, and Skylar Wheeler