Creative Forces: Using Creative Arts, Providing Holistic Healing to our Veterans

Creative Forces is a Military Healing Arts Initiative created as a partnership between the National Endowment for the Arts, the Departments of Defense and Veterans Affairs, and different local arts agencies.  The program uses creative arts therapies and increase access to community arts activities to promote health, wellness and quality of life for military service members, veterans, and their families and caregivers.

 

Understanding Creative Forces

 

Military personnel, particularly those exposed to deployment and combat, are more vulnerable to experience trauma and/or acquired a brain injury, which commonly manifests in traumatic brain injury (TBI) and/or post-traumatic stress disorders (PTSD). More than two million U.S. troops have been deployed since 2001 in countries like Afghanistan, Iraq, and Syria ("About Creative Forces", 2018). While the combat death rates have decreased compared to previous conflicts, military forces have been exposed to multiple deployments, to nontraditional combat (e.g., use of improvised explosive devices), and to shortened time at home between deployments ("About Creative Forces", 2018). As such, there has been an increase in the number of service members returning home who suffer from both physical and psychological traumas. [1]

 

Exposure to trauma can result in a constellation of acute and/or chronic biological, psychological, and physiological symptoms (Van der Kolk, 2006). Some symptoms include flashbacks, nightmares, mood disorders, suicidal ideation, sleeplessness, cognitive difficulties, and chronic pain (Lobban, 2014). Service members and veterans with these conditions may experience emotional numbness, have problems verbalizing their experiences and acknowledging their symptoms, and may have difficulties with relationships, work, and activities of daily life (American Psychiatric Association, 2013). These conditions are associated with higher incidence of patient’s depression, substance abuse, and even suicide. Moreover, repeated deployments may also interfere with relationships. Military personnel are often trained to be vigilant, as well as sensitive to changes in the environment that may pose threats. This vigilance often persists beyond the combat setting, leading to chronic arousal and reactivity. Behaviors or reactions that can be lifesaving in the context of war may be disruptive for individuals outside combat settings.

 

Despite the gravity of the pathology, not all veterans and military personnel receive proper treatment to cope with PTSD and TBI symptoms. Indeed, lower than desirable rates of treatment initiation (utilizing care; starting treatment), retention (completing the intended course of treatment), and adherence (performing behaviors in the treatment plan) constitute a significant challenge. This occurs because patients often have negative attitudes towards psychotherapy and pharmacotherapy (e.g., believing that treatment wouldn’t be helpful) and/or believing that there are stigmas or side effects associated to these type of treatment (Bachtler, et al., 2017 and Kehle-Forbes and Kimerling, 2017). As a result, most service members and veterans suffering from trauma do not properly engage in and/or complete adequate medical treatment (Hoge et al., 2014; Spoont et al., 2010).

 

Creative Arts Therapies (CAT) – A brief review of the literature

 

CATs are therapeutic practices that include the arts to reinforce and complement psychotherapy, counseling, rehabilitation, and/or medicine. Their main characteristic is that they integrate creative arts practices into the therapeutic process. Available evidence indicates that engagement with artistic activities, either as an observer or as an active participant, can enhance patients’ moods, emotions, psychological states; and improve the patient’s capacity to understand the world and themselves (Staricoff and Loppert, 2003).  There are different CAT disciplines, each with a distinct objective, clinical practice, hypothesized mechanisms of change, and intended outcomes (Vick, 2012). The most common CATs used for healthcare provision are art therapy, music therapy, dance/movement therapy, and therapeutic/expressive writings (Bachtler et al., 2017). CATs have been used in several therapeutic settings with patients suffering a series of psychological and physical conditions. CATs objectives are mainly to decrease distress, foster personal growth, and support positive change (Stuckey and Nobel, 2010).

 

While the implementation of CATs tends to differ across the medical practice, there are some essential elements common to CATs, such as (i) encouragement of patients to actively participate in the therapeutic process through art-making, movement, performance, and/or writing; (ii) utilization imagination and creativity therapeutically; and (iii) enhancement of mind-body connections through the use of senses and movement (Malchiodi, 2005). Nevertheless, there are ample variations across CAT practices and practitioners (Greenstone, 2016). This occurs because CATs are often delivered using different dosages and methods to patients through professionals licensed in different fields, such as social workers, professional counselors, or mental health professionals.

 

Most of the available research about CATs has been used in the context of integrated medicine. Indeed, CATs within integrative medicine have been used with several different populations, including patients dealing with pain, cancer, palliative care, psychiatric issues, and geriatric issues, as well as military veterans with PTSD and TBI. Available studies indicate that CATs can contribute to managing chronic pain, decrease psychiatric symptoms, improve social functioning, improve mood, reduce fatigue, improve memory and concentration, and improve emotional well-being. However, available research on the effects of CATs limited, with most of the findings suggesting low to moderate effects (Bao et al., 2014; Crawford et al., 2014; O’Kelly and Koffman, 2007). Some authors claim that CATs interventions have the potential to be cost-effective, as they can reduce the cost of end-of-life care, psychiatric treatment, and pharmacological treatment (Beauchet et al., 2017).

 

CATS in the Creative Forces Network (CFN)

 

CATs have been employed to address the symptoms and underlying causes of PTSD, TBI, and related concerns for service members, veterans, and their families. Nowadays, CATs therapists provide services for military personnel in inpatient and outpatient military treatment facilities across the country. CATs are also delivered through clinics, community mental health settings, and independent practice. Clinical practices of CATs for treating service members and veterans vary depending upon the therapy of choice and patient’s symptoms (Beauchet, et al., 2017).

 

Reported outcomes from CATs with service members and veterans include improvements in cognitive function, such as increased concentration, attention, memory, organization, as well as reductions in nightmares and trauma-related arousal. Also, recent studies have shown that military personnel receiving CATs have improved positive emotions, emotional self-efficacy, and self-esteem, also, have ameliorated social relationships (Walker et al., 2016; Ramirez, 2016). Furthermore, CATs have shown potential to help address the stresses in the lives of family members, related to military service (Gajic, 2016).

 

On November 15, 2012, military, government, the private sector, and nonprofit leaders gathered at The John F. Kennedy Center for the Performing Arts in Washington, DC for the Arts & Health in the Military National Roundtable. The main output arising from this Roundtable was: the Arts Health and Well-being Across the Military Continuum: White Paper and Framing a National Plan for Action (the ‘White Paper’). One of the recommendations of this report was to promote policies to support the use of CATs within the Department of Defense and the Veteran’s Administration.

 

To support the implementation of this policy initiative, Creative Forces: NEA Military Healing Arts Network (CFN) – a partnership of the National Endowment for the Arts, Department of Defense, Department of Veterans Affairs, and state and local arts agencies –  was created to address the special needs of military service members and veterans, along with their families and caregivers, who are dealing with traumatic brain injury (TBI) and psychological health conditions. The Creative Forces Network supports a 3-pillar program:

  • “Place creative arts therapies at the core of patient-centered care in military medical facilities, as well as a telehealth program for patients in rural and remote areas; 
  • Provides increased community-based arts opportunities for military and veteran family populations around clinical site locations; and 
  • Invests in capacity-building efforts, including the development of manuals, training, and research on the impacts and benefits of the treatment methods” [2].

In 2016, the CFN piloted a CAT program in the National Intrepid Center of Excellence (NICoE) at the Walter Reed National Military Medical Center. The program uses an integrative healthcare model that incorporates CATs at the core of the integrative care treatment for military patients with mild PTSD and associated physiological health conditions. Thanks to Congress’s appropriation of this pilot, the CFN recently expanded to 11 clinical sites/demonstration projects aiming to expand access to CATs to military personnel and their families.[3] Most demonstration projects are at early implementation stages.

 

 


[1] The US Department of Veteran Affairs reports that about 20 to 30% of all military personnel who participated in these recent conflicts have experienced PTSD and that about 30% of all veterans (6 million out of a total of 22 million) are affected by either PTSD or TBI (MPH, 2017). The National Endowment for the Arts estimates that more than 500 thousand men and women in the armed services currently live with these pathologies ("About Creative Forces,” 2018).

[3] Sites include: (1) Alaska: Joint Base Elmendorf-Richardson (JBER), Anchorage; (2) California: Marine Corps Base Camp Pendleton, Oceanside; (3) Colorado: Fort Carson, near Colorado Springs; (4) Florida: James A. Haley Veterans’ Hospital and (5) Tampa and Malcom Randall Veterans’ Medical Center, Gainesville; (6) Maryland: National Intrepid Center of Excellence (NICoE) at Walter Reed, Bethesda; (7) North Carolina: Marine Corps Base Camp Lejeune, Jacksonville; (8) Texas: Fort Hood, Killeen ; (9) Virginia: Fort Belvoir, Fairfax County, and (10) Naval Medical Center, Portsmouth; and (11) Washington: Joint Base Lewis-McChord, Tacoma