Art and Post Traumatic Stress

Art and Posttraumatic Stress 1

ART AND POST TRAUMATIC
STRESS
A WHITE PAPER
BY

VISUAL IMAGE RESEARCH @ AMERICAN ART RESOURCES



CONTRIBUTING AUTHORS:

Upali Nanda, PhD, Assoc.AIA, EDAC

Vice President, Director of Research

American Art Resources, Houston

Lea H.Gaydos, PhD, RN, CS, AHN‐BC

Associate Professor

Beth‐El College of Nursing and Health Sciences, University of Colorado

Kathy Hathorn, MA, EDAC

CEO & Creative Director

American Art Resources, Houston

Nick Watkins, PhD

Director of Research and Innovation

HOK, New York



Art and Posttraumatic Stress: A Review of the Empirical
Literature on the Therapeutic Implications of Artwork
for War Veterans with Posttraumatic Stress Disorder1

Background .........................................................................................................................6

Art, Stress, and Anxiety: A Look at The Evidence and Supporting Theory...........................6

Stress, Anxiety, Coping and Posttraumatic Stress Disorder ................................................9

Case Studies......................................................................................................................12

Mourning, Collective Memory and Autobiographical Memory:  Use of Visual Imagery in
War Memorials .................................................................................................................12

Engagement with Visual Art through Art Therapy............................................................13

Discussion .........................................................................................................................14

Revisiting Theories for Evidence‐based Guidelines for War Veterans...............................15

Revisiting Evidence‐based Guidelines for Visual Art in Healthcare Settings for War
Veterans............................................................................................................................15

Final Thoughts and Need for New Research.....................................................................18


1
An abridged version of this paper will be published in the Environment and Behavior

Journal in early 2010



A BSTRACT
Little is known about the role of art and the impact it can have on the healing process of
returning war veterans within the context of Veterans Administration (VA) healthcare
settings.  Of special concern is the lack of information on how visual art can impact
veterans who suffer from PTSD.   Through an extensive review of the literature this
paper re‐assesses existing theories and guidelines on use of visual art in general acute‐
care healthcare settings with the specific objective of developing restorative healthcare
environments for returning war veterans who might experience some variant of war‐
related PTSD. Case studies on the use of visual imagery during art therapy sessions and
visits to war memorials are discussed, and their relevance to healthcare explored.  The
stress and anxiety experienced in general, acute care settings is examined in light of
PTSD‐related emotional and cognitive deficits. Finally, the paper proposes a re‐
conceptualization of evidence‐based guidelines for visual art to create restorative
healthcare environments for returning war veterans with PTSD. Given the limited
research available on this area, the paper also recommends directions for future
research.



A RT AND P OSTTRAUMATIC S TRESS : A R EVIEW OF
THE E MPIRICAL L ITERATURE ON THE T HERAPEUTIC
I MPLICATIONS OF A RTWORK FOR W AR V ETERANS
WITH P OSTTRAUMATIC S TRESS D ISORDER

According to a report published by RAND and the Center for Military Health Research
(Tanielian & Jaycox, 2008), since October 2001, approximately 1.64 million United States
(U.S.) troops have been deployed as part of Operation Enduring Freedom (OEF) and
Operation Iraqi Freedom (OIF). Because of advances in medical technology and body
armor, the casualty rates of killed or wounded have been historically lower than in
previous wars such as the Vietnam War or the Korean War. However, “casualties of a
different kind are beginning to emerge—invisible wounds such as mental health
conditions and cognitive impairments resulting from deployment services” (Tanielian &
Jaycox, 2008; p.xix). The three major conditions covered by the report are posttraumatic
stress disorder (PTSD), major depressive disorder, and traumatic brain injury (TBI).
Incidence of PTSD in war veterans of OEF and OIF is conservatively estimated at a total
of 29% (Collie, Backos, Malchiodi, & Speigel, 2006) compared with a lifetime prevalence
of the adult population of the United States of about 8% (American Psychiatric
Association, 2000, p. 466.).  Furthermore, it is suspected that PTSD may be under‐
reported for veterans of OEF and OIF since veterans might fear stigmatization (Collie, et
al., 2006).

The RAND report makes a compelling economic case for the attention now given to
PTSD.  Two‐year costs associated with PTSD were projected at $5,904 to $10,298, per
veteran, and with major depression and PTSD at $4 to $6.2 billion dollars nationally
(Tanielian & Jaycox, 2008). The report also states that using treatment that is shown to
be effective (evidence‐based), for PTSD and major depression could save as much as
$1.7 billion dollars or $1063 per veteran, paying for itself within 2 years. In addition to
evidence‐based treatment, evidence‐based design could also be a powerful driver to
improve the healthcare experience of returning war veterans. “Evidence‐based design is
the process of basing decisions about the built environment on credible research to
achieve the best possible outcomes” (Center for Health Design, 2009). A key
environmental variable studied in this context is exposure to visual images through
views and visual art.

According to Hathorn and Nanda (2008) the use of visual art has become increasingly
prevalent in the healthcare industry.   In 2003, the Society for the Arts in Healthcare
(SAH) and the National Endowment for the Arts (NEA) conducted a survey of hospitals
to identify the current level of arts activities in healthcare settings.    Results from the
survey indicated that more than 50% of U.S. hospitals invest in art programs for their
facilities with the prime objective of improving patient experience (Wikoff, 2004).



Research shows that visual art can alleviate stress and anxiety in patients within acute
care hospital settings (Nanda, Eisen & Baladandayuthpani, 2008; Ulrich & Gilpin, 2003;
Ulrich, 2009). Art with nature content has been found to be particularly beneficial for
restoration from stress (Ulrich, 2009; Ulrich, 2008).  This paper seeks to extend this body
of knowledge to healthcare environments for veterans suffering from PTSD.

The primary purpose of this paper is to investigate how visual art can play a restorative
role for war veterans with PTSD.  Toward this purpose, the paper reviews current
research, theory, and practice guidelines on the use of visual art to relieve stress and
anxiety in the majority of healthcare environments.  Second, the paper explores the
relationship of stress and anxiety to PTSD using an interactional definition of stress.  An
interactional definition of stress overcomes the limitations of current research, theory,
and practice guidelines on the restorative aspects of visual art when applied to anxiety
disorders such as PTSD because unique emotional and cognitive processing deficits of
PTSD can be discussed in light of an interactional definition of stress.  Third, the paper
examines veterans’ experiences with war memorials and art therapy.   Research of war
memorials and art therapy offer case studies that illustrate how visual art may work as
therapeutic devices for war veterans who struggle to cope with traumatic memories.
However, a limitation of these case studies is that they do not explore how imagery
used in war memorials and art therapy sessions can facilitate recovery from stress,
especially during a hospital visit or stay.  Finally, the paper reassesses existing theories
and practice guidelines on visual art with the specific objective of creating restorative
healthcare environments for returning war veterans who might experience some variant
of war‐related PTSD.  Consequently, the paper proposes a re‐conceptualization of
evidence‐based guidelines for visual art to create restorative healthcare environments
for returning war veterans with PTSD. Given the limited research available on this area,
the paper also recommends directions for future research.

B ACKGROUND
A R T , S T R E SS , A N D A N XI E T Y : A L O O K A T T H E E V I D E N C E A N D
S U P P O R T IN G T H E O R Y
A retrospective study analyzing data over a period of 8 years found that patients
assigned to rooms with windows looking out on a nature scene had shorter
postoperative hospital stays, received fewer negative evaluative comments in nurses'
notes, and took fewer potent analgesics than matched patients in similar rooms with
windows facing a brick building wall (Ulrich, 1984). Nanda et al. (2008) argue that when
an actual view of nature is not available, artwork can promote similar restorative
effects.  Restorative environments can be either real, illusory or imagined places
(Kaplan, Kaplan, & Ryan, 1998). In an extensive review of the literature, Ulrich and Gilpin
(2003) identified studies that validate the therapeutic effects of visual art on stress,
anxiety and pain perception. For example, physiological data collected via skin
conductance, muscle tension, and pulse transit time from university students who
watched photographic simulations of natural settings after watching a stress inducing
video showed faster recovery (return to baseline) than subjects who viewed simulated



urban settings (Ulrich, Simmons, Losito, Fiorito, Miles, & Zelson, 1991). Heart rate
measurements collected in a dental clinic showed that patients experienced lower stress
on days that a large mural depicting a natural scene was hung on the waiting room wall
versus days when the wall was left blank (Heerwagen & Orians, 1990).   In another study
patients on gurneys viewing ceiling mounted scenes of nature and/or water had systolic
blood pressure levels 10 to15 points lower than patients exposed to either aesthetically
pleasing “arousing” pictures or a control condition of no picture (Coss, 1990).

Exposure to visual art has also been found to have a restorative effect on anxiety and
perception of pain. For example, adults in a procedure room reported better pain
control and less anxiety when exposed to nature scenes projected on the ceiling with
accompanying sounds (Diette, Lechtzin, Haponik, Devrotes, & Rubin, 2003).   Breast
cancer patients reported reduced anxiety, fatigue, and distress during chemotherapy
when exposed to a virtual reality intervention of underwater scenes and museum art
(Schneider, Ellis, Coombs, Shonkwiler, & Folsom, 2003). Exposure to nature murals
resulted in decrease in reported pain quality, intensity, and anxiety in burn patients
(Miller, Hickman & Lemasters, 1992).

One limitation of the above studies is lack of emphasis on the impact of different types
of image content and styles (Nanda, et al., 2008). An exception is a study with heart
surgery patients in the intensive care unit (ICU) of a Swedish hospital that compared
recovery outcomes across six groups of patients assigned to different image conditions
(nature and abstract images similarly dominated by greens and blues but varying in
complexity levels, and two control conditions). Patients exposed to a representational,
nature image with a high depth of field, experienced less postoperative anxiety and took
fewer doses of strong pain medication than patients assigned to the five other visual
conditions, although the patients did take more moderate strength pain analgesics.
Patients exposed to abstract art with rectilinear forms experienced worsened outcomes:
more postoperative anxiety and larger doses of strong pain medication (Ulrich, Lunden,
& Eltinge, 1993).

According to Ulrich and Gilpin (2003) the healing effect of visual art, particularly nature
images can be explained by two theories. First, the evolutionary theory which argues
that evolution has hardwired humans to find non‐threatening images of nature calming
and restorative. Millions of years of evolution have left modern humans with a partly
genetic predisposition for responding positively to nature (Appleton, 1975; Orians,
1986). Second, the emotional congruence theory that holds that people perceive their
environment in a manner congruent with their current emotional state, sensitizing them
to process information that corresponds with their mood (Bower,1981). This suggests
that patients during a hospital stay are likely to project the negative emotions they feel
on to the surrounding environment. Thus, ambiguous artwork with content that is open
to interpretation is likely to be interpreted in a manner congruent to a patient’s feelings
and may not be appropriate in a healthcare context (Ulrich & Gilpin, 2003; Hathorn &
Nanda, 2008).  However, outside of healthcare settings, ambiguity is often heralded as a
quality of high art. In fact, research shows that artists and experienced art viewers



prefer artwork that is challenging and emotionally provocative (Winston & Cupchik,
1992). Preference studies with hospital patients show the opposite‐ indicating a
preference for unambiguous, realistic imagery with nature content over more classic or
best‐selling art (Nanda et al., 2008).

In general, research suggests that healthcare art should realistically depict the following
(Ulrich & Gilpin, 2003; Hathorn & Ulrich, 2001):

1. Waterscapes, containing calm or non‐turbulent water

2. Landscapes, containing visual depth or open foreground, trees with broad
canopy, savannah landscapes, verdant vegetation

3. Positive cultural artifacts (e.g. barns and older houses)

4. Flowers, which are healthy and fresh, familiar, in gardens with open foreground

5. Figurative, with emotionally positive faces, diverse and leisurely.

Healthcare art should avoid natural elements and situations that can signal threats or
dangers such as snakes and spiders, large mammals that gaze directly at the viewer,
pointed or piercing forms, shadowy enclosed spaces, and angry or fearful human faces
(Ulrich & Gilpin, 2003).

Another theory that explains the appropriateness of nature images is the attention
restoration theory (Kaplan & Kaplan, 1989).  According to this theory nature images help
in restoration from directed attention by offering the following components:

1. Being away (for people in urban settings nature images can connote “getting
away” to an idyllic place)

2. Fascination (nature is endowed with fascinating objects that hold a person’s
attention without particular effort)

3. Extent (a sense of extent can come from scenes of distant wilderness, trails and
paths leading to idyllic destinations, and a sense of being connected to a larger
world)

4. Compatibility (a resonance between the natural setting and human
inclinations)

Each of the theories discussed above has a strong body of literature supporting it.
However, none of them have been explored in the context of posttraumatic stress
disorder (PTSD).  Unlike the ordinary stress and anxiety experienced during short‐term
hospital stays, PTSD is an anxiety disorder, with clinically significant distress and
impairment developing over a period of time due to exposure to a single, or series of,
traumatic events (Tanielian & Jaycox, 2008). This difference is addressed in the following
s ection.



S T R E S S , A N X I E T Y , C O P I N G A N D P OS T T R A U M A T I C S T R E S S D I S O R D E R

An interactional definition of stress defines stress as an interrelationship among a
stressor, anxiety, and coping. For example, Evans and Cohen (1987) state that stress
results from a misfit between individual needs and environmental attributes and may
occur when responding to situations that are demanding, over‐stimulating, or
threatening to well‐being. Kneisl and Trigoboff (2009) define stress as “a broad class of
experiences in which a demanding situation taxes a person’s resources or coping
capabilities, causing a negative effect” (p. 137).  A stressor (source of stress) produces
an internal state of “tension, anxiety, or strain” (p. 137).  An interactional definition of
stress is crucial to understanding how stress and recovery from stress may occur for a
variety of individuals who experience various degrees of stress.  The transactional
(sometimes referred to as interactional) view of stress holds that stress is a process of
complex interactions between perceived demands and a person’s internal and external
resources to meet those demands (Lazarus & Folkman, 1984).

Stress.  The general adaptation syndrome (GAS) identifies the three stages through
which the body adapts to the stress:  alarm, resistance, and exhaustion.  The alarm stage
is an immediate, short‐ term response to crisis (the fight or flight response),  the
resistance phase results in long term metabolic adjustments that can be harmful, and
the exhaustion phase results in a collapse of vital systems (Selye, 1956).. In healthcare
settings, stress can be caused by fear about impending surgery, lack of information,
painful medical procedures, reduced physical capabilities, depersonalization, loss of
control, and disruption of social relationships (Ulrich, 2008). According to Ulrich (2008)
psychological, physiological, neuroendocrine, and behavioral manifestations account for
the unhealthy effects of stress. Psychological manifestations include experiences of fear,
anxiety, sadness, and helplessness.  Physiological manifestations include elevated blood
pressure and heart rate.  Neuroendocrine manifestations are reflected in increased
levels of cortisol and stress hormones (which could result in suppression of immune‐
system functioning and increased risk of infection).  Behavioral manifestations include
social withdrawal, verbal outbursts, sleeplessness and failure to take medications.

Anxiety.  Anxiety is an experience of uneasiness or discomfort made in response to
stress  (Kneisl & Trigoboff, 2009).  Anxiety follows a continuum from mild anxiety to the
panic (Kneisl & Trigoboff, 2009; Townsend, 2009; Fontaine, 2009).  Mild anxiety allows
people to deal effectively with stress by heightening the ability to process sensory
stimuli, broadening the perceptual field, and motivating a person to organize perception
and cognition.  During moderate anxiety, the perceptual field narrows.  Though alert,
the individual ignores peripheral stimuli and becomes more focused. This selective
inattention of peripheral stimuli is under voluntary control.  During severe anxiety, a
person’s perceptual field diminishes and the ability for problem solving deteriorates.
The ability to focus is impaired and attention is scattered on small, disconnected details.
Selective inattention is less likely to be under voluntary control.   At its most severe,
anxiety escalates to panic.  During panic, the perceptual field is disrupted.  The person is


Art and Posttraumatic Stress
10

unable to initiate or maintain goal‐directed activity or communicate effectively. Severe
and panic levels of anxiety are associated with the dread and terror victims of PTSD
experience (Herman, 1992).

Coping.  In order to deal with stress and the anxiety it produces, people develop
problem‐solving and defense‐oriented strategies (Kneisl & Trigoboff, 2009). The
Diagnostic and Statistical Manual of Mental Disorders IV‐Text Revision (DSM IV‐TR)
describes psychological defense mechanisms as largely unconscious strategies a person
uses to defend their well‐being against stressors allowing  a person to deny or distort
the anxiety‐producing stressor to reduce awareness and/or emotional response
(American Psychiatric Association, 2000).   The DSM IV‐TR  also links defense
mechanisms and coping styles, identifies common defense mechanisms, and orders
defense mechanisms in a hierarchy of more adaptive to less adaptive mechanisms
(pp.807‐813).  PTSD symptoms include maladaptive ways of coping.

Posttraumatic Stress Disorder. Research on the constellation of symptoms classified as
PTSD began during the post‐Vietnam War era (Buckley, Blanchard, & Neill, 2000).
Collie, et al. (2006) note that 18.7 % of Vietnam veterans developed war‐related PTSD
with 9% of those still suffering from the disorder 11 to 12 years after the War.  In 1980,
posttraumatic stress disorder (PTSD) was officially introduced into the Diagnostic and
Statistical Manual of Mental Disorders‐ Third Edition  (DSM‐III).

Currently, PTSD is described as an anxiety disorder that follows a traumatic event.  The
traumatic event causes intense fear and/or helplessness in an individual (American
Psychiatric Association, 2000).  For war veterans, combat‐related traumatic events may
have included having a friend seriously wounded or killed, seeing dead or seriously
injured combatants, witnessing an accident resulting in serious injury or death, smelling
decomposed bodies, being physically moved or knocked over by an explosion, being
injured and requiring hospitalization, engaging in hand‐to‐hand combat, witnessing
brutality towards prisoners/ detainees and being responsible for the death of a civilian
(Tanielian & Jaycox, 2008).The physiological symptoms of PTSD result from exposure to
internal or external cues that either symbolize or resemble the experienced trauma
(American Psychiatric Association, 2000) and include shortness of breath, increased
heart rate, possible premature contractions, elevated blood pressure, dry mouth,
gastrointestinal distress, trembling, tense muscles, and difficulty relaxing, and difficulty
sleeping.  With panic‐level anxiety, the person might experience a choking or
smothering sensation, low blood pressure, chest pain, dizziness, and nausea (Fontaine,
2009).

Additionally, PTSD is characterized by psychological, behavioral, emotional, and
cognitive symptoms that are recurrent, intrusive, and involuntary (American Psychiatric
Association, 2000). Intrusive symptoms include recollections of the event through
images, thoughts or perceptions, nightmares, illusions, hallucinations, and flashbacks
during which a person re‐experiences the traumatic situation. Persistent avoidance of
thoughts, conversations, situations, people, locations, images, and/or objects that are
reminiscent of the traumatic event is also a diagnostic feature.


11

Emotional Processing and Posttraumatic Stress Disorder.  Monson, Price, Rodrigues,
Ripley and Warner  (2004) observe that PTSD has been linked to emotional dysfunction.
Alexithymia is an expression of this emotional dysfunction (Monson et al, 2004; Frewen,
Dozois, Neufeld, & Lanius, 2008a; Frewen, Dozois, Neufeld, Lanius, Hooper, & Pain,
2008b).  Alexithymia was first described as a set of psychological symptoms in which
individuals experience difficulty in labeling and identifying emotions.  A meta‐analysis of
the studies on PTSD and alexithymia demonstrated a large effect size of alexithymia
with PTSD and effect sizes even larger in studies of male war veterans with PTSD in
comparison to other PTSD samples (Frewen, et al., 2008a). The exact mechanism of
alexithymia is not clearly known.  However, it has been associated with the emotional
numbing and hyperarousal experienced by PTSD sufferers, and it may also signal an
“uncoupling of cognitive and emotional processing” (Frewen, et al., 2008a, p. 171)

Emotional numbing is considered an early predictor of chronic PTSD (Feeny, Zoellner,
Fitzgibbons, & Foa, 2000).  It is often evidenced by disinterest in activities, detachment,
and restricted emotional expressiveness (National Institute of Mental Health, 2002).  It
is linked to dissociation; a defense mechanism used to avoid distressing stimuli
(American Psychiatric Association, 2000) though Kashdhan, Elhai and Frueh (2006) argue
that emotional numbing is not just a result of avoidance to protect against painful
emotions, but also a result of emotional exhaustion due to prolonged hyperaraousal.
Persistent symptoms of hyper‐arousal and hyper‐vigilance that occur in PTSD are
characterized by a heightened startle response, difficulty sleeping, difficulty
concentrating, and outbursts of irritability or anger (American Psychiatric Association,
2000).

Cognitive Processing and Posttraumatic Stress Disorder.  A core element of PTSD is the
failure to process information symbolically and verbally (van Der Kolk & Fisler, 1995).
Brain imaging studies performed on individuals with PTSD show a lack of activity in areas
of the brain associated with speech.  These same studies show an increased activity in
areas of the brain associated with fear, anger, memory and visual processing (Rauch and
Shin, 1997). A comprehensive review of the literature on information processing in PTSD
(Buckley, et al., 2000, pp. 1041‐1065) found an intense research interest for cognitive
impairments associated with PTSD in populations of war veterans.

Autobiographical Memory.  Fredrickson (2001) describes emotions as a subset of
affective responses that begin with an appraisal of the “personal meaning of an
antecedent event” (p. 218). The appraisal may be conscious or unconscious, but
attribution of personal meaning to an event is linked to the individual’s personal
narrative and autobiographical memory. Autobiographical memories may be voluntary
or involuntary.  Involuntary reliving of autobiographical memories is a diagnostic feature
of PTSD.  In a study of autobiographical memory in both controlled and naturalistic
laboratory conditions, Shlagman and Kvavilashvili (2008) found that involuntary
memories were more specific and retrieved faster than voluntary memories. They also
found that involuntary memories are associated with specific rather than general
events, and are more likely to be triggered by negative cues.


12

PTSD is also characterized by impairments in autobiographical memory (Rubin, Feldman
& Beckman, 2004). In contrast to the findings of Frewen and Lanius (2008) that
traumatic memories may be fragmented, Rubin, et al., (2004) found that a person with
trauma‐related memories and PTSD symptoms has more coherent involuntary
autobiographical memories.  This coherence may make the memories more vivid and
implies that individuals with PTSD are potentially more vulnerable to imagery that
reminds them of a trauma.  The following case studies discuss the use of visual imagery
through the experience of war memorials and art therapy.

C ASE S TUDIES
M O U R N I N G , C OL L E C T I VE M E M O R Y A N D A U T OB I O G R A P H I C A L
MEMORY:  USE OF VISUAL IMAGERY IN WAR MEMORIALS
A returning war veteran is compelled to address traumatic memories, especially within
the context of mourning.  Mourning characterizes the process of confronting and
addressing losses and is recognized as a difficult, repetitive, and shifting process (Janet,
1925).  By composing a narrative or account of the traumatic memory, the trauma and
its emotional content are assimilated into a person’s life history.  War veterans exposed
to traumatic events need opportunities to confront and address losses in an attempt to
assimilate them into their autobiographical memory (Watkins, 2008).

One purpose of a war memorial is to express the attitudes and values of a community
towards the persons and deeds memorialized (Barber, 1949). In this sense, memorials
are common objects used by the entire community to mourn losses.  Memorials help
communities rationalize losses by offering settings for rituals that reinforce a
community’s solidarity around a “common ideal” and survival of the ideal over threat
and loss (Wasserman, 2002).  Attitudes of the community may be clear, positive, and
proud as when a victorious conflict is memorialized.  These can be classified as the
collective memories; memories that are collectively shared representations of the past
(Kansteiner, 2002). The relationship between the individual and the collective remains
an unsettled area of research in collective memory studies (Kansteiner, 2002).
Traditionally, memorials glorify the purpose of the conflict and the individual sacrifices
of its veterans.

However, when a common ideal is questioned or missing, the task of a memorial
becomes more challenging.  The Vietnam War differed from other conflicts because it
resulted in a dubious conclusion without clear victory or defeat (Wagner‐Pacifi &
Schwartz, 1991).   Memorials like the Vietnam Veterans Memorial in Washington, D.C.,
recognize the individual sacrifices of veterans.  A common ideal or the outcome of a
conflict is secondary (Watkins, 2008).  Unlike other memorials, the VVM does not
commemorate the war using imagery associated with the war directly.  The purpose of
the design is to convey feelings, thoughts, and actions of a private nature (Wagner‐Pacifi
& Schwartz, 1991). This intent is congruent with research that shows individual Vietnam
War combat veterans suffering from PTSD vary in their perceptions and use of the
Vietnam Veterans Memorial depending on the stage of the mourning process they are
in (Watkins, 2008).


13

The Vietnam Veterans Memorial consists of two black granite walls 246 feet 9 inches
(75 meters) long. The walls are sunk into the ground, with the earth behind them. At the
highest tip (the apex where they meet), they are 10.1 feet (3 m) high, and they taper to
a height of eight inches (20cm) at their extremities.  The granite wall is a highly reflective
wall upon which the names of the names of servicemen who were either confirmed to
be KIA (Killed in Action) or remained classified as MIA (Missing in Action) when the walls
were constructed in 1982, have been inscribed.

Watkins (2007) argues that memorials, such as the VVM, can be therapeutic by
transforming indescribable and unstructured emotions into a meaningful response.  A
person is confronted with an opportunity to react to an image, sound, taste, smell, or
texture.  The clarity of sensation is more convincing and comprehensible than the
memory of the dissociated traumatic event an individual struggles to make sense of.
The offerings that visitors leave at the VVM add another temporal and ephemeral
dimension.  These offerings reflect the individual and evolving feelings of visitors
(Berdahl, 1994). The imagery of the names on a polished surface, the reflection of the
veteran upon these names, the black granite both opaque and reflective, and the silence
of the surroundings, enables a retrograde confrontation with past traumatic memories
and an opportunity to redeem a failed sacrifice.

The experience of visiting the war memorial can be intense for returning war veterans.
During visits to the Vietnam Veterans Memorial, groups of war veterans from Vet
Centers are often accompanied by qualified psychiatrists, psychologists, and social
workers in order to guide the veterans through the VVM and its precinct while helping
them interpret what they perceive (Watkins, 2008).  Another medium through which
traumatic memories are confronted is through the facilitation of Art Therapy.

E N G AG E M E N T W I T H V IS U A L A R T T H R O U G H A R T T H E R A P Y
The use of art expression in trauma intervention appeared as early as the 1970s when
clinicians initiated protocols using drawing to help survivors express their experiences.
The drawings were used as a means to convey details of the trauma and gain mastery
over feelings (Pynoos & Eth, 1986). The American Art Therapy Association (AATA) offers
this current description of art therapy (AATA, 2009):

Art therapy is a mental health profession that uses the creative process of art making to
improve and enhance the physical, mental and emotional well‐being of individuals of all
ages. It is based on the belief that the creative process involved in artistic self‐
expression helps people to resolve conflicts and problems, develop interpersonal skills,
manage behavior, reduce stress, increase self‐esteem and self‐awareness, and achieve
insight.” The use of art expression in trauma intervention appeared as early as the 1970s
when clinicians initiated protocols using drawing to help survivors express their
experiences.  The drawings were used as a means to convey details of the trauma and
gain mastery over feelings.

In a study analyzing various specialized inpatient PTSD programs, researchers found that
art therapy was the most effective, of 15 different programs, for veterans with the most


14

severe PTSD symptoms ‐ veterans could tolerate war‐zone content during art therapy,
which was not true of other activities such as group therapy, community service, and
journaling. The researchers concluded that art therapy was the most effective because it
combined pleasurable distraction with exposure to difficult content (Johnson, Lubin,
James, & Hale, 1997). In fact, Kashdhan, et al. (2006) argue that treatment of emotional
numbing in PTSD should include pleasant activities to rekindle responses to rewards and
re‐establish adaptive social functioning. According to Avrahami ( 2005) visual art therapy
is a modality that allows patients’ trauma to speak in the language of visual form.

Art therapy facilitates the clarification of imagery and memory disruptions that are
associated with PTSD (Appleton, 2001). Art‐making engages the veterans in an
exploration of “novelty” through engagement with art materials. Moreover the art‐
making process involves creative interactions with a variety of media including
kinesthetic/sensory, perceptual/affective and cognitive/symbolic methods (Lusebrink,
1990). Visual imagery may be necessary for the symbolic processing involved in creating
a trauma narrative (Van der kolk & Fisler, 1995).

D ISCUSSION
Art therapy and visits to war memorials involve active engagement of the war veteran.
Art therapy is often part of a formal therapy session facilitated by a trained professional
with the specific objective of diagnosis or treatment.  The argument that treatment of
emotional numbing in PTSD should include pleasant activities to rekindle responses to
rewards and re‐establish adaptive social functioning (Kashdhan et al., 2006) holds true
even for the visit to a war memorial such as the VVM that can be self‐driven, informal,
anticipated, and easily repeated (Rubin, 1982; Watkins, 2008). However, the practice of
conducting facilitated tours with qualified therapists suggests that the experience can
be emotionally intense for war veterans.  Both cases are distinct from the passive act of
viewing images in a setting not specifically designed for confronting traumatic memories
of war.  Such settings constitute the majority of a veteran’s life after they return from
war and where they experience most of their PTSD symptoms.  What follows is a
discussion of the advantages and limitations of prior research of war veterans’
experiences with PTSD and visual imagery as applicable to the healing impact of visual
imagery for war veterans in healthcare settings.

During a visit to the VVM, a combat veteran simultaneously experiences approach and
avoidance impulses toward the memorial (Watkins, 2008).  The reflectivity of the VVM’s
black granite surface and the etched names of deceased soldiers encourages individuals
to  project themselves into the past and self‐reflect on their personal losses (by viewing
one’s own reflection behind those names) (Smith, 2000; Watkins, 2008).  Indeed, the
mirrored surface of the VVM is a powerful therapeutic tool. Yet, one visit to the VVM
might aggravate PTSD symptoms, not lessen them. A veteran might not progress in the
mourning process unless he or she makes repeated visits to the VVM, benefits from the
insight and security of trusted others, and modulates his or her approach to the VVM
and the imagery it evokes (Watkins, 2008).  Second, unless accompanied by a qualified
therapist or trusted others, the veterans might not notice key therapeutic features of


15

the memorial (e.g., reflection behind a name) or remain fixated to a feature of the
memorial at the expense of progressing through the mourning process (e.g., the
names).  A literature review of research on imagery and stress disorders revealed that in
a clinical context, imagery must be carefully controlled because a traumatic memory
evoked by an image can cause excessive anxiety (Brett & Ostroff, 1985).This makes an
ethical argument for the careful selection of visual images for healthcare settings in the
case of war veterans suffering from combat‐related PTSD.     .

R E V I S I T I N G T H E O R I E S F O R E V I D E N C E ‐ B A S E D G U I D E L I N E S F O R W A R
VETERANS
In general, healthcare environments support coping with stress and thereby promote
improved outcomes if their design features foster: 1) Sense of control and access to
privacy 2) Social support 3) Access to nature and other positive distractions (Ulrich,
2000).  Hathorn and Nanda (2008) have found that in the context of art, art cart
programs that provide patients choice in artwork in their room are successful because
they fulfill all three criteria‐ sense of control by providing patients with a choice, social
support by interaction with an art cart volunteer, and access to nature and other
distractions via the actual artwork. However, it is possible that the visual imagery in the
artwork that promotes healing among general acute care patients might not be
appropriate for individuals with PTSD such as war veterans.

Consistent with emotional congruence theory, individuals with PTSD have a heightened
awareness for negative information.  Also, they process negative information more
quickly than positive information (Buckley, et al., 2000). This suggests that a complex or
ambiguous image with layered meanings may not be conducive to emotional and
information processing in veterans with PTSD, especially without facilitation by a
qualified therapist.  Additionally, enticing visual imagery supported by attention
restoration theory might have unintended negative consequences for war veterans with
PTSD.  Attention restoration theory condones the use of scenes of distant wilderness,
trails, and paths leading to idyllic destinations (Kaplan & Kaplan, 1989). Such imagery
could be therapeutic among general acute patient populations.  However, it is possible
that an image of a path without a clear destination could be extremely frightening to a
war veteran with PTSD who could imagine a hidden danger.

R E V I S I T I N G E V I D E N C E ‐ B A S E D G U I D E L IN E S F OR V I S U A L A R T I N
H E A L T H C A R E S E T T IN G S F O R W A R V E T E R A N S
There is no consensus on what would constitute appropriate, non‐ambiguous content
for war veterans with PTSD in healthcare settings. Given the nature of their symptoms,
war veterans with PTSD might benefit from unique, non‐ambiguous visual imagery to
foster healing within healthcare settings.  A typical savannah image, for example, with a
high depth of field (that is supported by evolutionary theory) might seem non‐
threatening for the average patient and connote escape from the confines of the
hospital.  The open vista could be particularly reassuring to war veterans, suggesting
that there are no hidden threats. On the other hand, the openness of the image may
suggest a lack of refuge, or place to hide, which could feel threatening in the context of


16

combat experiences.Research on such typical image types needs to be conducted under
the specific context of returning war veterans who suffer from PTSD. Combat veterans
are carefully trained to hone their attack and survival instincts specific to the
geographies in which they fight (Grossman, 1996). Landscapes that are reminiscent of
the geography of combat, even while following the evidence‐based guidelines, could be
inappropriate.

The importance of the socio‐ cultural elements of visual imagery is worthy of
investigation with war veterans, especially those suffering from PTSD.  Commemorative
elements such as flags and plaques commonly found in public and civic settings are
prominent in VA healthcare facilities.  These elements might provide the social
recognition and honor that war veterans deserve and seek.  However, there is no
research to investigate if such elements create a sense of belonging, or serve as a
reminder of the context of war. Again, given the vulnerability of war veterans who suffer
from PTSD, and the challenge of emotional and cognitive processing, it is incumbent to
investigate before assuming.

Length of stay is an important factor that should be taken into consideration while
considering art selection for any patient population (Hathorn & Nanda, 2008).
Rehabilitation services are a key component of VA hospitals and are distinguished by
typically longer length of stay as compared to the length of stay for short‐term acute
care patients.  In a rehabilitation unit where patients recover from an extreme physical
impairment, patients may experience different physical symptoms‐ but would share the
common feelings of anxiety and depression associated with an extended hospital stay‐
sometimes as long as a full year (Hathorn, 2000). Hathorn (2000) recommends the use
of clear, realistic pictures, avoiding any kind of double or reflecting images that could be
confusing or disorienting. She also suggests avoiding fuzzy or impressionistic images that
would be difficult to focus on. Given that the high frustration levels may lead to
occasional violence, Hathorn (2000) recommends static and serene art in the patient
spaces with distant horizon lines to create a focal point for viewers exposed to images
for a long period of time. Finally, she recommends the use of positively reinforcing
figurative art that would be congruent with the most frequent goal of rehab patients‐ to
go home. In the case of war veterans who may be subject to extensive rehabilitation
treatment, such images must be filtered further through the lens of the veteran’s own
traumatic memories and notions of homecoming.

Some considerations for designers who create healthcare environments housing war
veterans with PTSD are:

1. The heightened level of anxiety war veterans with PTSD may experience at any
given time in the healthcare setting.

2. The level of anxiety for war veterans with PTSD as a factor of the different
functions of the hospital.  For example, anxiety in a procedure room may be
different from anxiety experienced in a lobby or waiting area.


17

3. The level of control war veterans with PTSD feel in specific areas of a
healthcare environment and its effect on the stress and anxiety experienced.
For example, a patient in a lobby has more freedom to move around and a
choice of destination as compared to a patient in a procedure room, or in an
inpatient room.

This paper proposes that images that refer symbolically, allegorically, or literally, to the
combat experience of the war veterans should be avoided in healthcare settings, unless
it is a facilitated therapy session. We further propose that images that should be
included in the healthcare setting of VA centers and hospitals be positively reinforcing
without alluding to elements that could trigger combat‐related memories. Finally, we
propose that the reasons for which abstract or ambiguous art is considered
inappropriate for mainstream healthcare (Ulrich, 2009), holds even more true for VA
health systems‐ given the emotional state of veterans suffering from PTSD. Within these
broad parameters, the question still remains‐ what kind of visual imagery is particularly
appropriate for veterans in the above settings? Since the research is not in place today,
this paper revisits the guidelines of evidence‐based art, and annotates them with
possible hypotheses, based on the insights gleaned from the discussion in the body of
the paper, as follows:

Guideline 1: Waterscapes, containing calm or non‐turbulent water
Hypothesis: Images of steep waterfalls or wild water rapids that could appeal to the love
of action in healthy military personnel, may be particularly traumatic for veterans in
rehab. Even depictions of calm and non‐turbulent water should not be remindful of the
geographical location of combat.

Guideline 2: Landscapes, containing visual depth or open foreground, trees with broad
canopy, savannah landscapes, verdant vegetation
Hypothesis: Certain landscapes could serve as reminders of the geography of combat
and should be avoided. Careful research on geographies of combat for the particular
veteran populations should be conducted before selecting artwork.  Images of familiar
landscapes, that are particular to the geography of their homeland, could be non‐
threatening and restorative as well.

Guideline 3: Positive cultural artifacts (e.g. barns and older houses)
Hypothesis: Barns and older houses, if too generic and remindful of the geography of
combat, could be particularly stressful. During combat soldiers often use abandoned
structures to hide in, or target such structures during combat. Thus, use of cultural
artifacts should be within a clear, non‐combat context.  Also, this has strong implications
for commemorative settings that recognize the veteran’s sacrifice and love for country,
without serving as explicit reminders of war.  Elements could include flags, images of
iconic American landmarks, settings for gatherings as a community etc.

Guideline 4: Flowers, which are healthy and fresh, familiar, in gardens with open
foreground
Hypothesis: Images of flowers used should be in natural locations, flowers that are


18

blooming in verdant vegetation could be reminders of growth and regeneration.
Flowers that are cut, or on a bleak background, could serve as reminders of funerals,
and should be avoided.

Guideline 5: Figurative, with emotionally positive faces, diverse and leisurely
Hypothesis: War veterans have difficulty reintegrating back into society, often feeling
isolated, and estranged from their family and friends (Shay, 2002). They may be able to
identify more with fellow veterans, than with the life that was previously familiar and
reassuring to them.  Images of positive social relationships in natural and familiar
surroundings could be positively reinforcing, allowing them to gradually approach this
reintegration.

F INAL T HOUGHTS AND N EED FOR N EW R ESEARCH
Research on art therapy establishes how creating art is therapeutic.  Little is known
about the effect of “viewing” art.  This is surprising given the amount of information on
art for mainstream healthcare. There is need for focused research on the kind of visual
imagery that is appropriate for art in VA centers and hospitals ‐ places where veterans
suffering from PTSD are subjected to additional stress and anxiety associated with a
typical hospital experience. A research agenda must be formed at the following levels:

1. Preference Studies: Qualitative studies and surveys with returning war veterans
on the artwork and visual images they would like to see displayed in healthcare
settings. This investigation could be taken further by comparing the
preferences of veterans, non‐veterans, and veterans suffering from PTSD.

2. Outcome Studies: Once research is in place on the stated preferences for
artwork, it is incumbent to investigate the therapeutic value of viewing
preferred images. Outcome studies could include monitoring blood pressure
and heart rate in response to carefully selected images, in controlled
conditions. This would allow a scientific investigation of the
psychophysiological effect of exposure to visual imagery. Studies on the effect
of visual images on perception of pain are also a possibility. Since precedent for
these studies exist with acute‐care inpatients, a research design could also
compare how evidence‐based images that were shown to be restorative with
patients suffering from acute‐stress and anxiety affect patients suffering from
PTSD. This line of inquiry could extend beyond war veterans to other
populations who suffer from PTSD such as rape and abuse victims, accident
victims, etc.

3. Satisfaction Studies: Studies that compare the effect of evidence‐based art, to
no art, or art that does not follow guidelines, in terms of the overall level of
reported satisfaction and well‐being of veterans are another line of inquiry.
These studies would go beyond the investigation of specific visual images, to
evaluating the impact of a specific environmental feature. Such studies could
also evaluate the correlation of artwork to ratings of perception of quality of
care. There is precedent to show that appropriate artwork can affect patient


19

perception of the image of the hospital and the overall quality of care (Hathorn
& Nanda, 2008).

The directive for patient perception may vary from VA hospital to VA medical centers,
and within the different areas of the healthcare facility itself. For example in waiting
rooms, procedure rooms and inpatient rooms in VA hospitals the directive may be to
decrease stress and anxiety in order to ensure a smooth and successful procedure and a
safe recovery. In a VA medical center that veterans may visit for therapy sessions, the
directive may be to aid their ability to verbalize or express anxiety and trauma. In public
areas like lobbies the directive may be to make the veterans feel welcome and like they
belong. In procedure rooms, the directive may be to help them escape mentally from
the stress or pain that they are currently experiencing. Healthcare delivery is complex
and patients’ perceptions often drive their recovery. Research on the type of art and
visual images that veterans with PTSD prefer, how different kinds of visual images
impact their physiological outcomes and on the overall role of the passive viewing of art
in healthcare settings for war veterans is needed.

What is restorative for mainstream healthcare environments could potentially have the
same effect for VA centers and hospitals.  Cathartic imagery that has been found to be
successful in memorials and art therapy sessions could aggravate PTSD symptoms and,
in fact, have an adverse effect on the specific health problem that causes a veteran to
visit a healthcare facility. Given the growing numbers of war veterans experiencing PTSD
and the devastating nature of the symptoms of the disorder research on this subject is
needed.  Careful consideration of PTSD symptoms is warranted before any visual
imagery is selected for environments providing healthcare to veterans.


20



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