[page 18]

[page 18] [Mental
Illness 2014; 6:5354]
Art therapy: an underutilized,
yet effective tool
Robert A. Bitonte,1 Marisa De Santo2
1Department of Physical Medicine and
Rehabilitation, University of California,
Irvine Medical Center, Orange, CA;
2University of California, Irvine, CA, USA
Abstract
Art therapy has been recognized as beneficial
and effective since first described by Adrian Hill
in 1942. Even before this time, art therapy was
utilized for moral reinforcement and psycho-
analysis. Art therapy aids patients with, but not
limited to, chronic illness, physical challenges,
and cancer in both pediatric and adult scenarios.
Although effective in patient care, the practice of
art therapy is extremely underutilized, especially
in suburban areas. While conducting our own
study in northeastern Ohio, USA, we found that
only one out of the five inpatient institutions in
the suburban area of Mahoning County, Ohio,
that we contacted provided continuous art ther-
apy to it’s patients. In the metropolitan area of
Cuyahoga County, Ohio, only eight of the twen-
ty-two inpatient institutions in the area provided
art therapy. There could be many reasons as to
why art therapy is not frequently used in these

areas, and medical institutions in general. The
cause of this could be the amount of research
done on the practice. Although difficult to con-
duct formal research on such a broad field, the
American Art Therapy Association has succeed-
ed in doing such, with studies showing improve-
ment of the patient groups emotionally and men-
tally in many case types.
Early works
Art is known as one of the earliest forms of
communication, dating back to the cave art of
the Paleolithic age.1 Art therapy has been
increasingly recognized as beneficial and
effective in the treatment of various types of
both mental and physical conditions. For
example, art therapy has shown to be effective
as a treatment for traumatic brain injury,
schizophrenia, sexual abuse, breast cancer,
post-traumatic stress disorder, as well as
numerous other conditions.2-6
This has been described and studied since
Adrian Hill’s published work in 1942. Art ther-
apy has been shown to be effective in a broad
range of conditions. It has been generally rec-
ognized that art therapy enhances communi-
cation, and bolsters self-esteem. Despite the
apparent effectiveness of art therapy, and its
ready acceptance by patients, the prevalence of
the utilization of art therapy was this studies’
inquiry. Despite ongoing and recent studies
showing art therapy to be beneficial, it’s uti-
lization appears to be underutilized for rea-

sons unknown at this time.
Adrian Hill is generally known as the first
person to use the term Art Therapy in 1942.
Many of his works of art are displayed in the
Imperial War Museum in London, works that
he painted from the front lines as an official
war artist during World War I. Hill personally
discovered the therapeutic quality of art mak-
ing when he was recovering from tuberculosis
himself in 1938, and recorded his ideas in 1945
in Art versus Illness.6 He was employed as the
first official art therapist in 1946 by the
Netherene, a state psychiatric hospital in the
United Kingdom. He later became the presi-
dent of the British Association of Art
Therapists. Hill’s contributions became a mile-
stone for the acceptance and practice of what
we know today as art therapy.
More developed practices
Art therapy is not specific in it’s practices,
making it customizable to the ever-changing
life of a patient. Adolescents who experience
abuse, low self-esteem, depression, or any
other psychological issues tend to withdraw
from their parental figures, which works
against traditional verbal therapy. Art therapy
is a way for these troubled adolescents to feel
expressive in a non-judgmental environment.7
Art therapy is also increasingly important with
children and adolescents facing chronic ill-
ness. These practices are used to enhance the
young patient’s emotional, physical, and cogni-
tive development. A very important example is

within the field of pediatric oncology, where
restoring self image for the patient is crucial to
continue battling their illness. Furthermore,
art therapy can provide some end-of-life care
for patients to create mementos for their fam-
ily before death, to help cope, and say
goodbye.6 These same principles are applicable
to adults as well. In adult oncology, art therapy
has been used to help survivors create a life
outside of cancer, helping these individuals
find their identity past their survivor label.6 Art
therapy in the healthcare setting has also been
used in adult cases of hemodialysis, HIV/AIDS,
Alzheimer’s, and traumatic brain injury. In
addition, adults with schizophrenia, bipolar
disorder, borderline personality disorder,
PTSD, trauma from sexual abuse, dementia,
and many other conditions can find lasting
benefits from art therapy.8 Again, although it
may be difficult to quantify the effectiveness of
art therapy, studies have repeatedly shown that
art therapy is beneficial to patients within a
broad spectrum of conditions.
Specific applications
Traumatic brain injury
In a pilot study addressing group art therapy for
patients with traumatic brain injury, six subjects
with traumatic brain injury between the ages of
24 and 71 participated in five one hour art therapy
sessions. The subjects were evaluated before and
after the study using the Depression Anxiety and
Stress Scales. Throughout the sessions, the sub-
jects participated in low-anxiety activities like
making collages and working with 3D figures.

After the study was completed, 4 of 6 subjects had
a decrease in depression, 3 of 6 had a decrease in
anxiety, and 5 of 6 had a decrease in stress.2
Schizophrenia
Several studies have been produced to show
the effectiveness of art therapy for schizophren-
ics. An interesting example is an 83-year-old male
schizophrenic who was not responding to med-
ications, and was reported by caretakers to have
very unusual behaviors. A psychiatrist initiated
art therapy practices with him, having him depict
parts of his life through drawing. The patient’s
verbal resistance began to disappear and the
patient’s progress was able to be documented.3
Sexual abuse
In a four-year follow up of a pilot study, it was
shown that for sexually abused children and ado-
lescents, art therapy, paired with cognitive behav-
ioral therapy, was an effective intervention to
reduce symptoms that are commonly associated
with childhood sexual abuse.4
Epilepsy in children and adoles-
cents
In a focus group with children with epilepsy,
the use of art enabled said children and adoles-
Mental Illness 2014; volume 6:5354
Correspondence: Marisa De Santo, 34102 Blue
Lantern, Dana Point, CA 92629, USA.

E-mail: [email protected]
Key words: art, therapy, mental illness, head trauma.
Contributions: the authors contributed equally.
Conflict of interests: the authors declare no
potential conflict of interests.
Received for publication: 14 February 2014.
Accepted for publication: 14 February 2014.
This work is licensed under a Creative Commons
Attribution NonCommercial 3.0 License (CC BY-
NC 3.0).
©Copyright R.A. Bitonte and M. De Santo, 2014
Licensee PAGEPress, Italy
Mental Illness 2014; 6:5354
doi:10.4081/mi.2014.5354
[Mental Illness 2014; 6:5354]
[page 19]
cents to express repressed emotions related to
their illness. With the finding that many of the
children in the focus group had never met
another adolescent afflicted with epilepsy, the
focus group served as an extremely valuable
outlet for these children and adolescents dur-
ing critical times in their lives. The art work
produced was able to record their growth along
the way, resulting in the participants feeling
self discovery and can be believed to aid in an
increase of social activity outside of the focus

group, rather than social isolation that can
become common in these cases.6
Acute stress disorder
In an intervention with a 48-year-old woman
who had injured a motorcyclist three weeks
prior in a car accident, the treatment seeked to
lower her overwhelming anxiety, sleep prob-
lems, heart palpitations, and excessive flash-
backs of the accident. With certain drawing
techniques and manipulation of various medi-
ums, and discussion of such in relation to her
experience with the art therapist, the client
was able to rearrange the sensory and cogni-
tive overexcitation, and thus feel a sense of
control over the traumatic experience.6
Study interest and design
The first author’s interest in the treatment
of traumatic brain injury, and the second
author’s interest in art, were the impetus of
interest for this study. Studied were two areas
in Ohio. An urban area Cuyahoga County
(which includes Metropolitan Cleveland), and
a more rural suburban Trumbull and Mahoning
counties were examined. The inquiry was to
determine the availability of art therapy servic-
es in both if these rural and urban atmos-
pheres in Northeast Ohio, in the midwest sec-
tion of the Unites States. The survey was per-
sonally conducted by the second author by
phone. Each listed inpatient psychiatric unit
was successfully contacted.

Results
Our study found that in urban Cuyahoga
County, only 8 of 22 (36%) inpatient facilities
utilize art therapy as a treatment modality. In
Trumbull and Mahoning counties, 1 of 5 (20%)
inpatient institutions offered and utilized art
therapy (Figure 1). Contrary to expectations,
we believed the practice of art therapy would
be much higher in urban areas, and our study
concluded that this is not necessarily true. We
attempted to clarify why art therapy was not
used in the non-utilizing-institutions. The
questionnaire included the response options
of i) lack of instructors; ii) lack of interest or
demand by staff or patients; iii) lack of support
personnel or administration; or iv) lack of
funding. This study was unable to locate per-
sons qualified to answer this inquiry and has
been left for further study.
Conclusions
Our concluding thoughts on this study is
that art therapy, although having the ability to
be beneficial to various patient populations, is
underutilized for unknown reasons at this
time. The underutilization of art therapy must
be studied and understood before progress can
be made. Advocacy can then be tailored to rem-
edy the precise reason for underutilization of
art therapy.
References

1. Roberts J.M. The new penguin history of
the new world. London: Penguin Books;
2007. pp 23-26.
2. Graves G. Group art therapy for patients
with traumatic brain injuries: a pilot study.
Degree Diss.; Virginia Commonwealth
University, Richmond, Virginia; 2006.
3. Morrow R. The use of art therapy in a
patient with chronic schizophrenia.
Jefferson Journal of Psychiatry. 1985.
Available from: http://jdc.jefferson.edu/cgi/
viewcontent.cgi?article=1084&context=je
ffjpsychiatry
4. Pifalo T. Art therapy with sexually abused
children and adolescents: extended
research study. Art Therapy 2006;23:181-5.
5. Chang F. From emptiness to energizing
body. In: Malchiodi CA, ed. Art therapy and
health care. New York: The Guilford Press;
2013. p 154.
6. Malchiodi CA. Art therapy and health care.
New York: Guilford Press; 2013.
7. Riley S. Art therapy with adolescents.
Western J Med 2013;175:54-7.
8. Rivera RA. Art therapy for individuals with
severe mental illness. Masters Diss.;
University of Southern California, Los
Angeles, USA; 2008.

Review
Figure 1. Institutions that conduct and do not conduct at therapy
in Trumbull and
Mahoning Counties versus Cuyahoga County.
1Kaimal G, et al. BMJ Open 2018;8:e021448.
doi:10.1136/bmjopen-2017-021448
Open access
Observational study of associations
between visual imagery and measures
of depression, anxiety and post-
traumatic stress among active-duty
military service members with traumatic
brain injury at the Walter Reed National
Military Medical Center
Girija Kaimal,1 Melissa S Walker,2 Joanna Herres,3 Louis M
French,2,4
Thomas J DeGraba2
To cite: Kaimal G, Walker MS,
Herres J, et al. Observational
study of associations between
visual imagery and measures of
depression, anxiety and post-
traumatic stress among active-
duty military service members
with traumatic brain injury at

the Walter Reed National Military
Medical Center. BMJ Open
2018;8:e021448. doi:10.1136/
bmjopen-2017-021448
► Prepublication history for
this paper is available online.
To view these files, please visit
the journal online (http:// dx. doi.
org/ 10. 1136/ bmjopen- 2017-
021448).
Received 11 January 2018
Revised 11 May 2018
Accepted 18 May 2018
For numbered affiliations see
end of article.
Correspondence to
Dr. Girija Kaimal;
[email protected] drexel. edu
Research
AbstrACt
Objectives The 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.
Design Observational study of correlations between
clinical symptoms of post-traumatic stress, depression and
anxiety and visual themes in mask imagery.
setting The National Intrepid Center of Excellence at the
Walter Reed National Military Medical Center, Bethesda,
Maryland, USA.
Participants Active-duty military SMs (n=370) with a
history of traumatic brain injury, post-traumatic stress
symptoms and related PH conditions.
Intervention The masks used for analysis were created
by the SMs during art therapy sessions in week 1 of a
4-week integrative treatment programme.
Primary outcomes Associations 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).
results Visual 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.
Conclusions Emergent patterns of resilience and risk
embedded in the use of images created by the participants
could provide valuable information for patients, clinicians
and caregivers.

IntrODuCtIOn
Since 2001, more than 2.7 million servicemen
and servicewomen have been deployed in
support of combat operations around the
world.1 A survey conducted by the Veterans
Administration from 2006 to 2010 estimated
strengths and limitations of this study
► This study offers the first systematic examination
of the associations between visual self-expression
and how it relates to standardised clinical self-report
measures.
► This is the first study to demonstrate patterns of risk
and resilience as they relate to visual imagery creat-
ed by military service members with traumatic brain
injury and symptoms of post-traumatic stress.
► The visual imagery was created in art therapy ses-
sions and cannot be applied to other contexts of art
making.
► The study was performed within the framework of
a comprehensive integrative outpatient assessment
and treatment programme.
► The findings are associative and correlational in
nature, which precludes attribution of any causal
relationships.
► The study findings are limited to men and women
actively serving in the US military.
http://bmjopen.bmj.com/

http://dx.doi.org/10.1136/bmjopen-2017-021448
http://crossmark.crossref.org/dialog/?doi=10.1136/bmjopen-
2017-021448&domain=pdf&date_stamp=2018-06-11
2 Kaimal G, et al. BMJ Open 2018;8:e021448.
doi:10.1136/bmjopen-2017-021448
Open access
that post-traumatic stress disorder (PTSD) has affected
about 480 748 service members (SMs).1 Additionally,
379 5192 military SMs were diagnosed as having suffered
a traumatic brain injury (TBI), the vast majority of them
in the mild range.3 Recent research has highlighted the
co-occurrence of these severe diagnoses in military SMs,
with the total financial costs of treating these disorders
estimated as high as $6 billion for those with PTSD and
$910 million for those with TBI.4 Effective care for those
with persistent neurological and behavioural symptoms
from these injuries is imperative, both for the society and
for the military health system. PTSD and TBI are condi-
tions that are particularly prevalent among veterans.3 5
Individually complex, the effects of these conditions are
exacerbated when they occur together.6 Because the
neuroanatomical disturbances and the symptoms of
PTSD and TBI may be similar, it is possible that they share
some common mechanisms.6 Individuals with TBI often
develop PTSD and experience psychological health (PH)
symptoms such as irritability, anger, heightened arousal,
lack of concentration and sleeping difficulties.7 Psycho-
logical disorders such as depression and anxiety have also
been found to be common comorbid conditions in indi-
viduals with PTSD and TBI.8 9 In addition, demographic

characteristics like time in the service, including multiple
deployments,10–13 race/ethnicity,14 15 and rank (officer
or enlisted SM)16 17 have been associated with severity of
symptoms.
One of the challenges with treating PTSD can be the
limited ability of the patient to express his or her symp-
toms verbally.18–20 Thus alternative forms of communi-
cation such as visual self-expression through art therapy
are increasingly accepted as treatments for individuals
with PTSD, TBI and PH.21–26 Mask-making is one such art
therapy approach that has shown significant promise.27–29
Specifically, ‘trauma masks’ have assisted military SMs
to visually communicate the effects of combat-related
trauma to help build a coherent sense of self postin-
jury.30–32 Through the use of symbols and sensations that
are externalised and shaped into a narrative, art therapy
can assist in the processing of traumatic material,30
making the traumatic material more tolerable through
its externalisation, and enable narrative construction
of fragmented trauma memories.25 32–35 Art therapy is a
particularly useful approach for symptoms of combat-re-
lated PTSD, such as avoidance and emotional numbing,
while also attending to underlying issues for this popu-
lation, including relaxation, non-verbal expression,
containment, symbolic expression, externalisation and
pleasure.24 25
Although cognitive processing therapy is the first line
of psychotherapy in the military,36 other approaches like
art therapy have been shown to decrease anxiety in adults
with a variety of mental health conditions.37 –41 Results
from the combination of cognitive behavioural therapy
and art therapy indicate that art therapy could be a viable
addition, particularly for patients with panic disorder
with agoraphobia and generalised anxiety disorder who

are not responsive to verbal therapies.41 By creating
visible depictions of their internal psychological states
in art therapy sessions, patients have the opportunity to
observe a tangible externalised object. This process and
the resulting image may aid them in developing strategies
to cope with feared situations, thereby desensitising them
to the fear at hand38 41 and helping them to engage their
senses to foster a connection between the mind and the
body.42 Similarly, art therapy has been found to reduce
depressive symptoms35 through evoking the expression of
positive emotions through the creative process, building
social connections43 and providing an alternative form of
self-expression.44
Most of the findings in art therapy and the military
have tended to be based on clinical observations and
small pilot studies.24 25 Despite clinical reports of the
potential of art therapy to address symptoms of depres-
sion and anxiety, no one has examined the associations
between the imagery created in art therapy sessions with
standardised measures of clinical symptoms. Analysis
of SMs’ visual representations in masks indicates that
they depict a range of experiences related to PTSD and
TBI, including the use of visual metaphors, depictions
of psychological injuries and reflections on the experi -
ences of belonging in the military and deployment in a
war zone. We present the associations between themes
in the mask imagery made during art therapy sessions
and corresponding measures of depression, anxiety and
PTSD.26
MethODs
setting
The National Intrepid Center of Excellence (NICoE)
located at the Walter Reed National Military Medical

Center (Bethesda, Maryland, USA) offers an interdis-
ciplinary intensive outpatient programme that uses an
integrative holistic model of care to serve active-duty SMs
with a history of TBI, a comorbid PH condition and symp-
toms that have not responded to first-line treatments. On
referral and acceptance, six new SMs and their families,
as available, are admitted to the centre each Monday and
move through the 4-week programme as a therapeutic
cohort. SMs undergo a standardised evaluation using core
assessment tools, which includes contact with 17 medical
and integrative health disciplines. As part of the initial
behavioural health assessment and treatment, all SMs
engage in a group art therapy mask-making session in
week 1 of their 4-week integrative treatment programme.
A series of neurological, psychiatric and psychological
assessments are conducted concurrently with the art
therapy sessions. The intake surveys are completed in the
same week as the mask-making (week 1), but prior to the
mask-making session as part of a battery of intake assess-
ments on admission.
The authors obtained the consent of the SMs to use all
of their clinical data for research purposes.
doi:10.1136/bmjopen-2017-021448
Open access
Patient and public involvement
Patients and the public did not participate in the research
design or data analysis for this study.
Participants

Participants in the study included SMs (n=370). They
ranged in age from 20 to 50 years and included SMs from
all branches of the Armed Services, including the National
Guard, who were referred to the Walter Reed National
Military Medical Center (NICoE intensive outpatient
treatment programme). These individuals had a history
of mild TBI and comorbid PH concerns, including mood
problems, stress symptoms (or overt PTSD) or other
related conditions.
Data sources
All data at the NICoE are archived in a specialised de-iden-
tified database that can link mask images, participants’
narrative descriptions of mask imagery, experiences in art
therapy as described in the clinical notes of the therapists
and standardised measures of psychological functioning.
In a previous publication, we described the process of
identifying thematic classifications in the mask-making
products created by SMs.26 Figures 1–8 describe the prom-
inent themes in the masks used for analysis and a sample
image visually depicting those themes. (Artwork credit:
NICoE and Veterans Affairs National Center for Ethics
in Health Care.) The thematic classifications generated
from this analysis were converted into a database that
Figure 1 Psychological injury (depiction of psychological
struggles with sadness, anger, inability to verbalise and social
isolation).
Figure 2 Identification with military unit (depiction of
sense of belonging to a military unit, for example, explosive
ordnance disposal badge, also known as the ‘crab’).
Figure 3 Use of fragmented military symbols (depiction
of fragmented symbols associated with the military such as

flags, camouflage fabric and dog tags).
doi:10.1136/bmjopen-2017-021448
Open access
included dichotomous variables (1=theme present and
0=theme absent). Thus, each SM’s mask included a 0 or
1 for each classification that was identified for the whole
data set. The data were coded by four members of the
research team. Two of the coders coded all the data and
then two more coders checked these codes. Discrepancies
in coding were reviewed, and a final code was assigned
as apt in consultation with the lead author. Masks were
coded for more than one thematic category if more than
one was represented in the image. Every mask had more
than one theme associated with the imagery and all of the
themes were included in the analysis. Additional details
on the coding process are described in a previous publica-
tion.26 Given that some of the themes recurred many times
and others only a few times, we chose a cut-off of n=20 for
the classifications to be included in the database in order
to have an adequate number for analyses. The coded
database was then integrated with the standardised data
from the PTSD Checklist-Military (PCL-M),45 the Patient
Health Questionnaire-9 (PHQ-9)46 and the Generalized
Anxiety Disorder 7-item (GAD-7)47 scale for further anal-
ysis. These questionnaires were administered to the SMs
during the same week as the mask-making art therapy
sessions. Although the data were collected at the Walter
Reed National Military Medical Center, the de-identified
data set was transferred to Drexel for analysis, per prior

agreement. No coded linkage information was kept at the
Walter Reed National Military Medical Center.
Data analysis
The data were first summarised using descriptive statistics
of study variables. For subsequent analyses, we focused
especially on the most frequently occurring elements
represented in the masks.26 Using the unique ID number
provided for each SM, we ran independent sample t-tests
to examine whether the mean scores for post-traumatic
stress symptoms as measured by the PCL-M, for depres-
sive symptoms as measured by the PHQ-9 and for anxiety
symptoms as measured by the GAD-7 differed depending
on whether the participants’ themes were psycholog-
ical injury, military identity or metaphors. Finally, we
explored the metaphor themes further by conducting
analysis of covariance tests to examine the unique effects
of the different uses of metaphors on the symptom scales.
Given that metaphors were represented in four different
ways, we wanted to examine if the type of visual metaphor
would be associated with symptoms of post-traumatic
stress, depression and anxiety.
results
Overall, based on clinical notes maintained by the art
therapist, when referring to the experience of making the
masks, SM participants reported that art therapy helped
Figure 4 Metaphors (depiction of inner psychological states
through a visual image).
Figure 5 Colour symbolism (specific individual colours as
metaphorical representations of experiences and emotions).

doi:10.1136/bmjopen-2017-021448
Open access
mainly with enjoyment (n=136), with focus and concen-
tration (n=72) and with relaxation/calming (n=52). In
addition, SMs (n=74) said the mask-making helped with
socialisation and with opening up about their injuries,
treatment processes and struggles. A small proportion
of participants (n=11) did not report a positive experi -
ence and cited reasons like dissatisfaction with the final
product and disinterest in art making. Table 1 shows
the descriptive statistics for the study variables.
Table 2 shows differences in mean symptoms for the
mask themes of ‘psychological injury’ and ‘metaphors’.
Participants whose masks reflected evidence of psycholog-
ical injury (n=102) in the mask-making reported higher
PTSD symptoms, whereas those whose masks coded
positive for metaphors (n=125) had lower anxiety symp-
toms. Those who used symbols that included fragmented
representations of military symbols (n=44) reported more
anxiety, whereas those who used representations of their
military unit identity (n=41) reported less PTSD and
depression. Fragmented refers here to pieces of items
associated with the military such as camouflage fabric
and pieces of weapons, flags and tags. Table 3 provides
three univariate analyses of covariance used to determine
whether there were mean differences in the subtypes of
the broad theme of metaphors while controlling for time
in the service, race/ethnicity and officer status. These
covariates were chosen as controls based on the literature
in order to account for any effects that might be related
to these demographic variables. As shown, participants

whose masks showed evidence of colour symbolism (use
of colour as a metaphor) (n=46) had higher PCL-M and
PHQ-9 scores. Participants whose masks showed evidence
of cultural/historical characters (n=21) and cultural/
societal symbols (n=42) had lower GAD-7 scores and
tended to have lower depressive symptom scores. In addi -
tion, the use of nature-related imagery (n=33) trended
towards lower post-traumatic stress symptom scores, indi-
cating the potential health-promoting aspect when SMs
depicted such imagery.
DIsCussIOn
This study examined participants’ experiences of art
therapy and associations between the visual imagery in
the masks and clinical data from standardised measures
of symptoms of post-traumatic stress, depression and
anxiety. The findings indicate that there are patterns of
recurring associations between clinical symptoms in the
visual imagery created by SMs in art therapy sessions.
Some of the specific findings of note are that participants
whose masks depicted psychological injury reported
Figure 6 Cultural or historical characters (depiction of
characters from history, films and literature).
Figure 7 Sociocultural symbols (inclusion of images from
objects commonly seen in society).
doi:10.1136/bmjopen-2017-021448
Open access
higher scores on the PCL-M scale. This finding indicates

a potential clinical significance when SMs depict their
psychological injuries and that this could be helpful to
direct specific focus on the clinical care of PTS symp-
toms when such imagery is depicted, such that depic-
tion of psychological struggles might be an indicator of
heightened symptoms of post-traumatic stress requiring
targeted care. When we reviewed artwork of combat
veterans with PTSD, we found evidence of ‘post-traumatic
conflict being experienced and depicted by the graphic
themes of war and the telling of self-portraits of disfig-
urement symbolic of alteration of one’s previous self’
(p44).30 SMs might be less likely to report mental health
issues due to the social stigma that these issues may be
misinterpreted as weakness or laziness.48–51 The associa-
tion between post-traumatic stress scores and visual depic-
tion of psychological injury suggests that this might be a
forum for safe self-expression.
Those participants whose masks coded positive for
metaphors also reported lower anxiety symptoms, indi-
cating that the use of metaphors is associated with the
SM reaching a level of insight into the psychological
issues in order to lower the level of anxiety and perhaps
develop some inner resilience that enables the SM to
depict images that involved imaginative variations on the
lived psychological experience. Further examination of
subtypes of metaphors revealed potential differences in
the associations with clinical data. For example, the use
of colour symbolism (eg, when an SM said that the colour
represented something specific like red represented
victory or blue represented sadness) was associated with
higher scores for PTSD and depression. These patterns
of association were also seen prominently in the use of
military symbols. Those who used fragmented military
symbols (eg, flag fragments, pieces of camouflage fabric
or dog tags) reported more anxiety. These fragmented

associations were associated with higher anxiety scores.
In contrast to fragmented symbols, those who used
visual symbols of their military unit reported less PTSD
and depression. These differences might imply that
representation of the military unit is akin to identifying
with a community and potentially reinforcing a sense of
belonging. The development of a group identity in the
military is well established as a means to ensure trust
and effectiveness in a war zone through shared commit-
ment and social cohesion.52–55 The findings highlight
the protective role of a sense of belonging and group
identity in the treatment process, beyond the period
of deployment in the war zones. In fact, a strong sense
of belonging could protect Air Force convoy opera-
tors against depression before and after their deploy-
ments.51 53 Some of the healing elements seen in art
therapy are the promotion of self-exploration, self-ex-
pression, symbolic thinking, creativity and sensory stim-
ulation.55 In a study of depression and dependency in
SMs, it was found that art therapy offered a sense of
control and served to integrate past experiences with
present connections.55
Figure 8 Nature images (inclusions of images from nature in
mask).
Table 1 Descriptive statistics for demographics and clinical
study variables
n % of sample
Male 361 97.0
African–American 14 3.8

Asian or Pacific Islander 8 2.2
Caucasian 329 89.2
Hispanic 15 4.1
Air Force 33 8.9
Army 119 32.2
Coast Guard 1 0.3
Marines 50 13.5
Navy 167 45.1
Officer 54 14.6
M SD
Age, years 36.08 7.62
Time in service, years 14.61 7.31
PCL-M score 51.98 15.86
PHQ-9 score 13.10 6.17
GAD-7 score 10.65 6.01
GAD-7, Generalized Anxiety Disorder 7-item scale; PCL-M,
PTSD
Checklist for DSM-5; PHQ-9, Patient Health Questionnaire-9;
PTSD, post-traumatic stress disorder.

doi:10.1136/bmjopen-2017-021448
Open access
The use of nature metaphors trended towards associ-
ation with lower PTSD scores. This finding suggests that
when SMs represented nature imagery, they might have
been tapping into inner resources of strength and resil -
ience. Reference to cultural historical characters was
also associated with less depression and anxiety. Taken
together, these visual metaphors might in general be
indicative of sources of creativity and resilience. However,
fragmented associations like depicting colours for specific
emotions might not be associated with the higher levels
of illness seen in PTSD and depressive symptoms. Imagery
that represents this integration might be associated with
more positive clinical scores compared with those repre-
senting more fragmented imagery.
This study has several limitations. All of the data related
to the masks are self-reported secondary data collected
as part of clinical practice. The findings indicate patterns
of occurrence in visual imagery and scores on stan-
dardised clinical symptoms and are not representative of
any causal relationships and must be interpreted accord-
ingly. The control variables in the study including time
in service, race/ethnicity and rank (officer or enlisted
SM) were selected based on information in the literature.
Most of the data are from male SMs; thus it is unclear if
similar patterns might be seen among female SMs. Addi-
tional research is needed to determine why metaphorical
depictions can denote the presence of different levels
of psychological risk and resilience and how they relate

to the demographic characteristics of the SM. In addi-
tion, further research is needed to determine why some
themes were more strongly associated with specific clin-
ical symptoms than others. One explanation for inconsis-
tent findings across symptom scales is the varying number
of participants who completed each scale. It is possible
that the study was underpowered for identifying differ-
ences in the GAD that were consistent with the PCL and
PHQ findings when the control variables were added to
the model.
In conclusion, this study addresses a new area of enquiry
associating patient clinical data with imagery to begin to
develop a framework for how psychological states might
be represented in visual media. The findings have the
potential to help clinicians identify sources of strength
and of risk factors for SMs with PTSD and TBI.
Table 2 Mean and SD for the symptom scores across mask
classifications
Outcome
Psychological injury Metaphors
No Yes t No Yes t
PCL-M (n=349) 50.66 (16.26) 55.51 (14.24) −2.72** 52.06
(15.94) 51.83 (15.78) 0.132
PHQ-9 (n=282) 12.95 (6.16) 13.54 (6.22) −0.710 13.25 (6.23)
12.84 (6.09) 0.530
GAD-7 (n=75) 9.96 (5.74) 12.83 (6.47) −1.79 11.96 (6.05) 8.46
(5.36) 2.52*

Outcome
Military symbols Identification with military unit
No Yes t No Yes t
PCL-M (n=349) 51.51 (16.05) 55.54 (14.07) 1.53 52.59 (15.73)
42.52 (15.33) 2.847**
PHQ-9 (n=282) 13.03 (6.26) 13.72 (5.41) −0.572 13.3 (6.10)
9.75 (6.57) 2.255*
GAD-7 (n=75) 10.23 (5.87) 18.25 (2.22) −6.128** 10.93 (6.01)
6.80 (5.07) 1.497
*P<0.05, **p<0.01, ***p<0.1.
PTSD Checklist for DSM-5; PHQ-9, Patient Health
Questionnaire-9; PTSD, post-
traumatic stress disorder.
Table 3 Mean differences in symptom scores for those whose
masks showed evidence of metaphor subtypes
Variable (%
coded positive)
PCL-M (η2 =0.23)
sη2
PHQ-9 (η2 =0.28)
sη2
GAD-7 (η2 =0.50)
sη2No Yes F(1, 306) No Yes F(1, 245) No Yes F(1, 54)

Colour symbolism
(12.2%)
51.14 58.34 8.23** 0.03 13.92 16.96 7.18** 0.03 10.08 9.22
0.07 0.002
Cultural/historical
characters (5.7%)
55.71 53.78 0.27 0.001 16.80 14.07 3.53*** 0.02 13.10 6.20
9.19** 0.20
Sociocultural
symbols (11.4%)
56.08 53.41 0.88 0.001 16.33 14.54 2.09 0.003 13.22 6.08 6.57*
0.15
Nature metaphors
(8.9%)
57.46 52.03 3.38*** 0.01 16.11 14.77 1.23 0.003 10.53 8.76
0.92 0.01
All three analyses of covariance tests were controlled for time
in service, ethnicity and officer status.
*P<0.05, **p<0.01, ***p<0.1
PTSD Checklist for DSM-5; PHQ-9, Patient Health
Questionnaire-9; PTSD, post-
traumatic stress disorder.
doi:10.1136/bmjopen-2017-021448

Open access
Author affiliations
1Creative Arts Therapies, Drexel University College of Nursing
and Health
Professions, Philadelphia, Pennsylvania, USA
2National Intrepid Center of Excellence, Walter Reed National
Military Medical
Center, Bethesda, Maryland, USA
3Department of Psychology, The College of New Jersey,
Stockton, New Jersey, USA
4Center for Neuroscience and Regenerative Medicine,
Uniformed Services University
of the Health Sciences, Bethesda, Maryland, USA
Acknowledgements We are grateful to Dr Jesus Caban, Ms
Kathy Williams, Ms
Pamela Fried, Ms Rebekka Dieterich-Hartwell and Ms Adele
Gonzaga for help with
gathering literature and preparing the data set for analysis.
Contributors All the authors contributed to the study as follows:
GK led the study
and conducted the review of the masks with MSW. JH
conducted the statistical data
analysis. LMF and TJD helped with manuscript review,
including the discussion and
implications sections. TJD designed the database protocol from
which the clinical
data for the analysis were used and patient consents were
obtained.
Funding We are grateful to the National Endowment for the
Arts’ Creative Forces:
The NEA Military Healing Arts Network for providing funding

to support this study.
Competing interests None declared.
Patient consent Not required.
ethics approval The study was conducted with approval from the
Walter Reed
National Military Medical Center (Bethesda, Maryland, USA)
institutional review
board, in accordance with all federal laws, regulations and
standards of practice, as
well as those of the Department of Defense and the Departments
of the Army, Navy
and Air Force and the partnering university.
Provenance and peer review Not commissioned; externally peer
reviewed.
Data sharing statement The raw data were shared between the
institutions as
part of a data-sharing agreement. These data are not available
for public sharing.
Open access This is an open access article distributed in
accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC
4.0) license, which
permits others to distribute, remix, adapt, build upon this work
non-commercially,
and license their derivative works on different terms, provided
the original work is
properly cited and the use is non-commercial. See: http://
creativecommons. org/
licenses/ by- nc/ 4. 0/

© 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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Observational study of associations between visual imagery and
measures of depression, anxiety and post-traumatic stress
among active-duty military service members with traumatic
brain injury at the Walter Reed National Military
Medical CenterAbstractMethodsSettingPatient and public
involvementParticipantsData sourcesData
analysisResultsDiscussionReferences
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The Arts in Psychotherapy 47 (2016) 55–65
Contents lists available at ScienceDirect
The Arts in Psychotherapy
linical outcomes from The BodyMind ApproachTM in the
treatment of

atients with medically unexplained symptoms in primary
health
are in England: Practice-based evidence
elen Payne, MPhil, PhD, UKCP Reg. Psychotherapist,
ADMP UK, AVR a,∗ ,
usan D.M. Brooks, BSc, MA, MA, MBA b
School of Education, University of Hertfordshire, De Havilland
Campus, Hatfield, Hertfordshire AL10 9EU, England, United
Kingdom
Pathways2wellbeing, 27 Bridge Street, Hitchin, Herts SG5 2DF,
England, United Kingdom
r t i c l e i n f o
rticle history:
vailable online 18 December 2015
eywords:
he BodyMind ApproachTM
edically unexplained symptoms
rimary care
ractice-based evidence
a b s t r a c t
This article builds on Payne (2015) and reports on
practice-based evidence arising out of the delivery
of a new and innovative service using The BodyMind
ApproachTM (TBMA) for the treatment of patients
with medically unexplained symptoms (MUS) in primary
care in the National Health Service (NHS) in
Hertfordshire, a county near London, England, in the UK.
The analysis of data collected for three groups

(N = 16) over 18 months used standardised assessment
tools and other relevant information at pre, post
and at a 6 month follow up. The outcomes for patients in
this small scale piece of practice based evidence
indicated that there were reductions in sympto m distress,
anxiety and depression, increased overall
wellbeing and improvement in activity levels. Patients
developed self-management of their symptoms
through understanding, acceptance and coping strategies.
The increased knowledge, exchange of expe-
riences together with understanding and acceptance from
others promoted a sense of wellbeing. Thus,
the programme was experienced to be a beneficial
intervention. In addition to the clinical outcomes
reported here there are other benefits for NHS England for
example, savings on medication and referral
costs and General Practitioner (GP) capacity enhanced. The
clinical service is based on previous research
conducted by Payne and Stott (2010). This article focusses
solely on the analysis and interpretation of
clinical outcomes from the practice-based evidence.
ntroduction
The innovative clinical service reported in this article is being
ffered to primary care patients with medically unexplained
symp-
oms (MUS) through the National Health Service (NHS) in a
county
n England. Edwards, Stern, Clarke, Ivbijaro, and Kasney (2010)
efine MUS as ‘a clinical and social predicament, includes broad
pectrum of presentations, difficulty accounting for symptoms
ased on known pathology’ (p. 1). They go on to say in Diagnos-
ic and Statistical Manual for Mental Disorders (DSM IV-TR)
that

he nomenclature for MUS has several categories including
soma-
isation disorder, conversion disorder, pain disorder, and that the
riteria is cumbersome and unhelpful in practice.
∗ Corresponding author. Tel.: +44 1707 285861.
E-mail addresses: [email protected] (H. Payne),
[email protected] (S.D.M. Brooks).
URLs: http://www.herts.ac.uk (H. Payne),
ttp://www.pathways2wellbeing.com (S.D.M. Brooks).
ttp://dx.doi.org/10.1016/j.aip.2015.12.001
197-4556/© 2015 Elsevier Ltd. All rights reserved.
© 2015 Elsevier Ltd. All rights reserved.
Both the DSM-5 and the proposed International Classification
of Diseases – 11th Revision (ICD-11) change the criteria for
MUS
and replace the term by Somatic Symptom and Related
Disorders
(SSD). In DSM-5 F45.1 SSD is cross-walked to ICD9 code
300.82
(ICD10-CM F45.1). SSD is defined in DSM-5 as symptoms that
are
distressing or result in significant disruption to feeling,
thoughts
and behaviour, related to somatic symptoms as manifested by at
least one of the following: disproportionate and persistent
thoughts
about the seriousness of one’s symptoms, or persistently high
lev-
els of anxiety about health symptoms and excessive time and

energy devoted to these symptoms of health concerns
(Diagnostic
and Statistical Manual of Mental Disorders-5, 2013). It states
that
somatic symptom and related disorders includes the diagnoses
of
somatic symptom disorder, illness anxiety disorder, conversion
dis-
order (functional neurological symptom disorder), psychological
factors affecting other medical conditions, factitious disorder
other
specified somatic symptom and related disorder, and
unspecified
somatic symptom and related disorder. All of the disorders
share
a common feature: the prominence of somatic symptoms associ -
ated with significant distress and impairment. Such patients are
dx.doi.org/10.1016/j.aip.2015.12.001
http://www.sciencedirect.com/science/journal/01974556
http://crossmark.crossref.org/dialog/?doi=10.1016/j.aip.2015.12
.001&domain=pdf
mailto:[email protected]
mailto:[email protected]
http://www.herts.ac.uk
http://www.pathways2wellbeing.com
dx.doi.org/10.1016/j.aip.2015.12.001

5 ts in P
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6 H. Payne, S.D.M. Brooks / The Ar

ommonly found in primary care and less encountered in mental
ealth settings. The term is thought to be more useful than that of
US in primary care (Creed et al., 2010).
SSD includes the former somatisation disorder, undifferenti -
ted somatoform disorder, and pain disorder. The change is that
he diagnostic criteria are no longer based on the presence of
US, but focuses on one or more somatic symptoms that are dis-
ressing and/or result in significant disruption of everyday life.
lthough there are criticisms (Frances, 2013; Voigt et al., 2012)
his change removes the diagnostic problem of having to distin-
uish between medically explained and unexplained symptoms
Creed et al., 2010). The shortcomings of the MUS category is
he mind-body dualism present in the unreliable classification of
omplaints as medically explained or not (Creed, 2009; Sharpe,
ayou, & Walker, 2006) and the random categorisation into dif-
erent somatoform disorders (Leiknes, Finset, Moum, &
Sandanger,
008).
This dualism reinforces the GP training to address physical
ather than mental health issues and the patient’s perception that
heir symptom is purely physical because of the sensory experi-
nce. It reinforces dualistic thinking and the idea that illness is
ither biological or psychological. The term defines the illness
by
hat it is not, i.e. it implies no organic cause which is not neces -
arily accurate and limits treatment. Research has shown that
most
atients prefer a positive description of symptoms, i.e. an
explana-
ion of what it is rather than what it is not. The term MUS may

seem
lib communicating that nothing can be done. Cognitive
Behaviour
herapy (CBT) with relaxation and/or graded exercise has some
ffectiveness for some symptoms (Whiting et al., 2001).
Although
sychological treatment may work in some cases this does not
eflect that the symptoms are necessarily psychological (Creed,
enningsen, & Fink, 2011). Other terms in use in a Department
f Health (DH) recent document on MUS (DH, 2014) are
claimed
o be more acceptable to patients such as persistent physical
symp-
oms or functional syndromes/symptoms (FS) (Stone et al.,
2002). The
erm “functional” here is used because it is assumed that the
disor-
er is one of function, which may be physical and/or
psychosocial
unction, rather than anatomical structure (Sharpe, 2000).
The clinical outcomes of TBMA as a treatment reported here are
ased upon the definition and criteria for MUS used in DSMIV,
i.e.
efore the changes made with reference to MUS in DSM-5.
The treatment service is delivered in the English NHS primary
are setting by a University of Hertfordshire spin-out company
athways2Wellbeing (P2W)TM. Primary care in the NHS refers
to
he first port of call for patients in the community which
involves
Ps working in local practices. Secondary care involves hospitals
nd other medical establishments or treatments to which GPs
refer
atients. GPs act as the access, by way of referral, to any

specialist
nterventions in either primary or secondary care. The treatment
ervice offered by P2W is called Symptoms Groups to patients
and
he MUS Clinic to the GPs referring patients with various
medically
nexplained symptoms (such as fibromyalgia, IBS, chronic pain
or
hronic fatigue) from primary care. At no time is the term MUS
used
ith patients.
The groups use TBMA, which is based on a bio-psychosocial
odel derived from aspects of interpersonal therapy, embodied
roup psychotherapy (dance movement psychotherapy/authentic
ovement), the arts and mindfulness. It is not designed as a form
of
sychotherapy, but an adaptation for non-psychologically minded
atients deriving from an integration of the above. The groups
are
alled workshops and the treatment is a course. This approach
has
een hitherto researched and delivered as a service in the NHS
ith patients with medically unexplained symptoms (MUS) (pre-
iously termed psychosomatic conditions). These patients have
ery limited pathways for supporting their wellbeing in primary
are and are high health utilisers (Bermingham, Cohen, Hague, &
sychotherapy 47 (2016) 55–65
Parsonage, 2010). They suffer with chronic, physical symptoms

or
conditions which do not appear to have an organic, medical
diagno-
sis and normally with co-occurring anxiety and/or depression.
The
negative impact of the conditions and lack of curative
treatments
means effective non-pharmacological interventions that promote
better coping abilities need to be developed.
TBMA treatment aims to bridge the gap between mental and
physical health services for these patients with chronic MUS. It
uses the inter-relationship between body and mind for the treat-
ment of such patients with these persistent symptoms. Further
details on the approach can be found in Payne (2015) and Lin
and
Payne (2014). The University’s newly endorsed company P2W
is
the vehicle for the service with the knowledge arising from the
pilot research being transferred into a real world service
delivery
as clinical progress reporting. This recent service delivery
project
(2012–2013) was funded by the DH initiative Quality, Innova-
tion, Productivity and Prevention (QIPP) scheme in a
competitive
bid from the authors and Hertfordshire Primary Care Trust
(Men-
tal Health). The delivery took place in community settings with
patients referred by GPs from primary care. The service was
free
at the point of delivery. The naturalistic delivery and the
lessons
learned from the experience are documented in Payne (2015).
This
article focusses solely on an evaluation of the clinical outcomes

for the patients from a small scale implementation of TBMA in
the
NHS. The small sample size (N = 16) and the lack of a control
arm
means that the outcomes cannot be generalised with any confi-
dence. However, the indicative outcomes which are very
positive
are consistent with a previous pilot study conducted at the
Univer-
sity of Hertfordshire (Payne & Stott, 2010) and may be
transferable.
Medically unexplained symptoms
Patients with chronic MUS (presenting for over 6 months with
the same symptom/s) are quite complex and are high health
utilisers for whom there are few pathways for support and self-
management other than (for a few symptoms) CBT and/or pain
relief. In a recent practice guideline published by the UK DH,
(July
2014) as a part of Improving Access to Psychological Therapies
(IAPT) initiative, it is concluded that “community mental health
teams and primary care mental health services have not been
suc-
cessful in engaging with patients experiencing MUS, as patients
often do not perceive their condition to be related to mental
health
problems, and attempting to engage them in traditional mental
health approaches is often ineffective” (DH, 2014, p. 5).
Therefore to review the research on self-management in CBT is
not relevant to the purpose of this article.
A systematic review of research (Du et al., 2011) was conducted
for the self-management programmes on pain and disability for
chronic musculoskeletal pain conditions (not necessarily MUS).

For chronic back pain, there was insufficient evidence to deter -
mine the effectiveness of self-management programmes. In a
more
recent review (Oliveira et al., 2012) for non-specific low back
pain
results showed moderate-quality evidence that self-management
has small effects on pain and disability which challenge the
endorsement of self-management in treatment guidelines.
MUS patients are high utilisers of health care resources. In
2008–2009 approximately £3 billion was spent on patients with
MUS in the NHS (11% of total budget) rising to £18 billion
includ-
ing the cost to the wider economy through lost productivity
(Bermingham et al., 2010).
No serious medical cause was the diagnosis in 25–50% of all
pri-
mary care visits (Barsky & Borus, 1995) and only 10–15% of
the
14 common, physical symptoms seen in half of GP consultations
over 12 months were found to be caused by an organic illness
(Morriss, Dowrick, & Salmon, 2007), resulting in 85–90% being
of
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H. Payne, S.D.M. Brooks / The Ar
nknown biological aetiology. These patients are often taking
med-
cation, regularly visit health professionals (more than five times
er year) and for longer consultations than the 11 min per visit
er symptom allowable in the NHS. Furthermore, they use many
esources accounting for as many as one in five new
consultations
Bridges & Goldberg, 1985). They frequently have high cost
referrals
o secondary care for tests and scans and usually present with
anx-
ety and/or depression, which is understandable (Aguera, Failde,

ervilla, Diaz-Fernandez, & Mico, 2010; Simon, VonKorff,
Piccinelli,
ullerton, & Ormel, 1999).
Dimsdale, Sharma, and Sharpe (2011) showed that although
US/somatoform disorders are common, for those health pro-
essionals seeing such patients there is considerable confusion
egarding the diagnostic terminology and a reluctance to use
hese diagnostic labels. For example, GPs rarely use the terms
US or somatoform disorder to their patients, instead diagnosing
bromyalgia, ME, IBS, chronic fatigue, etc. Neither do GPs
routinely
se the ICD-10 subcategories of various somatoform disorders.
onsequently, in the experience of the authors the specific
number
f this huge population in each GP practice is hidden from the
GP
ractice database. However, GPs can identify those known as
heart-
ink, frequent flyer and fat file patients whom they refer to the
MUS
linic. As a result of a systemic lack of classification many
patients
ho have MUS/somatoform disorder are not able to be identified
o receive the support of the MUS Clinic.
Grover et al. (2014) found no significant differences between
he various subcategories of somatoform disorders with regard
o the prevalence of somatic symptoms (including somatoform
ain disorder), anxiety or depression and psychological
correlates
f alexithymia, hypochondriasis and somato-sensory amplifica-
ion. Their findings also supported the co-occurrence of anxiety

nd depression in two-thirds of this population. Anxiety disor-
er (formally hypochondriasis) or functional neurological
disorder
formally conversion) may also be diagnosed.
Khan, Khan, and Harezlak (2003) call for better management
trategies to be developed in primary care for prevalent,
medically
nexplained, persistent somatic symptoms which are a health
care
riority and a long-term condition. Currently patients either
attend
hysical or mental health services and the treatment is separately
elivered as medication/pain management or psychological ther -
pies, respectively. This system is unhelpful to the patient since
t splits off mental from physical health aspects. In England,
CBT
or three conditions: IBS; chronic fatigue and fibromyalgia, has
een found to help mental health in the short term and encour-
ged through a government initiative called Improving Access to
sychological Therapies (IAPT) which also targets people with
long-
erm conditions in which MUS can be categorised. However,
only a
hird of MUS patients with varied symptoms attend this
treatment
Hague, 2008), probably due to their physical explanation for
their
ymptoms and the stigma attached to mental health services.
Thus
t seems CBT is unacceptable to this patient population, they
require
n accessible and integrated approach which acknowledges their
odily based physical experience whilst exploring this at
emotional
nd cognitive levels.

he research on which TBMA is founded
A pilot study into the TBMA intervention took place near Lon-
on, England in 2005–20071 (Payne, 2009; Payne & Stott, 2010).
rom these earlier research studies, specifically the proof of
concept
ilot study (Payne & Stott, 2010), patient benefits from TBMA
inter-
ention were improved wellbeing and activity levels; decreased
1 Funded by the East of England Development Fund and The
University of Hert-
ordshire.
sychotherapy 47 (2016) 55–65 57
symptom/anxiety/depression levels; improved self-management
of symptoms; and lower or stabilised medication levels. For GPs
the benefits included reduced attendance at GPs and/or hospitals
and reduced costs of medication.
Furthermore, a previous health economic analysis of TBMA
com-
pared with CBT showed that the cost savings would be large in
primary care but that secondary care they would be even greater
(Payne & Fordham, 2008) the findings of which are supported
by a
report from the DH (2012). Thus this evidence makes TBMA
courses
attractive for the NHS due to the current austerity situation in
England.
Following extensive consultation with primary care GPs in a
market research study by Payne, Eskioglou, and Story (2009),

funded by the East of England Development Agency, a need was
identified by the GPs for a pathway for the treatment and sup-
port of this patient population, for most of whom they thought
CBT/psychological therapies was inaccessible and/or
inappropriate.
In support of the lack of accessibility for patients of
psychological
therapies and/or referrals from GPs psychologists in IAPT com-
plained that they were not getting enough referrals from GPs.
When
TBMA was described to these GPs in a focus group (and later in
the
QIPP project) as a possible pathway it was welcomed
enthusiasti-
cally as being more acceptable and providing choice for
patients.
The pilot study led to the development of a manual for the
delivery of TBMA by experienced and qualified Masters level
dance movement psychotherapists trained in TBMA by path-
ways2wellbeing. This manual is not a recipe for sessions but
rather
offers nudges for the planning, specific themes which need to be
covered and when and for the conducting of group sessions. The
mind-set/attitude of the facilitator is described as the most
impor-
tant ingredient for promoting change. The facilitator is
encouraged
to be mindful, sensitive, adapting practices to each group’s
needs,
ensuring interventions, aims and outcomes are explained clearly
to patients and addressing needs as they arise rather than being
prescriptive. The manual content gives examples of sessions and
case studies, emphasising the facilitator’s competencies
expected.
The manual was further refined as the QIPP service delivery

was
conducted in an evaluation by the facilitators during the
delivery,
and no doubt it will be honed still further with each new
delivery
of the groups by more facilitators.
As well as the manual being continuously updated TBMA is
being evaluated as an on-going process during delivery of the
service. Manuals developed for conducting psychological
therapies
in research studies are not widely distributed and their contents
do not appear to have been evaluated (Payne, Westland, Karkou,
& Warneke, 2014). Research findings based on the application
of
treatment manuals have led to the endorsement of psychological
treatments based on the use of brand names, e.g. Body Orien-
tated Psychotherapy, CBT or Interpersonal Therapy. Endorsing
brand-named treatments assumes they are practised in a man-
ner consistent with the research treatment manuals but without
evidence to support this assertion. In this service delivery treat-
ment integrity has been ensured by a triangulation (a three-way
comparative analysis) between what patients have said about
their
experience of the approach what the facilitator says she did in
the
pilot study (Payne, 2009), and the manual which will continue
to
be evaluated by the facilitators and by expert opinion evaluators
external to the delivery.
The BodyMind ApproachTM
There are many different definitions of psychotherapy, for
example ‘The treatment of disorders of the mind or personal-
ity by psychological methods’ (Oxford English Dictionary,
2015)

or ‘the informed and intentional application of clinical methods
5 ts in P
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nd interpersonal stances derived from established psychologi -
al principles for the purpose of assisting people to modify their
ehaviours, cognitions, emotions, and/or other personal
character-
stics in directions that the participants deem desirable’
(Campbell,
orcross, Vasquez, & Kaslow, 2013, p. 98). It is normally the
esponse to specific or non-specific signs of clinically
diagnosable
nd/or existential crises, often dubbed talking therapy aiming to
elp clients to fulfil their potential or cope better with the emo-
ional problems of life.
Whilst TBMA is not psychotherapy in the narrow definition of
he term it has its roots in a psychotherapy school of thought. It
orks not only with the mind, emotions and cognition but also
ith the physical symptoms, it is a bio-psychosocial model.
TBMA can be seen as one solution to the problem of patients
with
US. It has been designed specifically to be accessible to this
patient
opulation and to provide choice. It aims towards integrating
body
nd mind, starting with the bodily symptom and its sensory expe-
ience to promote self-management and wellbeing in people with
hronic MUS. It employs somatic mindfulness (or bodymindful-
ess) – movement, a moment-to-moment awareness of the body
n motion or stillness, from the discipline of Authentic
Movement

Adler, 2002; Chodorow, 1992; Payne, 2006; Whitehouse, 1999)
hich is sometimes employed in dance movement psychotherapy.
uthentic movement is where the mover moves spontaneously
ith eyes closed/downwardly focussed in the presence of a wit-
ess. In TBMA authentic movement is coupled with mindfulness
ractices, adapted to be accessible to people with persistent
symp-
oms employing simple practices scaffolding them into elements
f the final form. There is no pressure to engage with anything
ith which patients might be uncomfortable. The facilitator
always
ffers alternatives and choices.
Kabat-Zinn (1982), Kabat-Zinn, Lipworth, and Burney (1985)
nd Kabat-Zinn, Lipworth, Burney, and Sellers (1986) pioneered
the
evelopment of mindfulness meditation with patients with
chronic
ain and a mindfulness stress reduction programme for psoriasis
Kabat-Zinn et al., 1998) as well as applying it to patients wi th
anxi-
ty (Miller, Fletcher, & Kabat-Zinn, 1995). Since then there has
been
prolific study of mindfulness. It has been shown to reduce
depres-
ion as well as anxiety. Hofmann, Sawyer, Witt, and Oh (2010)
onducted a meta-analysis of 39 studies that explored the use
f mindfulness-based stress reduction. The researchers concluded
hat mindfulness-based therapy may be useful in altering affec-
ive and self-regulatory processes that underlie multiple clinical
ssues particularly anxiety and/or depression. Others have sup-
orted these findings, for example, Vøllestad, Nielsen, and
Nielsen
2012), Roemer et al. (2009) and an earlier study by Grossman,

ieman, Schmidt, and Walach (2004). A systematic review con-
ucted by Sharma and Rush (2014) found that out of 17 studies
ombining mindfulness meditation and yoga 16 demonstrated
pos-
tive changes in psychological or physiological outcomes related
o anxiety and/or stress. Williams (2008) reviewed four stud-
es showing a correlation between measures of mindfulness as a
rait and cognitive features of depressive vulnerability,
specifically
ecreased rumination, avoidance of internal experiences and an
ncrease in the relinquishment of negative thoughts and unattain-
ble goals. Other studies demonstrate that a mindful or
experiential
ode of self-attention in depressed subjects is relatively more
onducive to both improved memory for autobiographical events
Watkins & Teasdale, 2004) and improved problem solving
ability
Watkins & Moulds, 2005).
Nevertheless none of these approaches address the lived bodily
elt sensory experience from a phenomenological perspective
r address the importance of body awareness as a vehicle for
hange. The subjective experiencing body (Gallagher & Zahavi,
007), whether engaging with the world’s affordances (Gibson,
979) through the tactile sense, movement or in stillness, is
the fundamental basis for all feelings, sensations, perceptions or
object manipulation which in turn actively underlies cognition
and meaning-making (Dewey, 1991; Merleau-Ponty, 1962,
1965).
There is thus an integration of physical and mental aspects, per -

ception and action, doing and being. TBMA builds on this
notion
of the body functioning as a dynamic constituent of the mind
rather than serving the mind. This enactive, subjectively body-
felt
sense, as described by Gendlin (1982), expresses basic mean-
ing from a sensory–motor modality and reflects the individual’s
life history and current situation. It is pre-verbal and prelimi-
nary to habitual/pre-conceptual/abstract thinking patterns.
During
TBMA the body is therefore experienced from inside-out, as a
lived container of sensations, images, thoughts and feelings,
etc.
Joint attention with the facilitator or another participant as wit-
ness extends the experience as reflections are embodied from
the
outside-in as well. This opportunity to experience the
connection
between the body and mind whilst doing/being it opens up
possi-
bilities for new discoveries about the nature, and the meaning
of,
symptoms as located in the bodymind. This is an embodied way
of knowing (Panhofer & Payne, 2011), contrasting with
conceptual
knowing.
Several disciplines cultivate mindfulness, such as yoga, tai chi
and qigong, although most of the research literature has concen-
trated on mindfulness developed through mindfulness
meditation.
This self-regulation practice trains attention and awareness to
bring mental processes under greater voluntary control thereby
promoting wellbeing and/or capacities such as calmness, clarity
and concentration (Walsh & Shapiro, 2006).

Mindfulness refers to a psychological state of awareness, the
practices that promote this awareness, a mode of processing
information and a character trait and can be defined as a
moment-
to-moment awareness of one’s experience without judgement. In
this sense, mindfulness is a state and not a trait. While it might
be
promoted by certain practices or activities, such as meditation,
it
is not necessarily synonymous with them. TBMA by using
kinetic
mindful practices engages with the patient’s attention to, and
rela-
tionship with, their bodily symptoms (including pain), for
example
by exploring the sensory experiences, and engaging in action-
based
inquiry such as examining the nature and purpose of the
symptoms.
This mindful relationship to the body and symptoms helps
patients
become less attached to/identified with their symptoms as well
as
less reactive to them which diminishes their experience of them.
TBMA coaches patients through exercises involving postures
and movement, breath and voice, mindfulness and body aware-
ness. Practicing such exploratory exercises regularly in the
group
session (and at home) the patient may regain balance and self-
regulation. For example, practising focussing on the breath (or
the
symptoms), then noticing any thoughts, images or bodily sensa-
tions, followed by re-focussing on the breath, and then
reflecting
on the experience through the creative arts thus nurturing a deep

awareness of the body. By putting difficult emotions and
sensations
in a bodily context an indication of a new perspective and
accom-
panying meanings can be gained. By holding all these aspects,
including pain, in direct sensory awareness metaphor/imagery
can
be generated spontaneously. These can be drawn, made out of
clay or written about in a personal journal often leading to
further
meaning-making and understanding of the role/nature/purpose
of
the symptoms. Participants are engaged in synchronous, effort-
ful movement together in a circle (accompanied by music or
not)
which has been shown to reduce pain and act as a way to
increase
group cohesion (Tarr, Launay, Cohen, & Dunbar, 2015).
TBMA helps patients to connect cognitive and emotional
aspects
with reference to their sensory/bodily states through the enact-
ment of expressive movement in structured exercises. Cognitive
activities are inseparable from the body as the brain takes an
impor-
tant part in intentionality which involves the process of
perceiving
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birth).
Gender mix: The ratio was 5:3 women to men in this small
sample of 16 completing the whole programme from pre-group
H. Payne, S.D.M. Brooks / The Ar
nd meaning-making (Koch, Caldwell, & Fuchs, 2013; Mills,
2005).

here is no explicit involvement of any underlying psychological
onflicts or the interpretation/identification (or subsequent modi -
cation of) unhelpful thought patterns. Patients learn to notice
their
odily signals and explore their symptoms often without the need
or verbalisation (McWhinney, Epstein, & Freeman, 1997),
thoughts
hange as a result of the embodied experience.
TBMA differs significantly from CBT in that it focuses on the
hysical symptom within an experiential inquiry-led learning
ramework to support patients to live well and cope better in a
ore meaningful way. There is an evidence base for the practice
f CBT with some specific conditions included in the MUS cate-
ory, e.g. IBS (Mahvi-Shirazi, Fathi-Ashtian, Rasoolzade-
Tabatabaei,
Amini, 2012) and fibromyalgia (Woolfolk, Allen, & Apter,
2012)
ut the method does not address the body-felt sensory experience
f the symptoms, favouring solely the mental aspects of depres-
ion and/or anxiety. CBT has been researched in large trials and
s recommended by the National Institute for Clinical and Health
are Excellence (NICE) for chronic fatigue and fibromyalgia.
How-
ver, patients and GPs in the service delivery reported in this
rticle spoke about patients’ reluctance to attend anything con-
erned with psychological/mental ill health, etc. There is
evidence
Sartorius, 2007) to suggest that these patients are very wary of
he stigma attached to any mental health label. It can be
concluded
hat patients with MUS may be less willing to access CBT as
they
elieve they have an organic cause rather than give a psycholog-

cal explanation for their symptoms. Allen and Woolfolk (2010)
nd Gonzalez, Williams, Noel, and Lee (2005) demonstrate that
this
atient population are often resistant to CBT.
In contrast TBMA is not presented to patients as a
psychological
herapy. It allows patients in the early phase to concentrate on
their
ensory experience and action patterns involved in the symptom.
owever, there is often a subtle psychological component to the
reatment discovered by the patient later in the process. Hence
atients do not concern themselves with the question of stigma
n relation to participating in the treatment. Furthermore, TBMA
ddresses a range of symptoms and the symptom itself. It can
nclude a number of different symptoms for a number of patients
n the same group, together with various accompanying aetiology
uch as alexithymia (Ogrodniczuk, Joyce, & Piper, 2013), in
which
here is confusion between emotions and bodily experiences,
poor
ffect regulation and a fearful/insecure attachment style (Payne,
016).
In TBMA the patient directs her/his attention to inner expe-
iences of self, actively reflecting and commenting on bodily
ensations as they are raised into awareness. Gradually
participants
ecome more connected to their embodied, direct experience of
elf. A more positive re-association with the body emerges which
as often become dissociated due to the patient’s symptom
distress.

n embracing the wisdom held by the symptom through the
embod-
ed, enactive dream state the patient enters into a more
meaningful
ialogue with their body. Levy Berg, Sandahl, and Bullington
(2010)
n a study of patient perspectives of the process of change in
ffect-focussed body psychotherapy for generalised anxiety
disor-
er found that ‘getting in touch with one’s body’ was a key (p.
151).
his in turn gave rise to feelings of being in control, for example
oticing bodily signals such as muscular tension and being able
to
nfluence them, and understanding the link between bodily
symp-
oms and emotions. They found that patients managed to
integrate
odily feelings into their perception of themselves resulting in a
eeper experience of their lived body.
tructure of the TBMA course
TBMA groups are short term for up to 12 patients per group;
here are three groups per programme. Each session is two hours
sychotherapy 47 (2016) 55–65 59
for 12 sessions over 10 weeks as in brief therapy (Yalom &
Leszcz,
2005). Groups are run locally in a suitable community setting.
Following the groups in phase one, in phase two, and over the
following 6 months contact is maintained. For example, a self-
addressed letter written by the participant in session 12 is sent
8 weeks after the end of the group, as is a letter personalised for
each participant written by their facilitator in month three after

the
end of the group. Finally, a text/email message is sent asking
how
they are doing, and, if indicated by their response to the
question,
in month nine, a referral to a self-help group is made, otherwise
a
discharge letter is sent to their GP.
Practice-based evidence
As well as the traditional trials in the evidence-based practice
paradigm another form of evidence is being derived from
natural-
istic practice settings termed practice-based evidence (Barkham
&
Mellor-Clark, 2000).
Practice-based evidence is described by Guy, Thomas,
Stephenson, and Loewenthal (2011) as complementary to the
quantitative, and dominant, randomised control trial-based
approach to evidence. A United Kingdom Council for
Psychother-
apy (UKCP) report (Ryan & Morgan, 2004, cited in Thomas,
Stephenson, & Loewenthal, 2006) suggests that practitioners
and
service users need to be given a voice, acknowledging that they
have direct knowledge and experience of what works and alter-
natively what needs to change, and how. Practice-based
evidence
can give them these opportunities.
P2W employs this practice-based methodology, albeit with
smaller numbers. It contrasts with evidence-based practice in
that
it starts with practitioners and patients in real-world settings

and builds up the evidence rather than as with the traditional
top down evidence-based medical paradigm. Furthermore, it
uses
national/common psychological therapies and primary care out-
come measures such as PHQ9 for measuring depression. Patient
evaluations of experience and outcomes form an important part
of
the evidence. Additionally, it is using real-world patients
electing
to participate in the treatment group, rather than selected
samples
willing to participate in research to which they would be blindly
allocated to either the treatment/treatment as usual without
exert-
ing any choice.
With this practice-based methodology and its evaluation using
qualitative and quantitative patient feedback and the
standardised
psychological assessment tools there is an opportunity to build
an
evidence base rooted in routine service delivery. This could
com-
plement the Cochrane data base2 and together with it, yield a
more
robust knowledge base for the psychological/arts therapies.
This methodology values expert opinion and acknowledges the
need to adjust practice according to the needs and preferences
of
the client and their socio-economic background. This
complemen-
tary paradigm of practice-based evidence also provides a means
for practitioners to own and generate an evidence base
embedded
in routine practice. Both paradigms are needed as the aim for all

practitioners and researchers alike is best practice.
Description of patients in the sample
Ethnicity: White British – 10; Chinese – 2; Indian – 4 (we do
not
know if born in Britain from this background or if their country
of
2 An international not-for-profit organisation preparing
maintaining and promot-
ing the accessibility of systematic reviews of the effects of
health care.
6 ts in P
a
w
t
a
c
t
G
g
8
3
m
t
h

1
1
A
g
w
h
m
o
(
w
N
t
o
2
b
i
r
r
o
p
t
h
t
w
u
•
•
•

•
•
•
•
•
•
•
•
•
hospital visits and improvement in their social support.
For the majority of patients’ depression scores were mild or
moderate reducing to zero, one patient reduced in her score
from severe to moderate. The literature (Löwe, Spitzer,
Williams,
0
20
40
60
80
Percent age Improveme nt
Percentage Im proveme nt
ssessment to follow up at 6 months. This reflects the literature
hereby more women than men somatise.
Age distribution: Results from this small sample of 16 suggest
hat adults of all ages are likely to experience MUS. The biggest
ge group category was the 50–59 year olds (5/16 were from this
ategory). The youngest patient was just below 20 years of age
and

he eldest patient was over 80 years old.
Number of patients in each group: Group 1: four; Group 2: six;
roup 3; six.
Number at completion: 16/19 patients completed the full pro-
ramme over the two phases to the end of the 6 month follow -
up.
The number of group sessions attended per patient ranged from
to 11.
Attendance figures: Group 1 had 67%, Group 2 – 86% and for
Group
it was 90%.
The following shows engagement throughout the programme:
Number entering treatment groups: 19 (one missed the intake
eeting but attended the first two sessions then withdrew, a fur -
her one withdrew after first two sessions as too unwell and one
ad to have an operation and could not drive so had to
discontinue).
Number remaining in treatment: 17 (one remained until session
0 but could not sustain thereafter).
Number completing TBMA group treatment through to follow
up:
6.
nalysis of questionnaire data
The majority of patients were in the moderate or mild cate-
ories for anxiety which is broadly consistent with the literature
hich states that at least two-thirds of patients with MUS will

ave anxiety (Grover et al., 2014). Higher levels of anxiety show
ore of an improvement than at these lower levels. The majority
f patients were women, a finding consistent with the literature
Speckens, VanHemert, Bolk, Rooijmans, & Hengeveld, 1996).
They
ere of a mixed educational background similar to that found by
imnuan, Hotopf, and Wessely (2001). Some studies claim that
hose unemployed, senior women and those from a non-Western
rigin experience more MUS (Verhaak, Meijer, Visser, &
Wolters,
006). However, participants in this project were from a variety
of
ackgrounds and ages. This is inconsistent with some other stud-
es which found, for example, the older age group to be overly
epresented or, in contrast, younger, employed women to be
over
epresented (Nimnuan et al., 2001). However, all of these
outcomes
n the demographics in the project are consistent with the
previous
ilot study.
Educational background: Patients came from a range of educa-
ional backgrounds.
Employment status: 5/16 retired, one of which was due to ill
ealth. 7/16 patients were in full-time employment; two in part
ime employment; one was unemployed and one a student.
Types of symptoms: There were 26 different symptoms for the
hole cohort of 16 patients completing the programme to follow
p. These included:

breathlessness,
headaches,
chronic pain,
tiredness,
insomnia,
hand pain,
leg pain,
chronic fatigue,
IBS,
ME,
palpitations,
seeing white lights,
• pain in the chest,
• backache,
• leg spasm and
• insomnia.
Assessment measures
Patients were assessed using standardised measures over the
telephone by a clinical psychologist on three occasions. Firstly
at
pre-group, secondly in the final week of the group and thirdly at
6
months follow up. The measures used were:
PHQ9: This is a client rated tool for depression. It scores each
of
the nine depression DSM-IV criteria as “0” (not at all) to “3”
(nearly
every day).

Measure Your Medical Outcomes Profile (MYMOP2): This is an
individualised outcome questionnaire, problem-specific
(measures
two symptoms chosen by the patient), including general
wellbeing
and impact of symptoms on a chosen activity. The greater the
score,
the more severe the symptoms will be experienced.
Generalised Anxiety Disorder 7 (GAD7): This is a brief
measure
for assessing Generalised anxiety disorder on a 7-item self-
rating
scale. It scores each item as “0” (not at all) to “3” (nearly every
day)
for each item. Severity of generalised anxiety is graded based
on the
GAD7 score as 0–4 none/5–9 mild/10–14 moderate/15–21
severe.
The Global Assessment of Functioning Scale (GAF): A clinician
rat-
ing tool used to measure overall level of psychological, social
and
occupational client functioning on a scale ranging from 1 to
100.
The higher the score, the higher the level of functioning will be.
GAF covers the range from positive mental health to severe psy-
chopathology.
P2W questionnaire: During a telephone interview the asses-
sor collected self-reported information on the participant’s age,
gender, ethnicity, socio economic group, occupation,
educational
levels, type and number of symptoms, amount of leisure activ-
ity, social support, work/school attendance, use of medication,

and
attendance at GP/hospital. In addition, GP referrals contained
case
histories and medical information.
Post-group outcomes from the standardised assessments
The outcomes are also presented as pie charts for greater visual
impact and ease of interpretation by the general reader.
Interpretation of outcomes pre to post group
Improvements are noted in all areas shown from pre to post
group on the Pie Charts 1–7 and in Graph 1. Particularly impor-
tant are improvements in the scores from pre to post group as
shown in Table 2 indicating decreased levels of depression,
anxiety
and symptom severity. There are also improved feelings of
overall
wellbeing, social support, activity levels and global functioning.
In
addition, patients report decreased GP visits, medication usage
and
medica�on social
support
GP visits Hospita l
visits
Pie Chart 1. Patients reporting reduced feelings of depression
81.25% of patients
reported a reduction in depression.
H. Payne, S.D.M. Brooks / The Arts in Psychotherapy 47 (2016)

55–65 61
depression
81.25% re duce d
6.25% increased
12.5% no change
Pie Chart 2. Percentage of patients reporting improved global
functioning 81.25%
of patients report and improvement in global functioning.
global func�oning
81.2 5% improved
6.25% redu ced
12.5% no change
Pie Chart 3. Percentage of patients reporting increased overall
score for MYMOP
including activity, symptom severity and wellbeing 81.25% of
patients report
improvement in overall scores.
mymop overall
81.2 5% in creased
6.25% de creased
12.5% no change
Pie Chart 4. Percentage of patients reporting reduced anxiety
levels 68.75% of
patients reported a reduction in anxiety.
anxi ety

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