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An Art Therapy Protocol for the Medical Trauma Setting

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Valerie E. Appleton EdD, A.T.R.
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Cheney, WA
Published online: 27 Dec 2013.

To cite this article: Valerie E. Appleton EdD, A.T.R. (1993) An Art Therapy Protocol for the Medical Trauma Setting, Art
Therapy: Journal of the American Art Therapy Association, 10:2, 71-77, DOI: 10.1080/07421656.1993.10758985

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 MTherapy: Journal of the American Art Therapy Association, IO(2) pp. 71-77 0 AATA, Inc. 1993
An Art Therapy Protocol for the Medical
Trauma Setting
Valerie E. Appleton, EdD, A.T.R., Cheney, WA
Abstract
Downloaded by [Monash University Library] at 16:09 04 May 2015
Art therapy as crisis intervention is relatively
new in the field of medical trauma care, outside of
the psychiatric setting. Art therapy on a trauma unit
provides unique opportunities for clinical interven-
tion and field research. This paper presents an art
therapy intervention protocol developed for a burn
trauma unit over a 10-year period. A research para-
digm f o r assessing artwork and the psychosocial
transition from trauma, rationabs for art therapy in
a medical setting, and documentation are consid-
ered. A case study illustrates the ways that art media
were used to review, integrate, and express the per-
sonal experience of recovery from severe burns.
Introduction
Crisis intervention has been developed only
within the past few decades. It cannot be directly re-
lated to any single theory of human behavior as all
have contributed to s o m e d e g r e e (Aguilera &
Messick, 1986). At a minimum, the therapeutic goal
of crisis intervention is the psychological resolution
of the individual’s immediate crisis and the restora-
tion of functioning that existed precrisis (Watkins,
Cook, May, & Ehlben, 1988). A larger goal is im-
provement of functioning above the precrisis level
(Aguilera & Messick, 1986). The implementation of
these goals requires an integration of allied profes-
sionals in the total care of trauma victims (Bowden,
Jones, & Feller, 1979).
Lusebrink (1990) notes the body of research evi-
dence (Achterberg, 1985; Achterberg & Lawlis,
1980; Korn & Johnson, 1983; Sheikh & Kunzendorf,
1984; Simonton, Simonton, & Creighton, 1978) sup-
71
porting the notion that “imagery can be used as a
healing agent to supplement conventional medical
procedures” (p. 219). Also, color, line quality, and
themes in artwork were observed to assist medical
patients in the expression of feelings surrounding ill-
ness, hospitalization, surgery, body imagery, and
medical procedures (Abel, 1953; Bach, 1966, 1975;
Furth, 1973, 1988; Lusebrink, 1990; Machinsky,
1982) as well as about home and family (Landgarten,
1981; Levinson & Ousterout, 1979), and staff (Mis-
ner, 1979). A panel describing innovations in “medi-
cal art therapy” was presented at the 20th Annual
Conference of the American Art Therapy Association
(Long, Chapman, Appleton, Abrams, & Palmer,
1989). Art therapy functions clinically in psychosocial
burn care as: (a) a projective base, (b) a diagnostic
tool, a n d (c) a mode of t r e a t m e n t (Levinson &
Ousterout, 1979).
As a colleague of Levinson’s, the author wrote a
research grant to provide art therapy with adolescent
and young adult burn patients. The study ranged
over a 10-year period, between 1981 and 1991. Lee’s
(1970) model of the salient psychosocial issues in the
transition from trauma provided the foundation for
the research paradigm. Artwork descriptors were
found to reflect Lee’s four stages as follows:
Stage 1. Impact: Morbidity was expressed in color
choice, line quality, and images reviewing trauma
impact.
Stage 2. Retreat: Regression was expressed through
fantasy imagery, superhuman figures, sunsets, and
designlabstracts.
Stage 3. Acknowledgement: Family and social inter-
actions were reflected in images of trees, and self-
concept through self-selected “healing” colors, and
mandalas.
 AN ART THERAPY PROTOCOL
Stage 4. Reconstruction: Psychosocial issues of mas-
tery, independence, and future goals were observed
in the patients’ selections of art processes and in
home images (Appleton, 1989).
Intervention Protocol
The following is an overview of the protocol de-
veloped for art therapy interventions on a burn trau-
ma u n i t . T h e i n t e r v e n t i o n s a r e b a s e d on t h e
achievement of eight clinical objectives. Each is
cited below with supporting rationale.
1 . T o establish a therapeutic framework f o r art
therapy interventions with the patient.
A trust relationship that reinforces the thera-
peutic alliance is established with t h e patient
through art processes. Symbolic processes are the
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focus of the intervention and offer ways to transcend
the verbal limitations exacerbated by the trauma se-
quelae (Lusebrink, 1990). Furthermore, symbolized
feelings and experiences can be a more powerful
mechanism of expression and communication than
verbal description alone, and at the same time
render these feelings and experiences less threaten-
ing (Dalley, 1984).
Art therapy interventions occur at the patient’s
bedside with media that are chosen by the patient
from a consistent selection presented by the art ther-
apist. For instance, the art media may include dry
watercolor cakes (12 colors), felt pens (wide and
thin), watercolor cartridge brushes, soft pastels (24
colors), and collage materials for use on paper or
boxes (magazines, colored papers, glitter, and medi-
cal supplies such as cotton swabs, tongue depressors,
and syringes). Both the art therapist and the media
provide the patient with a sense of continuity. In re-
covering from trauma, a consistent relationship with
key care givers is essential, both for the quality of
the therapeutic relationship and as a reality refer-
ence for the trauma survivor who suffers from a
sense of depersonalization, disorientation, and loss of
identity.
2. To utilize the patient’s natural coping mechanisms
of denial and projection through art processes.
The process of art therapy is based on the rec-
ognition that an individual’s most fundamental
thoughts and feelings, derived from the unconscious,
reach expression in images r a t h e r than words
(Naumburg, 1973). When the symbolic aspects of
imagery are accessed, along with the verbal and cog-
nitive, art therapy can provide an integrative and
healing opportunity for the individual (Rubin, 1984).
72
The art therapist works with the patient to eval-
uate his or her coping capacity. Art processes are
discussed and ideas and media offered to the patient.
The majority of the art therapy activities are either
spontaneous or impromptu. For the purposes of
assessment and projection, the art therapist specifi-
cally requests that patients render the traumatic
event and subsequent experience of hospitalization
and administers Bucks (1978) House-Tree-Person di-
agnostic.
3. To clear up misconceptions regarding hospitaliza-
tion, medical procedures, andlor the burn injury
event.
The therapist works with the treatment team
preparing patients for surgery and daily hospital pro-
cedures in burn care. Through art processes patients
are observed to place the burnltrauma event into a
temporal perspective. The art products provide, as
Dalley (1984) describes, a concrete visual record that
exists over time. The visual and symbolic images be-
come important for both the staff and the patient, re-
cording gains or set-backs in psychosocial adjust-
ment.
4 . To encourage mastery and creativity, enhance
self-esteem, and reaffirm the patient’s appropriate
age-level abilities.
It i s documented that burn patients who are ac-
tively involved in their own care have better prog-
nostic outcomes than those patients who remain pas-
sive (Scanlon & Levesque, 1981). The art therapy
activities provided on the trauma unit (drawing,
painting, and building collages on paper and boxes)
require active and creative interaction with media.
The ability to control media becomes an opportunity
for the projective control of the feelings of anxiety,
helplessness, immobilization, and sensory depriva-
tion common among trauma victims.
Burn and trauma victims typically regress dur-
ing crisis and the stress of injury and hospitalization.
Extremely regressed patients are not compliant with
procedures and may become overwhelmed, exhibit-
ing behaviors ranging from acute depression to hys-
teria. Art processes offer the patient a vehicle for
self-expression through creative and generative ac-
tivity.
5. To offer the patient emotional, physical, and so-
cial outlets to decrease stress.
As pain is directly linked to stress response, the
relaxation benefits of art activities assist in pain con-
trol. The therapist can encourage more compliance
with nursing staff and physical therapy by initiating
activities where the focus is nonmedical. For exam-
ple, art activities where the patient must reach with
 APPLETON
a paintbrush or move around a sculpture indirectly
encourage the stretching of scarred areas and the
getting out of bed and becoming mobile, and en-
hance social interaction with others. Art products in
the patient’s room or conjoint art-mahng processes
between patient, staff, and family facilitate discus-
sion and verbalization.
Art materials are offered to the patient from a
full range of color and media choices. The patient’s
level of physical energy can be seen in his or her se-
lection and use of the media, each of which has spe-
cific physical properties and capabilities. Media are
viewed on a continuum ranging from those more
easily controlled, such as sharp pencils and felt tip
pens, to those more d s c u l t to control, such as wa-
tercolor paint (Landgarten, 1981).
6. To bridge the gap between home and hospital
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through all phases of the recove y from trauma.
The goal is to return the patient, as much as
possible, to precrisis life. Thus, predischarge plan-
ning and preparation are an important phase of care.
Patients need to feel they will be cared for after they
leave the hospital. After the home situation is evalu-
ated, follow-up art therapy may be recommended.
Also, the therapist may refer the patient to a social
worker and/or psychiatrist for postdischarge psycho-
therapy, when appropriate. Patients often report
that they learned through the therapeutic rela-
tionship with the art therapist that it can be appro-
priate to “ask for help.”
7. To evaluate the premorbid family situation and to
assess evidence of abuse, neglect, or family crisis in
the course of ongoing art therapy and psychosocial
evaluation.
The art therapist is an advocate for the patient
and works with the treatment team during assess-
ment. Abuse may not be overtly verbalized, but can
appear projectively in artwork. The art therapist re-
ports graphic representation of abuse for the legal
defense of victims.
8. To provide art therapy follow-up groups and ap-
propriate referral to support agencies in the commu-
nity prior to discharge from the hospital.
Patients often experience a regression to less ef-
fective levels of coping when faced with returning
home. Often the patient will be returning to the
locale of the original burn trauma and will suddenly
be fraught with unexpressed feelings. Art therapy fa-
cilitates the transition from the hospital to home by
reinforcing the expression of feelings. With the pa-
tient’s permission, the art therapist utilizes the pa-
tient’s artwork in predischarge evaluation with the
burn team where a plan is created to support the
73
physical and psychosocial needs of the patient out-
side of the hospital. Follow-up art therapy groups or
individual sessions may be indicated at this time.
Documentation
Art therapy interventions are documented in
the medical chart much the same way as other treat-
ments accorded the patient. These notes are part of
the patient’s records referenced by all members of
the team: social workers, psychiatrists, physicians,
nurses, and consultants. Charting reflects interven-
tion protocols in the following ways:
1. The art therapist meets the patient upon admis-
sion to the hospital. As the patient proceeds
through hospitalization, the art therapist con-
tinues to evaluate the interventions that might be
required through consultation with patient, the
medical staff, and the medical record.
2. The patient is seen for art therapy two to five
times weekly at the bedside, which helps prepare
the patient for surgery and other medical proce-
dures, and for discharge.
3. Notes of the doctor, nurses, psychiatrists, social
worker, and art therapist are kept in each pa-
tient’s medical chart and reviewed at case rounds
and meetings.
4. Artwork is dated, and the art therapy interview
and interventions are documented in the medical
chart according to a format designed by the au-
thor to avoid duplication of services with other
members of the team. The charting format in-
cludes: Interaction, Affect, ProcessIProduct, Ob-
servation, and Plan (IAPOP). Direct quotes and
patient descriptions of art processes are recorded
verbatim to preserve idiosyncratic meaning.
5. With the patient’s signed permission, original art-
work and/or slides of artwork are kept as part of
the research data. Patients a r e informed that
their art contributes to an understanding of the
experiences of medical trauma patients.
Case Example
The following is part of a case study developed
for a research dissertation (Appleton, 1989) and pre-
serves the anonymity of the study participant. It
presents the ways “Michael, patient #13,” used art
media to make therapeutic gains-moving from re-
gression toward a sense of mastery over his recovery
from severe bums.
 AN ART THERAPY PROTOCOL
While driving home intoxicated after his high
school reunion, Michael, age 24, was burned after
his car rolled on an exit ramp. He claimed through-
out hospitalization that he was not drinking that
night. Michael’s medical report noted fractures to
the vertebra of the spine and sixth rib, requiring a
long period of immobility and physical dependency
on nursing care. He was emotionally overwhelmed
with his burns, exhibiting overly dependent, re-
gressive behavior and low pain tolerance. His behav-
ior was described by the nursing staff as “acting like
a four-year-old.”
Art therapy interventions were begun as soon as
Michael was conscious for 24 hours, the ninth day of
his 35-day hospitalization (5 weeks). He stated then
“I just want to be dead. This is the worst pain I have
ever had” and rendered the accident in black and
red including a diagram of the highway, an image of
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what a passerby would have seen, and an image from
his perspective pinned underneath the car (Figures
Figure 1. “Accident diagram of freeway exit.“
Figure 2. “Accident from my perspective.”
74
1, 2, and 3). The next day he drew a nightmare of
the accident and tore it up to throw away. These im-
ages reflect the impact of trauma, and his artwork is
characterized by black, orange, and red color choices
often observed among burn patients (Appleton,
1989). During this period he was beset with night-
mares of the accident.
After some relaxation training with the art ther-
apist, he painted a mandala and began to explore a
difficult media, watercolor. He worked slowly, was
absorbed in the painting process for two hours, and
called the work “the many aspects of pain” (Figure
4). He continued painting on his own throughout the
week to complete the mandala. At this point in his
recovery, his main concern was how people (women,
in particular) would react when they saw the scars on
his chest and abdomen.
Figure 3. ‘What the passers-by saw.”
Figure 4. ’*Themany aspects of pain.”
 APPLETON
The acknowledgement stage, as described by
Lee (1970), is typified by periods of mourning and
frustration when the patient realizes that his former
self has been significantly altered. Michael drew an
image in soft pastels which he titled “Frusteration
(sic)” (Figure 5). The image includes scratchy lines,
restriction of the body posture, and lack of hands
and lower body, and may reflect Michael’s emotions
regarding his changed body as well as his physical
limitations at this stage of healing. He was still im-
mobilized in bed at this point in his care.
By the midpoint of his hospitalization, the 19th
day, Michael painted a watercolor of Hawaii and was
able to hold the paper without assistance from the
art therapist (Figure 6). This ability pleased him and
he stated, “I’m not in as much pain now.” His at-
titude with the media was exploratory and his behav-
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ior became less demanding, regressive, and depend-
ent. By the 26th day of hospitalization, he requested
Figure 5. ”Frusteration [sicj ,I‘
Figure 6. ”Sunset.”
75
a reclarification of the art therapist’s role. He stated,
“I want you to know, I have my own ideas about my
care, and I don’t need all the help I did before. I’m
accepting my burns better now. ” The following day
he asked his mother to leave his bedside for the first
time. He told her, “This is my therapy time now.”
During this session he created images reflecting his
world travels while in the Army. The collage, called
“The Old World,” includes images of Europe (Fig-
ure 7 ) .
The final stage of Michael’s recovery from bum
trauma was reflected in three works (Figures 8 and
9, and a clay piece; no figure available). “Spanish
Galleon” with three masts was created before re-
turning home to his three family members (Figure
8). The ship is a form of transportation, perhaps sym-
bolic of sailing away or a way out of the hospital.
However, Michael expressed ambivalence about
leaving intensive care. This ambivalence may be
Figure 7. Collage. “The Old World.”
Figure 8. “Spanish Galleon, 1535.”
 AN ART M E W PROTOCOL
Figure 9. “The City.”
seen in the fact that his sailboat has no sails. The im-
age titled “The City” (Figure 9) leans toward the
left, perhaps reflecting his stated hesitance to leave
the unit and concern over his ability to care for him-
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self. This resistance to leaving the burn unit was
temporary. His last art process while an inpatient
was to build a house in plasticene clay. The sides
were cleverly constructed so the structure would not
fall when the roof was positioned. He stated, “Notice
how my house can stand without supports.” Buck
(1966) suggests that the house is a projection of the
self; perhaps Michael was symbolically stating his
ability to support the burden of his own care.
During the last session with the art therapist,
Michael made numerous statements about his plans
to do things for himself. He wanted to see his medi-
cal chart and arranged for in-home art therapy visits
postdischarge. H e stated, “I learned from this art
therapy that sometimes it’s O.K. to seek counsel-
ing-something I never would have done before.”
He had overcome the emotional and physical regres-
sions he experienced in burn trauma through the
mastery of art media and had acquired a new per-
spective and value of his own care.
Conclusion
Art therapy in the sterile, medical environment
validates the deeply personal nature of the patient’s
experiences by focusing on feelings and expressive
processes. I n this way, art therapy supports t h e
clinical understanding of trauma as an idiosyncratic
process that is impacted by social perception, pre-
morbid adjustment, prior psychiatric diagnoses, sup-
port systems, coping styles, cultural reference, gen-
der, and personality (Andreason, Noyes, & Hartford,
1972; Gaines, 1986; Jacobson, 1965; Mestrovic, 1985;
Peterson, 1986, 1983; Silverman, 1986; Viney, Ben-
jamin, Clark, & Bunn, 1985).
76
At the burn unit, patients ranging from pedi-
atric to geriatric age groups were extremely recep-
tive to art therapy interventions. O n a Likert-style
survey developed for this research, 100 percent of
the study participants reported that “art therapy has
been helpful to me during my hospitalization” (Ap-
pleton, 1989).
The protocol described in this paper offers a
therapeutic and educational tool for settings other
than the burn trauma unit, when and wherever brief
therapy and/or trauma assessment and counseling
services are required. Such services may include
crisis and emergency housing, disaster intervention,
abuse recovery counseling, pediatric surgery units,
emergency rooms, intensive care units, oncology
units, and rehabilitation units. Examining the art-
work of trauma survivors contributes to the under-
standing of the complexities of their adaptations.
Thus, art therapy allows the exploration of the many
ways individuals make the transition from trauma to
recovery, a most beneficial process for all concerned.
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