The mask is green with black stripes, the pattern echoing the face paint many Soldiers wear in the field. It’s an image of toughness, of strength, of discipline. It’s the image Sgt. Robert Fox wants to project to the world. But turn the mask around, and the face is pale and bloody, battered. Tears trail from one of the eyes.
“It showed the pain and the suffering and how I actually felt on the inside as opposed to being that tough Soldier on the outside,” said Fox, who is currently assigned to the 3rd U.S. Infantry Regiment (The Old Guard) at Fort Myer, Virginia. He survived five long deployments to Iraq and Afghanistan with the 101st Airborne Division out of Fort Campbell, Kentucky.
Like many combat-hardened Soldiers, Fox has killed. He’s watched his buddies die. He’s seen horrors most civilians can never imagine. Several close-proximity blasts left him with traumatic brain injuries and a severe ringing in his ears that caused debilitating migraines. The ringing finally induced him to get help, but survivor’s guilt and post-traumatic stress have had the biggest effects on his life.
Some of his memories were so painful that talking about them – even in therapy – seemed like an almost impossible task. So when his team of doctors at the National Center of Excellence for the Intrepid’s satellite office at Fort Belvoir, Virginia, suggested art therapy, Fox was skeptical. He was willing to try it, but he didn’t think it could possibly work.
The art therapist, Jackie Jones Biggs, handed him a blank paper mache mask and explained that he was welcome to use any material in the art room to decorate it. It should either represent Fox’s identity, she said, or the identity of someone significant to him.
Fox started painting, and then something extraordinary happened: He started to talk, to open up. He didn’t even realize what was happening at first.
“While I was distracted doing the art, she was able to begin the actual therapy process,” he said. “I’m not sure why. I guess maybe because I was more focused on what I was doing and trying to put everything I thought about into that one piece. My mind was more focused on doing that as opposed to the related incidents.
“She’s very manipulative,” he joked.
Fox is one of about 120 service members Biggs has seen since helping start the program a little more than a year ago, and over the past three years, many more have participated in the pilot program at Walter Reed National Military Medical Center. Originally founded in partnership with the National Endowment for the Arts, the art therapy program actually continues a correlation between the military, the arts and healing that she said dates to the close of World War II.
“What is art?” asked Bill O’Brien, senior advisor for program innovation at the NEA. “It’s really about making sense of things, making meaning of things. … We thought we might be able to bring something to the table, particularly when we started to learn a little bit more about the signature wounds of these wars.”
Like Fox, many service members are initially reluctant or suspicious of art therapy, but a lot of them actually need – yes, need – it, said Dr. Heechin Chae, director of the Intrepid Spirit One at Fort Belvoir. As a physiatrist, Chae is a specialist in physical medicine and rehabilitation.
“A lot of service members are not good about describing what’s going on inside them,” said Chae. “There’s a lot of information that’s withheld. There’s some mistrust issues. The injury itself makes them unable to actually process their feelings and put them into words. A lot of times, these people can fall through the cracks because their issues are not reported properly to health care providers.”
“They’re like professional suppressors,” added Biggs, explaining that art taps into the subconscious and strips away filters. So even Soldiers are adamant about not talking about a particular experience or feeling, it almost always ends up coming out through their art.
“When you recall or experience something traumatic, the verbal areas of your brain become inhibited,” she continued. “But the sensory and emotion processing areas of the brain become more active, and those are also the same areas of the brain that are active when you’re art making. It feels like a back-door approach, but neurologically it’s actually a more direct route.”
That area of the brain is on the temporal lobe, according Chae. It’s a portion most Soldiers don’t often use because their jobs don’t require it. “When we deal with injured brains … there are many parts of the brain that are still intact, that are still healthy. … If you injure the area that you use very often to get things done, you can have a significant amount of impairment and disability. What you want to do as a brain specialist is ‘Let’s tap into that area that you didn’t even know you had.’ If we use that part of the brain, it actually helps the healing of the injured area.” He explained that a lot of recent research shows that it’s actually rewiring the brain.
In addition, the very act of creating art also eases anxiety and releases stress. “It decreases cortisol so it lowers stress and anxiety,” said Biggs. “It feels good. A lot of patients say this a lot: ‘Wow. This is magic. It feels like medicine. I feel good now.’ Because they’re working on something that is grounding and they’re manipulating something at the same time, oftentimes they are able to get farther in processing events that would otherwise be distressing to just talk about.”
After service members are referred to art therapy, they participate in three group sessions, and then meet one-on-one with Biggs to decide if they’ll continue with the therapy. The first project is the mask, which often brings up themes of identity: split sense of self, outside self versus inside self or deployed self versus home self, and positive side versus negative side. Biggs said other topics that come up are transitions, the injury itself, grief and loss. She has regular meetings with other providers at the NICoE to discuss patients’ goals and the themes that come out in their work.
During the next two sessions, patients try expressive writing and create mixed media artwork. They can draw. They can paint. They can cut out words and images from magazines and create collages. It’s totally up to them. Fox, for example, started out painting a picture of a friend who was killed by an improvised-explosive device while conducting dismounted route clearance. However, as he painted, the art slowly morphed into a self-portrait of Fox himself running away from his fears during that deployment. The number of IEDs they were exposed to were so numerous, he and his squad mates would preposition tourniquets on their arms and legs before heading out on missions, figuring that when someone inevitably tripped an IED, it would save some time.
The therapy was so helpful for Fox that after his initial three sessions, he met with Biggs and decided to keep going. Some patients continue in group sessions while others move to one-on-one therapy with Biggs. She helps them explore transitions, identity, self-perception, and grief and loss more deeply. “That can be grieving buddies who died in battle,” she said. “It can also be grieving aspects of self or career that at this point are lost. It’s really hard to move on and accept that you’re going to be stepping out of the military and into another career before you’re able to have time to commemorate the good things, and also grieve what’s lost. We do memorial boxes for that kind of thing.”
Fox decorated his memorial box with his nametape, a combat action badge and his unit patches, as well as photos of his unit. Inside, he placed a letter to the friend who was killed by that IED, photos of other friends – one lost – and a model of a can of his friend’s favorite beer. Fox also created a small model car for the box to represent the lost innocence of a child who had been killed.
The box is one of the most impactful pieces he has created, “simply because the memorial box brought back a flood of memories, both good and bad, and it helped me process some of the trauma, as well as remember some of my buddies who were killed, in positive ways.”
Then he painted two more masks and mounted them on canvas. One is a Soldier wearing a desert-patterned combat helmet with blood pouring down his face, the other a civilian with bullet holes in both the center of his forehead and his cheek. Red paint – more blood – surrounds the second mask. On a black background, using red again, Fox painted a message: “You didn’t take his innocence. He did that when he picked up the rifle.”
Although Fox didn’t explain exactly what happened, it haunts him. “This piece is something that I try to tell myself every day,” he said. “Part of me believes it, but another part of me doesn’t. I have to tell myself this every day to help me believe that because the child was killed, it wasn’t my fault.”
After a little more than a year of art therapy in addition to behavioral therapy, it’s getting easier for Fox to believe that. The ringing in his ears is a little less intense. He isn’t quite as angry as he used to be. And while he has never been able to remember his nightmares, he definitely had them. His wife would tell him and he would wake up drenched in sweat with his heart racing. That happens less.
“I was able to process the traumatic events a little bit easier and was able to open up a little bit more about them, which combined with behavioral therapy – it helped me out a lot,” Fox said. “I was able to remember some things that I couldn’t remember before. … Instead of clamming up whenever I’m asked about my events, I can now, at least on some level, open up a little bit more.
“The anxiety level increased as I progressed through therapy, but at the same time, once I leave this room, it’s like a huge weight is lifted off my shoulders,” he continued, adding that at times he’s been embarrassed by everything that’s come out, and that sometimes he needs to spend 15 or 20 minutes in the car decompressing after a session. “The more therapy goes on, the more the anxiety starts to decrease. It will raise for a short time, and then it will decrease even more than what it was before.”
Because art therapy does tend to open so many scabbed over wounds and drag out so many buried emotions patients might not be ready to face yet, Biggs and Chae both recommend that service members avoid taking a do-it-yourself approach.
“If their main goal is decreased irritability, increased emotional regulation, I might teach them some art techniques that are grounding … that they can do in their free time,” said Biggs. “Patients who choose to primarily focus on trauma processing, we usually keep that stuff here. It’s good practice to open Pandora’s box for an hour knowing that you can close it when you leave these walls. And then next week, you’re going to open it for another hour, but you can close it when you leave these walls. Over time, your body trusts that you’re going to deal with it and it eases up on some nightmares.”
So far almost every patient has rated the art therapy program as beneficial, and most have ranked it as one of their top five therapies. (Biggs is collecting before and after patient surveys for a more precise outcome study.) And if providers can’t always separate to what extent art has helped an individual versus another therapy, it doesn’t matter. All that matters is that it helped. The response has been so positive that, according to O’Brien, the NEA would like to work with the military to expand the program at other hospitals.
Soldiers should give it a chance, said Fox. “I understand fully how people can be skeptical of (art therapy), whether or not it works and whether or not it’s stupid, but give it a shot. I was in the same boat and it’s helped me. Not every therapy is for everybody. People respond differently to different therapies. This is one that helped me out a lot. It’s been a really big changer in my life.”
Editor’s Note: The Military Health System has produced a series of videos about art therapy and TBI and PTSD, featuring Fox, Chae and Biggs. For more information about how art can help wounded Soldiers, visit the National Initiative for Arts & Health in the Military website. To read about how writing can also help Soldiers heal, read “Owning your story: How writing helps veterans heal.”