Explainer – Working with trauma through the creative arts therapies

Ying Wang

Introduction

Trauma is a pervasive global issue, affecting millions of individuals across different demographics. The impact of trauma is profound and multifaceted, affecting every survivor differently. In recent years, creative arts therapies have gained recognition as a potential treatment for trauma, offering an holistic and expressive means to address the complex effects of traumatic experiences. Common creative approaches used in trauma-informed work include narrative inquiry (Hirakata, 2009; Mountz, 2018), creative writing and poetry (Gildea, 2021), photovoice (Plumb et al., 2018; Sandlin et al., 2018), drama (Pufahl et al., 2021), dance, drama and movement (Grasser et al., 2019; Lai et al., 2021; Hunt, 2022), visual art (Jacobs-Kayam et al., 2013; McKinnon, 2019), clay work (Elbrecht, 2013; Morrison, 2020) and music (Archambault et al., 2019). The use of arts-based interventions offers an holistic, embodied, and creative approach to healing, allowing trauma survivors to express themselves, process their experiences, and engage in a transformative journey of recovery (Jacobs-Kayam et al., 2013; Morrison, 2020; King, 2022). 

Types of trauma

The term ‘trauma’ originates from the Greek language, signifying a ‘wound’ or ‘hurt’; in psychology, ‘trauma’ denotes an experience that is emotionally painful, distressing, or shocking, often leading to long-term mental and physical consequences (Straussner & Calnan, 2014). Trauma can be categorised into different types based on the nature and duration of the traumatic events, including single-time, multiple or long-lasting repetitive traumatic experiences.

Francine Shapiro, the originator of the Eye Movement Desensitisation and Reprocessing (EMDR) treatment approach, classified trauma into “large-T” and “small-t” categories (Shapiro, 1995). “Large-T” traumas include significant events impacting individuals, families, groups, and communities, such as natural disasters like hurricanes, floods, and wildfires, as well as human-caused incidents like deadly car accidents and acts of violence. In contrast, “small-t” or “micro-traumas” are more common and often go unrecognised. These include experiences like bullying at school or work, being stalked, living in severe poverty, childbirth, or facing ongoing discrimination due to race, religion, gender identity or sexual orientation (Straussner & Calnan, 2014). Despite being less conspicuous than large-T traumas, micro-traumas can still cause significant psychological pain and long-term damage.

Judith Herman referred to prolonged or multiple traumatic events as “complex traumas”, also known as Complex Traumas and Disorders of Extreme Stress (1997). Examples include ongoing interpersonal violence, long-term child abuse, continuous wars, or persistent acts of terrorism. Complex trauma involves distressing responses to severe and / or multiple events that often persist over time, significantly impacting an individual’s personality and behaviour (Herman, 1997; Briere & Lanktree, 2012), such as PTSD in military veterans when they are facing difficult transitions back to civilian life (Beliveau, et al., 2019). These traumatic events, whether occurring in childhood or later in life, can severely harm mental health and well-being (Herman, 1997).

Another type of trauma is vicarious trauma, which has been defined as an occupational challenge. Vicarious trauma is part of a spectrum of responses to trauma exposure, including secondary traumatic stress, caregiver fatigue, compassion fatigue, and burnout affecting individuals working and volunteering in fields such as victim services, law enforcement, emergency medical services, fire services, and other allied professions (Ravi et al., 2021). Vicarious trauma is an occupational hazard for those in helping professions who engage in empathetic relationships with clients such as creative arts therapists (Branson, 2019; Ravi et al., 2021). Creative arts therapists, along with other therapists, often face the risk of vicarious trauma due to the empathetic nature of their work (Wang, 2023). This can lead to emotional and physical exhaustion, making self-care practices crucial.

Impact of trauma

The idea that trauma could result in specific clusters of symptoms was first formalised by the inclusion of the diagnosis of PTSD in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980). Psychological and physical trauma are pervasive and universal, presenting complex challenges for professionals in providing clinical care (King, 2022). Trauma disrupts both physical and mental homeostasis, causing changes in the sympathetic nervous system, endocrine system, and brain structures, which in turn affect the cardiovascular, respiratory, and muscular systems (Solomon & Heide, 2005; King, 2022). This dysregulation creates various physical and sensory integration problems, making it difficult for individuals to identify, understand, and express their lived experiences coherently (Solomon & Heide, 2005).

Trauma survivors, particularly those who have experienced early trauma, often have difficulty expressing themselves verbally. Some trauma survivors develop emotional dysregulations such as anger, anxiety, sadness and shame, especially when the events occurred at a young age (van der Kolk et al., 1993). Additionally, early trauma can interfere with haptic perception and the development of fundamental language skills (Elbrecht, 2013). The disruption and fragmentation of bodily systems impair the capacity for verbal communication, often seen in clinical practice as the inability to integrate memories of traumatic experiences with verbal processing (King, 2022).

Another impact from trauma, re-traumatisation, occurs when current experiences trigger memories of past trauma, causing an individual to feel traumatised again. The existing mental health system often views severe distress and extreme behaviours as symptoms of mental illnesses rather than as coping mechanisms for past or present traumas (Sweeney et al., 2018). This perspective can lead to responses that are unhelpful or even retraumatising, as they fail to address the underlying trauma and may inadvertently replicate aspects of the original traumatic experience, such as a sense of helplessness or threat (Sweeney et al., 2018). Trauma-informed approaches recognise the widespread prevalence and effects of trauma, prompting a shift in focus from ‘What is wrong with you?’ to ‘What happened to you?’ (Sweeney et al., 2018). These approaches, including interventions used in creative arts therapies, aim to create environments and relationships that promote recovery and prevent re-traumatisation.

What the creative arts therapies can achieve

Numerous studies highlight the benefits of the creative arts therapies for individuals who have experienced trauma. Advanced technologies like mobile electroencephalography (EEG), functional magnetic resonance imaging (fMRI), and functional near-infrared spectroscopy (fNIRS) have been used to understand the brain wave activities involved in art therapy processes (King, 2022). Creative arts therapies support self-regulation, co-regulation, and the identification and amelioration of the body’s experiences of distress, establishing a sense of safety, positive attachment, and prosocial relationships. It enhances resilience, supports self-expression of trauma narratives, and facilitates meaning-making experiences and the development of new narratives post-trauma (Malchiodi, 2020). Different art forms provide a range of benefits, including facilitating emotional expression, promoting catharsis of traumatic memories, improving nonverbal communication, fostering trust, and enhancing emotional regulation (Jacobs-Kayam et al., 2013; Diamond & Lev-Wiesel, 2016; McKinnon, 2019; Morrison, 2020).

Involvement in arts-based approaches such as movement and dance, visual arts, drama, and music evoke sensory and embodied experiences, enabling the survivor to express the distress and characteristics of the traumatic event nonverbally; this allows for the recollection of past relational experiences (Goldner et al., 2021; Lev-Wiesel, 2022). As the trauma survivor’s brain activates the various systems involved in storing traumatic memories, the artwork serves as a container for these memories (McKinnon, 2019). Engaging in creative activities to represent the trauma can bypass dissociation mechanisms and be perceived as a proactive response to the memory of the abusive event, rather than a passive or freezing response (McKinnon, 2019). Arts-based approaches enable trauma survivors to access, construct, and process the trauma cognitively, emotionally, and sensorily, aiding in reducing the avoidance often associated with traumatic memories (Shuman et al., 2022).

Due to its integration of exposure, mindfulness, and somatic components, dance/movement therapy may be an effective multifaceted treatment approach for trauma and stress, addressing both psychological and somatic symptoms commonly associated with trauma-related conditions (Grasser et al., 2019). The somatic elements in creative arts therapies are vital for trauma processing and expression, as they allow individuals to engage their bodies in therapeutic work. This bodily engagement can facilitate the release of stored trauma, enhance emotional regulation, and promote a sense of bodily awareness and empowerment. Dramatherapy, while sharing the potential for movement work with dance therapy, the use of symbolism and imagery with art therapy, and the incorporation of sound and voice with music therapy, offers unique elements in trauma treatment. Specifically, dramatherapy utilises role (Landy, 1991), story (Johnson, 1993), and the potential for embodied language within the ‘as if’ space of dramatic reality (Pendzik, 2003, 2013). These elements create a safe and controlled environment where clients can explore and express their experiences, fostering healing through the enactment and re-authoring of traumatic narratives.

Creativity can facilitate quicker rapport-building between trauma survivors and therapists, helping alleviate some psychological effects of sexual violence, such as anxiety, post-traumatic stress disorder, and dissociation (Lev-Wiesel, 2022). By engaging with the traumatic memory captured within the artwork, survivors can gradually build up their tolerance for the resulting symptoms, leading to memory desensitisation over time (King-West & Hass Cohen, 2008; Saltzman et al., 2013). This enables professionals to work with these sensitive materials more safely and provides therapists with more insightful materials through observing the arts-making process of trauma survivors. Survivors can turn their feelings of disconnection, detachment, and numbness into an holistic snapshot in their artworks (Saltzman et al., 2013).

Arts-making allows trauma survivors to reflect on their experiences, feelings, and challenges from different perspectives. It provides the opportunity to “phenomenologically interpret the human condition” and enables survivors to create meaning in their “own understanding of self, others, and the world” (Saltzman et al., 2013, p.225). This creative process not only allows survivors to gain awareness of how these violent experiences affected them, such as their ways of perceiving the world and interacting with people, but also offers opportunities “to understand themselves and others from a new perspective” (Ho, 2015, p.14). Through arts-based approaches, trauma survivors can improve emotional expression, self-awareness, and self-esteem, and create new perspectives for a sense of belonging (Visser & Plessis, 2015).

Conclusion

The creative arts therapies have emerged as powerful tools for addressing trauma, offering a holistic approach to healing that integrates neurodevelopment and neurobiology to reconnect with implicit and explicit memories of trauma. These therapies support self-regulation, enhance resilience, and facilitate the expression and processing of trauma narratives. Different art forms, including movement, visual arts, drama, and music, provide various benefits, such as emotional expression, catharsis of traumatic memories, and improved nonverbal communication. Engaging in creative arts therapies helps trauma survivors reflect on their experiences, build new perspectives, and achieve a sense of belonging and self-actualisation. The therapeutic process aids in reducing avoidance associated with traumatic memories, fostering positive attachment, and promoting psychological well-being. Moreover, somatic-based interventions, such as dance/movement therapy and drama, specifically address both psychological and physical symptoms, offering a multifaceted approach to trauma treatment.

To avoid the risk of re-traumatisation, it is crucial for creative arts therapists to adopt trauma-informed approaches that recognise the prevalence and impact of trauma. It is recommended that creative arts therapists receive comprehensive training in trauma-informed care to understand and address the needs of trauma survivors. This training should include knowledge of trauma’s impact on the brain and body, as well as strategies to create safe therapeutic environments. Moreover, adopting client-centred approaches that empower trauma survivors and respect their autonomy is essential. Creative arts therapists should involve clients in the therapeutic process, allowing them to guide the direction and pace of their healing journey.

Additionally, creative arts therapists should prioritise their own self-care to sustain their effectiveness and prevent burnout. Self-care strategies may include regular supervision, peer support, setting professional boundaries, engaging in creative activities, and maintaining a balanced lifestyle promoting physical and emotional well-being.