Examining Associations Between Montage Painting Imagery and Symptoms of Depression and Posttraumatic Stress Among Active-Duty Military Service Members

Art therapy has traditionally been used as a treatment approach but it can also be applied successfully as a clinical behavioral health assessment tool in the care of military service members suffering from the effects of traumatic brain injury (TBI) and operational stressors. This observational study examined patterns of associations between visual imagery (mask and montage paintings) and clinical symptoms among 240 active-duty military service members with TBI, and associated psychological health conditions to include posttraumatic stress disorder (PTSD). The service members had participated in a 4-week intensive outpatient assessment and treatment program at the Walter Reed National Military Medical Center in the United States. Themes seen in the visual imagery were examined in correlation with standardized measures of PTSD (Posttraumatic Stress Disorder Checklist: Military Version) and depressive symptoms (Patient Health Questionnaire-9). The analysis showed that certain themes, like the use of color symbolism to depict psychological states, were associated with greater PTSD and depressive symptoms at the beginning of the program. In addition, patients who depicted themes like physical injury, psychological injury, and memories of deployment in Week 1 of the program were more likely to continue to represent them in Week 4. Depiction of themes like color metaphors and duality was associated with lower depressive symptoms at the end of the program. The findings indicate the potential clinical and prognostic value of tracking the content of visual imagery created by military service members with TBI and associated psychological health conditions. Clinical applications include the recognition that certain visual themes could indicate higher or lower levels of distress and may help guide targeted care.