PTSD and the Arts: A Path to Healing Our Healers

More than two months into the pandemic, experts are raising concerns over the long-term mental health implications for healthcare and other frontline workers.

Behind the hospital ward weddings, standing ovations and donated meals, there are thousands of doctors, nurses and paramedics who are exhausted, anxious and traumatized by their experiences caring for those with COVID-19.

Much of the anxiety stems from the fear of contracting the virus and passing it on to loved ones. More than 60,000 U.S. healthcare workers have fallen ill with COVID-19 as of late May, according to CDC data. Because of the risk of exposure, many healthcare workers have been quarantined from their families for weeks or months. The WHO also reports that healthcare workers in a pandemic face long working hours, psychological distress, fatigue, occupational burnout, stigma and physical and psychological violence.

Together, these experiences make post-traumatic stress disorder (PTSD) a well-established risk among healthcare workers facing deadly outbreaks and disasters. Employers are scrambling to answer a question central to everyone’s recovery: how best to heal our healers?

PTSD and Its Precursors

PTSD develops after experiencing a traumatic event firsthand, like an accident, abuse or natural disaster, or witnessing another’s trauma. Most exposed to trauma will experience heightened stress responses and recover. If symptoms persist for months and begin to interfere with work and relationships, a diagnosis of PTSD is made. The symptoms of PTSD include flashbacks and nightmares, feeling tense or “on edge,” a doom loop of negative thoughts and avoidance of anything that could be a painful reminder of the trauma itself.

The pandemic has all the necessary ingredients that make caregivers especially vulnerable to developing PTSD. Even before the pandemic, half of doctors and one-third of nurses reported experiencing burnout, marked by exhaustion, cynicism and feelings of ineffectiveness.

The exhausting nature of caring for the sick can also cause “compassion fatigue.” With COVID-19 units on lockdown, healthcare workers are frequently standing in as a surrogate family to comfort patients in their final moments. Without opportunities to refuel, workers are left feeling drained and emotionally numb, depleting their empathy for patients and families.

In military settings, “moral injury” is often associated with PTSD and can result from either witnessing or being involved in events that violate deep moral beliefs, or feeling betrayed when an organization fails to protect its people. For healthcare workers fighting on the fronlines of the pandemic, feelings of shame and guilt can stem from having to make impossible choices when distributing scarce life-sustaining equipment like ventilators. Workers have also voiced feelings of betrayal and anguish when they lack the personal protective equipment (PPE) needed to do their jobs safely, resigned to using garbage bags for gowns or recycling masks well beyond their intended use.

Psychological First Aid for the Frontline

Prior efforts have been made to address the psychological burdens of the healthcare workforce, which have been especially critical during the pandemic. Albert Wu, MD, MPH, co-founded Resilience in Stressful Events (RISE), a 24-hour peer-support program designed to provide “psychological first aid” to healthcare workers at Johns Hopkins.

“We’ve seen 20-30 times the number of people accessing our services since the pandemic began,” said Wu, who is also a doctor of internal medicine and professor of health policy and management at Johns Hopkins Bloomberg School of Public Health.

That’s more than 2,000 staff at Johns Hopkins Hospital alone in just eight weeks.

Peer support can “stop the bleeding” of immediate stress, and for many people, that’s enough.

For those suffering from longer-term distress, psychological counseling or medication along with complementary treatments like yoga, meditation or creative arts therapies may be necessary to recover from PTSD.

Trauma and the Brain

The body reacts to trauma by secreting stress hormones, which in some cases, may result in changes to brain areas involved with fear conditioning, threat detection, emotion regulation and information processing.

In patients with PTSD, the amygdala, a threat detection and fear center of the brain, becomes hyperactive. This hyperactivity is likely why people with PTSD have fear-related memories that are harder to extinguish or forget, which is key to recovery. PTSD also reduces the size of the hippocampus, the brain’s memory formation center, which may cause people to misremember and misread non-threatening situations as dangerous ones.

At the same time, PTSD patients also have difficulties regulating their emotions due to less activity in the medial prefrontal cortex, a brain area essential to executive function. They may alternate between feeling anxious and on edge, irritable and angry or numb and detached, without much control or understanding of their shifting moods.

PTSD also robs survivors of their ability to find the words to express their memories and emotions by deactivating their brain’s language center, known as Broca’s area.

Together, these brain changes keep people with PTSD stuck in the past with a heightened sense of fear and “speechless terrors.”

Restoring the Brain through Art

Military service member painting

The arts, in particular, offer a unique and accessible pathway to healing.

“People cannot put traumatic events behind until they are able to acknowledge what has happened and start to recognize the invisible demons they’re struggling with,” explains Bessel van der Kolk, M.D. in The Body Keeps The Score. 

The arts may help PTSD survivors ground themselves in the present where they can safely process and place their trauma in the past. Different art forms, like painting, music, and dance, have been consistently found to activate a wide swath of sensory processing regions in the brain and enhance the perception of visual, auditory, and touch cues. This sensory engagement during art-making helps survivors integrate disconnected or fragmented memories associated with PTSD and develop a coherent story of their experience.

Art and music also help survivors give voice to their experience when words fail, as is often the case in trauma. By activating the prefrontal cortex and hippocampus, these art forms facilitate the processing of emotions nonverbally and may compensate for the deactivation of these brain areas during PTSD. These alternate modes of expression can help survivors reclaim their ability to communicate and restore their self of sense on their road to recovery.

The arts are also calming. In PTSD, the hypothalamic-pituitary-adrenal (HPA) axis, which regulates and controls stress response, is dysregulated, which results in changes in levels of the stress hormone cortisol. The arts have the power to help regulate mood and cortisol, which can help alleviate the severity of PTSD and make each day easier to face.

The Healing Potential of Art Therapy

While work is underway to study creative arts therapies as a tool to help healthcare workers specifically, a growing body of research has examined their effectiveness in other traumatized populations, such as military service members, refugees and survivors of domestic violence. Visual arts, expressive writing, music, and dance are some of the modalities, used individually or in combination, that have consistently reduced PTSD symptoms across these diverse groups.

The U.S. military has studied and used an integrated arts therapy approach through Creative Forces, a partnership of the National Endowment for the Arts, the Department of Defense and the Department of Veterans Affairs. Research found that integrated creative arts therapies, including music, creative writing, movement therapy and mask making help heal service members and veterans with PTSD and traumatic brain injury. Participants reported that art therapy helped most with developing a sense of self after injury, experiencing positive emotions, processing trauma, and reducing feelings of guilt, grief and loss. In a 2016 study, integrated creative arts therapies were also shown to reduce anxiety symptoms of refugee adolescents from Burma experiencing PTSD.

Visual arts therapy, like painting, drawing, or sculpting, allow participants to depict trauma experiences and then view the finished image at a physical distance, externalizing memories in an emotionally safe way. Adults with PTSD symptoms who depicted trauma-related feelings experienced a more significant reduction in symptoms of PTSD than those who drew everyday objects instead. Similarly, adolescents with PTSD who made a narrative book of their life stories demonstrated significant PTSD symptom relief when compared to adolescents who participated in a standard arts and crafts activity.

Expressive writing can also be helpful for those living with PTSD. While writing may not reduce the symptoms directly, it can reduce the body’s stress response to traumatic memories, contributing to resilience and post-traumatic growth.

Music provides additional modes for expression, tapping into the motor, auditory and limbic (emotional) regions of the brain to reduce PTSD symptoms. Veterans in one 10-week music therapy program showed a significantly greater reduction in post-traumatic stress symptoms, such as re-experiencing unwanted memories and hyperarousal, than those in the control group. Another study with women survivors of domestic violence showed that listening to musical recordings while following a muscle relaxation script contributed to lower anxiety and better sleep.

Dance/movement therapy may reduce the length of treatment for trauma by making connections among many parts of the brain. Movement is key to resetting the somatic nervous system, the nerves that control voluntary muscle movement, where trauma may remain “stuck” in the body. Dance/movement therapy can be effective for refugee children who are dealing with trauma. Similarly, yoga can be as effective as psychotherapy and pharmaceutical treatments for PTSD.

More research is needed across modalities and populations to understand the full potential of creative arts therapies for trauma. But with multiple promising avenues for healing, the arts can be an important part of a broader treatment plan for PTSD, complementing psychotherapy, peer support and self-care strategies.

PTSD Resources

PTSD is a serious condition. If you or a loved one are showing symptoms of PTSD, seek treatment from a licensed medical professional. If you need immediate help, please text SHARE to 741741 to reach a crisis counselor with Crisis Text Line. You can also call The Lifeline at 1-800-273-8255 to connect with free and confidential support and crisis resources for you or your loved ones.

Know the Signs, Symptoms and Treatment Options for PTSD

Where to Find Help

It’s best to speak with your primary care doctor about your health and treatment options. You can also find referrals to licensed trauma-informed experts below.

Mental Health Resources for Healthcare Workers and First Responders

More About Trauma-informed Creative Arts Therapy

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This is article is a part of IAM Lab’s regularly updated COVID-19 NeuroArts Field Guide. Be sure to check the Guide for the latest, evidence-based tips on how the arts can support our wellbeing during the pandemic.

We would also like to hear from you: Are you, your loved ones or colleagues dealing with specific issues and want to learn more about art-based solutions? Are you already using the arts to help you cope? 

Please share your thoughts, ideas and concerns with us at covid19arts@artsandmindlab.org. Be well and stay safe.

Lead Image: Shutterstock / Eldar Nurkovic

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