Motivation and emotion/Book/2021/Creative arts and trauma

Background
Trauma refers to experiencing intense physical or psychological distress resulting from various circumstances affecting psychological, social, emotional, spiritual and physical wellbeing("Trauma-Informed Care in Behavioural Health Services", 2021). Types of trauma include adverse childhood experiences e.g. abuse and violence, domestic violence, mass cultural or political trauma, sexual assault, and combat trauma. In addition to this, trauma can also have adverse neurological effects. Neurological responses to trauma include decreased activity in the prefrontal cortex, increased activity in the amygdala, increased norepinephrine levels, decreased serotonin, and decreased hippocampus activity. While behavioural effects of trauma include "emotional upset, depressive symptoms or anxiety, behavioural changes, difficulties with self-regulation, problems relating to others or forming attachments, regression or loss of previously acquired skills, attention and academic or professional achievement can occur("Trauma-Informed Care in Behavioural Health Services", 2021).

Creative arts therapy encompasses various therapeutic creative interventions, specifically revolving around the arts. These include therapies of art, music, dance, narrative as well as both psychodrama and drama (de Witte et al., 2021). Art interventions are utilised in individual, family, healthcare, mental healthcare, rehabilitation and community-based environment. This type of intervention was developed in the 1940s to 1950s by psychotherapist Margaret Naumburg within psychiatric institutions, primarily expanding into various support settings. (de Witte et al., 2021) Creativity is used as a psychodynamic approach through externalisation and transformation, using imagery, metaphors and non-verbal modalities. There are five creative arts therapy clusters: hedonism (pleasure), aesthetics, symbolism and inactive space. Creative arts therapy includes an Illustration as unconscious and conscious communication to disclose inner conflicts, self-esteem, self-awareness, reducing stress and rebuilding the physical, emotional, and social sense of well being.

Techniques
There are multiple mechanisms and clinical approaches to trauma using creative arts therapy. Progressive exposure involves the gradual exposure to avoided material, commonalities found amongst traumatised individuals. Re-consolidating memories involve connecting implicit and declarative memories and resolving the sense of dispersal (Spiegel et al., 2006); materials are used as a non-verbal continuation of memories. Externalisation creates a separation between the traumatic material and individual, re-scripting narratives consciously through identification and redefinition, lowering levels of hyper-arousal or hypo-arousal as a result of physiological trauma (Spiegel et al., 2006). {Creative arts therapy is rooted in psychodynamic theory? + True - False
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{Positive psychology can be linked to creative arts therapy when dealing with trauma? + True - False
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Mind-body
The mind-body is described as the bodily sensations and accompanying emotions that follow the tactile experience of creative arts interventions. Imagery is attached to positive affect and emotionality due to three pathway systems of sensory stimulation, brain arousal and memory activation(Czamanski-Cohen & Weihs, 2016). Three neural systems interact during emotional regulation. This framework conceptualises interoceptive (body stimuli) and soma-sensory (sensory stimuli) based on information responsible for emotional meaning. Physiologically the experience of trauma activates neurobiological systems (neural, endocrine, immune systems). Exposure to repeated stresses leads to an overstimulation of allostatic systems. This maladaptive response is overwhelming, causing behavioural changes such as sleeplessness, depression, substance abuse, and anxiety raising risk factors for mental health disorders(Czamanski-Cohen & Weihs, 2016). Sensory responses are activated during the intervention process, activating the amygdala through sensory information input in the primary somatosensory cortex, creating an emotional response, translating into meaning that contributes to psychological and physical health. Tactile and sensory stimulation is linked with arousal levels releasing hormones maintaining relaxation through allostasis(Czamanski-Cohen & Weihs, 2016).

Unconscious to conscious
Creative arts therapy can be analysed as a contemporary model of psychoanalysis. As art is used to address unconscious memories in the human mind through externalisation or bringing the subconscious to the forefront of the brain, achieving this through the use of rich symbolism(Tran, 2015). Psychoanalysts perceive symbolism as a method of revelation leading to a relationship between the unconscious and unconscious(Tran, 2015). According to Freud, thoughts and memories that are non-verbal are represented through pictures; this art-making creates a reconciliation between both realities that may lead to psychological distress(Tran, 2015). Art can lead to a sense of catharsis through the repeated exposure of the subconscious to conscious memories in a safe non-intimidating environment using externalising tools, further regaining a sense of internal control.

Memory reconsolidating
Trauma psychology focuses upon cognitive coping within the context of stress levels and threatening stimuli, the components of perceived control, interpersonal security and capacity for positive emotional states which is also referred to as a strengths-based or resilience-based approach(Hass-Cohen et al., 2018). A significant contribution of therapeutic change within trauma and creative arts therapy is memory reconsolidating. Memory reconsolidating is the revisiting of specific trauma-based memories. Neurologically, proteins are destabilised then re-synthesised; the memory previously residing in the fear centres of the brain form are transferred within four to six hours(Hass-Cohen et al., 2018). Revisiting memories are linked to lower rates of hyper-arousal, which leads to the extinction of the effects leading vulnerable individuals towards recovery(Hass-Cohen et al., 2018). Creativity and art-making create consolidation through accessing non-verbal memories through resiliency as well as neurobiological factors.

Dance therapy
Empowerment focused movement therapies primary goal is psychophysical and social recovery. The leading theory regarding dance therapy is that storing emotion within the body movement can alleviate experiences regarding stressors (Bernstein, 2019). Dance movement therapy explores traumatic nonverbal experiences through physical vocabulary, creating a tangible link between memories and the body on a physiological and psychological level. According to the dance therapy theory, trauma is stored in the implicit memory as opposed to the explicit memory(Bernstein, 2019), residing in the body through sensation. Trauma is linked to our internal survival mechanisms experiencing fight, flight or freeze with the body and brain (linked to mind-body theory) monitoring for external and internal signals of danger, leading to a system of alert. Dance movement therapy stresses the accessing of this trauma during intervention through sensation leading to bodily control, an alternative method of therapy focusing upon the bodily and metaphorical processes. In order to understand the implications of physical-based therapies such as dance, the physiological and bodily impacts of trauma must be addressed. The areas of the brain impacted by trauma include the amygdala, hippocampus and prefrontal cortex(Bernstein, 2019). The chemicals impacted by trauma include cortisol, norepinephrine associated with post-traumatic stress disorder. It has also been found that those with traumatic disorders show a smaller anterior cingulate and decreased prefrontal activity and issues with cognitive functioning, including memory and focus. In terms of the body, both increased stress and trauma creates a biological response impacting our physiological systems affecting the nervous system, genetic composition, and researchers have even linked immune system, cardiovascular, gastrointestinal and endocrine changes in response to the association of these high-stress events(Bernstein, 2019).

The APA or American Psychological Association defines body memory as “a sensory recollection of trauma in the form of pain, arousal, tension, or discomfort, usually unaccompanied by words or images” as a result of sensorimotor based trauma (Bräuninger, 2014). Specific dance therapy approaches include the psychodynamic approach, which uses dance to represent conflicts in past experiences. An authentic movement approach is a self-directed non-judgemental observational meditative experiential type movement(Bräuninger, 2014), and integrative dance therapies express nonverbal emotion. A research study was completed measuring the reduction of stress through dance management therapy measuring stress using a checklist (intervention one and intervention two) before and after each group session(Bräuninger, 2014). The sample size was 162, with a median age of 44 ranging from 16 to 65. Stress was measured using the standardised multidimensional self-assessment tool (coping and stress management) and the World health organisation quality of life questionnaire (physical, psychological and social health). After each dance management therapy intervention,, results found a positive relationship between stress level improvement with a p-value of 0.01 and quality of life improvement p= 0.01(Bräuninger, 2014). The five senses, interrelation, group cohesion, accessing then releasing memories, the experience of trauma is reduced. Each type of creative arts therapy (music, dance, poetry, narrative and art) has been shown through research mentioned to significantly affect the experience of trauma and by-products of identity dissociation, emotional fragmentation, and relational needs.

Music therapy
Relational needs are defined as interpersonal requirements throughout life; failure of fulfilment in relational needs leads to ‘disturbances in mood, thought, body, behaviour (Spiegel et al., 2006). Within humanistic psychology, relational needs can be fulfilled through client-therapist psychotherapeutic relationships, particularly within music therapy beneficial for individuals experiencing trauma(Spiegel et al., 2006). This is the triangular relationship, a psychotherapeutic method of analysing the intervention where the creative arts tools, mental health professional, and client are perceived within a relationship that benefits psychological well-being. Drumming or music therapy is particularly effective in treating combat stress or combat PTSD amongst soldier populations historically within specific communities and through the use of rhythms to communicate(Spiegel et al., 2006). Music therapy, within-group settings, creates a sense of interpersonal relation, fulfilling belonging relational needs through eye contact, feedback and collective musical cohesion. It is theorised that music therapy is a helpful intervention for individuals experiencing trauma as sensory experiences are mediated. A study was conducted on PTSD and group drumming(Spiegel et al., 2006). Clients were 20 to 23 serving in the military as soldiers. (Spiegel et al., 2006) The participants proceeded with four weekly group music sessions. Results found, after each session of drumming, group cohesion or relational need fulfilment was formed, leading to feelings of belonging as shown in the triangular relationship model. Furthermore, loud drumming served as a physical outlet significantly reducing levels of stress, further linking to the mind-body (Spiegel et al., 2006).

Emotion theories
Positive psychology can be linked to the emotive component of creative arts therapy and according to this particular field of psychology, art therapy can facilitate flow, positive emotions, purpose and meaning(Wilkinson & Chilton, 2013). Positive psychology is an emotional theory relating to positive characteristics and inherent good focusing upon self actualisation and pro-social behaviours(Wilkinson & Chilton, 2013). This particular method of psychology views mental health through the perspective of alleviating suffering and weakness leading to positive functioning. A large component of wellbeing can be attributed to purpose and meaning causing cognitive-emotional shifts through the use of imagery and symbolism when dealing with traumatic circumstances(Wilkinson & Chilton, 2013). Expressing and communicating meaning using metaphors is linked to post-traumatic growth,  a method of finding new meaning following incidents of trauma(Wilkinson & Chilton, 2013). Art therapy further facilitates flow which is the complete absorption into an activity. Flow theory states this absorption leads too engaging in personal strengths, facilitating positive emotion by focusing on positive personal strengths(Wilkinson & Chilton, 2013). In general, positive emotions are elicited through the creation of art, and the therapeutic relationship using flow theory and a strength based approach. Creative arts therapy can help in dealing with trauma through the lens of the  theoretical model of emotional regulation. “Emotion regulation refers to the ability to manage one’s emotional experiences in a way that enables adaptive engagement in daily life within one’s environment”(Fancourt, Garnett, Spiro, West & Müllensiefen, 2019). Emotional regulation is based upon psychoanalytic theory and psychodynamic theory. There are various emotional regulation strategies such as modification of behaviour, diverting attention and cognitive change and divided into two categories of maladaptive and adaptive(Fancourt, Garnett, Spiro, West & Müllensiefen, 2019). Through this framework creativity is viewed as a cognitive process so when positive emotions are elicited both motivation and cognitions are enhanced increasing levels of creativity(Fancourt, Garnett, Spiro, West & Müllensiefen, 2019). By focusing on thoughts and feelings using creativity emotional regulation can be achieved helping in dealing with trauma.

Conclusion
Trauma refers to experiencing intense physical or psychological distress resulting from various circumstances affecting psychological, social, emotional, spiritual and physical wellbeing. Trauma can be dealt with using creative arts therapy which is an intervention utilised in various settings utilising a psychodynamic approach. Various methods of externalisation are used such as symbolism, metaphors, physical interpretation, and various other non-verbal techniques. Creative arts is useful when dealing with trauma due to the mind-body connection, the subconscious becoming conscious, memory reconsolidating, the triangular relationship, emotional regulation and positive psychology. Although supported by research in the future studies should focus upon cross-cultural application, inclusivity of a wider range of genders, a specific placebo group and significantly larger sample sizes as well as neurological evidence in order to measure biological changes as a confirmation of the results.