The term TBI refers to a traumatic injury to the brain by an outside force, which causes altered brain functioning or pathology (Brain Injury Association of America, 2014). These injuries usually result from an accident, and they affect each person differently causing a vast array of cognitive, emotional and behavioral symptoms, and in some cases death (Auday & Abrahamsen, 2015).
Health Implications of TBI
According to the Centers for Disease Control and Prevention, (CDC, 2016), nearly 1.7 million people are diagnosed with TBI every year in the United States. Although 75% of TBIs are considered “mild,” nearly 5.3 million people in the United States live with a long-term disability following TBI and only about 5% have access to funding for services (BIAA, 2014). The leading cause of TBI is falls at 40.5%, with accidental blunt trauma at 15.5% at second, and motor-vehicle accidents at 14.3%. (Auday & Abrahamsen, 2015; CDC, 2016) Men are almost three times as likely to obtain a TBI than women. (Auday & Abrahamsen, 2015; CDC, 2016)
TBI can cause physical, cognitive, emotional and behavioral symptoms, ranging in difficulty based on the location, severity and cause of the injury contributing to an individual’s display of symptoms (Auday & Abrahamsen, 2015). Symptoms are often caused by primary or “focal” injuries and secondary or “diffuse” injuries, with primary injuries being caused by something such as the impact of the skull hitting another object, as in a fall, or are secondary and occur within minutes or hours after the initial TBI (Auday & Abrahamsen, 2015). Secondary injuries often occur when intracranial pressure due to cerebral edema, and an infection or hemorrhages can cause brain herniation, which can in turn lead to an increase in intracranial pressure, and could eventually lead to death (Auday & Abrahamsen, 2015). In addition to the risk of death as a possible consequence of an increase in intracranial pressure, herniation and infection can inhibit the functioning of the lower brain-stem which controls the autonomic nervous system (Auday & Abrahamsen, 2015).
To fully grasp the variety of issues that can be caused by a TBI, a better understanding of the types of injuries and their descriptions is needed. TBI is usually categorized upon the injury’s onset as mild, moderate or severe (Brain Injury Association of America, 2014). The most common traumatic brain injury is known as a concussion, which can result from either a “penetrating” or “closed head” injury, and happens when the brain is damaged by an abrupt movement change or collision (Brain Injury Association of America, 2014). A person who has experienced a concussion may or may not lose consciousness, may experience brain bleeds, swelling, or a skull fracture, and may or may not experience permanent damage from the concussion (Brain Injury Association of America, 2014).
A common way to further categorize brain injuries is by either a “penetrating” or “closed-head” injury, with a penetrating injury referring to the skull being breached by another object and a closed-head injury usually resulting from acceleration-deceleration injuries (Auday & Abrahamsen, 2015). Some examples of a penetrating brain injury include a “through and through” injury, firearms, and objects which travel at a low rate of speed, such as knives or arrows (Faraz Kazim, Shahzad Shamim, Zubair Tahir, Athar Enam, & Waheed, 2011). A through and through injury refers to an object entering one part of the skull, passing through the brain, and exiting the skull in another area. This type of injury is unique because it can feature ruptures, shearing and tearing in the brain as well as characteristics of a penetrating brain injury (Brain Injury Association of America, 2014). Although less common than closed head injury, these injuries tend to have worse long term health consequences (Faraz Kazim, et al., 2011).
Closed head injuries occur when something outside of the head causes swelling of the brain, increasing intracranial pressure resulting in brain injury (Brain Injury Association of America, 2014). The brain looks for a space to expand into to relieve pressure, and as such, will sometimes stretch into the eye sockets. Physicians will monitor dilation of a patient’s pupils to determine if intracranial pressure may be compressing eye nerves (Brain Injury Association of America, 2011). Additional, albeit less common forms of TBI include contusions, abusive head trauma (more commonly known as “shaken baby syndrome”), second impact syndrome, coup-countrecoup injury, and diffuse axonal injury (Brain Injury Association of America, 2014).
Cognitive changes include such common occurrences as amnesia, which can be loss of memory of past events (retrograde amnesia) or diminished ability to form new memories (anterograde amnesia). In addition, aphasia, or deficits in language production and/or comprehension can occur. (Auday & Abrahamsen, 2015; CDC, 2016) Overall, TBI sufferers may experience mental clouding and difficulty making decisions, preventing them from returning to their jobs and otherwise managing their affairs. (Auday & Abrahamsen, 2015) Emotional symptoms can include mood swings, irritability, depression and anxiety. (Auday & Abrahamsen, 2015) In instances of repeated concussions, post-concussion syndrome (PCS) can occur, bringing about symptoms such as headaches, irritability, dizziness, lack of concentration and impaired memory (Auday & Abrahamsen, 2015).
Whatever the categorization of the TBI, the injuries can be caused by an innumerable range of incidents, varying from domestic violence, falls, workplace injuries, sports injuries, motor vehicle accidents, and more (Brain Injury Association of America, 2014). With the symptomatic expression of TBI in individuals being vastly varied, considerations must be given to best practices for the preservation and enhancement of the lives of those who have obtained a TBI.
Therapeutic Needs of TBI Population
TBI presents differently in each person because of the nature and damage caused by the injury sustained and as such, each person’s treatment should ideally be tailored to accommodate client’s individualized presentations (Kline, 2016). To support rehabilitation, BIAA (2014) outlines a number of goals and guidelines for brain injury rehabilitation. These include returning clients to their communities, helping them to regain the most independent level of functioning possible, and utilizing outcome-drive treatment in the most integrative environment possible (Kline, 2016; Brain Injury Association of America, 2014). Central to these guidelines are person-centered treatments that are supportive, simple, consistent, flexible, individualized and positive (Kline, 2016).
The range of a TBI sufferer’s therapeutic needs can vary greatly. A neuropsychologist is brought in to conduct a neuropsychological test to asses cognitive and behavioral deficits. Once an assessment has been completed, a treatment plan is developed to help the individual progress as far as he or she is capable (Auday & Abrahamsen, 2015). It is common for an interdisciplinary team to work with TBI patients because of its possible influence on several bodily systems. Various therapies can be implemented in the treatment of TBI, including but not limited to, cognitive therapy, sensory-motor therapy, occupational therapy, speech and language therapy, physical therapy, and art therapy (Auday & Abrahamsen, 2015; Malchiodi, 2013).
With so much variance in the severity and treatment needs in the approach to treatment for TBI, many things need to be considered. The acute care after the trauma is first considered, then post-acute, or long-term care can be planned. After the goals and objectives for treatment are established between the patient, their family or caretakers and clinicians, with treatment being needed for the rest of their life or intermittently (Brain Injury Association of America, 2014).
As an integrative mental health profession, art therapy is valuable and versatile treatment modality to use in countless settings with a diverse range of populations. Art therapy stands as a creative way to grapple with life’s issues, from physical, to mental, to behavioral. Additionally, with many different media to explore in practice, even more variety and treatment option potentials are unlocked. With TBI patients, considerations need to be made in the possible array of physical deficits that may be present with each patient. Adaptations may need to be made, or physical assistance from another person in the form of hand-over-hand may need to be employed when executing an art therapy directive. Art therapy, by its inherent nature, is flexible in its approach to individualization for each person it aims to treat. This built-in flexibility makes it a well-suited option in the treatment for TBI clients because each individual to be treated can require vastly different considerations that another with the same condition.
Arts-based research has shown art therapy to provide many benefits for clients with TBI. Lusebrink (2004, 2014), McGraw (1989), Sell and Murrey (2006), have all provided evidence that art therapy serves a multitude of purposes including, but not limited to, compensation of perceptual dysfunctions, as well as emotional, mental, and physical healing. An additional benefit of art therapy in the approach to treating this population is that it offers a non-verbal assessment method for the therapist, which can be beneficial if the client may be experiencing speech deficits (Sell & Murrey, 2006) This means that although a client may not be able to adequately verbally express their feelings, concerns, or thoughts, the provision of another means of communication can be instrumental in gaining understanding of the client, an exploratory means of communication, sensory activation, improved quality of life, and provide for bilateral brain activity (Sell and Murrey, 2006; Kline, 2016; Jones, 2016).
Art therapy is a great asset in the treatment of TBI because it provides a therapeutically beneficial activity that forgets the client’s disabilities, and instead seeks to enhance and highlight their abilities. This shift in focus can help to motivate the client in the art therapy setting and encourage exploration of self (Symons, Clark, Williams, Hansen & Orphin, 2011). Although physical limitations should be considered when designing any art therapy directive for TBI patients, some media may offer a more inclusive practice that allow for physical assistance while still preserving the artist’s own artistic voice. For example, collage as a simple, easy to access and handle media that is appropriate for all ages and offers several benefits for those using it in the art therapy setting. These visual artworks incorporate different media such as printed images, textural elements and various papers, fabrics, or other assortment of materials that are affixed to a two-dimensional surface. Collage allows for creative expression in a non-threatening way, with many reporting “feeling ‘relieved’ and ‘more relaxed than usual’ when cutting meaningful pictures in an organized manner” (Buchalter, 2004, p.80). This media can be designed and structured from an innumerous assortment of materials, making it well-suited for its implementation in most art therapy settings. When physical limitations may inhibit art therapy participants from using other media, collage stands as an option where the user still has the ability to choose their materials, images, and placement on the page, therefore preserving their artistic voice and expression.
Collage not only allows for the individual voices of those who are not able to execute their own artwork in a traditional media such as painting, drawing, or clay, for example, but it gives the artist a chance to explore and commit to the expression of new ideas. By assembling seemingly innocuous two-dimensional bits and pieces into a cohesive image is a challenging, albeit freeing and inherently creative activity that can be enjoyed and benefited from by many. Arts-based research has shown collage to be an effective media to for a multitude of purposes and uses that translate into the world of art therapeutic practice. A primary benefit to the use of collage in arts-based research studies for art therapy is that it is a media that is easily accessible, and therefore, studies can easily be repeated and tested again (Creswell, 2011). Another perk of the use of collage in research studies is that it challenges the artist’s thoughts in that it is the joining of multiple images to focus on one imaginal, illustrated pictorial goal. The result of this could create “associations and connections that might otherwise remain unconscious” (Butler-Kisber, 2008, p.270).
While much of the research is focused on art psychotherapy with trauma survivors, and while many of those who have suffered a TBI have experience trauma, the interest in this study lies in the exploration of expanding the available information base for those who are committed to using sensory art therapy for this population. Expansion of the integral value of art therapy, and specifically sensory art therapy, can provide for another avenue of effective treatment for the specific and unique needs of adults with TBI.