Art Therapy

Journal of the American Art Therapy Association

ISSN: 0742-1656 (Print) 2159-9394 (Online) Journal homepage: http://www.tandfonline.com/loi/uart20

Art Therapy for Individuals With Traumatic Brain

Injury: A Comprehensive NeurorehabilitationInformed Approach to Treatment
Tori Kline
To cite this article: Tori Kline (2016) Art Therapy for Individuals With Traumatic Brain Injury:
A Comprehensive Neurorehabilitation-Informed Approach to Treatment, Art Therapy, 33:2,
67-73, DOI: 10.1080/07421656.2016.1164002
To link to this article: http://dx.doi.org/10.1080/07421656.2016.1164002

Published online: 23 May 2016.

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Art Therapy: Journal of the American Art Therapy Association, 33(2) pp. 6773, AATA, Inc. 2016

Art Therapy for Individuals With Traumatic Brain Injury: A

Comprehensive Neurorehabilitation-Informed Approach
to Treatment
Tori Kline
interpersonal, and emotional impairments. These can affect
activities of daily living and such domains as awareness,
communication, judgement, executive functioning, and
other skills depending on the location and severity of the
injury. Often, these impairments impact the individuals
community and recreational engagement, employment,
relationships, and general well-being.
In order to support recovery and an improved quality
of life for those with brain injury, comprehensive neurorehabilitation (CN) can improve psychosocial functioning,
particularly in terms of helping individuals be as active
and engaged in meaningful activities as possible (Sarajuuri
et al., 2005). CN is a holistic treatment program supported by clinical evidence, which includes a highly intensive, task-specic, repetitive neurorehabilitation treatment
regime. Interventions include but are not limited to a
post-acute therapeutic milieu, psychotherapy, cognitive
rehabilitation (the basic recovery process for repairing normal functioning in those with cognitive impairments),
retraining within an intensive and interdisciplinary treatment program, and continued medical and psychosocial
support posttreatment (Sarajuuri et al., 2005). CN is integrated and implemented over a period of time to promote
neuroplastic changes, with the aim of improving a persons
sensory, motor, cognitive, and behavioral processes in a
holistic manner (Jang, You & Ahn, 2007), and utilizes
neuropsychological rehabilitation in conjunction with psychotherapy (Sarajuuri et al., 2005). An area of focus in
TBI rehabilitation is use-dependent (experience-dependent) plasticity, the ability of the brain to undergo changes
when certain areas or pathways are activated during rehabilitation (Westlake & Byl, 2013). To support rehabilitation, BIAA (2014) outlined a number of goals and
guidelines for brain injury rehabilitation. These include
returning clients to their communities, helping them
regain the most independent level of functioning possible,
and utilizing outcome-driven treatment in the most integrative environment possible. The core guidelines of brain
injury rehabilitation include person-centered treatments
that are supportive, simple, consistent, exible, individualized, and positive.
McGraw (1989) advocated for the use of art therapy
with clients with TBI, and highlighted its ability to be individualized to accommodate each clients needs and decits
or disabilities. Cheyne-King (1990) asserted that art therapy
may be useful to remediate perceptual dysfunctions, or at
least help compensate for them (p.73). Lusebrink (2004)

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Abstract
I describe an approach to art therapy treatment for
survivors of traumatic brain injury developed at a
rehabilitation facility for adults that serves inpatient,
outpatient, and long-term residential clients. This approach is
based on a review of the literature on traumatic brain injury,
comprehensive neurorehabilitation, brain plasticity, and art
therapy, as well as personal experiences working with clients.
There is a paucity of recent art therapy literature on working
with this population, and given the continually advancing
knowledge of the brain and its plastic qualities, attention to a
framework for treatment is needed. The comprehensive
neurorehabilitation art therapy treatment approach presented
is tailored to accommodate clients individualized presentations
while following the goals and core guidelines of brain injury
rehabilitation.

Introduction
According to the Centers for Disease Control and
Prevention (2014), nearly 1.7 million people are diagnosed
with traumatic brain injury (TBI) annually in the United
States. That number jumps to 2,617,000 people when
acquired brain injury is also considered (Brain Injury
Association of America [BIAA], 2014). TBI is dened as
any alteration in brain function or pathology due to an
external force, and can lead to a number of complications,
disabilities, and even death (BIAA, 2014). Similarly,
acquired brain injuries, or ABIs, are injuries that occur to
the brain after birth, such as stroke, seizures, electric shock,
tumor, substance use or abuse, toxic exposure, and other
causes, excluding an external force. Such an injury may
cause physical, cognitive, and emotional disturbances, calling for a comprehensive, holistic, intensive, and individualized treatment for rehabilitation. Although 75% of TBIs
are classied as mild, and may be termed a concussion,
nearly 5.3 million people in the United States live with
long-term disability following TBI, and only about 5%
have access to funding for services (BIAA, 2014).
Koehler (2011) highlighted the fact that TBI can cause
a number of physical, cognitive, behavioral, social/
Tori Kline is an art therapist at ReMed in Paoli, PA. Correspondence concerning this article may be addressed to the author
at tkline711@gmail.com
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highlighted that art therapy interventions could not only

serve to reconstitute and rehabilitate physical impairments,
but could promote mental, emotional, and physical healing.
According to Sell and Murrey (2006), art therapy can be
used as a nonverbal method of assessment, a means to gain
insight and understanding of the client, and a means to
help structure the development of a treatment plan. It can
also support communication, expression, exploration, sensory activation, engagement, community reintegration,
bilateral brain activation, and an improved quality of life.
Garner (1996) developed a neuropsychological art therapy program, which was based on cognitive eldinteraction
theory, and observed that such a protocol proved useful as a
means of understanding functional levels and performance
changes over time for those with TBI. Chapman (2014)
stated that art therapy is both a right-hemisphere and a
left-hemisphere process, which uses unconscious emotional
content along with verbal dialogue (p. 114). She noted that
emotions precede knowing, and that metaphor may indirectly bring into consciousness content and meaning, while
maintaining a safe distance (p. 115).
Lusebrink (2004) explored the areas of the brain that are
activated during emotional states, memory processing, and
information processing, and proposed that the process of art
making be seen as forging a mind/body connection, via the
activations of interconnected brain systems. Makuuchi,
Kaminaga, and Sugishita (2003) found in an experimental
study that creative engagement involves both the fact-based
left brain and the more creatively aligned right brain. Along
with activations in both parietal lobes during drawing and
naming tasks, Makuuchi et al. also found activations in previously undocumented areas of the brain.

Benefits of Art Therapy for Individuals

With TBI
Art therapy can serve an integral role in promoting
treatment progress and recovery. Making art can serve as an
intrinsic motivator to encourage client participation and
engagement, while also enabling exploration of self-identity
and a focus on abilities instead of disabilities (Symons,
Clark, Williams, Hansen, & Orpin, 2011). Symons et al.
(2011) concluded that art also has a place as a rehabilitation tool for change in the areas of meeting goals, time use,
enjoyment, regaining condence and engagement in future
activities, through its intrinsic values (p. 51).
Following TBI, individuals may experience both poor
self-concept and decreased self-awareness as they are forced
to redene their lives (Prigatano, 1999). Often, the impact
of brain injury is not recognized or integrated into a new
sense of self post-injury (Douglas, 2013). Through the
informed use of materials and directives, art therapy can
provide structure, containment, and direction, while also
supporting exploration, individual expression, and a sense
of control (Sell & Murrey, 2006). Douglas (2013) suggested that creating a unique personal life story or narrative helps to facilitate meaning making as well as a stronger
self-concept and understanding during treatment (p. 71).

TBI

Perruzza and Kinsella (2010) identied through a literature review that the creative arts help enhance clients perceived control; build a sense of self, purpose, and social
support; aid in emotional expression; and transform the
perception of illness. Reynolds and Prior (2003) also found,
in a phenomenological study, that participation in the
visual arts helped participants express grief; lled an occupational void; increased a sense of choice; helped revise priorities; enabled ow and spontaneity; supported humor, joy,
positive emotions, and contribution to others; and broadened horizons.
In terms of promoting psychosocial experiences, the
use of art therapy may serve cognitive, emotional, psychological, spiritual, physical, and behavioral needs. Prigatano
(1999) highlighted that for people with TBI, many important experiences are inexpressible or, at best, expressible
only indirectly and approximately (p. 202). Because many
individuals with TBI may also suffer from aphasia (a language disorder with symptoms ranging from word-nding
difculties to speechlessness), their ability to effectively and
reliably communicate and express themselves may be
impaired. Sell and Murrey (2006) highlighted that art making as a nonverbal approach contributes to facilitating
change in clients with TBI.
Prigatano (1999) advocated for the implementation of
a holistic milieu-oriented neuropsychological rehabilitation
program for post-acute TBI patients in order to support
clients needs for socialization (p. 245). Douglas (2013)
highlighted the importance of community engagement and
social integration as a way to support ones self-concept,
engagement, and quality of life, as well as to decrease experiences of social isolation and lack of social ties. Perna,
Snyder, Bubier, Rousselle, and Oken (2004) concluded,
following their review of the literature, that activity-based
groups tend to be more productive and benecial than traditional verbal therapy, in that such groups support socialization, problem solving, decision making, cooperation,
organization, planning, and follow-through, as well as result
in a tangible nal product. Peer support and feedback can
help to enhance and support coping while fostering a sense
of community and belongingness. According to Sell and
Murrey (2006), group interactions serve to support not
only positive social skills, but also self-understanding. Wald
(1999) supported the use of group art therapy in order to
address psychosocial losses, which can be of particular use
with TBI because interactions with others may be limited
during treatment.
Art therapy for promoting brain plasticity is especially
important to consider. It is generally understood that the
degree of plasticity possible for any individual is roughly
reective of their chronological age, with the most plasticity occurring at a younger age (Kolb, 1999). Stepankova
et al.s (2014) randomized controlled study found evidence that, contrary to prior belief, it may be possible to
support some degree of plasticity in older age. Their study
investigated the generalizing effects of working memory
interventions/training on both working memory and
visuospatial skills, and found reliable group effects in both
areas.

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Using fMRIs, Makuuchi et al. (2003) identied that

both parietal lobes of the brain were activated during creative activity. This bilateral activation could serve to support
integration and recovery post-injury, and may be further
explored in relation to use-dependent plasticity. Conti
(2009) highlighted that use-dependent plasticity could be
supported through experience, engagement, and learning.
This activation and engagement, coupled with an understanding of use-dependent plasticity and reorganization,
supports art making as a means to spark and support plasticity in these areas of the brain.
Related to this, Jung et al. (2010) highlighted a number of constructs involved in creativity that hold implications for promoting plasticity. These include divergent
thinking (the thought process of generating ideas from possible solutions), uid intelligence (logic and problem solving), insight, and ow. From this, the authors linked
creative behavior with activation within and between a host
of different brain circuits. This serves to support the use of
creative engagement in rehabilitation from brain injury, as
a means of harnessing the healing potential of use-dependent plasticity throughout the brain.

A Comprehensive NeurorehabilitationInformed Approach

Considering the above along with my work with
adults with TBI, I developed a comprehensive neurorehabilitation-informed approach to art therapy treatment with

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individuals with TBI at a recovery center. This approach

is grounded in a framework for providing art therapy in
an informed way that accounts for our current understanding of brain plasticity. I have attempted to integrate the
key aspects of art therapy practice, theories of comprehensive neurorehabilitation, and an understanding of brain
injury and neuroplasticity, to address the specic goals and
core guidelines of brain injury rehabilitation. A comprehensive approach needs to include several components:
practitioner knowledge of the mechanisms of brain injury
rehabilitation, the careful development of a safe therapeutic space, an understanding of the distinctive role of the
art therapist, and the ability to establish rapport. The CNinformed art therapist should enter treatment with a clear
understanding of the basics of TBI rehabilitation treatment and a holistic understanding of traumatic brain
injury, CN, and art therapy. Table 1 illustrates the CN
framework as explained next.
Knowledge

Along with knowledge of art therapy theory and skill in

clinical practice, I worked to gain a basic understanding of
neuroanatomy, brain injury, and the mechanisms of brain
injury rehabilitation, essential for understanding clients
diagnoses, symptom presentations, decits, and treatment
goals, as well as their abilities. This knowledge is required
to effectively communicate with treatment team members
and to understand the overall arch of the clients treatment.
Throughout treatment, it is essential to continually

Table 1. A Comprehensive Neurorehabilitation-Informed Approach

Framework Key
Aspects
Knowledge

Therapeutic
space
Role of the art
therapist

Rapport

Includes. . .
Neurobiology, neuroanatomy,
neuroplasticity
Comprehensive neurorehabilitation
Physical, cognitive, behavioral, social/
interpersonal, emotional
impairments
Safety
Acceptance
Support, empowerment, engagement
Environment (distractions)
Flexibility
Psychosocial support
Approachability

Unconditional positive regard

Acute attunement/anticipation

Consider. . .

Utilize. . .

Executive functioning
Aggression
Sexual disinhibition
Fatigue/cognitive fatigue

Team cohesion

Loss of self post-injury

Depression
Social isolation

Empathy
Unconditional
positive regard

Cognitive, emotional, psychological,

spiritual, physical, behavioral
needs
Supporting plasticity
Hierarchical brain organization
Foster mind/body connection
Support choice, control, exploration
Nonverbal cues
Communication challenges
Behavioral presentation
Resistance/refusals
Lack of motivation or skill

Person-centered
approach
Trauma approach
Cohesion and
consistency
Sense of humor
Consistency
Flexibility

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reference the goals and guidelines of brain injury rehabilitation in order to drive art therapy treatment. BIAA (2007)
outlined a number of guidelines, including maintaining a
person-centered, supportive, and simplistic approach with a
consistent, exible, calm, and positive attitude. BIAA has
also highlighted the importance of maintaining a sense of
humor and not interpreting client behaviors as personal
attacks. This understanding has been imperative, as I have
experienced rsthand the personal insults that often accompany verbal aggression and behavioral dyscontrol when clients are suffering the aftereffects of TBI.
It is also necessary to actively advocate for clients by
providing education to coworkers, the local community,
insurance companies, and other medical professionals. This
supports patient inclusion and integration into the community; inclusion involves acceptance and understanding of
those with disabilities and differences. Persons with TBI are
often misunderstood and underserved. They need people to
advocate for them and to understand and empathize with
their struggles.
To provide comprehensive and effective care it is
important for the treatment to actively and coherently function well. This is particularly important due to the rapid
changes that may occur in the functioning level of a client
with TBI, even over a short amount of time. Individualized
strategies are often developed in order to minimize physical,
behavioral, emotional, or cognitive decits, and must
remain consistent in order to provide repetitive reinforcement of desired treatment goals. Factors such as a persons
memory decits and concrete thinking may undergo unexpected changes resulting in situations that might be difcult
to manage, and highlight the importance of cohesion and
consistency in providing exceptional team care.
The Therapeutic Space

When constructing the therapeutic space, the art therapist should create a sense of safety and support by considering a number of key elements: environmental factors (such
as distractions and stimuli in the treatment location), the
nature of the individual needs each client has (inuenced
by injury location, behavioral presentation, psychosocial
needs, and available supports), and the preexisting roles clients managed prior to injury (including their responsibilities and expectations for themselves and others). LazarusLeff (1998) explored the link between the aesthetic quality
of the environment for a person with TBI (including the
family and the quality of the surroundings), and its effects
on the persons attitudes and behaviors. By humanizing
and personalizing the environment of those with TBI, the
persons relationship to both the surroundings and the family can improve. I implement this by featuring art in the
milieu, personalizing clients rooms with artwork, and guiding clients to create decorations for holiday events in the
facility.
An additional environmental consideration arises with
clients who, due to cognitive decits, may be easily distracted and unable to focus or engage if the environment is
overly stimulating (Constantinidou & Thomas, 2010).

TBI

Interference in the form of distractions and other stimuli

may limit or disrupt information storage, impacting longterm memory. Learning and information retention can be
enhanced through the use of repetition and other compensatory strategies. This calls for structuring the environment
to minimize distractions by carefully considering when and
how to limit materials, remove clutter, and provide continuous yet gentle redirection when uncontrollable environmental stimuli take a clients focus away from the task at
hand. Attentional training may also assist clients to resist
distractions, and improve the effectiveness and retention of
functional tasks (Constantinidou & Thomas, 2010). External memory aids and alerting devices (such as calendars,
timers, clocks, photos, and phones) help increase independence and functioning.
Role of the Art Therapist

Throughout neurocognitive art therapy treatment, the

therapeutic relationship serves as a key element in the rehabilitative process (Chapman, 2014). The therapists role can
range from acting as witness to the therapeutic process to
serving as a role model or functioning as an educator by
providing guidance; this highlights the importance of cultivating therapist creativity required to address clients feelings
of helplessness, anxiety, and anger that often present in a
medical environment, as was observed by McGraw (1999).
The most important aspect here is the therapists ability to
create a sense of safety and approachability for each client
with a exible, consistent, and supportive approach. It is
useful to approach treatment from a trauma-informed
understanding, recognizing the physical and psychological
trauma that was sustained with TBI. McGraw (1999)
highlighted art making as useful for helping to cope with
traumatic events, as well as for making sense of the changes
that accompany them. Following TBI, it is difcult for
many clients to accept their disabilities, redene their sense
of self, and adjust to the changes that are now a part of
everyday life. Chapman (2014) outlined a neurodevelopmental art therapy model that can be employed to address
trauma. This mind/body approach to trauma resolution
therapy emphasizes the importance of developing the lower
structures of the brain before addressing higher level processes by assisting the client in exploring the self, identifying
problems, making changes, and integrating experiences and
skills learned (p. 50). Lusebrink (2004) outlined additional
neurological considerations in working with clients with
TBI, highlighting that some brain areas are specialized for
distinctive tasks, and that art therapy can harness alternative
pathways of information processing in the brain.
McGraw (1989) identied memory loss, loss of executive and organizational functions, depression, impaired control, and anxiety as areas for therapeutic focus. Additionally,
Weinberg (1985) highlighted difculties that may arise for
the therapist including client resistance, lack of self-control, short attention span, distortion of reality, emotional
lability, depression, distractibility, [and] irregular attendance (p. 66). Garner (1996) stated that the art therapists
goal should be to facilitate the transfer of learning that

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takes place in the [neuropsychological art therapy] environment to the individuals external environment, or daily living (p.111). This highlights the importance of a consistent
treatment team that remains cohesive in their approach.

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Beyond Traditional Rapport

Because the therapeutic relationship acts as a key element in rehabilitation, the art therapist must also develop
an acute degree of attunement with the client to anticipate
and respond to their needs and provide person-centered
treatment. I think about this as going beyond traditional
rapport building. It involves anticipation, and a high degree
of attention to subtle and nonverbal interpersonal cues,
because many clients do not, or cannot, reliably express
their needs. The therapist must gain an understanding of
the individuals unique presentation and behaviors (such as
aggression, disinhibition, poor judgement, lack of motivation, and limited interaction styles, among other factors).
Meeting clients where they are is important, as is supporting clients through whatever means is necessary, considering their level of functioning. The therapist must learn how
to approach each client in a way that suits the clients needs,
creates a sense of safety and empowerment, engages the client in a meaningful way, and supports behavioral strategies
already in place (even if this means playing cards and leaving art materials in the corner for the time being).
This high degree of sensitive attunement is necessary
to accommodate a number of challenges that may arise
in treatment. Physical impairments, such as hemiplegia
(paralysis of a side of the body), hemiparesis (weakness in
a side of the body), apraxia (difculty planning or performing motor movements), or ataxia (difculty coordinating motor movements) may signicantly inuence a
clients ability to manipulate materials. Severe impairments may even require hand-over-hand assistance from
the therapist. Speech disorders may also complicate the
rapport-building phase, as the client may suffer from
aphasia (a speech/language disorder), which can range
from word-nding difculties to the inability to speak, or
dysarthria (a motor speech disorder), which affects speech
production. Often, I found myself needing to spend
nearly a month with one client or another to begin to
understand their verbalizations and the subtlety of their
nonverbal interpersonal skills.
Cognitively, decits in memory, attention, insight, and
initiation may further complicate the therapeutic process,
and should be remediated or compensated for with specic
strategies and assistive devices (e.g., apps as memory aids,
incentive programs for initiation, and attentional training).
Often, clients may exhibit a slower processing speed and an
inability to think abstractly. This can be accompanied by
widely varying differences in working memory and response
times (Constantinidou & Thomas, 2010), function and
structure of the brain, limitations on activities, abilities to
participate in society (Koehler, 2011), and awareness of
ones disabilities (Wald, 1989). It is also important to
respect cognitive fatigue in treatment and to allow space
and exibility as the brain works to heal itself; this can

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occur through spontaneous reorganization and traininginduced recovery (Chen, Epstein, & Stern, 2010). This
type of fatigue occurs when the brain has to focus and concentrate on utilizing cognitive capacities (even tasks such as
tying shoes or brushing teeth), as disruptions in connectivity may lead to remapping of neural circuits. Sometimes,
the most helpful intervention involves allowing the client
the time they need to rest, in order to function at their optimal level.
I quickly discovered the importance of remaining consistent and exible in approaching and inviting a client to
sessions; in some cases, it took 2 months of declines, and a
consistent and positive approach, to engage a client in art
therapy. I discovered it helpful to maintain a exible understanding of each clients abilities, even from day to day or
hour to hour; it was important to continually adjust my
approach with each client in order to make necessary modications to meet that clients needs at any given moment.

Treatment
Peters (2015) suggested taking an adaptive counseling
approach that includes modifying verbal and written information to be clear and simple, providing notes, repeating
and helping establish storage for important information,
respecting the clients pace, and working through a discovery approach. Additionally, it is essential to follow established strategies, routines, and restrictions in a consistent,
coherent, and repetitive way. Each strategy is individualized
and developed in a way to enhance independent functioning while remaining as simple as possible to promote retention of information.
The therapist must examine and evaluate relevant
goals and objectives of the treatment team in order to
shape those of art therapy treatment. This should be a
continuous process in order to ensure that treatment is
meeting the clients needs, ensuring stabilization, and supporting generalizability to other settings post-discharge.
For clients with TBI, it is important to constantly evaluate
the goals and objectives of treatment and to make small,
incremental changes that will have a lasting impact on
their quality of life. It is important to do so slowly and
repetitively, to ensure continuous and consistent progression, stabilization, and follow-through, which may take
months or even years. Therapists should also integrate and
support the goals of the team to the best of their ability,
and evaluate discharge plans to ensure the generalizability
of the skills used and taught in the rehabilitation setting.
Treatment should be highly outcome-driven, and aim at
supporting clients in the most integrative environment
possible for them to be successful. This serves to support
the maintenance of their level of functioning, and an
improved quality of life.

Challenges
The difculties that arise in session call for consistency,
exibility, empathy, and truly unconditional positive
regard. Dysregulated behaviors, medical instability, and

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72

TBI

failure to engage may all be disheartening to the therapist. I

often have to resist the urge to step in and help clients with
a problem, in order to allow them the time and space to
attempt to remedy a situation at their own pace and experience success with minimal guidance. Again, acute attunement and patience is necessary to determine when clients
are lacking the motivation or drive to complete a task versus
the actual skills to complete it, which does necessitate help
from the therapist.
In addition to supporting adaptive client behaviors and
interactions, the art therapist must be prepared to step in if
a client needs assistance with activities of daily living.
Although it is often outside of the therapists repertoire, it is
sometimes necessary in TBI treatment. Due to brain injury
and associated nerve damage, neurogenic bowel and/or
bladder is common among individuals with TBI, which
often leads to incontinence. Thus, therapists must be
trained in the needs and strategies of each client.
With this population, in a long-term residential setting,
I learned that the therapeutic relationship may create
unique experiences of transference and countertransference.
This is heavily inuenced by the social implications of a
brain injury such as isolation and discrimination. Often clients do not have social supports, as families and friends
may be estranged for any number of reasons. Due to this,
team members, who are with clients in their homes on a
daily basis, become the primary social support system and
at times the only sense of family or community some clients
experience.
Considering the behavioral, cognitive, and social decits a client with TBI may exhibit, the therapist may nd it
difcult to maintain unconditional positive regard at times.
Continual requests for assistance, a seeming lack of motivation or initiation, client aggression, and apathetic behavior
might all wear on the therapist. When this occurs, it is useful to remain aware of emotions that arise, take a step back,
and inventory the situation. I often take time to reect that,
although not much is stable and reliable in the lives of clients with TBI, I can work to improve their quality of life by
maintaining a consistent and accepting approach to help
them cope optimally with the often unfortunate circumstances of their injury.

The most important consideration is to work with the

client to accommodate and compensate for physical and
cognitive decits, and at the same time provide supportive
strategies to reduce the impact of problem behaviors. Clients should be approached with consideration for their
unique presentation and individual needs. Treatment
should aim to support both psychological and physical
safety, as well as experiences of empowerment, success, and
emotional expression as much as possible, while the therapist maintains a stance of unconditional positive regard.
There is a signicant need for research in neurorehabilitation, and in the use of art therapy to support the inherently healing powers of creativity for individuals with TBI.
A number of studies have explored the implications of
music therapy with clients with brain injury including
music therapy to improve executive function and emotional
adjustment (Thaut et al., 2009), to improve social functioning and participation in rehabilitation (Nayak,
Wheeler, Shiett & Agostinelli, 2000), and to promote
independence as a compensatory technique (Gervin, 1991).
There is a lack of comparable studies in art therapy. Future
research should aim to examine art therapys effectiveness
for supporting rehabilitation, activating the brain and its
plastic qualities, improving emotional and psychosocial
functioning and well-being, supporting executive functioning, and providing an alternative means of communication
and expression for individuals with traumatic brain injury.

Summary

Chen, H., Epstein, J., & Stern, E. (2010). Neural plasticity after
acquired brain injury: Evidence from functional neuroimaging.
Physical Medicine and Rehabilitation Journal, 2(12), 306311.
doi:10.1016/j.prmrj.2010.10.006

Since the development of various art therapy

approaches for individuals with traumatic brain injury,
there have been a number of advances and discoveries in
understanding the plastic qualities of the brain. The concept of neuroplasticity, although still not completely or
thoroughly understood, is recognized as integral to learning,
development, and recovery from TBI, which can be fostered as a means to aid in rehabilitation of some decits.
The comprehensive neurorehabilitationinformed art therapy framework I use seeks to provide the art therapist with
guidance for treating individuals with TBI who are often
misunderstood and devalued due to problem behaviors,
impairments, and decits in social skills.

References
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Centers for Disease Control and Prevention. (2014). Traumatic
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ninjury/pdf/BlueBook_factsheet-a.pdf
Chapman, L. (2014). Neurobiologically informed trauma therapy
with children and adolescents: Understanding mechanisms of
change. New York, NY: W. W. Norton.

Cheyne-King, S. E. (1990). Effects of brain injury on visual perception and art production. The Arts In Psychotherapy, 17(1),
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