Creative Forces (NEA)

1. Introduction

Version followed: the Creative Forces Clinical Program and Community Arts Engagement Program as described by the National Endowment for the Arts (programme pages and June 2025 fact sheet; clinical figures as of Dec 2024), with clinical procedures taken from the published NICoE (Walter Reed, Bethesda) and Intrepid Spirit One (Fort Belvoir) art therapy models in Jones, Walker, Masino Drass & Kaimal (2018), the NICoE mask studies (Walker et al. 2017; Kaimal et al. 2018), and the music therapy clinic-to-community model in Vaudreuil, Bronson & Bradt (2019).

Creative Forces: NEA Military Healing Arts Network is a programme, not a single therapy. It is a National Endowment for the Arts initiative run with the US Department of Defense (shown on the current NEA page as the Department of War) and the Department of Veterans Affairs, aimed at military and veteran populations exposed to trauma and their families and caregivers [source: NEA fact sheet 2025]. It has two distinct tracks that a psychotherapist must keep apart:

Clinical track (therapy). Credentialed creative arts therapists (CATs: art therapists, music therapists, dance/movement therapists) are embedded in interdisciplinary teams at 12 DoD and VA medical sites and via telehealth, treating post-traumatic stress, military traumatic brain injury (TBI) and related conditions. CATs are employed by DoD, VA or the Henry M. Jackson Foundation; 32 CATs, 25,063 patients and 141,214 therapy encounters are reported since 2017 [source: NEA Clinical Program page].
Community arts engagement track (not therapy). Since 2017, grants support community-based arts activity (classes, family arts, exhibitions; in community, healthcare or virtual settings) for service members, veterans, families and caregivers, including people who have had or are having clinical arts therapies. Its stated aims are creative expression, relationships, resilience and adjustment to civilian life [source: NEA fact sheet 2025].

Core idea of change, as the sources give it: art-making, music and movement let service members externalise and give form to experiences that are hard to speak (the "invisible wounds of war" phrase used at NICoE), so that symptoms, identity changes, grief and trauma can be seen, shared with peers, family and the team, contained and integrated; community arts then sustain connection and reintegration after clinical care [source: Jones et al. 2018; Drexel News 2016; Vaudreuil et al. 2019].

Evidence status as the sources give it: NEA pages say creative arts therapies "can" help health, resilience and social integration but report no effectiveness results; the published clinical work is qualitative, case-based, observational and programme-evaluation research; the 2019 music therapy summary calls its findings "preliminary evidence" and recommends multisite studies before music therapy is treated as standard of care; NEA describes community-engagement research as still investigating [source: NEA Clinical Program page; NEA fact sheet 2025; Creative Forces music therapy summary 2019].

This guide covers the programme frame and the military-specific procedures. For the general method of each discipline, use the separate Art therapy, Music therapy and Dance/movement therapy guides in this collection rather than this one.

2. Framework

2.1 Professional frame and who may do what

Clinical-track interventions are delivered by credentialed CATs within DoD or VA medical care [source: NEA Clinical Program page]. In the US the usual credentials are ATR-BC (Art Therapy Credentials Board; professional body AATA), MT-BC (Certification Board for Music Therapists; AMTA) and R-DMT / BC-DMT (ADTA) [synthesis: standard US credentialing; the NEA page itself lists no credentials]. The music sources identify their clinicians as board-certified music therapists [source: Vaudreuil et al. 2019].
The emotionally provocative Level 2 art directives are to be facilitated only by trained art therapists able to contain traumatic material, and the Intensive Trauma Therapy graphic narrative only by therapists trained in it [source: Jones et al. 2018].
A psychotherapist without CAT training should not run the clinical directives below as trauma work. Your roles are: referring to a CAT, coordinating as a team member, using artwork the client brings, and referring into or alongside community arts [synthesis].
Community-track activity is led by teaching artists and arts organisations (e.g. a military-spouse teaching artist) and is arts participation, not therapy [source: NEA fact sheet 2025]. There is no regulated profession for that role [synthesis].

2.2 Clinical track, Model One: NICoE four-week intensive outpatient programme (IOP)

Setting: interdisciplinary IOP for TBI, PTSD and co-occurring mood disorders; the NICoE template (medical examinations, family evaluation, nutrition, complementary medicine, creative arts therapies) became the model for the Clinical Program [source: NEA History page].
Intake: cohorts of up to six service members admitted weekly [source: Jones et al. 2018].
Week 1: group mask-making; every member also receives at least one individual art therapy evaluation [source: Jones et al. 2018; Kaimal et al. 2018 via Drexel News 2018].
Weeks 3–4: open studio; follow-up individual sessions for members whose sessions the art therapist, member and team judge especially beneficial [source: Jones et al. 2018].
Final week: group montage painting [source: Jones et al. 2018].
Since 2015: referral-based long-term weekly one-hour individual art therapy alongside the IOP, for as long as clinically appropriate [source: Jones et al. 2018].
Exact total session counts are not published [uncertain].

2.3 Clinical track, Model Two: Intrepid Spirit One long-term outpatient art therapy

Physicians evaluate and refer by treatment goal; the protocol is staged on Herman's model (safety and structure; remembrance and mourning; reconnection), with a programme-evaluation survey at the end of each level [source: Jones et al. 2018].

Level	Format	Length	Goals	Move-on criteria
1	Group (max 5, for space)	3-week initial commitment	Introduction to art therapy; insight, emotional regulation, empathy, baseline safety and containment (masks, montage, writing)	Individual exit evaluation: review, set goals, choose further care or discharge; about 80% continue
2	Closed cohort group	2 h weekly for 6 weeks	Identity, grief and loss, peer support through structured directives	Requires team clearance to enter; readiness and comfort with therapist and space
3	Individual sessions + open studio	Open studio 2 h weekly; individual check-ins twice monthly	Self-directed work on individual goals, including trauma processing (Herman stage 2), moral injury, reconnection	About 30% end after the individual phase (goals met, retirement, relocation); about 70% continue

[source: Jones et al. 2018]

2.4 Clinical track: music therapy and dance/movement therapy

Music therapy runs in both IOP and longitudinal care, individual and group; a group music therapy protocol serves as an entry experience; case examples include weekly individual and small-group work for 12–15 months [source: Vaudreuil et al. 2019; Creative Forces music therapy summary 2019; Bronson, Vaudreuil & Bradt 2018 cited there, not drawn on].
Clinic-to-community continuum (described, with no formal gates): individual music therapy → group or jam group → performance within therapy (often a supported duet) → on-site Creative Arts Café → wider community performance [source: Vaudreuil et al. 2019].
Dance/movement therapy is named as a clinical discipline, with mirroring movement and mind-body skills training given as examples [source: NEA fact sheet 2025]. Published military DMT protocols are not drawn on here [uncertain]; follow the Dance/movement therapy guide.
Families, couples and parent–child dyads are seen in discipline-specific sessions [source: Herman et al. 2021 abstract].
Telehealth delivery is part of the programme [source: NEA Clinical Program page]. One published example is the VA rural telehealth creative arts therapy service run with the University of Florida Center for Arts in Medicine: each veteran first had an in-person appointment at the local VA, then had home sessions over a secure VA video system, with a device supplied where needed; therapists worked with the veteran to set up a comfortable, safe space, and the veteran angled the camera to show artwork or stepped back so movement could be seen [source: NEA blog, Spotlight on Creative Arts Therapies and Telehealth, 2017]. The Creative Forces telehealth papers (Spooner et al.; Vaudreuil et al. 2022) are not drawn on here [uncertain].

2.5 Community arts engagement track

Format: free or low-cost classes, family arts programmes, exhibitions and virtual activity, run by arts organisations with military partners. Examples: a museum art-class series with a military and first-responders centre, led by a military-spouse teaching artist and ending in a public exhibit; a play-based arts programme for children and caregivers at Joint Base Lewis-McChord [source: NEA fact sheet 2025].
Movement from clinical to community: offered as continued opportunity for people who have received or are receiving clinical therapies [source: NEA fact sheet 2025]. No referral criteria are published [uncertain]; see 4.24 for a working protocol [synthesis].

3. Guiding principles

Patient-centred, interdisciplinary care. CATs sit at the core of a team and tailor treatment to each patient; act as one team member, sharing goals and observations with physicians and other clinicians [source: NEA Clinical Program page].
Structure lowers the threat of making. A pre-formed mask removes the anxiety of creating from nothing and moves attention to content; give a starting form rather than a blank page early on [source: Jones et al. 2018].
Process before product early; product later is allowed. Level 1 directives are open springboards with a non-product focus; Level 3 open studio permits product-oriented projects; match the emphasis to stage [source: Jones et al. 2018].
Stage-based pacing. Safety and containment first, trauma processing later, reconnection last (Herman); do not begin trauma narrative work in an introductory group [source: Jones et al. 2018].
Team clearance before provocative work. Level 2 entry needs team clearance; check with the team before any directive likely to open trauma, grief or moral injury [source: Jones et al. 2018].
Fit trauma work to the member's duties. Outpatient service members continue daily duties; gauge how much material to open against what they return to [source: Jones et al. 2018].
Move exposed work to individual sessions. Trauma, grief or moral injury content too exposed for a group goes to individual work [source: Jones et al. 2018].
Containment is built into the art. Boxes, lids and closing a container give control over traumatic material; offer physical ways to put material away [source: Jones et al. 2018; Drexel News 2016].
Art as a bridge to others. Masks and artwork are used to open conversations with family, caregivers and medical staff, with the member's agreement [source: Jones et al. 2018].
Client autonomy over sharing and performance. Performance is optional; the member controls audience, arrangement and co-performers; consent and transparency about risks come first [source: Vaudreuil et al. 2019].
Process, not performance, is the therapy. Performance must not become the goal of treatment and can blur confidentiality; assess each client's capacity for risk-taking [source: Vaudreuil et al. 2019].
Belonging is a resource. Integrated unit and military-belonging imagery was associated with lower PTSD symptoms in mask research; notice and build on connection and belonging [source: Kaimal et al. 2018 via Drexel News 2018].
Artwork is not a diagnostic test. Imagery–symptom associations come from observational data in active-duty, almost all male, samples; use imagery to open dialogue, never to diagnose, rate risk or infer events [source: Drexel News 2018; synthesis].
Therapy versus arts activity. Clinical-track work is treatment inside medical care; community arts are participation; keep roles, confidentiality and expectations distinct for each [source: NEA fact sheet 2025; synthesis].

4. Intervention inventory

The inventory lists every procedure the published Creative Forces sources used here describe. Items 4.1–4.15 are art therapy, 4.16–4.21 music therapy, 4.22 dance/movement therapy, 4.23 family work and 4.24 the community track. Discipline-general technique belongs in the Art therapy, Music therapy and Dance/movement therapy guides.

4.0 Safety frame for military and veteran work (applies to every item)

Screening and clearance. Work from the team's referral and goals; get team clearance before emotionally provocative directives; check readiness (some understanding of the therapy, comfort with therapist and space) before deeper work [source: Jones et al. 2018]. Before starting, review the current risk assessment, TBI severity and cognitive profile, sleep, substance use, pain, medication changes, legal or duty status and upcoming transitions (deployment, separation, relocation) [synthesis].
TBI. Use pre-formed materials and structured starts to cut cognitive demand [source: Jones et al. 2018]. Sources give no detailed cognitive or sensory adaptations [uncertain]; working practice: one-step instructions also written on a card, short segments with breaks, fatigue and headache checks, reduced visual clutter and glare, a written or photographed record of the session for memory, and check-back of what was understood [synthesis].
PTSD triggers. Expect injury, blood, weapon and death imagery; it is ordinary content, not an alarm by itself [source: Drexel News 2016; Walker et al. 2017]. Seat members with a view of the door and backs to a wall where possible, announce loud or sudden actions, avoid dimmed lights or confined spaces without consent, and agree a non-verbal "pause" signal [synthesis].
Music: hearing safety and musical triggers. Blast-exposed members often have tinnitus or sound sensitivity [synthesis]. Keep group drumming and amplified sound at moderate levels, start quiet and build gradually, avoid sudden loud attacks, offer earplugs or a seat further from sources, and stop if a member reports ringing, pain or ear fullness [synthesis]. Ask in advance about songs, genres, cadences, bugle calls or anthems tied to deployment, loss or funerals, and about percussion or rotor-like sounds that resemble gunfire, explosions or aircraft; let members veto material [synthesis].
Suicide risk. NEA cites an estimated 17 veteran suicides per day [source: NEA fact sheet 2025]; the published Creative Forces clinical sources do not set out a suicide protocol [uncertain]. Use the site's standard suicide risk screening and assessment, a current safety plan, and lethal-means counselling (secure or off-site storage of firearms and medicines, involving family where agreed); escalate within the team the same day for any new intent, plan, recent rehearsal or access to means; in the US the Veterans Crisis Line is reached by dialling 988 then pressing 1 [synthesis: standard practice]. Treat imagery or lyrics of death as material for a direct risk question, not as a risk score [synthesis].
Moral injury, guilt and grief appear regularly in masks and writing [source: Drexel News 2016; Jones et al. 2018]; move such work to individual sessions when group exposure is too much [source: Jones et al. 2018].
Materials safety. Craft knives and scissors for cutting masks, glue guns, solvent-based or spray paints (ventilation, non-toxic acrylics preferred), clay dust (wet clean-up, no dry sweeping), sharp found objects, and pour-painting mediums; count and store sharps when risk is raised [synthesis].
Confidentiality of artwork. Agree in writing who sees the work (team, family, exhibition, research), how it is stored or photographed, and whether it is left behind [synthesis; leave-behind and research use are documented in Drexel News 2016].

4.1 Individual art therapy evaluation and tailored sessions

Purpose: every IOP member gets at least one individual evaluation; it identifies goals and whether follow-up sessions are useful [source: Jones et al. 2018]. Level 1 at Intrepid Spirit One ends with an individual exit evaluation to review, set goals and decide on further care or discharge [source: Jones et al. 2018].
Steps: (1) review referral goals and safety information; (2) explain what art therapy is and is not (no skill needed, no interpretation imposed); (3) offer a simple, structured art task; (4) talk about the process and the work; (5) agree goals and next step (follow-up, Level 2, open studio, discharge) and feed back to the team [source: Jones et al. 2018 for purpose and outcomes of the evaluation; steps are synthesis].
Example language (illustrative): "This isn't an art test. I'm interested in what it's like for you to make something, and what you notice."
Watch for: performance anxiety about artistic skill, fatigue, avoidance; working if the member engages and can name a goal [synthesis].

4.2 Mask-making (week 1, group)

Purpose: focus on the experience of TBI and PTSD, externalise inner states and identity, and reduce isolation through peers [source: Jones et al. 2018]. Published themes include the injury, relational supports and losses, identity transitions, cultural metaphors, existential reflection and a conflicted sense of self [source: Walker et al. 2017 abstract]; also split faces (intact or patriotic versus injured), armour or helmets as an outer face, and locks, stitches or gags over the mouth [source: Drexel News 2016].
Materials: a pre-made blank papier-mâché face mask; paint, clay, markers, found objects; members may bring personal materials; they may paint, add to or cut the base [source: Jones et al. 2018; Drexel News 2016].
Steps: (1) introduce identity as the focus; (2) name common themes others have used (for example split self, deployed versus home identity, injuries, grief) so members know such content is welcome; (3) members may sketch a plan or start directly; (4) work may continue across the four weeks; (5) members give a narrative description of what the mask represents, recorded in therapist notes; (6) members decide whether to keep the mask, show it to family or clinicians, or leave it at the centre to encourage future cohorts [source: Jones et al. 2018; Drexel News 2016].
Example language (illustrative): "You can use the mask to show something about who you are now: what others see, what they don't, or both."
Containment option: in a published case, a member who re-created a face from a recurring flashback placed the mask in a box and closed it with his art therapist's guidance; his flashbacks were reported to decrease (single case, not generalisable) [source: Drexel News 2016].
Watch for: imagery of blood, wounds, gags or hollow skulls is common and not itself a crisis sign; follow up any depiction of death or self-harm with a direct risk question [source: Drexel News 2016; synthesis]. Signs of benefit: the member can describe the mask, uses it to explain injuries to family or team, peers report "I'm not alone" (Kaimal's phrase) [source: Drexel News 2016]. Research associations (unit symbols with lower PTSD; fragmented military symbols with higher anxiety; psychological injury depictions with higher PTSD; metaphor with lower anxiety) are observational group findings and must not be used to score an individual [source: Drexel News 2018].

4.3 Montage painting (final IOP week, group)

Purpose: integrate experience in a layered, non-linear narrative of past, present and future; support stabilisation, safety and understanding of symptoms; used once members have been able to talk about their trauma [source: Jones et al. 2018].
Materials: small canvas (about 20 × 25 cm), paint and collage including magazine images [source: Jones et al. 2018].
Steps: (1) in the fourth IOP week, invite each member to make a montage painting: a canvas layered with mixed media around a theme the member chooses [source: Berberian, Walker & Kaimal 2019, BMJ Medical Humanities blog summary]; (2) members either plan an image or start by collecting magazine images and organising them; (3) painting and collage may alternate and layer over each other [source: Jones et al. 2018 for steps 2–3]; (4) group sharing of what the layers hold; (5) agree what the member takes forward after discharge [steps 4–5 synthesis].
Example language (illustrative): "Layers can cover, show through or sit side by side. Use them however your last few weeks feel."
Watch for: discharge anxiety; working if the member can link past, present and future pieces. In a thematic analysis of 240 NICoE montage paintings and their clinical notes, the work was linked with better interpersonal relatedness, hope and gratification, and with externalising problems, gradual exposure and building a trauma narrative [source: Berberian, Walker & Kaimal 2019].

4.4 Anxiety-reducing art processes (pour painting, mandala drawing)

Purpose: listed by NEA as anxiety-reducing arts processes in the clinical programme [source: NEA fact sheet 2025]. No published Creative Forces procedure for these is known [uncertain].
Steps (synthesis): pour painting: prepare cups of fluid acrylic, tilt a primed board and let colour run, focusing on watching rather than controlling; mandala: draw or colour within a pre-drawn circle from the centre out at a slow pace with paced breathing.
Example language (illustrative): "There's no right result. Just notice the paint moving and your breathing."
Watch for: frustration at loss of control (pour) or rigid perfectionism (mandala); working if arousal ratings fall within the session [synthesis]. Mandala symbolism beyond its use as a structured form belongs to the traditions that hold it, not to this method [synthesis].

4.5 Therapeutic and creative writing

Purpose: offered alongside art therapy at both sites; continues the NEA Operation Homecoming writing workshops that entered the NICoE programme in 2012 [source: Jones et al. 2018; NEA History page]. At NICoE, writing sessions were held in the art therapy studio in the second week; members mostly reported positive emotions and relief during and after writing, and many saw it as a coping skill [source: Landless, Walker & Kaimal 2019].
Steps: (1) hold the writing session in the art studio, and let a member keep working on an earlier art project, such as the mask, if they prefer [source: Landless et al. 2019]; (2) give short timed prompts tied to the art (a caption for the mask, a letter from the montage), with reading aloud optional [synthesis]; (3) let the member decide what happens to the writing: keep it, destroy it, share it or give it away, all of which NICoE members chose [source: Landless et al. 2019].
Example language (illustrative): "Write three lines your mask might say if it could talk. You don't have to read them out."
Watch for: reading or fine-motor difficulties after TBI (offer dictation or voice recording) [synthesis].

4.6 Greatest fear / greatest comfort (Level 2, week 1)

Purpose: externalise main concerns and balance them with positive resources [source: Jones et al. 2018].
Steps: two sheets (about 23 × 30 cm), any 2D media; give both prompts at once and let the member choose the order; then group discussion [source: Jones et al. 2018].
Example language (illustrative): "Two pages: your greatest fear and your greatest comfort. Start with whichever you want."
Watch for: members who complete only the fear page; end with the comfort page in view [synthesis].

4.7 Dialogue with an entity of choice (Level 2, week 2)

Purpose: meaning-making, unfinished relationships and alternative perspectives; adapted from Adams's dialogue journal exercise [source: Jones et al. 2018].
Steps: two pens in different colours, one for the member and one for the entity (a person, event, the body or injury, an emotion, society, inner wisdom or a spiritual figure); write without planning and let the dialogue unfold; group discussion follows [source: Jones et al. 2018].
Example language (illustrative): "Pick who or what you want to talk with. Switch pens when they answer. Don't plan it."
Watch for: dialogues with a dead comrade or with the self who acted in combat can open grief or moral injury quickly; move to individual work if needed [source: Jones et al. 2018 on moving exposed work; synthesis].

4.8 Depict your soul (Level 2, week 3)

Purpose: clarify core self-image and identify internal resources; often a turning point, and peers share community resources [source: Jones et al. 2018].
Steps: about 40 minutes to depict the soul with the supplies provided; then a second sheet showing what the soul needs to reach greater well-being; share [source: Jones et al. 2018].
Example language (illustrative): "However you understand the word 'soul', show it. Then show what it needs."
Watch for: religious or spiritual distress; respect the member's own framework and refer to chaplaincy if wanted [synthesis].

4.9 Box project (Level 2, weeks 4–6)

Purpose: validate the new reality, grieve and contain material [source: Jones et al. 2018].
Steps: choose a container by size and shape, ideally large enough for personal military objects kept at home; the outside celebrates career and self; the inside commemorates loss, memorialises comrades, depicts traumatic scenes or grieves lost abilities; the lid can be open or closed, giving control; many keep the box after treatment [source: Jones et al. 2018].
Example language (illustrative): "The outside can show what you're proud of. The inside is for what you carry. You decide when the lid is open."
Watch for: the box becoming a shrine for suicidal planning (giving away belongings, farewell content): ask directly [synthesis].

4.10 Visual metaphor for triggers and reactions (Level 3)

Purpose: individual work on triggers, reactions and emotional regulation [source: Jones et al. 2018].
Steps (synthesis on the source's listed option): (1) member names a recent trigger; (2) depicts it as an image or metaphor (weather, animal, machine); (3) depicts their reaction beside it; (4) adds a third image of what helps, then links it to coping skills from the wider team.
Example language (illustrative): "If that trigger were a picture, what would it look like? And your reaction next to it?"
Watch for: literal re-depiction of a traumatic scene before stage-2 readiness; steer back to metaphor [synthesis].

4.11 Meditative, relaxation-based, experiential, flow-based and long-term projects (Level 3)

Purpose: listed options for relaxation, regulation and sustained engagement in individual sessions [source: Jones et al. 2018]. Detailed steps are not published [uncertain].
Steps (synthesis): pair repetitive mark-making or clay forming with paced breathing; for long-term projects, agree a plan, break it into weekly tasks and review progress against the member's goals.
Example language (illustrative): "Let's pick something you can work on across several weeks and see where it goes."
Watch for: absorption used to avoid all talk of goals; agree time for reflection each session [synthesis].

4.12 Grief and memorial projects (Level 3)

Purpose: complicated or disenfranchised grief and memorialising comrades [source: Jones et al. 2018].
Forms named: memorial stones, memorial books, memorial tiles, combat cross sculptures, and portraits of the deceased [source: Jones et al. 2018].
Steps (synthesis): choose the person or loss, gather memories and objects, decide what the memorial says and where it will live, plan an ending ritual the member chooses (keeping, giving to family, placing at a memorial).
Example language (illustrative): "What would you want someone who never met him to know?"
Watch for: survivor guilt and anniversary reactions; ask about suicidal thoughts around anniversaries [synthesis].

4.13 Past, present and future self-portraits (Level 3)

Purpose: identity across military-to-civilian or injury transitions; attributed in the source to Carr [source: Jones et al. 2018].
Steps (synthesis): three portraits in any medium; compare what has stayed, changed and is hoped for.
Example language (illustrative): "Who were you before, who are you now, and who do you want to be?"
Watch for: a blank or absent future self as a cue for hopelessness and risk questions [synthesis].

4.14 Intensive Trauma Therapy graphic narrative (Level 3, trained therapists only)

Purpose: trauma processing by storyboarding a traumatic event in drawings according to the stages of the Instinctual Trauma Response (Gantt & Tinnin); used only by therapists trained in it [source: Jones et al. 2018].
Steps: not given here; this is a specialist trauma-processing method requiring its own training. Refer to a trained art therapist [source: Jones et al. 2018; synthesis].
Example language (illustrative): (when referring) "There's a structured way of working through that event in drawings, but it needs a therapist trained in it. I'd like to talk with the team about a referral when you feel ready." [synthesis]
Watch for: stage-2 readiness, team agreement and stable risk before referral [synthesis].

4.15 Open studio (NICoE weeks 3–4; Intrepid Spirit One Level 3)

Purpose: self-directed, product-oriented work alongside peers; cognitive problem-solving in art is interpreted by the authors as re-engaging pathways affected by PTSD or TBI (their interpretation) [source: Jones et al. 2018].
Steps: 2 hours weekly at Level 3; the therapist acts mainly as consultant and sometimes as teacher (e.g. charcoal or realistic painting technique) [source: Jones et al. 2018].
Example language (illustrative): "Work on whatever you want today. Call me over if you want a technique or a second opinion."
Watch for: the drift from therapy to art class; keep brief individual check-ins on goals [source: Jones et al. 2018 (twice-monthly check-ins); synthesis].

4.16 Group music therapy entry protocol

Purpose: an introductory group that helps members get used to music therapy and is structured to make emotional risk-taking feel safer. It doubles as an initial assessment of each member's responses to receptive and interactive music experiences, and includes psychoeducation on music therapy's role in interdisciplinary care. In 201 post-session evaluations from four US military bases, members rated it moderately to very helpful for expressing emotions and noticing bodily responses, and many asked for continued music therapy [source: Vaudreuil, Biondo & Bradt 2020, abstract; Creative Forces music therapy summary 2019]. The full session script is not reproduced here [uncertain].
Steps: agree hearing and trigger rules first (4.0) [synthesis]. Then follow the published sequence of a phased military music therapy group (six weekly 60-minute sessions at a military outpatient TBI clinic): (1) check-in about musical interests and everyday music use, then a brief music-based relaxation; (2) introduce musical material through familiar songs, with verbal cues and demonstration; (3) active music making on instruments and voice, adding lyric analysis and songwriting in weeks 4–6; (4) check-out and group processing, including how to use music outside the clinic. When frustration rises, return members to the check-in relaxation [source: Vetro-Kalseth, Vaudreuil & Segall 2021]. Offer continued music therapy to members who ask for it [source: Vaudreuil, Biondo & Bradt 2020].
Example language (illustrative): "No one has to play well. Notice what happens in your body when the group plays together."
Watch for: hypervigilance in a noisy room, startle; working if members stay, play and name body responses [synthesis].

4.17 Songwriting

Purpose: members share thoughts, emotions and experiences, often for the first time; may reduce loneliness [source: Creative Forces music therapy summary 2019]. At NICoE, members wrote songs over two or more individual sessions; their lyrics dealt with personal struggles and barriers to recovery, moving forward, relational challenges, and positive relationships and support, and let members tell family, friends and providers what they had not said before [source: Bradt, Biondo & Vaudreuil 2019]. The songwriting method used is not described in the published abstract [uncertain].
Steps (synthesis): choose a theme, brainstorm words, shape a chorus that holds the central message, fit to a chosen style or chords, record; decide who hears it.
Example language (illustrative): "What's the one line you'd want in the chorus?"
Watch for: lyrics about death or hopelessness: ask about risk directly; songs naming identifiable people or operations: agree confidentiality before any sharing [synthesis].

4.18 Active music making and instrument learning

Purpose: active music making and playing instruments; one member worked toward singing while playing, described as a high-level cognitive goal [source: Vaudreuil et al. 2019; NEA fact sheet 2025].
Steps (synthesis): choose an instrument suited to motor and hearing status, set graded goals, practise in session and at home, track progress.
Example language (illustrative): "Let's set one small target for this week: these two chords, slowly."
Watch for: frustration from motor or memory limits after TBI; grade tasks so success is likely [synthesis].

4.19 Lyric analysis

Purpose: listed among music therapy methods in the clinical cases [source: Vaudreuil et al. 2019].
Steps (synthesis): member or therapist brings a song (screened for triggers), listen, read the lyrics, discuss lines that fit the member's experience.
Example language (illustrative): "Which line in that song feels closest to where you are?"
Watch for: songs tied to lost comrades or funerals; ask before playing [synthesis].

4.20 Music-based speech, breathing and cognitive rehabilitation

Purpose: singing, rhythmic cueing and vocal prosody exercises for speech; breathing and rhythmic phrasing; targets also include memory, attention, auditory processing and motor control; designed in consultation with speech therapy within an interdisciplinary model [source: Vaudreuil et al. 2019; Creative Forces music therapy summary 2019].
Steps: set jointly with the speech-language pathologist and rehabilitation team; procedures are specialist music therapy and neurorehabilitation work; see the Music therapy guide and neurologic music therapy entries [source: Vaudreuil et al. 2019; synthesis]. This is an adjunct within medical rehabilitation, not a replacement for it [synthesis].
Example language (illustrative): "Your speech therapist and I have picked two song phrases to practise. Tell me if the sound or the effort brings on a headache." [synthesis]
Watch for: fatigue, headaches, sound sensitivity [synthesis].

4.21 Clinic-to-community performance and the Creative Arts Café

Purpose: support individual rehabilitation and community reintegration through optional performance; the Creative Arts Café (NICoE, 2016, later replicated across Creative Forces sites) is an on-site performance platform open to all art forms; the Semper Sound Band (Resounding Joy) is a partner example [source: Vaudreuil et al. 2019].
Steps: (1) assess the member's capacity for risk-taking; (2) be transparent about benefits and risks, including performance stress and possible adverse audience reactions, and obtain informed consent; (3) member chooses whether to perform, audience, arrangement, accompaniment and co-performers (peers, therapists, other providers, visiting musicians); (4) select and rehearse songs, sometimes original; (5) write a short spoken introduction explaining what the piece means; (6) support during the performance; (7) process afterwards; recordings may be used as feedback and keepsake [source: Vaudreuil et al. 2019].
Example language (illustrative): "Performing is entirely your call, and you can change your mind up to the last minute."
Watch for: the authors warn that without enough internal resources performance may be counter-therapeutic or re-traumatising, and that performance can blur privacy; it must not become the goal of therapy [source: Vaudreuil et al. 2019].

4.22 Dance/movement therapy: mirroring and mind-body skills

Purpose: NEA lists mirroring movement with another person and mind-body skills training among clinical methods [source: NEA fact sheet 2025]. No published military DMT protocol is drawn on here [uncertain]; follow the Dance/movement therapy guide.
Steps (synthesis): obtain explicit consent for any shared movement; start seated or standing with ample space and clear exits; therapist follows the member's movement first, then turns are swapped; no touch unless explicitly agreed, and never sexual or genital touch; opt-out at any time.
Example language (illustrative): "I'll follow your movement first. You lead; stop whenever you want."
Watch for: balance problems and dizziness after TBI (fall risk), pain, dissociation, startle at movement behind the member [synthesis].

4.23 Family, couple and parent–child sessions

Purpose: art therapy, dance/movement therapy and music therapy sessions with families, couples and parent–child dyads affected by TBI and PTSD to promote family bonding; reported gains were naming challenges and strengths, better interactions and connectedness [source: Herman et al. 2021 abstract]. Session content is not drawn on [uncertain]; an "animal strengths and family environment" art directive is published (Herman & Chilton 2023) but is not drawn on [uncertain].
Steps (synthesis): shared art or music task, reflection on how each member contributed, link to family goals; masks or artwork from the member's own treatment can be shown to family to explain injuries, only with consent [source: Jones et al. 2018 for sharing artwork with family].
Example language (illustrative): "Let's make one picture together, and afterwards talk about how you each found a place in it."
Watch for: children: age-appropriate content, safeguarding and mandatory-reporting duties, assent as well as parental consent; do not expose children to a parent's trauma imagery [synthesis].

4.24 Community arts engagement: referring in and working alongside

Purpose: continued community-based arts for military-connected people, including those who have had clinical arts therapies [source: NEA fact sheet 2025].
Steps (synthesis): (1) identify local Creative Forces-funded or similar programmes (arts organisations, base or VA partnerships); (2) check the activity's format, group size, noise levels, venue access and whether the leader has military-cultural training; (3) agree with the client what personal material they want to bring or keep private, since it is not a confidential therapy space; (4) keep trauma processing in therapy and treat the arts activity as connection, skill and enjoyment; (5) review how it is going in sessions; (6) plan for public exhibitions or performances as in 4.21.
Example language (illustrative): "This class isn't therapy. It's a place to make things with people who get it. Anything heavy that comes up, bring here."
Watch for: teaching artists drawn into therapeutic roles, disclosures in public settings, exhibition pressure; liaise with the organiser with the client's consent [synthesis].

5. Handling problems

The published sources address readiness, pacing, group-versus-individual choice and performance risk; most other guidance below is marked [synthesis].

"I can't do art" / "I'm not musical". Use pre-formed starts (blank mask, small canvas, magazine images) to remove the blank-page demand [source: Jones et al. 2018]. Offer a peer's left-behind mask as an example, with the maker's consent, and stress that no skill is judged [source: Drexel News 2016 (masks left to inspire others); synthesis].
Military stoicism and stigma about "soft" therapies. Frame the work in mission and skills terms (regulation, focus, communication with family), cite that peers rated art therapy among the most helpful NICoE techniques [source: Jones et al. 2018 (top-five ranking in programme evaluation)], and let the member observe before participating [synthesis].
Stuck in surface content. Move from open springboards (Level 1) to more structured directives such as greatest fear / greatest comfort or dialogue with an entity, once team clearance and readiness are in place [source: Jones et al. 2018]. Do not push trauma narrative work as a way to get unstuck [synthesis].
Overwhelm or flashback during making. Stop the task, orient to the room (name the date, place, people), use paced breathing, physically set the work aside or close it in a box or folder, and return to a regulating task; check risk before the member leaves and inform the team that day [source: Drexel News 2016 (box containment); synthesis for the sequence]. For repeated overwhelm, step back to stage-1 safety work and move content to individual sessions [source: Jones et al. 2018].
Content too exposed for the group (moral injury, killing, a comrade's death). Pause it kindly in group and offer individual time [source: Jones et al. 2018]. Brief the group without detail if others were affected [synthesis].
Group contagion or competitive war stories. Set group agreements at the start (no graphic detail, no rank-pulling, permission to pass); redirect to the art and to the here-and-now [synthesis].
Rank and unit dynamics in cohorts. Agree that rank stays outside the studio as far as the setting allows, and watch for juniors deferring to seniors in sharing; where a senior member's presence blocks disclosure, offer individual sessions (a senior member's art therapy course is published as a case study by Walker et al. 2016, not drawn on) [synthesis; uncertain].
Non-adherence and drop-out. Outpatient members balance treatment with duties; adjust the depth of each session to what they return to and schedule around duty [source: Jones et al. 2018]. Relocation and retirement end treatment for some; plan endings and hand-offs early, including community-track options [source: Jones et al. 2018; synthesis].
Ruptures (feeling analysed, art "read" against them). Never interpret imagery as diagnosis; ask the member what it means and correct course openly [synthesis]. Explain that research on mask imagery describes group patterns and is not used to score individuals [source: Drexel News 2018; synthesis].
Worrying imagery or lyrics (death, weapons, farewell themes). Treat as a cue to ask directly about suicidal thoughts, intent, plan, preparatory behaviour and access to firearms or stockpiled medicines; update the safety plan and do lethal-means counselling; escalate to the team the same day if risk has risen [synthesis: standard risk practice]. Do not refuse such content; refusal teaches concealment [synthesis].
TBI-related difficulties (forgetting instructions, fatigue, irritability, headaches). Shorter sessions, written one-step prompts, breaks, photographic records of each session, and coordination with occupational and speech therapy [synthesis; Vaudreuil et al. 2019 for interdisciplinary music work with speech therapy].
Sound-triggered startle or hearing pain in music groups. Stop loud sound at once, check the member, lower volume, remove the triggering instrument or sound, offer earplugs, and agree in advance which sounds are excluded [synthesis].
Performance pressure or regret after performing. Remind that performance is optional and that the member can withdraw at any point; debrief after every performance; if a performance went badly or audience response was hurtful, process it in individual sessions and pause further performance [source: Vaudreuil et al. 2019; synthesis for the response].
Leaving artwork behind, or wanting it destroyed. Respect the choice; agree storage, return or ritual disposal, and confirm consent for any display or research use [source: Drexel News 2016 (leaving masks); synthesis].
Family conflict in joint sessions. Return to a shared, low-stakes making task, slow the pace, and move unresolved conflict to couples or family therapy; observe safeguarding duties where children are present [synthesis].
Community-track problems (a class becoming a disclosure space, a teaching artist taking on a therapist role, exhibition pressure). Clarify the boundary with the client, contact the organiser with consent, and keep clinical work in therapy [synthesis].
Telehealth. Start with an in-person appointment where possible, use the service's secure video platform, and help the member set up a private, comfortable space with the camera able to show artwork or movement [source: NEA blog 2017, VA rural telehealth programme]. Before each session, check privacy at home, a safety plan with the member's location and a local emergency contact, materials the member has at hand, and audio settings that do not distort music [synthesis].
Unclear evidence when the client or referrer asks. Say plainly that the published military work is qualitative, case-based, observational or programme evaluation, described by the authors as promising or preliminary, and that creative arts therapies are offered within, not instead of, evidence-based PTSD and TBI care [source: Creative Forces music therapy summary 2019; NEA Clinical Program page; synthesis].

Sources

Web pages and articles:

Also listed in the 2023 publications inventory and not drawn on for content [uncertain]: Bronson, Vaudreuil & Bradt (2018), Music Therapy Perspectives 36(2); Vaudreuil et al. (2022), music therapy through telehealth, Disability and Rehabilitation: Assistive Technology 17(2); Spooner et al., distance delivery of creative arts therapies to veterans; Walker, Kaimal, Koffman & DeGraba (2016), The Arts in Psychotherapy 49; Herman & Chilton (2023), animal strengths and family environment directive, The Arts in Psychotherapy 83.

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