Effects of an art-based intervention on cognitive functions, social avoidance, and distress in traumatized females: a pre- and post-experimental investigation

Introduction

Genocidal war and other forms of group violence, such as armed conflict and civil strife, have a wide range of negative consequences for individuals, communities, and societies. This impact is measured by physical damage as well as persistent emotional trauma. Therefore, community recovery should be an essential focus (Gangi and Barowsky 2009; Pearlman 2013). Some studies consistently showed that war-related traumatic events have long-term aftereffects on the mental health of civilians, and the psychological distress may continue for many years (Amir and Lev-Wiesel 2003; Schaal and Elbert 2006). Holocaust survivors, for example, after six decades still bear the pain of their past in the form of various posttraumatic stress symptoms (Barel et al. 2010). There has been a growing consensus that trauma is a necessary factor for developing posttraumatic stress disorder (PTSD) (Paris 2000), and the disorder may endure over time if not addressed by clinical intervention (Schaal et al. 2011).
The hallmark of PTSD is the recurrence of intrusive, intensely disturbing memories of a traumatic incident. The ability to discriminate between the memory and current perceptions may be lost, and the event may be relived as a flashback (Halligan et al. 2003). The symptoms of PTSD include co-morbid depression, fear, and traumas that frequently contradict and upend the victims’ fundamental beliefs in the goodness, justice, and significance of their physical and social environments. Thus, psychosocial therapy is needed when working with trauma victims by repaying attention to reconstructing the victims’ fundamental convictions about the general goodness of the world in addition to putting an end to their fear and emotions of great vulnerability (Bower and Sivers 1998; Sheikh et al. 2014). Several studies link posttraumatic stress symptoms, trauma exposure, and cognitive performance, and highlight the critical relationship between exposure to emotionally intense events and cognitive function and emphasize the importance of paying attention to both the mental and cognitive health of populations exposed to political violence (Blanchette et al. 2019).
In one of its crimes against the people in Middle East regions, in August 2014, an extremist militant group – the so-called Islamic State of Iraq and Syria (ISIS) – attacked the Yazidi people in the center of the Nineveh governorate in Iraq and captured the Sinjar region. As part of its genocidal campaign, ISIS fighters had a predetermined strategy to exterminate the Yazidi religious minority through rape, mass murders, forced conversions from their religion, and the radicalization of young people. In addition to committing innumerable crimes against the civilian populace, they announced a program to rid its Caliphate of non-Arab and non-Sunni Muslim groups. Yazidis, a Kurdish religious minority, were among the most badly impacted communities because of their ethnicity and religion. ISIS used deeply rooted historical misconceptions to publicly justify these crimes by claiming that Yazidis are pagans, atheists, or kuffars (in Arabic) who worship the devil. An estimated 3,100 Yazidis were killed by militants, mainly men and boys, while 6,417 were kidnapped, largely women and children. Women and girls are still missing, and at least some of them are probably being detained by ISIS supporters and members (Murad 2018; Minwalla et al. 2022).
Women and girls who survived the genocide are currently suffering. Their poor mental health is a result of events related to enslavement and experiences with genocide, along with social rejection. Yazidi girls and women experienced a high number of traumatic events, and former slaves were more likely to exhibit symptoms of depression, suicide, flashbacks, and PTSD (Ibrahim et al. 2018; Lobanov-Rostovsky and Kiss 2022). Moreover, many Yazidis still believe in the risk of future genocides (Cook et al. 2022). Therefore, people must recover from the negative psychological, sociocultural, and spiritual effects of genocide for a better life, to engage in social interaction, and to preclude future atrocities. This can be achieved through a variety of therapeutic models such as psychosocial rehabilitation, art therapy, and cultural activities (Lin et al. 2009; Crone et al. 2013; Delfa-Lobato et al. 2023). Arts therapies is an umbrella term for a range of therapies that use various therapeutic models for treatments, such as music therapy, art therapy, drawing, painting, drama therapy, dance movement psychotherapy, body psychotherapy, and craft therapy. They have a non-verbal component, with the focus on applying creative activities to obtain psychological change (Priebe et al. 2013). Art therapy could be a powerful treatment if its effectiveness is tested in the same rigorous manner as conventional medical interventions (Mirabella 2015). A hallmark of art therapy is the systematic use of art means, such as painting, drawing, collage, and sculpting, to shape and express feelings, memories, and thoughts (Schouten et al. 2015).
Since the displacement of the Yazidi religious minority from the Sinjar District following the ISIS invasion in 2014, there has been limited information available on the experiences and conditions of those affected by war-related trauma. For example, only three studies have investigated the role of art-based intervention on psychological wellbeing, reducing suicidal ideation, and the lived experience of surviving the ISIS attack of Yezidi girls and women following group art-based intervention (Abdulah and Abdulla 2019, 2020; Abdulah et al. 2023). The literature has not reported the positive effects of art therapy on cognition status yet (Shukla et al. 2022).
However, no studies have examined the impact of art therapy on neuropsychological and cognitive functions in females who have experienced trauma. Moreover, it has been stated that sending survivors of sexual and gender-based violence abroad for treatment is not the most proper action to take. Instead, action should be taken in the Kurdistan Region to help the survivors and their families and utilize local services to support them better (Mohammadi 2016). Thus, the present project aimed to examine the effectiveness of six-month creative art therapy sessions on cognitive functions, distress and social avoidance in traumatized females.

Material and methods

Study design and sampling

In this pre- and post-experimental investigation, female individuals who were distressed during the invasion of ISIS in the Sinjar Kurdish District in 2014 were included. The females who visited an NGO in the Khanke internally displaced person (IDP) camp were invited to participate in this study. Yazidi girls were invited to the camp mentioned in coordination with the International Organization for Migration (IOM) NGO. Female Yazidi girls and women aged 18 years and older were invited to participate in a six-month creative art therapy program (including painting and drawing) using a pre- and post-study design. The participants were selected from the Khanke IDP camp in the Duhok governorate in 2020. The cognitive functions of the participants were measured before the project’s start and following its completion. The art-based sessions were provided free of charge to the participants. The current project was funded by the International Organization for Migration (IOM) NGO. The art-based intervention was held in a calm room inside the NGO, close to the Khanke IDP camp. Out of the total 17 girls who were initially enrolled in the course, two of them left after attending a few sessions. Fifteen girls were included in the final analysis. The girls who stayed in the program only missed a few sessions within the six-month art-based intervention.

Inclusion and exclusion criteria

We invited distressed girls residing in the Khanke Camp to participate in this study. Eligible participants were those living in the camp with diverse socio-demographic backgrounds, including those from various areas of the Sinjar District. However, we excluded girls who were undergoing psychotherapy or taking medication during the study period. Additionally, we did not include girls who did not express interest in participating, as participation was voluntary. The girls included in this study were confirmed to have no pre-existing psychological disorders, as determined by self-reporting techniques and prior medical examinations conducted by the NGO.

Intervention

The participants underwent an art-based intervention where they were trained to create various types of artwork, such as paintings and drawings. An art instructor guided them and taught them the necessary techniques. Initially, the artist demonstrated basic art examples such as lines, circles, squares, and three-dimensional shapes on a whiteboard, which the participants used as a guide for drawing perspectives, shading, and columns. The participants were also taught the meaning of different colors; for instance, red represented blood, war, and violence, white represented peace and coexistence, green symbolized the environment, life, and happiness, and black represented illness and discomfort. The participants were encouraged to draw fruits, materials, nature, animals, houses, and human faces using colored pencils and oil paints. Watercolor painting was particularly emphasized to depict non-violent, positive, and peaceful perspectives of nature. The art media provided to the participants included paintbrushes, watercolors, oil paints, and colored pencils.
The artist explained the watercolor painting technique and allowed the participants to choose their colors for their artwork. Throughout the art-making process, the girls received emotional and individual support, with open communication (free discussion of the girls with the artist during the work) and encouragement. No fixed structures or time limitations were imposed on their work. The girls even shared and explained their artwork to others in the training course. The art program lasted for six months. The girls received four two-hour sessions per week for the first two months; then they received two two-hour sessions per week from months three to six (72 sessions in total). The classes involved multiple art forms, such as painting and drawing. Notably, the participants included in the final analysis did not miss significant sessions, primarily because the classes were easily accessible as they were held within the camp where they resided. At the end of the art program, the participants’ artwork was showcased in an art exhibition held in the Khanke IDP Camp, open to everyone residing there. The girls were also allowed to explain their works to the visitors during the exhibition. The artist who applied this intervention has sufficient (20 years) experience in fine arts and 7 years’ experience in working with patients with mental disorders.

Measures

Childhood Trauma Questionnaire – Short Form (CTQ-SF)
The CTQ-SF is a retrospective self-reporting tool used for assessing childhood maltreatment in both adults and adolescents. It consists of 28 items and evaluates five types of maltreatment: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect (Bernstein et al. 2003). Each scale comprises five items, and respondents rate their experiences on a 5-point Likert-type scale, ranging from never true (score of 1) to very often true (score of 5). The CTQ-SF provides both dimensional and categorical levels for each form of maltreatment. Researchers derived several cutoff scores based on the responses of female members of a health maintenance organization (Fink and Bernstein 1998). The primary objective of these cutoffs was to identify a maximum number of low-severity abuse cases (at least 80% of cases reported in the criterion interview) while maintaining the rate of false positives below 20%. The American cutoff scores for low-severity abuse are as follows: emotional neglect ≥ 10, emotional abuse ≥ 9, sexual abuse ≥ 6, physical abuse ≥ 8, and physical neglect ≥ 8. These cutoff scores are used to identify and assess cases of low-severity abuse in individuals who have completed the CTQ-SF questionnaire.

Modified Mini-Mental State Examination (3MS)
The 3MS is an enhanced version of the traditional Mini-Mental State Examination (MMSE) designed to assess cognitive functions in individuals more comprehensively. The 3MS test includes four additional items related to long-term memory, abstract thinking, category fluency, and delayed recall. It also ensures more consistent administration and improved scoring methods, along with some minor adjustments. The adjustments involved using Kurdish words instead of English ones for tasks such as remembering, recalling, and writing. This was necessary because the original scale was developed for English words. The primary objectives of these modifications were to sample a broader range of cognitive functions, cover various difficulty levels, and increase the reliability and validity of the test scores. The 3MS test is scored on a range from 1 to 100, offering an estimated score of the MMSE and the ability to track cognitive changes over time. In terms of administration and scoring, the 3MS test typically takes between 8 to 15 minutes, making it relatively user-friendly for both the examiner and the individual being assessed. These improvements have made the 3MS a valuable tool for evaluating cognitive abilities and monitoring cognitive changes over time.

Social Avoidance and Distress Scale (SADS) The SADS is a questionnaire-based instrument designed to measure social anxiety. It consists of 28 true/false items and aims to assess two aspects of anxiety: the emotional experiences, including distress, discomfort, fear, and anxiety, and the avoidance of social situations. The SADS has demonstrated high reliability, as indicated by its internal consistency coefficient of 0.94, which suggests that the items in the questionnaire are strongly interrelated. Additionally, the test-reliability of the SADS is reported to be 0.68, indicating that the instrument can yield consistent results over repeated administrations. By using the SADS, researchers and clinicians can effectively quantify social anxiety and gain insights into the emotional experiences and avoidance behaviors related to social situations. Its strong reliability further enhances its usefulness as a tool for assessing and understanding social anxiety in individuals (Watson and Friend 1969).

Statistical analysis

For descriptive statistics of the study data, categorical variables are presented as frequency and percentage, continuous variables as mean and standard deviation. The statistical difference between the pre and post-intervention phases of the study was evaluated using the Wilcoxon signed rank test. A p-value of less than 0.05 was considered statistically significant. The statistical calculations were performed using IBM SPSS Statistics version 25.0.

Ethical views

The study obtained permission from the Board of Relief and Humanitarian Affairs (BRHA), the executive department of the refugees and IDP camps of the Duhok governorate in Duhok, and the administrative unit of the Khanke camp by the IOM NGO. The permission to conduct this course was registered as number 1970 on 15.08.2017, following the guidelines of the Declaration of Helsinki. The confidentiality of the girls’ personal information was rigorously protected throughout all stages of the study. Written informed consent was obtained from the parents of all participating girls. Additionally, the girls were free to leave the course at any time if they were not interested in the art-based intervention. This study was part of a project funded by the IOM in displacement camps. The IOM holds official authorization to implement such interventions in the camp, eliminating the need for additional ethical approval from an ethics committee. Notably, the ethics committee falls under the Ministry of Health, while camp staff operate under the jurisdiction of a different ministry.

Results

The study found that the median age of the traumatized girls was 23.5, between 17 and 33 years. The education of the traumatized girls was illiterate (n = 3), under high school (n = 3), high school (n = 8), and institute/diploma (n = 1). The median number of family members of the girls was 9, and the median sleep duration was 8 hours (Table 1). The study showed that most of the girls had experienced emotional abuse (60.0%), physical neglect (93.33%), and sexual abuse (53.33%), and all girls had been exposed to emotional neglect (100%). Only a small percentage of females had been exposed to physical abuse (13.33%; Table 2). The study showed that creative art-based intervention did not result in a significant change in the score of mental state (from 95.4 to 94.67, p = 0.9348) and social avoidance and distress score (from 11.6 to 9.8, p = 0.0747) among traumatized girls. Most of the girls had an intermediate level of distress and social avoidance at both baseline (66.67%) and follow-up (60.0%) (Table 3, Fig. 1).

Discussion

Our initial overall finding showed that a six-month creative art-based intervention is not effective in improving cognitive functions, social avoidance, and distress among traumatized Yazidi girls. Most of the girls had intermediate levels of distress and social avoidance at baseline. These results are consistent with the literature in which art-based therapy can be an effective intervention for some mental disorders and another mental disorder may not. Substantial observational and anecdotal evidence indicates that different types of arts-based therapy can improve the cognitive function and quality of life of patients with different mental health or neurologic problems. Nonetheless, the outcomes of such therapy are highly influenced by the variability of patients’ traits and different types of mental disorders (Mirabella 2015). A critical review of the role of art-based therapy did not provide sufficient evidence of high-quality trials on the promotion of mental health, including depression, phobic disorder and panic disorder, and sleep disorders (Shukla et al. 2022). However, a critical review reported the potential benefit of art-based practices for psychological and social recovery. They reported that involvement in art-based practices improved self-discovery, self-esteem, self-expression, social relationships, social identity, and focus and cognition (Van Lith et al. 2013).
Since this study was undertaken a few years after the genocide event, participants were children at the time of war. The memories of such devastating events remain with the violated people for many years, with a high prevalence of recalling catastrophic experiences. A meta-analysis reported that Holocaust survivors continue to experience the pain of their past in the form of numerous mental disorders, including PTSD, even six decades after the end of World War II (Barel et al. 2010). A study by Neugebauer et al. (2009) concluded that children and adolescent survivors of the Rwanda genocide reported experiencing intrusive, unbidden thoughts and images of what they had visualized, avoidance, emotional numbing, and arousal. Furthermore, the amount of trauma exposure was directly related to the child’s age but not to the child’s gender or years of education. The findings of our study showed that most of the girls who had experienced childhood trauma as a victim or as a witness had been subjected to emotional abuse, physical neglect, and sexual abuse, while all girls had been exposed to emotional neglect. The current findings highlight a call for special attention to the care of these survivors for a deeper understanding of the survivor’s mental health. Consistent with other studies in the literature, Gerdau et al. (2017) reported that in addition to PTSD, Yazidi females had adjustment disorders, which are specific forms of stress response syndrome in which social avoidance and failure to adapt are the central processes and symptoms. Furthermore, internally displaced Yazidi women encounter more deprivation, insecurity, and psychological, sexual, and physical violence compared to internally displaced Yazidi men (Rudaw.Net 2019) due to exposure to ISIS terrorist attacks or torture (Tekin et al. 2016). Therefore, understanding the impact of social systems involving abuse, neglect, and ethnic and cultural rejection is of paramount importance to guide policymakers and clinicians to assist and address the social, cultural, and political perspectives of trauma (Womersley and Arikut-Treece 2019).
In terms of mental status, we did not find any study that measured the effect of art therapy on the cognitive functions of distressed females. Congruent with our search, some researchers claimed that, according to the American Art Therapy Association, art therapy can improve cognitive functions, enhance social skills, and reduce and resolve conflicts and distress, along with many other advantages (United Nations 2023). However, published systematic reviews on these topics are lacking (Hu et al. 2021). A systematic review revealed that art therapy had mainly been used for cancer patients, Alzheimer’s, dementia, depression and anxiety, autism, and cognitive impairment, as these patients are indisposed to express themselves in words (Hu et al. 2021). Consistent with our findings, the notion that art therapy improves cognitive function is inconclusive. For example, it has been reported that art therapy naturally incorporates physical activity through the manual creation of drawings or sculptures, problem-solving through choosing colors or compositional elements, and socialization through creating and describing artwork to others in a group, thereby increasing the likelihood of neurogenesis (American Art Therapy Association 2018).
The hippocampus, which is responsible for the production of new brain cells, is stimulated by the use of colors, textures, and pliable materials (Hass-Cohen 2008). A critical review argued that there is a lack of robust evidence to support the efficacy of art therapy on mental health (Shukla et al. 2022). More well-powered, high-quality trials with pertinent outcome measures are needed to address this issue. Similarly, a systematic review pointed out that a good explanation for the large difference in the reduction of trauma symptom severity in some studies might be due to utilizing a combination of art therapy intervention and psychotherapy treatment (Schouten et al. 2015). Another review limited to studies that solely used art therapy as the specific intervention found that little evidence is available to support the claim that art therapy is an effective intervention in treating a variety of symptoms and disorders (Slayton et al. 2010). Therefore, it can be stated that art therapy may be more effective in combination with other treatments than art therapy as a separate intervention (Schouten et al. 2015). The effectiveness of art therapy cannot be evaluated with studies of different types of mental disorders because patients’ abilities may vary widely, significantly influencing their cognitive abilities and capacity to appreciate the aesthetic experience (Mirabella 2015). Congruent with these findings, we also believe that art therapy may not be effective in improving cognitive function. This might be due to the fact that in clinical practice, art intervention is mostly used alongside, or in combination with, other treatments and seldom as a separate therapy; thus, the evidence base for art therapy with traumatized adults remains relatively weak (Schouten et al. 2015).
This study indicated that social avoidance and social distress were not significantly improved after art-based intervention. The avoidance of engagement, communication, or contact with another person for any reason, including actual avoidance conduct and avoidance tendencies, is referred to as social avoidance (Kaldewaij et al. 2017). Based on the local and global research that has been conducted so far, it has been stated that PTSD is higher in women than in men. This may be due to a variety of factors, such as the type of trauma they experienced, their younger age at the time of exposure to trauma, and their more intense perceptions of threat and loss of control (Olff et al. 2007; Tekin et al. 2016).
Consistent with the mentioned factors, the majority of our study participants experienced factors that predispose them to PTSD; for example, when they were exposed to trauma, they were younger, and they were exposed to genocide. It should not be forgotten that, although the Yazidi notions of honor were transformed by allowing raped and enslaved females to return, traditional beliefs and practices and surrounding communities, on the other hand, are largely intact and still losing honor is frequently parallel to dying socially (Minwalla et al. 2022). This may also put women at risk of developing PTSD. Although numerous systematic reviews are documented in the literature concerning the efficacy of art therapy for PTSD, it seems highly likely that studies documenting the impact of art therapy on social avoidance and social distress are still scarce. A recent systematic literature review of the impact of art therapy on PTSD reported that only five case studies concluded anecdotal changes in PTSD symptomatology, particularly avoidance and social withdrawal; nevertheless, only one of the case studies used standardized tests. The paper failed to statistically support their claims (Schnitzer et al. 2021). When considering the effectiveness of the art-based intervention, it is important to note that our participants already had a good level of social interaction before the course. While there was some improvement in the social interaction score after the course, it was not statistically significant. It is worth mentioning that we conducted the art-based intervention a few years after the genocide event. As a result, the level of social interaction among the females might have already seen substantial improvement before the intervention took place.

Strengths, limitations, and recommendations

The strong point of this study is that this study represents the inaugural effort to examine the effects of a creative art-based intervention on cognitive functions concerning social avoidance in individuals who have experienced trauma. However, as a limitation, it must be mentioned that the conclusions drawn from this study may not be universally applicable to other distressed females in varying contexts due to potential differences in levels of psychological and social disorders. In addition, we did not diagnose the mental disorders of the individuals before inclusion in the study; instead, we relied on their previous experience of traumatic events. We recommend using community-based socio-therapy. Community-based socio-therapy is a potent approach that assists individuals in discarding harmful behaviors and adopting positive habits, ultimately resulting in enhanced self-awareness. It is worth noting that community-based socio-therapy as an intervention has been used in Rwandan survivors over the past 10 years with positive outcomes. We could not rule out confounding factors as another limitation of this study. This intervention assisted survivors in coping with traumatic past experiences and daily social stressors related to a history of political violence and was used to alleviate tensions between people and ethnic groups at different levels of society (Jansen et al. 2015).

Conclusions

This study found that a creative art-based intervention was not effective in alleviating the mental state and social avoidance and distress among traumatized Yazidi girls.

Acknowledgments

We would like to thank all patients who participated in this study.

Disclosures

The funding to conduct the art-based intervention was received by the International Organization for Migration (IOM) NGO organization. However, the organization had no effect on the results and methodology of this study.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References