Education, Faculty of
Educational and Counselling Psychology, and Special Education (ECPS), Department of
DSpace
UBCV
Kerr, Mark Stuart
Master of Arts - MA
University of British Columbia
Much of the literature on therapeutic treatments for military personnel who have suffered an operational stress injury or PTSD from active duty focuses on individual therapy models. While models of group therapy for military veterans do exist, limited understanding of the impact of their process is known, particularly with Canadian military veterans. This study attempts to understand the experience of one particular type of group therapy called Therapeutic Enactment (TE) through the lens of a Canadian Armed Forces veteran. A case study research design was employed for this study. The participant of this study was a male, Canadian military veteran who had suffered an operational stress injury related to his role in the military and had completed at least one prior Therapeutic Enactment in relation to this difficulty. Data was collected through a 1-hour semi-structured, open-ended interview with a participant via a virtual recorded interview over Zoom. The results of the study were analyzed using the six-phase process of thematic analysis from Braun and Clarke (2006). Four main themes, each with two or three subthemes emerged from this data analysis. The four major themes were: 1) Trust, 2) Beneficial aspects of Therapeutic Enactment, 3) Challenges in Therapeutic Enactment, and 4) Recommendations for future Therapeutic Enactments. This study contributes to our overall understanding of how Therapeutic Enactment is experienced and gives guidance for practical application for clinicians. Implications for future research are also discussed.
THERAPEUTIC ENACTMENT: A CASE STUDY OF THE EXPERIENCE OF A CANADIAN MILITARY VETERAN by MARK STUART KERR B.A., Simon Fraser University, 2015 A THESIS SUBMITTED IN PARTIAL FULLFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Counselling Psychology) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) April 2021 © Mark Stuart Kerr, 2021 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: Therapeutic enactment: A case study of the experience of a Canadian military veteran submitted by Mark Stuart Kerr in partial fulfillment of the requirements for the degree of Master of Arts in Counselling Psychology Examining Committee: Marla Buchanan, Counselling Psychology, UBC Supervisor Dr. Marvin Westwood, Professor Emeritus, UBC Supervisory Committee Member ____ iii Abstract Much of the literature on therapeutic treatments for military personnel who have suffered an operational stress injury or PTSD from active duty focuses on individual therapy models. While models of group therapy for military veterans do exist, limited understanding of the impact of their process is known, particularly with Canadian military veterans. This study attempts to understand the experience of one particular type of group therapy called Therapeutic Enactment (TE) through the lens of a Canadian Armed Forces veteran. A case study research design was employed for this study. The participant of this study was a male, Canadian military veteran who had suffered an operational stress injury related to his role in the military and had completed at least one prior Therapeutic Enactment in relation to this difficulty. Data was collected through a 1-hour semi-structured, open-ended interview with a participant via a virtual recorded interview over Zoom. The results of the study were analyzed using the six-phase process of thematic analysis from Braun and Clarke (2006). Four main themes, each with two or three subthemes emerged from this data analysis. The four major themes were: 1) Trust, 2) Beneficial aspects of Therapeutic Enactment, 3) Challenges in Therapeutic Enactment, and 4) Recommendations for future Therapeutic Enactments. This study contributes to our overall understanding of how Therapeutic Enactment is experienced and gives guidance for practical application for clinicians. Implications for future research are also discussed. iv Lay Summary Canadian military personnel experience many challenging situations on and off the battlefield and while many of them resolve in time, some of them do not, and result in emotional injuries can continue to cause harm long after the incident is over. To help support veterans, different therapeutic interventions have been used with one of those treatment models being an action-based form of group therapy called Therapeutic Enactment. This study aimed to provide an overview of the experience of Therapeutic Enactment through the lens of a male, military veteran from the Canadian Armed Forces who had experienced a trauma-related injury from active military duty. The findings show us the importance of trust within the therapeutic process as well as give us an idea of some of the main benefits that were experienced, the challenges that comes from the work, and discuss the potential for future recommendations to the treatment model. v Preface This thesis is an original, unpublished, and independent work by the author, Mark S. Kerr. All data was collected and analyzed by Mark S. Kerr under the supervision of Dr. Marla Buchanan. This research project was approved by the University of British Columbia’s Behavioural Research Ethics Board (Certificate # H19-02212). vi Table of Contents Abstract……………………………………………………………………….…….…………..iii Lay Summary……………………………………………………………………..……………iv Preface…………………………………………………………………….….……..…………..v Table of Contents…………………………………………………………….……….….……vi List of Figures……………………………………………………………..….….…….……..vii Acknowledgements………………………………………………..……….…….………….viii Dedication………………………..…………………………………………….…..…………..ix Chapter I: Introduction…………………………………………….…………….………..….1 Statement of the Problem………………………………………………….…………..1 Rationale for the Study…………………………………………………………………4 Purpose of the Study……………………………………………………………………5 Research Questions………………………………………………………………….…5 Chapter II: Review of the Literature………………………………………………………...6 Approaches to Therapy for Military Populations………………..…………………...6 Research on Group-based Interventions for Trauma……………..………...………7 Therapeutic Enactment: A Group-based Trauma Approach………...……………11 vii Chapter III: Method……...…………..……………………………………………………….18 Research Design………………………………………………...……………..……..18 Procedures……………………………………………………………………………..19 Recruitment…………………………………………………...………………..19 Participant Description……………………….………………………………..19 Data Collection Process…………………………..…………………………..20 Data Collection……………………….………………………………..20 Data Analysis…………………………………………………………..20 Criteria for Trustworthiness………………………………………….………..22 Informed Consent Procedures……………………………...………………..23 Ethics……………………………………………………………..……………..24 Chapter IV: Findings ………………………………………………….…………………….25 Theme One: Trust…………………………………………………….……………….25 Theme Two: The Most Beneficial Aspects of Therapeutic Enactment………..…28 Theme Three: The Challenges in Therapeutic Enactment…………………….….31 Theme Four: Recommendations for Future Therapeutic Enactments…………..33 Chapter V: Discussion…………………………….………………………………………..39 Situate Findings within Existing Research………………………………………….39 viii Trust within therapeutic enactments……………………………………..….39 Beneficial aspects of therapeutic enactment…………………………….…40 Challenges in Therapeutic Enactment………………………………………41 Recommendations for future Therapeutic Enactments………………...….43 Implications for Counselling…………………………………………………………..44 Implications for Future Research………………………………………………...…..45 Strengths and Limitations of the Methodology and Study……………..………….46 References………………..…………………………….……………………………………..47 Appendices……………………………………………………..……………………………..57 Appendix A: Letter of Initial Contact (email)………………………………...………57 Appendix B: Participant Consent Form……………………….……………………..58 ix List of Figures Figure 3.1: The five phases of Therapeutic Enactment from Westwood and Wilensky (2005)………………………………………………………………………...…………………25 x Acknowledgements They say it takes a village to raise a child – I believe it takes a village to support a graduate student as well. This has been one of the most challenging yet rewarding experiences of my life and without the help and efforts of my research supervisor, Dr. Marla Buchanan and my committee member, Dr. Marvin Westwood completion of this project would not have been possible. Their passion, wisdom, and dedication to this work and those they serve is honourable to say the least. I also want to give massive gratitude to my friend and colleague, Phillip, for all the support he has offered throughout this long journey and all of my fellow colleagues that have offered guidance and support in one form or another. I also give my deepest sense of gratitude to my partner Ashley for her support through the long days and busy weekends that it took for me to reach this point – again, someone I could not have made it this far without. Finally, to my parents who have seen me through my entire academic career so far and have supported me in every way possible. Thank you for all that you have done for me. xi Dedication I dedicate this research project to the men and women who have served and continue to serve in the Canadian Armed Forces who sacrifice so much to support their country and the citizens who live here. Working with these individuals has been an honour and I have learned an immense amount from my interactions with the participants in this study and all of the other veterans I have met and become friends with along the way. 1 Chapter I: Introduction Statement of the Problem While Canada may not be viewed as a military country on the world stage, our military forces are broad and wide ranging with Canadian Armed Forces (CAF) currently being involved in approximately 24 peace-keeping operations in Canada, North America, and across the globe (National Defence, 2020a). While our military service personnel are an integral part of military operations within our borders and around the globe (Veterans Affairs Canada, 2020), the transition out of military life into civilian life for many military personnel is still a challenge. New programs have been developed to help aid in this transition (e.g., the Career Transition Services (CTS) Program, the Veterans Independence Program, and the Rehabilitation and New Veterans Charter (NVC) Support Services) and further development has been made with mental health initiatives for those enlisted (e.g., The Road to Mental Readiness (R2MR) program and post-deployment mental health screening procedures) (National Defence, 2020b). However, mental health issues are still prevalent in military populations because of the difficult psychological nature of the duties these individuals routinely perform (Black, 2009). Approximately 75% of Canadians will experience some kind of traumatic event in their lifetime, with 9.2% experiencing full diagnostic symptoms of posttraumatic stress disorder (PTSD) (Van Ameringen, et al., 2008). This number is even higher for military populations who suffer greatly due to the intense events that they are subjected to while in active duty (Westwood, et al., 2010). This suffering costs the Government of Canada millions of dollars every year in terms of funding for those veterans who need help post- 2 deployment. The Veterans Affairs Canada (2018) Facts and Figures article states that “Disability Award (DA) payments were $1,621.4 million which was an increase of 132% from $700 million in 2016-17” (p.7) and the number of people accessing these payments is expected to increase over the next several years. With a large amount of this funding being accessed by veterans for mental health services, of those Veterans who seek mental health services, 72% seek treatment for post-traumatic stress disorder (Veterans Affairs Canada, 2018). The link between PTSD and military populations returning from active duty is evident (e.g., Institute of Medicine, 2014; Ready, et al., 2012; Veterans Affairs Canada, 2018), but many treatment methods fail to achieve results for veterans and drop-out rates can by quite high, particularly when symptoms are high and when veterans are involved in certain types of therapy (Goetter, et al., 2015). Military men who have experienced PTSD often find it difficult to engage in individual counselling due to the idea that counselling is associated to mental weakness and the fear of being identified with the abject masculine (Brooks, 1998; Kuhl & Westwood, 2017; Shields, 2016). There is also a considerable gender difference within military populations, particularly front-line combat personnel, even though there are more females being enlisted into the military than previous decades. With high numbers of military enlistees being male and male veterans often not seeking help due to traditional masculine values and roles placed within the military cultural landscape (Hinojosa, 2010) and the stigma associated to mental health treatment and help-seeking behaviours (Galdas, Cheater, & Marshall, 2005), finding an appropriate form of therapy that suits the needs of these veterans is crucial. There is also the consideration of high suicide rates for men in Canada which is stated in an article from Statistics 3 Canada (2009) and shows that “males were three times more likely to commit suicide than females” (p. 3). The article goes on to state that “the much higher rate of male suicide is a long-term pattern in Canada” (p. 3) and that this has persisted for over the past 60 years of data collection (Statistics Canada, 2009). When considered collectively, the topics of men, their connection to the military, and the high rates of suicide we see in military populations who deal with trauma-related injuries (Bryan, 2016), it is imperative that we seek to further explore, develop, and improve approaches to treatment so that this population can have a chance to heal from the traumatic experiences that active duty and combat can instill in them. There have been various studies into veterans with PTSD that utilize cognitive therapies and various other forms of evidence-based therapies, many with successful results (Monson, 2006; Ready et al., 2012). These types of therapies include, but are not strictly limited to, cognitive behavioural therapy (CBT; including cognitive processing therapy [CPT] and prolonged exposure [PE]), group-based exposure therapy (GBET), virtual reality exposure therapy (VRET), imaginal exposure therapy / in vivo exposure therapy, and a more recent introduction of interpersonal process (IP) group therapy (Bryan et al., 2016; Monson, 2006; Ready et al., 2012; van Reekum, & Watt, 2019). In addition to the various types of therapeutic modalities being implemented, clinicians have also utilized both individual and group therapies, although it seems sufficient outcome data may be lacking. According to Ready, et al., (2012), “The VA health care system has had more than 140 specialized treatment programs operating concurrently for over a decade, yet detailed accounts of the treatment provided in these programs and their outcomes are rare.” (p. 85). The authors of this paper recognize that 4 this is from our American counterparts to the south, but our experience in the field tells us a similar story here in Canada. While there are studies that exist, which aim to discuss PTSD within Canadian veteran populations, such as the research completed by Irwin et al. (2014) out of the University of Calgary that aimed to examine the impact of PTSD on mediating factors such as anxiety, depression, and alcohol consumption, there remains a deficit within the literature. It is this lack of data primarily within Canada, but also across both borders that we believe more is needed. One of the few studies that was available was recently published by K. Lutz (2019) out of the University of British Columbia and his work focused on the very group-based intervention that this paper aims to discuss: therapeutic enactment. Although this data is a step forward, it is quite apparent that we need further studies in group modalities for our Canadian military veterans. Rationale for the Study Having a strong understanding of the impact that types of group therapy such as therapeutic enactment have on military populations is something that is crucial for future applications of these group protocols. The rationale for this study is based on the following gaps found in the current research literature on group-based trauma approaches for veterans who have Occupational Stress Injuries from their military experiences. 1. Few qualitative studies have been conducted on veterans’ experiences of group-based trauma interventions. 2. There is a need to have first-hand accounts of veteran’s experiences of therapy in order to address program implementation issues. 5 3. There is a need to have a Canadian perspective on group-based trauma programming for veterans experiencing OSIs as there may be distinct cultural differences in the CAF. Purpose of the Study This study aimed to further understand the internal experiences of military personnel who have completed an action-based form of group therapy (Westwood & Wilensky, 2005). To achieve this, an in-depth case study was developed with a veteran who had previously participated in a group-based form of trauma therapy entitled: Therapeutic Enactment (T.E.). A case-study design was warranted given the exploratory nature of this study and the need to have more in-depth understanding of the personal experience of veterans participating in T.E. work. Research Questions In this research project, an in-depth case study was designed to explore the following research questions: 1) What is the experience of “Therapeutic Enactment”? 2) What benefits were gained through participation in a therapeutic enactment? 3) What were the challenges experienced in participation in a therapeutic enactment? 4) What recommendations can be made for the improvement of this group-based therapy for Veterans? 6 Chapter II: Review of the Literature In review of the literature for this thesis, I recognize the importance of understanding how different forms of psychotherapy have influenced the way we treat PTSD and other trauma-related disorders. Therefore, a reasonable place to start the literature review would be with an overview of some of the different kinds of psychotherapies that have been found efficacious in working with military veterans who suffer from trauma-related issues and/or PTSD. Following this brief review, several different kinds of group-based psychotherapy for military veterans who have experienced trauma will be discussed along with a more detailed look at a specific type of group therapy called therapeutic enactment (TE) which will be the focus of the focus of this study. Approaches to Therapy for Military Populations Individual therapy has been a primary focus of therapy for PTSD with both military and non-military populations (Goetter, et al., 2015), although in recent years, group therapy has become more popular due to its financial feasibility and the fact that group therapy can offer significant therapeutic value for its participants (Lutz, 2019; Ready, et al., 2012; van der Kolk, B. A., 1987; Williams, 2014). While many authors have found benefits for those using group therapy interventions, there are some studies that have shown that group therapy can also have a negative impact on individual outcomes and therapy retention rates (Sloan, et al., 2013; Goetter, et al., 2015). Some of the potential reasons suggested are that military personnel do not feel comfortable with disclosure in a group setting and potentially not enough one to one time with clients and clinicians in group work (Goetter, et al., 2015). Nevertheless, there is further 7 conflicting evidence as Ready, et al., (2012) found that a group-based intervention led to low dropout rates and explained that the “high level of compliance may be due to the creation of strong group cohesion…” and that group therapy “seems to produce positive peer pressure to stay with the group and complete assignments” (p. 90). In addition, both van der Kolk (1987) and Yalom and Leszcz (2005) concluded that group forms of therapy have incredible benefits for participants as they are able to provide a space where individuals cannot only gain further insight through the interaction with others dealing with similar issues, but also provide a safe container to process psychological and emotional issues. There is also continued promise and evidence that supports a strong connection to interpersonal trust within a group setting and that of positive outcomes for successful recovery from PTSD for military veterans (Williams et al., 2014). In summary, while the research on group-based interventions for military veterans is still in its infancy, more and more associations and professionals are becoming aware of the benefits that group therapy holds for the veterans who participate within it which can include its cost and time savings as well as group cohesion, and expressiveness (Haynes, et al., 2020; Yalom, 2005). Research on Group-based Interventions for Trauma One particular type of group therapy that has been shown to support military veterans who have suffered from traumatic events is Mindfulness-based Cognitive Therapy (MBCT). King et al. (2013) completed a pilot study for combat veterans who were diagnosed with PTSD that aimed to understand the impact that group based MBCT therapy can have on participants’ PTSD symptom reduction. Their study used a 8 quantitative design that included 4 groups (n=20) of participants who engaged in an 8-week MBCT program that was slightly modified for clients with chronic PTSD. In addition, King at al. (2013) included a comparison group that consisted of 3 different groups (N=17) who all received brief treatment as usual (TAU) interventions. Participant levels of mental well being were measured by using pre and post treatment psychological assessments along with clinician administered PTSD scale (CAPS) that were performed with all patients, and self‐report measures (PTSD diagnostic scale, PDS, and Posttraumatic Cognitions Inventory, PTCI) that were administered in the MBCT group (King at al., 2013). Their results showed a significant improvement overall in the MBCT condition, but not in the TAU condition with MBCT completers (N=15, 75%) showing good compliance with assigned homework exercises, and significant and clinically meaningful improvement in PTSD symptom severity on posttreatment assessment in CAPS and PDS (particularly in avoidance/numbing symptoms), and reduced PTSD‐relevant cognitions in PTCI (self blame). Another study that was completed by Haynes, et al. (2020) looked at a cognitive behavioural group intervention called Cognitive Behavioral Social Rhythm Group Therapy (CBSRT) for military veterans suffering from PTSD and major depression disorder (MDD). Their quantitative study used a randomized control design that compared CBSRT against group-based present centred therapy (PCT) for veterans. In total, 43 male veterans with combat-related PTSD, co-occurring MDD, and sleep disturbances were randomly assigned to either the CBSRT group treatment or the PCT group treatment (Haynes, et al., 2020). Participants in both groups were interviewed and assessed using “follow-up feasibility and gold standard PTSD, MDD, and 9 subjective/objective sleep assessments” that were conducted immediately after the treatment, at 3 months, and then lastly at 6 months post-treatment (Hayes, et al., 2020, p. 800). Their results showed that veterans who were assigned to the CBSRT group treatment showed higher rates of attendance when compared to those in the PCT treatment condition, but that both groups showed improvements in PTSD and MDD symptoms, sleep efficiency, and number of awakenings with veterans in the CBSRT group showing a greater reduction in nightmares (Haynes, et al., 2020). A recent study conducted by Yalch, et al. (2021) aimed to further our understanding of group-based therapeutic interventions for military veterans through a specific lens called interpersonal theory that was coupled with collaborative/therapeutic assessment (C/TA). In their quantitative study that included military veterans seeking treatment for PTSD symptoms, a total of 14 participants attended and completed treatment in the group therapy that “consisted of 10 group sessions and one pre group screening session” (Yalch, et al., 2021, p. 24). All group members were required to complete the PCL-5, a 20-item checklist of PTSD symptoms, the international personality item pool-interpersonal circumplex which is a 32-item inventory of interpersonal traits, the circumplex scale of interpersonal values (Locke, 2000, as cited in Yalch, et al., 2021) which is 64-item inventory of interpersonal values. The researchers also included a DSM-5 cross-cutting symptom inventory measure (CCSI-5) which assessed general psychological distress both pre and post group treatments (Yalch, et al., 2021). The results of this study were mixed with slightly above half of the individual participants (8 of 14) showing clinically significant reductions in theirs scores using the PCL-5, about a quarter of the participants (3 of 14) displaying scores that did 10 not change, and another of the same number of participants (3 of 4) whose scores increased (Yalch, et al., 2021). Another qualitative study that was completed on group therapy by Johnson, et al. (2019) compared a usual assessment group therapy (UAGT) to suicide-focused group therapy that included a suicide status form as an additional measure (SSF-Assessment Group Therapy). Their final sample contained 134 veterans in total who were randomized to either one of the above treatment groups with initial baseline measurements taking place at a first interview with a clinician and then followed up by two more clinical interviews at 1 month and 3-month time intervals (Johnson, et al., 2019). While Johnson et al. (2019) clearly states that “The current study was not deemed to be a clinical trial based on the emphasis on assessment rather than treatment…” (p. 20), the results show that those who were admitted to the UAGT showed greater reduction in symptoms of distress across a 3-month follow-up window showing that the group therapy intervention provided relief of symptoms. During a follow-up analysis they found “that more frequent session attendance was significantly related to less suicidal ideation at 1-month, higher working alliance between individual members and group facilitators was associated with greater suicidal ideation at 1-month, and higher group cohesion among group members at 1-month was significantly associated with less thwarted belongingness at 1-month” (Johnson, et al., 2019, p. 15). An additional quantitative study on the benefits of psychodynamic group therapy (PGT) for military veterans was completed by Levi et al. (2017). Their population of choice was male military veterans from the Israel Defense Force who had been clinically diagnosed with PTSD. These researchers used the clinician-administered 11 PTSD scale (CAPS) as their primary outcome measure which was conducted with 158 total participants through semi-structured clinical interviews that looked at the “frequency and intensity of PTSD symptoms as according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition” (Levi et al., 2017, p. 1247). The results from their findings showed a significant reduction in PTSD symptoms based on the CAPS measurement up completion of the program and similar results were maintained at 12-month follow-up (Levi, et al., 2017). In consideration of these studies, evidence that points to the issue as to whether a group therapy intervention works or not has more to do with the manner in which the group is established and the norms and bonds that are created within it than it does with what intervention is selected. One intervention that has garnered attention is the group-based trauma informed intervention called “Therapeutic Enactment” developed by Dr. Marvin Westwood and Dr. Patricia Wilensky (2005). Therapeutic enactment was designed to address posttraumatic stress among various populations, however, in the last decade, this intervention has been utilized exclusively with veterans through the Veterans Transition Program. Therapeutic Enactment: A Group-based Trauma Approach The majority of treatment options available to veterans offer support for PTSD; however, do not address interpersonal relationships (Westwood, McLean, Cave, Borgen, & Slakov, 2010). Treating trauma injuries in this population through group work also assists in developing a sense of belonging, which is reminiscent of their working unit (Rozynko & Dondershine, 1991). Furthermore, trauma induced disruptions that separate paramilitary first responders from their community - whose core training is 12 contextualized through hierarchical, team-based relationships - add to emotional distress (Sweet, Stoler, Kelter, & Thurrell, 1989). This may be a result of questioning deeper identity and meaning if they are no longer a functional member of their team. A group-based approach can serve to repair interpersonal relationships that may have resulted from trauma injuries. Moreover, peer support and member-to-member learning and feedback can foster connection, creating a new, adaptive working unit (Westwood, McLean, & Cave, 2004). When working with individuals living with PTSD, it is critical to understand how their symptoms contribute to increasingly pervasive social isolation. Reexperiencing symptoms, such as intrusive thoughts of the traumatic event (especially surrounding recurring reminders of the trauma), can serve to isolate individuals by limiting drive to engage outside of perceived “safe” boundaries (Chapman, Gratz, & Tull, 2011). Hyperarousal symptoms, such as constant hypervigilance and irritable or angry outbursts, can exacerbate already strained relationships, with traumatized individuals feeling that they are beyond assistance and alone in their suffering. Finally, emotional avoidance and numbing symptoms, such as disconnection and detachment from loved ones and loss of interest in previously enjoyed activities, amplify self-isolating behaviours as it is often easier to avoid triggers than attempt to deal with them (Chapman, Gratz, & Tull, 2011). In light of these challenges, group counselling provides a safe setting that encourages members to share and take risks, which allows them to participate in their own healing process (Corey, Corey, & Corey, 2017). Additionally, group therapy has been suggested to serve as a means of preventing overwhelming emotional distress 13 through safe, structured emotional release (Rozynko & Dondershine, 1991). Group process can also correct distorted thinking and reduce feelings of shame and guilt through normalization of experience (Rozynko & Dondershine, 1991). Research has also shown that individual therapy may not improve interpersonal difficulties that result from trauma, thus group therapy may be a more effective treatment setting for individuals living with PTSD (Glynn et al., 1999). Time and cost-effectiveness are also important factors to consider, especially when trying to meet the needs of an underserved population (Klein & Schermer, 2000). The Veteran’s Transition Program (VTP) is an immersive program that is designed to help support veterans by helping to process their traumatic experiences, learn new ways to adapt and cope, and reintegrate into civilian life in a healthy manner (Westwood, et al., 2010). The non-profit program began in 1999 and has been rolled out across Canada in nearly every province as part of the Canadian Government’s initiative to combat operational stress injuries that many former and current members of the Canadian Armed Forces struggle to contend with. Embedded within this program is a movement-based group therapeutic intervention called therapeutic enactment (TE) which helps support the integration of the traumatic experiences of these veterans (Westwood & Wilensky, 2005). TE was originally formulated by Dr. Marin Westwood and Dr. Patricia Wilensky as a method of group therapy that would aim to support military veterans and builds off the work of Jacob Moreno who created psychodrama as a re-enactment based method of therapy in the 1920’s (Westwood & Wilensky, 2005). While psychodrama is only one part of TE work, it does play a pivotal role and therefore should be defined. Riva, Grassi, and 14 Belingheri (2020) define psychodrama as “a method used in psychotherapy, in which patients dramatize their lives to explore and solve personal problems.” (p. 369). There is also a significant amount of work that goes into the preplanning of TE work and that involves the therapist (or lead) and client carefully planning the enactment through a series of individual counselling sessions and often rely on the development of a life review (Balfour, Westwood, & Buchanan, 2014) before being fully emersed in the enactments. Enactments typically span over 3 hours, and critical moments or scenes from the client’s past are recreated in a manner that promotes healing and growth. Enactments often focus on relational ruptures by “returning to action—to re-experience the event as a means to alter and re-shift the original self-schema and, in doing so, endeavor to resolve shame, abandonment, abuse, or neglect” (Westwood et al., 2003, p. 126). Approaching therapy in this way allows clients to re-create critical moments, creating an opportunity to re-experiencing the event with time to more fully process thoughts, feelings, and actions that were associated with the original event. The mobilization of movement and action is the key tenant of any TE and the therapeutic benefits for the client come from the embodiment of experience, emotional expression, and sensory motor functioning, making possible a reprocessing and “restorying” of the self (Westwood & Wilensky, 2005). The experiences of therapeutic change through the proposed model are often solidified through one-to-one follow up counseling sessions where a clinician and client review the recording of the client’s TE work together in a process called interpersonal process recall. While interpersonal process is not always included in the post-TE follow-up, there are debriefs, one-on-one check-ins, and resources given to clients so that they are supported after the intervention. Ultimately, 15 therapeutic enactment helps clients restore meaning to their lives, pick up parts of their selves that were lost, and repair psychological injuries (Westwood & Wilensky, 2005), and the changes experienced by the clients would not be possible without the group (Yalom, 2005). To more clearly demonstrate the various components of a TE, which is conducted by the therapist (the lead), the participant (the client), assistants (para-professionals), and witnesses (the group members), a visual model is provided below. Figure 3.1. The five phases of Therapeutic Enactment. Westwood, M., & Wilensky, P. (2005). 16 The TE model has five phases: (1) assessment and preparation; (2) group building; (3) enactment; (4) sharing, reconnection, and closure; and (5) integration and transfer (see Figure 1). During the first phase, participants work with a trained facilitator, often a registered psychologist, to assess their needs and readiness for the program and to design a plan. One area of concern for readiness is often substance abuse and determining whether or not the client is able to manage any substance related addictions. As previously mentioned, central to this preparation is deciding upon the crucial life event to be explored, which is uncovered by the life review process. Once a clinical plan is in place, the client is placed into a group, which provides a space for doing the work of building a safe and supportive environment. Once group trust is established, the participant and facilitator begin by walking within a circle of others, retelling the particular life event central to their traumatization. Beginning with movement helps the client access deeper emotions while simultaneously regulating the autonomic nervous system (Westwood & Wilensky, 2005). After being introduced to the client’s story, fellow group members take on various identities in the story beginning the enactment. Through techniques including role simulation, rehearsal, witnessing, and modelling participants “access and express the buried feelings and negative cognitions attached to the problematic event” (Westwood et al. 2010, pp. 49–50). Following the enactment, those who took roles and those who witnessed are given an opportunity to provide feedback on how they were affected. In the last phase of the TE process, participants are encouraged to look forward to ways of integrating the experience into achievable goals and objectives as they work on “dropping their baggage” (Westwood et al. 2010, p. 49). The day after the TE, during a follow-up debriefing, the participant 17 begins to reframe and consolidate the personal learning of the enactment and upon completion of the full intervention, veterans are contacted at three end points for a follow up assessment: three months, 6 months and 12 months. This thesis explores an individual’s personal experience of Therapeutic Enactment using a case study research design and conducting a thematic analysis of the research interview. The research question for this study was: “What is the personal experience of a Canadian Armed Forces veteran who has engaged in a Therapeutic Enactment for his Occupational Stress Injury?”. 18 Chapter III: Method Research Design In order to answer the research question as effectively as possible, a case study research design has been employed. Using a case study allows for an in-depth look at an individual’s experience and can help understand this experience through their lens (Stake, 1995; Yin, 2017). Although there are those who believe case study research does not deliver proper amounts of data to be considered a rigorous methodology (Stake, 1995), there are many who believe just the opposite. Case study research can be utilized for appropriate understanding of individual circumstances to a degree of depth that is not only reasonable, but appropriate for scientific literature (Creswell, 2014; Yin, 2017). In discussion of when to utilize a case study, Yin (2018) states that “case studies are preferred when the relevant behaviors still cannot be manipulated and when the desire is to study some contemporary event or set of events” (p. 32). This claim suits the current research proposal considering the desire to understand the present-day experiences of someone who has completed a group-based intervention for traumatic stress. To this end, the present qualitative study sought to answer the following research questions: How did a veteran in the Canadian Armed Forces experience a group-based therapy intervention for trauma-related stress? What did this individual find useful from the intervention and what did he find not useful? Does this individual have any suggestions or recommendations of its use with other military personal; why or why not? 19 Procedures Recruitment Recruitment for this study will be done through the Centre for Group Counselling and Trauma at the University of British Columbia. Telephone contact was made with the centre and contact was made with Dr. Marvin Westwood and he was given the purpose of the study and details of the proposed research. The requirements for the study were described and Dr. Westwood was asked to reach out to potential candidates that fit the inclusion criteria. A single participant will be selected for this study based on fulfilling the following requirements: 1. Male between the ages of 19-40 2. Veteran of the Canadian Armed Forces who has previously seen active duty 3. Must have completed a TE within the past year 4. Must have suffered an operational stress injury from involvement with the Canadian Armed Forces Participant Description The population proposed for this study will be an individual who identifies as a male military veteran who is not currently in active duty but has been at some point in the past. A single person was approved by the research committee for this case study. 20 The individual selected for this study has been in the Canadian Armed Forces since he was 18 years old and early in his military career he saw active-duty when he was sent to the 2009 tour to Afghanistan. The participant has been in the Canadian Armed Forces in different roles for 14 years as of this writing. The participant lost a fellow soldier and best friend to suicide while in active duty and one of his three Therapeutic Enactments revolved around the processing of this event. He was in his mid 20’s when the event occurred. Before this event, the participant was a typical male in his 20’s with ambitions and goals for the future, but after it he felt a huge sense of loss and an inability to find purpose in things at times. He decided, after watching another veteran complete their own Therapeutic Enactment, to take the step and participate in his own. Data Collection Process The data collection process for this study consisted of a semi-structured, open-ended interview with a participant via a virtual recorded interview over Zoom. The interview was conducted after the participant was involved in his own therapeutic enactment for an occupational stress injury. The interview was 1 hour in length. Before the interview commenced, the participant was provided the informed consent form which was discussed, and consent was given to participate in the study. Data Analysis. Thematic analysis (TA) has been shown to be helpful in the analysis of qualitative data and is often utilized to discover themes in data (Braun & Clarke, 2006; Clarke & Braun, 2017); or as Holloway and Todres (2003) discuss it in their article as 21 ‘thematizing meanings’. In addition to this, TA has been considered a flexible method that allows researchers to apply it in a wide variety of disciplines as well as with a number of different applications (Clarke & Braun, 2017). One of those disciplines is Counselling Psychology and one of those applications is with the qualitative data that this study aims to extract from the case study of the individual’s experience of participating in TE. Following this, Clarke and Braun (2017) state that “the aim of TA is not simply to summarize the data content, but to identify, and interpret, key, but not necessarily all, features of the data, guided by the research question” (p. 297). A thematic analysis was conducted after the research interview was completed. Braun and Clarke’s (2006) 6 phase approach was used to analyze the research interview as follows: 1) Familiarize yourself with your data. The researcher re-read the transcript that was created from the interview over several different days and engaged in an immersive manner to more fully understand some of the themes present 2) Generating initial codes. After the researcher familiarized themselves with the data, they began to code some of the data into the most basic ideas that stood out 3) Searching for themes. After this coding, the researcher then began to view the codes from a more macro perspective and made connections between the codes which revealed four distinct overall themes 4) Reviewing themes. Upon completion of step three, the researcher reviewed the four themes at the level of the coded data extracts and then in relation to the data set as a whole. 5) Defining and naming themes. At this stage of the process the researcher refined and defined the various themes and made clear that each theme was distinct and could easily be defined as a separate category from the others 6) Producing the report. Once all themes were solidified, the researcher started 22 to write the story that was being told from the themes that were presented and provided evidence for the existence of those themes. Criteria for Trustworthiness In qualitative research, the criterion for trustworthiness varies depending on the type of research that is being conducted (Creswell, 2014). There are no explicit criteria for trustworthiness in case study research; therefore, the researcher followed the general recommendations typically found in qualitative research methods (Creswell, 2014; MörtI & Gelo, 2015). The following three criteria will be used to evaluate the trustworthiness of the study. Using a member checking procedure, the following three criteria were used to evaluate the trustworthiness of the study. Once the research interview is transcribed, a copy of the transcription will be sent to the participant to validate it. Once the transcript was verified by the participant, a second member checking procedure was conducted on the thematic themes found using the and the following three criteria : • Criteria 1 – Comprehensiveness: “Do you believe that the themes are comprehensive enough to capture your experience of therapeutic enactment? Is there anything missing?” • Criteria 2 – Resonance: “After reading the findings, do you feel that everything that was stated resonates with your experience? If no, what part do you feel does not resonate well?” • Criteria 3 – Pragmatic Value: “Do you feel that these findings will be useful for other veterans and/or the continued development of Therapeutic Enactment as an intervention for veterans with Occupational Stress Injuries?” 23 Steps in achieving the evaluation: - Members checking stage 1 – send the original transcript to the participant for verification of accuracy. o If the participant has questions I will incorporate those into the transcript - Member checking stage 2 – send the final themes to the participant for verification using the 3 criteria of trustworthiness. Incorporate feedback received. - Expert peer reviewer who has conducted research and has clinical training in therapeutic enactment and has worked with vets who have trauma and knows the intervention and works in groups will review the transcript by using the criteria above. o Two committee members with the above expertise will review the results and give any feedback if necessary Informed Consent Procedures The participant will be emailed a copy of the consent form in advance so that he will have an opportunity to review the document and ask any questions upon our initial Zoom call. During the day of the Zoom interview, both the participant and the interviewer will have a copy of the consent form and it will be reviewed thoroughly with the participant and he will have the opportunity to ask questions at any point throughout and confirmation will be given for clarity for each point. 24 Ethics In case the participant becomes overwhelmed due to the interview, support will be available from two clinical experts in the area of trauma who have also both worked extensively with military veterans: Dr. Marla Buchanan and Dr. Marvin Westwood. The participant will also be emailed a list of free counselling services that include the Vancouver Suicide and Crisis Line and the Psychological Services and Counselling Training Centre (PSCTC) out of the University of British Columbia if needed. In further consideration of ethical duties, the data that is collected from the Zoom interview and the transcription created from the interview will both be kept on an encrypted USB drive that will be placed in a locked cabinet in the PI’s office. The data will be destroyed within five years of completion of the study. 25 Chapter IV: Findings This chapter will discuss the findings of the research project and of the data collected from the interview process. The four major themes of the data collected will be discussed and evidence of these four themes will be given by direct quotes from the actual interview with the military veteran who participated in this study. Theme One: Trust Trust was a key construct of importance in the participant’s experience of his Therapeutic Enactment (TE). He defined the importance of trust at three levels: 1) trust within the group, 2) trust of the clinicians/facilitators of the group and 3) trust of key members of the group who were involved in taking roles in the Enactment. The participant emphasized that trust within the group was extremely important in order for this intervention to work. He explained how the group facilitators developed trust within the group by being well prepared and structured and by creating a type of rhythm to the process overall that was not too clinical. An example of this is his description of how one of the leaders developed trust within one of the groups he participated in: Probably the flow, so he made it. . . .not like a clinic or anything, we must do this, this, and this. There’s a flow that we went through and I knew that he knew what he was doing and the way it was happening, there was a lot more going on behind the scenes, but it didn’t feel that way. In addition to the development of trust within the group, there was also a strong sense of how important it is for the clinicians themselves to be of trustworthiness. The main 26 components of developing this trust stemmed from these three particular notable areas beginning with the participant viewing the group leader as someone who had experience in conducting Therapeutic Enactments. Closely connected to this was the idea that the leader had a particular dedication to military veterans as evidenced by his background and previous work conducted in the field. The following statement from the participant connects these two elements: Seeing him in action doing things and knowing the history of what he has done within the program, I think that is where my trust was. The third notable component that related to the trustworthiness of the clinician and/or group leader was that the participant had seen the group leader in action previously by participating as an active observer in another veterans’ Therapeutic Enactment. The participant also stated the following in relation to the importance of observing TE work and understanding some of the methods that may be utilized during one prior to completing your own: And then when I saw the group and heard all their stories like we do in the program it allowed me more space to do that and confidence and trust. The third aspect of this theme on trust was trusting members of the group. For military veterans it is important to be able to trust others in the group and generally that means by having other military vets and excluding anyone who does not have that same experience. So having other group members being part of the military was a key aspect for this participant. 27 Yeah, it was the similarities in some of our stories, that was definitely beneficial and allowed me to trust a little bit more and carrying out what I needed to hear. The participant described the importance of belonging in a group and finding a common understanding because they were all part of the military culture. This common bond helped build the trust that is needed to do this intervention that requires the clients to go back to the traumatic event and enact its effects. This participant explained that this common bond is needed to be able to retrieve the trauma experience and mentioned that Therapeutic Enactment is “something you don’t really get anywhere else too” when asked about the importance of trust within the group setting. Another excerpt that connected to this importance of the group and its members is this statement by the client: “It is all about that group too so if you cannot connect with the group, you probably wouldn’t even share that information with them”. In other words, without having a sense of trust between members of the group, very little sharing of information will take place. However, it seems this can be avoided by starting things off on a strong foundation of trust. Try and develop a good trust early, and you can’t do this without meeting everybody in the group or clinicians developing it so try to get that trust and then come forward with what you are going to do. Otherwise, you are not going to bring the right thing forward to work on. It would seem that trust is very intimately connected to the process from inception and that without it, veterans who engage in this work may not have the most useful experience by potentially not identifying the most critical items to work on for therapy. 28 Theme Two: The Most Beneficial Aspects of Therapeutic Enactment There were several different aspects the participant discussed with regard to what he considered the most beneficial aspects of a Therapeutic Enactment and they included various stages of the process. In particular, the ending of one Therapeutic Enactment session stuck out for him and when he was asked what part of the overall process he found the most useful, the participant’s response was: Probably right at the end of the TE. I had the ability to say goodbye, because I wasn’t able to do that in real-life. I had to go away and do…or, I was already on a tasking, so when the incident happened, I wasn’t able to grieve. I was not able to do anything and that [being able to grieve what happened] helped out the most, I think. In this response, it is evident that the participant was not able to process what had happened in real-time because of the responsibilities of being on active duty as part of the Canadian Armed Forces. He was not able to grieve for the loss of his friend or find any closure until it was re-enacted as part of the ending of his own Therapeutic Enactment. In addition to being able to find some closure, the participant stated that there were other benefits that were gained through the process of Therapeutic Enactment which included the ability to talk about things more openly, being able to face his fears more directly, and not avoiding the difficult parts of his trauma experience. When asked about this experience and what it felt like, the participant stated that it was: 29 Just like they say like a ‘weight off your shoulder’. I felt I could actually talk about it now. Before I remember I would get choked up and couldn’t do it or I would walk away or do something else and forget about it. Then the ability to talk about it was like almost taking something off your back like a backpack. He was finally able to relieve himself of the burden of holding all this inside and rather than using an avoidance strategy to cope with the emotions, he was able to face them directly in a safe and contained manner within the group. There was also a sense that the participant felt a forward progression in his life after being stuck in the trauma for so many years, not really knowing how to deal with the traumatic incident and the loss. Having had the opportunity to open up about the incident, the participant was able to unhinge that part of his life and begin the process of moving forward and moving on with his own life, while never having to leave the memory of his friend. In relation to this idea, the participant stated: Maybe knowing that I am working on myself, and that making progress, seeing the process and talking about it without, burying it. I can talk about my friend and everything that happened and before I could not. I would just hide it and never talk about it. The Therapeutic Enactment of his loss allowed him to face his grief and publicly acknowledge what had happened. For the first time, he shared his story with others, putting his pain externally where it could be witnessed by the group. He found this aspect of the intervention very beneficial. He further stated: 30 Yeah, it connects myself with my buddy in a different way, rather than just remembering the bad times, I remember he’s not here, but I am doing my best and not taking two casualties instead of one. The participant is stating the importance of how he changed his relationship not only with his friend, but also to himself – he was able to see things from a unique and different perspective and see some of the good through all the bad. He went on to explain how he was able to move past this part of his life: “No, it was freeing almost. You make a promise in the end too, right? You kind of stick to it.” There is a sense of purpose and duty when the participant talks about doing his best to not allow himself to follow the same path and cause more casualties by seeking help rather than suffering in silence. There is a huge message of relief in these words and there is something powerful about making a promise to people who you have served with and who you have cared about which was clear when the participant was asked who he made the promise to: I made it to my buddy, the whole point of it was to make a promise that you are going to live your best life and progress and do what you need to do. So that is what I made the promise for. The final and perhaps one of the most powerful and encouraging reflections from this section came when the client finished discussing the power of the process for him: Looking back now I am like, everything that I have done right now came after that. [I] feel like I am doing well right now, that [the Therapeutic Enactment] might have been the starting point. 31 Theme Three: The Challenges in Therapeutic Enactment The participant spoke about the challenges in completing a Therapeutic Enactment that incorporated both somatic and emotional experiences, as well as that of cultural experiences. After a moment to reflect on his previous Therapeutic Enactments and in consideration of both the physical and mental experiences, the participant stated: The ones that I did personally I knew that it would be hard and by hard I don’t mean it is more physically and mentally hard. Not like doing a bunch of paperwork or something like that. It [doing the enactment] was something that took over your whole body and I knew I was going to go into that because I have seen other people go through it and I knew it would be beneficial. While this process was difficult for him, it was apparent that he knew the benefits of going through the tough stuff by observing the benefits that others had received while watching them engage in their own Therapeutic Enactments. The participant noted several times an experience of the body where it felt as though he was being taken over in a way. In terms of the participant’s physical state during the Enactment, he stated: When it gets physical, and you are like you can’t even tell you know . . . you get that [emotional] pain, knowing you were going to do that, that was hard. But I knew that pushing past it and working with it. But that was the hardest part, knowing you are going into that, you’re sweating you know it’s like physical. The participant further explained what the physical experience was like: 32 Yeah, it is like when you run up a hill or go on a really good hike, you hate it when you are going through it then you get to the top and it was so worth it. Good feeling, right? In this analogy, the participant is describing the difficult process of going through a traumatic event using Therapeutic Enactment where the “real story” is recreated and enacted once again. The process as he describes it is very difficult at the beginning, but it seems it is a necessary challenge that is part of the treatment process. In addition to the physical and emotional challenges, the participant identified some of the challenges that come with participating in military culture and adhering to strong masculine norms and roles: Yeah, especially just being a male, you don’t talk about stuff. If it affects you—you don’t let it show. So, it was a chance to be vulnerable when you are not normally like that I guess. The participant continued to discuss the connection to masculine identities in roles that are non-military: Yeah, military is similar to fire, police, they have this masculinity side to it and same with the females that join they also have that mentality, to never let up that you are weak. You need to be on point, useable right? Deployable. The previous points connected with his piece about emotional vulnerability and how difficult it can be for military personnel to show this in therapy because during training and active duty it is not something seen as a positive trait out of necessity for the requirements of duty. 33 Yeah, in basic training, stuff like that or basic infantry training, if you go to a hospital, which they call the MAR, ‘you’re a piece of crap right’, ‘weakling’, ‘why don’t you just leave?’ Those kinds of comments come up and it shapes you into, never going in for a small little scratch or anything like that. Or like a bigger thing like a broken ankle. There are guys that will hide it and tape up their ankle until the course is done. That is the mentality that we are going through. Theme Four: Recommendations for Future Therapeutic Enactments The fourth and final theme revolved around a variety of different implicit and explicit recommendations that could potentially be useful for future clinicians who engage in TE work. However, before these themes are discussed, it has to be noted that the participant was hesitant to make any strong suggestions for change and when asked about changing anything to do with the pre-session planning and interview during stage one (Westwood & Wilensky, 2005), the participant stated, “I wouldn’t change anything because it’s the process, right? I wouldn’t know how to change it to make anything better.” He felt strongly about this point and it connected to the first theme of trust in that the participant felt as long as there was trust for the clinicians running the therapeutic enactments, there should be no reason not to trust the rest of the process itself. When asked about the benefits experienced from the first stage pre-session planning and interview the participant said the following: “Yes, by being as honest as possible, and letting it go. It takes a bit of time to do that right?”. The participant viewed being open and honest right from the beginning of the process as being a key component to success in the group. 34 It was just like getting loaded onto something, someone asking you a question and you know these are going to be coming up later. So, I tried to be super, super honest and give them the best information I could about what I wanted to work on, and the issue I had been struggling with. It worked out better in my favor because I felt when I actually was done it, I felt such a benefit after both times. The participant also stated the following with regard to being open and honest right from, the beginning: Both times I trusted everybody and the second time I had to get into it, so I did what I mentioned I jumped right into all the activities and made sure I was super honest what came out and what I wanted to work on. Another one of the important considerations that came up for the participant during the interview was that he believed it would be beneficial for those who want to complete their own TE work to participate in and observe the TE work of another veteran so they have an idea about the way a TE might run. It was due to this awareness of the process that the participant was able to engage fully in the process itself. Yeah, because I knew they were just trying to link everybody, they are trying to get everybody together. And I just jumped right into it, it was more beneficial for me and I wasn’t going to say, or I wasn’t going to bring forward one I wanted to work on. 35 For this participant, understanding the details of what was happening and why it was happening was helpful in getting him to become more comfortable with completing his own therapeutic enactment. And actually, experiencing it with [one of the therapists] when he did one for somebody that was having an issue with something. And I got to see how he did that and what he was doing while he did it and he was actually explaining it to me too. What he was doing so it was really nice. One of the final pieces the participant suggested about the process when asked if he would add anything or take anything away was the idea that the entire process should seem more like a conversation rather than a clinical process. Even though the participant restated his trust in the group leaders to deliver, this was still an important part for him as it made him feel more at ease and it allowed for a certain type of flow to the intervention. No because it is more of the clinicians, what they need, so I would just want to provide what they need. And if I had advice, it would be trying to make it more like a conversation, like the way that [one of the clinicians] did, you and everyone did, you are pulling out little pieces and it is not like ‘okay, question number one’, it was more like ‘tell me about this’. It was more of a conversation. Lastly, the client was asked specifically if there was any advice he might have for programs that might use Therapeutic Enactment or for those veterans who might be thinking of joining a program and completing their own work. To the programs he stated the following: 36 My advice would be trying to have less [travel], for me a flight and I had to drive there at 3 in the morning and wake up and do the whole stuff right? So that might be something is maybe not beneficial. So, it would be better to actually be in your local area or you’re going to do it closer to your home and having a whole flight and everything involved [was too much]. The participant felt strongly that some of the travel requirements to attend TE retreats in other provinces may be overwhelming and exhausting which is counter to how one would want to start therapeutic work of any kind. However, when it came to specifically completing the work in a retreat-style program, the participant had this to say: It was but I remember for the ten day one, being a resort area, I felt also like a feeling, I don’t know if I ever mentioned, it was almost like meditating and I was ready to heal and do all that and give all the information that I needed to. But that was just me because I know the benefit of the program. I’m not sure if another military person would be the same. Overall, the participant felt that with regard to the physical space, having one that is close enough to home that there does not need to be too much rushed travel, but one where you are somewhat secluded and removed from your regular daily life can offer the right setting for healing to occur. When it came to his advice for other veterans who are thinking of completing their own TE work, the participant had this to say: I would have to say the biggest thing is that someone could be struggling with this for 20 years right and for me it was ten years. And just shaking it off and 37 moving forward, is one of the biggest things you could ever take from it. It is a new life almost, right? The participant had carried the emotional weight of things for so long and being able to relieve himself of this through participating in his own therapeutic enactment was one of the most freeing things he could have done. As a final comment to the process as a whole, the participant stated the following when asked if he had any final recommendations for running therapeutic enactments in the future: Not too much, I like the whole process and you kind of must go through it to talk about it right? No, I can’t really put a finger on it. It is a great process. In summary, the findings of this study delivered four overall themes that were created based on the interview with the participant, and they included: what the most important components of a therapeutic enactment were for him, what kinds of benefits the individual received from the process, the different challenges that occurred for him in relation to starting and completing the treatment process, and finally, his future recommendations for clinicians running Therapeutic Enactments. Theme one connected to past literature in terms of our understanding of group therapy in general and its important components such as trust and openness (Williams, 2014). Regarding group therapy and its particular application to military populations and masculine culture – theme one also connected to the literature in terms of understanding how this cultural influence can manifest itself upon soldiers (Kuhl & Westwood, 2017; Shields, 2016; 38 Westwood, et al., 2012) and the importance of being able to share and process trauma within a group setting (Yalom, 2005) after avoiding it for so long. Theme three confirmed our understanding of how trauma operates within the body (van der Kolk, 1987), and gave us a unique insight into understanding how to develop an ability to fight through the pain of the emotional response of the work. Theme four helped further clarify future TE work by offering suggestions that might reduce travel time for the participants and ensure that future clinicians make sure to make the process more of a conversation than a clinical interview. The four themes and their connection within the literature will be discussed further in the final chapter. 39 Chapter V: Discussion The purpose of this study was to better understand the experience of a group-based form of therapy called Therapeutic Enactment through the lens of a male military veteran who had previously been involved in at least one group-based intervention. It was demonstrated that, through review of the four main themes and the various subthemes associated to the data that was collected, all four themes had a connection to previous research in this area. This chapter aims to situate the findings of this study within that existing literature and examine new discoveries brought forth by the results. In addition to this, implications in the field of counselling, implications for future research, and strengths and limitations of this study will be examined. Situate Findings within Existing Research Trust within therapeutic enactments. In this section the similarities and a few of the new learnings will be discussed starting with a review of theme one: Trust, which was broken down into three subgroups of 1) trust within the group, 2) trust of the clinicians/facilitators of the group, and 3) trust of key individual members within the group who take on important roles. While trust has been shown to be an integral part of trauma work and the general therapeutic process (van der Kolk, 1987; Foa et al., 2009), it is certainly an important part of doing group therapy (Corey et al., 2017; Yalom, 2005), and in particular group therapy with military veterans (Brooks, 2008; Cave, 2004; Westwood et al., 2010; Westwood et al., 2012). In this manner, the client’s focus on trust as an important factor in his experience relates to what the previous research has suggested. While the research literature strongly relates to trust within the group and trust of the clinicians/facilitators of the group, what was perhaps less known in the 40 literature was the trusting relationship of the key members within the group. Therapeutic Enactment is an action-based form of group therapy and it requires the members of the group to be active, not passive members within the group (Cave, 2004; Westwood & Wilensky, 2005). This is a key difference when compared to traditional group therapy where members are individuals within their groups and are usually encouraged to participate, however, they will rarely participate in the same intimate active roleplaying as one might have to during therapeutic enactment (Balfour et al., 2014; Hirakata & Buchanan-Arvay, 2005). This finding highlights a crucial need to be able to have that trust between members from the beginning or to take measures to ensure that the people who play these important roles in a veteran’s enactment be of close relationship to them already. This can be done through the shared, common experience of being in military training together, being deployed together, or having the experiences of either one of these whether or not it was completed simultaneously. Beneficial aspects of therapeutic enactment. There were different aspects and different stages of the process that were discussed as beneficial by the participant. One of those aspects was near the end of stage three, which is the enactment component of the group process (Westwood & Wilensky, 2005). The participant stated that during this section he was able to offer himself closure through enacting a part of his story that required letting go and saying goodbye. This resonates with what Westwood and Wilensky (2005) state in Chapter 7 of their clinical textbook on Therapeutic Enactment that speaks to the denial or avoidance of death: “facing up to the reality of the death and the truth of its impact seems to free the person to fully grieve accept and integrate the death into their lives as part of their identity that nurtures and 41 sustains them” (p. 109). From this excerpt, we can see the importance of letting go or what the military vernacular terms ‘dropping the baggage’ (Balfour, 2014) for those who are completing their own TE work. This almost ceremonial or ritualistic part of the process has been discussed in the previous literature (Balfour, 2014; Lutz, 2019; Westwood & Wilensky, 2005) and confirms the importance of this in terms of the clients healing journey. When discussing additional parts of the process that the participant felt were beneficial, one of the other subthemes was the power of the bond he had created with his friend who had passed away. As is common with this type of work there is a recreation of a relationship and a new dynamic formed during that process which can be healing to the person experiencing it (van der Kolk, 1987). This subtheme seemed to connect with what was known in the literature, but an additional piece that came from this section was the idea that making a promise to someone, even if they are no longer physically present, can be a strong facilitator for future goals that someone completing a TE may have set out for themselves. This strong desire to be honourable to one’s word and follow through with action has been shown in the literature on masculinity and military populations (Kuhl & Westwood, 2017; Shield, 2017), but it has not specifically been implicated in the Therapeutic Enactment literature as specific part of post-treatment planning. Incorporating a type of promissory process into the enactment itself may lend to future goal attainment and success in post-treatment life. Challenges in Therapeutic Enactment. From this overarching theme in the data, there were a few subthemes that were extracted with one being about the difficulty in experiencing the physical portion of the process. This difficulty connects with what we know about how trauma is experienced in the body and how that experience is part of 42 the healing journey but can be incredible overwhelming in the moment (van der Kolk, 1987). While understanding this is helpful, what may be more difficult to assess is how to encourage someone to challenge themselves to experience the physiological process of trauma work. This is something that is not discussed at length in the data as for most people doing clinical work this is completed through psychoeducation which is where the teaching aspect of therapy comes into play (Foa, 2009; Monson, 2006). The participant defined the importance of observing others in addition to understanding more about how trauma works from a neurological and physiological perspective as part of the reason for engaging in his own work. In addition to this challenge of the process, the participant identified a strong connection to the difficulties with identity and culture – particularly those identifying as male or as masculine and belonging to military culture. The idea of the abject masculine is represented in this idea and has been discussed in the literature on military personnel (Brooks, 1998; Kuhl & Westwood, 2017; Shields, 2016) as a central component of why hyper-masculine traits seem to be so prominent in these populations. Shields (2016) states the following about the abject masculine and military culture: “Military training, in emphasizing and exaggerating masculine norms, invokes both masculine ideals and abjections in order to define military cultural norms and define who belongs and who does not” (p. 3). Part of that abject masculine is vulnerability and as the participant noted, and is evidenced in the literature (Hinjosa, 2010; Galdas, 2005), vulnerability is a key part of the process toward healing whether in group or individual therapy (Shields, 2016). 43 Recommendations for future Therapeutic Enactments. The participant in this study was clear to state that there were no changes he would make to the process because he had trust in the groups leaders and the people who created the process. However, there were subthemes seen upon analysis of the data and they included suggestions to future participants and to future group clinicians/facilitators. The first subtheme was for future participants to be as open and honest as possible at each stage of the process, but particularly during the pre-interview stage as this stage sets you up for the entire process (Westwood & Wilensky, 2005). As with trust, openness and honesty are paramount to most clinical work (van der Kolk, 1987; Foa et al., 2009), however, what is particular for TE work is that the more open and honest you are at the beginning stages, the more benefit you will receive in the later stages. This focus on being open and honest has implications not only for the clients, but for the clinicians who are running the pre-interviews to build enough rapport and comfort that it allows for the client to feel connected enough to share openly and honestly right from the start. In terms of suggestions for the clinicians and programs running Therapeutic Enactments, the participant stated that remaining in a conversation-style and not a clinical-style format was beneficial throughout the process. This statement is somewhat implied in the literature (Balfour, 2014; Lutz, 2019; Westwood & Wilensky, 2005), but it has not been explicitly stated in the manual, it more likely came naturally to those who were delivering the group therapy sessions. This may be a future consideration for something that could be manualized and developed as part of the clinical training for Therapeutic Enactments. 44 Implications for Counselling This research has given an in-depth look at how group therapy, in particular therapeutic enactment, is experienced by a male military veteran who has suffered from a traumatic experience. Understanding this experience has revealed and reinforced the necessary requirements of building trust and safety within groups. It has confirmed that therapists who work within the model must practice diligently and put forth any and all efforts to create and build trust. Without this trust, these groups will not work as they have been designed for and may cause the veterans who participate in them to miss out on potential therapeutic gains. It has also reminded us of the interconnectedness of masculinity and the military role, which is a necessary one when on the battlefield, but can be harmful to mental well-being when not. Perhaps this can be a continued reminder that unlike the participant, there are many veterans who are out there who still suffer because of this cultural adherence to masculine norms and that we need to break these cultural barriers down when they no longer serve the individual. Allowing veterans to participate as observers of other enactments first may be the solution to reducing the discomfort and stigma of completing their own work. This could be looked at as an introductory step that would reduce the risk for adherence to vulnerability, while at the same time creating safety and the perception that one can be successful in this treatment model if witnessing the success of other military veterans. From a more practical lens, this research has highlighted the importance of making therapeutic enactments more local and accessible to the participants who attend them. This could mean reducing the amount of travel required or it could be 45 allowing more time for that travel to occur. This does not mean removing the retreat-style format as this was seen as therapeutically beneficial by the participant. The final practical implication discovered was the idea that clinicians who are running these groups should make the therapy process more of a conversational-style process than a clinical one. This was seen as an important fact for success by the participant and while it was recognized that this was clinical work, in the moment to moment interactions it was not perceived as such. Implications for Future Research While this study aimed to complete a deep dive rather than a shallow plunge in terms of understanding the experience of therapeutic enactment, the sample size of only a single participant is a limitation in its scope. Including more participants in this work would certainty increase the value of the data collected and enable the researchers to conduct a more thorough analysis of themes across different veterans’ perspectives. It would enable connections between themes and perhaps it would allow for new and different themes to emerge. In addition to having more participants, the researcher notes that some questions could have been considered more deeply or asked in a different way to extract a more meaningful answer. A possible future solution to this might be to have the participant(s) receive questions in advance so that they have some time to think about them and formulate a response to them. The researcher could also set up two interviews at different time intervals and see if any answers to questions have changed or if any new answers have been created by the participant(s). Lastly, after the completion of this project, the researcher is in a much better position to modify questions for future 46 potential participants and highlight some of the domains and themes that were discovered through this study. Strengths and Limitations of the Methodology and Study As with most qualitative research, and in particular research conducted through a phenomenological lens of inquiry, the quality of the data depends on the direct experiences and interpretations of those experiences from the participants involved (Moustakas, 1994). It is also contingent on the researcher’s experience within the field and how they may interpret and analyze the data they receive (Creswell, 2014). Even though there is a systematic process to this type of inquiry, there is little way to remove subjectivity completely from this procedure and therefore this must be considered by all who review this data. 47 References Balfour, M., Westwood, M., & Buchanan, M. J. (2014). Protecting into emotion: therapeutic enactments with military veterans transitioning back into civilian life. Research in Drama Education, 19(2), 165–181. https://doi-org.ezproxy.library.ubc.ca/10.1080/13569783.2014.911806 Brooks, G. R. (1998). Group therapy for traditional men. In W. S. Pollack & R. F. Levant (Eds.), New Psychotherapy for Men. (pp. 83–96). John Wiley & Sons Inc. Black, T. G. (2009). Stories from the heart: Narratives of change in therapeutic enactment. Canadian Journal of Counselling, 43(2), 92–104. Retrieved from http://search.ebscohost.com.ezproxy.library.ubc.ca/login.aspx?direct=true&db=psyh&AN=2010-19455-002&site=ehost-live&scope=site Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi-org.ezproxy.library.ubc.ca/10.1191/1478088706qp063oa Bryan, C. J., Clemans, T. A., Hernandez, A. M., Mintz, J., Peterson, A. L., Yarvis, J. S., & Resick, P. A. (2016). Evaluating potential iatrogenic suicide risk in trauma‐focused group cognitive behavioral therapy for the treatment of PTSD in active duty military personnel. Depression and Anxiety, 33(6), 549–557. https://doi-org.ezproxy.library.ubc.ca/10.1002/da.22456 Cave, D. G. (2004). Enacting change: A therapeutic enactment group-based program for traumatized soldiers. Dissertation Abstracts International Section A: Humanities and Social Sciences. ProQuest Information & Learning. 48 Http://search.ebscohost.com.ezproxy.library.ubc.ca/login.aspx?direct=true&db=psyh&AN=2004-99011-093&site=ehost-live&scope=site Chapman, A. L., Gratz, K. L., & Tull, M. T. (2011). The Dialectical Behaviour Therapy Skills Workbook for Anxiety: Breaking Free from Worry, Panic, PTSD & Other Anxiety Symptoms. New Harbinger Publications. Clarke, V., & Braun, V. (2017). Thematic analysis. The Journal of Positive Psychology, 12(3), 297–298. https://doi-org.ezproxy.library.ubc.ca/10.1080/17439760.2016.1262613 Clarke, V., & Braun, V. (2018). Using thematic analysis in counselling and psychotherapy research: A critical reflection. Counselling & Psychotherapy Research, 18(2), 107–110. https://doi-org.ezproxy.library.ubc.ca/10.1002/capr.12165 Corey, M.S., Corey, G., & Corey, C. (2017). Groups: Process and practice (10th ed.). Belmont, CA: Brooks/Cole. Creswell, J. W. (2014). Research design: Qualitative, quantitative, and mixed methods approaches. (4th ed.). Sage Publications. Galdas, P. M., Cheater, F., & Marshall, P. (2005). Men and health help-seeking behaviour: literature review. Journal of Advanced Nursing (Wiley-Blackwell), 49(6), 616–622. https://doi-org.ezproxy.library.ubc.ca/10.1111/j.1365-2648.2004.03331.x 49 Glynn, S. M., Eth, S., Randolph, E. T., Foy, D. W., Urbaitis, M., Boxer, L.,Crothers, J. (1999). A test of behavioral family therapy to augment exposure for combat-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 67(2), 243-251. Goetter, E. M., Bui, E., Ojserkis, R. A., Zakarian, R. J., Brendel, R. W., & Simon, N. M. (2015). A systematic review of dropout from psychotherapy for posttraumatic stress disorder among Iraq and Afghanistan combat veterans. Journal of Traumatic Stress, 28(5), 401–409. https://doi-org.ezproxy.library.ubc.ca/10.1002/jts.22038 Foa, E. B., Keane, T. M., Friedman, M. J., & Cohen, J. A. (2009). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies, 2nd ed. (E. B. Foa, T. M. Keane, M. J. Friedman, & J. A. Cohen (Eds.)). Guilford Press. Haynes, P. L., Burger, S. B., Kelly, M., Emert, S., Perkins, S., & Shea, M. T. (2020). Cognitive behavioral social rhythm group therapy versus present centered group therapy for veterans with posttraumatic stress disorder and major depressive disorder: A randomized controlled pilot trial. Journal of Affective Disorders, 277, 800–809. https://doi-org.ezproxy.library.ubc.ca/10.1016/j.jad.2020.09.009 Hinojosa, R. (2010). Doing hegemony: Military, men, and constructing a hegemonic masculinity. The Journal of Men’s Studies, 18(2), 179–194. https://doi-org.ezproxy.library.ubc.ca/10.3149/jms.1802.179 50 Hirakata, P., & Buchanan-Arvay, M. J. (2005). Into the fire: Using therapeutic enactments to bridge early traumatic memories of childhood sexual abuse. International Journal for the Advancement of Counselling, 27(3), 445–455. https://doi-org.ezproxy.library.ubc.ca/10.1007/s10447-005-8205-9 Holloway, I., & Todres, L. (2003). The status of method: Flexibility, consistency and coherence. Qualitative Research, 3(3), 345–357. https://doi-org.ezproxy.library.ubc.ca/10.1177/1468794103033004 Institute of Medicine (2014). Treatment for posttraumatic stress disorder in military and veteran populations: Final assessment. Washington, DC: National Academies Press. Retrieved from http://search.ebscohost.com.ezproxy.library.ubc.ca/login.aspx?direct=true&db=psyh&AN=2015-12566-000&site=ehost-live&scope=site Irwin, K. C., Konnert, C., Wong, M., & O’Neill, T. A. (2014). PTSD symptoms and pain in Canadian military veterans: The mediating roles of anxiety, depression, and alcohol use. Journal of Traumatic Stress, 27(2), 175–181. https://doi-org.ezproxy.library.ubc.ca/10.1002/jts.21897 Johnson, L. L., O’Connor, S. S., Kaminer, B., Gutierrez, P. M., Carney, E., Groh, B., & Jobes, D. A. (2019). Evaluation of structured assessment and mediating factors of suicide-focused group therapy for veterans recently discharged from inpatient psychiatry. Archives of Suicide Research, 23(1), 15–33. https://doi-org.ezproxy.library.ubc.ca/10.1080/13811118.2017.1402722 51 King, A. P., Erickson, T. M., Giardino, N. D., Favorite, T., Rauch, S. A. M., Robinson, E., Kulkarni, M., & Liberzon, I. (2013). A pilot study of group mindfulness-based cognitive therapy (MBCT) for combat veterans with posttraumatic stress disorder (PTSD). Depression and Anxiety, 30(7), 638–645. https://doi-org.ezproxy.library.ubc.ca/10.1002/da.22104 Klein, R. H., & Schermer, V. L. (Eds.). (2000). Group psychotherapy for psychological trauma. Guilford Press. Kuhl, D., & Westwood, M. (2017). Abject masculinity and the military: Articulating a fulcrum of struggle and change. Psychology of Men & Masculinity, 18(3), 215-225. doi:10.1037/men0000114 Levi, O., Shoval, Z. Y., Fruchter, E., Bibi, A., Bar, H. Y., & Wald, I. (2017). Benefits of a psychodynamic group therapy (PGT) model for treating veterans with PTSD. Journal of Clinical Psychology, 73(10), 1247–1258. https://doi-org.ezproxy.library.ubc.ca/10.1002/jclp.22443 Lutz, K. T. (2019). Effectiveness of a Group-Therapeutic Model for Veterans [Unpublished doctoral dissertation]. The University of British Columbia. Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., Young-Xu, Y., & Stevens, S. P. (2006). Cognitive processing therapy for veterans with military-related posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 74(5), 898–907. https://doi-org.ezproxy.library.ubc.ca/10.1037/0022-006X.74.5.898 52 MörtI, K., & Gelo, O. C. G. (2015). Qualitative methods in psychotherapy process research. In O. C. G. Gelo, A. Pritz, & B. Rieken (Eds.), Psychotherapy research: Foundations, process, and outcome. (pp. 381–428). Springer-Verlag Publishing. https://doi-org.ezproxy.library.ubc.ca/10.1007/978-3-7091-1382-0_20 Moustakas, C. E. (1994). Phenomenological research methods. Sage Publications, Inc. National Defence. (2020a). Current operations list - Canada.ca. Retrieved 7 February 2020, from The Government of Canada website: https://www.canada.ca/en/department-national-defence/services/operations/military-operations/current-operations/list.html National Defence. (2020b) The Road to Mental Readiness (R2MR) program - Canada.ca. Retrieved 10 February 2020, from https://www.canada.ca/en/department-national-defence/services/guide/dcsm/r2mr.html Ready, D. J., Sylvers, P., Worley, V., Butt, J., Mascaro, N., & Bradley, B. (2012). The impact of group-based exposure therapy on the PTSD and depression of 30 combat veterans. Psychological Trauma: Theory, Research, Practice, and Policy, 4(1), 84–93. https://doi-org.ezproxy.library.ubc.ca/10.1037/a0021997 Riva, M. A., Grassi, L., & Belingheri, M. (2020). Jacob L. Moreno and psychodrama – psychiatry in history. British Journal of Psychiatry, 217(1), 369. https://doi-org.ezproxy.library.ubc.ca/10.1192/bjp.2020.65 53 Rozynko, V., & Dondershine, H. E. (1991). Trauma focus group therapy for Vietnam veterans with PTSD. Psychotherapy: Theory, Research, Practice, Training, 28(1), 157. Shields, D. M. (2016). Military masculinity, movies, and the DSM: Narratives of institutionally (en)gendered trauma. Psychology of Men & Masculinity, 17(1), 64–73. https://doi-org.ezproxy.library.ubc.ca/10.1037/a0039218 Sloan, D. M., Feinstein, B. A., Gallagher, M. W., Beck, J. G., & Keane, T. M. (2013). Efficacy of group treatment for posttraumatic stress disorder symptoms: A meta-analysis. Psychological Trauma: Theory, Research, Practice, and Policy, 5(2), 176–183. https://doi-org.ezproxy.library.ubc.ca/10.1037/a0026291 Stake R.E. (1995). The art of case study research. Thousand Oaks, CA: Sage Sweet, M., Stoler, N., Kelter, R., & Thurrell, R. J. (1989). A community of buddies: Support groups for veterans forced into early retirement. Psychiatric Services, 40(2), 172-176. Statistics Canada (2009). Suicide rates: An overview. Retrieved from https://www.statcan.gc.ca/pub/82-624-x/2012001/article/11696-eng.htm Westwood, M. J., & Black, T. G. (2012). Introduction to the Special Issue of the Canadian Journal of Counselling and Psychotherapy. Canadian Journal of Counselling & Psychotherapy, 46(4), 285–291. 54 Westwood, M. J., Kuhl, D. & Shields, D. (2012). Counseling Active Military Personnel, Veterans and their Families in. Multicultural Issues in Counseling: New Approaches to Diversity (4th ed). Sage Publications. Westwood, M. J., & Ewasiw, J. F. (2011). Integrating narrative and action processes in group counseling practice: A multimodal approach for helping clients. The Journal for Specialists in Group Work, 36(1), 78-93. doi:10.1080/01933922.2010.537738 Westwood, M. J., McLean, H., Cave, D., Borgen, W., & Slakov, P. (2010). Coming Home: A Group-Based Approach for Assisting Military Veterans in Transition. Journal for Specialists in Group Work, 35(1), 44–68. https://doi-org.ezproxy.library.ubc.ca/10.1080/01933920903466059 Westwood, M. J., McLean, H. B., & Cave, D. (2004). Soldiers transition program: Personal and career rehabilitation following operational stress injury. Unpublished research evaluation report submitted to Jack Stagg, Deputy Minister, Veterans Affairs Canada. Westwood, M. J., Keats, P. A., & Wilensky, P. (2003). Therapeutic enactment: Integrating individual and group counseling models for change. Journal for Specialists in Group Work, 28(2), 122–138. https://doi-org.ezproxy.library.ubc.ca/10.1177/0193392203028002004 Westwood, M.J. & Wilensky, P. (2005). Therapeutic enactment: Restoring vitality through trauma repair in groups. Vancouver: Group Action Publications. 55 Williams, W., Graham, D. P., McCurry, K., Sanders, A., Eiseman, J., Chiu, P. H., & King-Casas, B. (2014). Group psychotherapy’s impact on trust in veterans with PTSD: A pilot study. Bulletin of the Menninger Clinic, 78(4), 335–348. https://doi-org.ezproxy.library.ubc.ca/10.1521/bumc.2014.78.4.335 van der Kolk, B. A. (1987). The role of group in the origin and resolution of the trauma response. In B. A. van der Kolk (Ed) Psychological Trauma. American Psychiatric Press. Veterans Affairs Canada. (2020). The Canadian Armed Forces in the Post-War Years. Retrieved 10 February 2020, from https://www.veterans.gc.ca/eng/remembrance/history/canadian-armed-forces/cf-post-war-years Veterans Affairs Canada. (2019, March). Facts & Figures. https://www.veterans.gc.ca/eng/about-vac/news-media/facts-figures Veterans Affairs Canada. (2018, March). Facts & Figures. https://www.veterans.gc.ca/pdf/about-vac/news-media/facts-figures/vac-statistics-mar2018.pdf Yalch, M. M., Burkman, K. M., Holleran, L. J., Karpenko, S., & Borsari, B. (2021). Integrating collaborative/therapeutic assessment of interpersonal functioning into group therapy for veterans with posttraumatic stress disorder. Journal of Psychotherapy Integration, 31(1), 19–33. https://doi-org.ezproxy.library.ubc.ca/10.1037/int0000197 56 Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). Basic Books. Yin, R. K. (2017). Case study research and applications: Design and methods (6th ed.). Sage Publications, Inc. 57 Appendices Appendix A: Letter of Initial Contact (email) Good afternoon (Insert name here), You are receiving this email on behalf of Dr. Marla Buchanan (research supervisor and principal investigator) and Mark Kerr (graduate student and co-investigator) from the University of British Columbia as part of a research project for my thesis research. We are inviting you to participate in a 1-hour Zoom interview that will be conducted by me as the co-investigator of this research project. We are looking to understand the experience of a military veteran who has completed an action-based form of group therapy called therapeutic enactment (TE). During the 1-hour interview I will be asking you questions about your experience during the therapeutic enactment that you completed over the past year. The questions will be in regard to the direct experience you had of TE work and will review what the process was like for you and if you think it would be beneficial for other military veterans such as yourself. The Zoom interview will be recorded, but only for transcription and after that it will be destroyed, and all data collected will be anonymous and stored in a lock filing cabinet. You are also free to deny the request for the meeting as well stop the interview at any moment during the process should you feel the need to do so for any reason. If you are comfortable with everything stated above and would like to participate, please reply to this email and we will set up a date and time that suits your schedule to conduct the 1hr interview. Thank you kindly for your time in reading this; I look forward to hearing back from you should you want to participate. Best regards, Mark Kerr UBC Graduate Student Department of Educational and Counselling Psychology, and Special Education 58 Appendix B: Participant Consent Form a place of mind T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A CONSENT FORM Therapeutic Enactment: A Case Study of the Experience of a Canadian Military Veteran Principal Investigator: Dr. Marla Buchanan, Professor & Deputy Department Head University of British Columbia Department of Educational and Counselling Psychology, and Special Education Ph: 604-822-4625 Co-Investigator(s): Mark Stuart Kerr, Master’s Graduate Student University of British Columbia Department of Educational and Counselling Psychology, and Special Education Ph: 778-862-8751 This research is being conducted as part of our requirements to fulfill professional duties within the Counselling Psychology program at the University of British Columbia (UBC). The results of this research will be included in doctoral research and/or master’s thesis that will become public documents in the UBC Library once completed. The results of the research may also be used for future publication in the appropriate professional and academic journals. Purpose You are being asked to participate in this study because the aim is to understand the experience of a form of group therapy called therapeutic enactment by a male military veteran who has struggled with an operational stress injury from military duties. We want to learn more about how therapeutic enactment helps military populations cope and deal with the mental challenges that come with active military duty. We are asking Faculty of Education Department of Educational and Counselling Psychology, and Special Education 2125 Main Mall Vancouver, BC Canada V6T 1Z4 Phone 604 822 4625 Fax 604 822 3302 59 people who have completed their own therapeutic enactments within the past year to help us with this objective. Procedures If participation in this study is accepted, you will be asked to take part in a one hour virtual interview that will be completed by the co-investigator for this study. During the interview you will be asked about your overall experience of completing a therapeutic enactment intervention. You will be asked questions about what you found useful, what you enjoyed most about it, what you want more of, what you might want to change, and if you found it useful in support of your own mental well-being. You will also be asked if you believe that therapeutic enactment will be beneficial to other military personnel in the future and why you think it may or may not be. You will only be required to attend the single one hour interview via Zoom. No follow-up interviews will be required or asked of you should you decide to participate in this study. Results The results of this study will be reported in a graduate thesis with a potential to be published in journal articles and/or books. With a very limited possibility, this research may be used publicly to inform future research in the area of group therapy, particularly with therapeutic enactments and it may also be used to inform future clinicians and clients who are engaging with the therapeutic process. Anything that will be public will still be anonymous and will contain no identifying information other than parts of the participant’s story. The only foreseen issue of risk to the participant would be if someone were to somehow identify the client through the answers that are given during the interview. Once data is made public, any participant involved will be unable to withdraw their data. Potential Risks of the Study While the potential risks for participating in this study are minimal, it is nevertheless still important that they are discussed ahead of time. In this study, you will be asked what your personal experiences were of therapeutic enactment and while the aim is not to discuss the content of the enactment, it may bring up some distressing emotions or thoughts when reflecting on the process of the therapeutic enactment itself. In recognizing these risks, we will make every attempt to reduce the risks involved by asking only questions in the positive (i.e., What was your experience of TE?), by allowing you to pass on anything you feel you do not want to answer, and by offering counselling resources and referrals through the Centre for Group Counselling and Trauma at UBC. Potential Benefits of the Study While we do not guarantee any benefits, it is important to recognize the potential for benefits to you, other military personal, and to the field of psychotherapy. You may 60 receive a benefit through the recalling of the therapeutic enactment itself and the parts of the process that you felt were most healing. The benefits to other military veterans could be the advancement of an understanding of how TE work is experienced by military veterans who have engaged in them. Finally, there may be a benefit to the field of counselling by helping to support research into different forms of group therapies for military veterans. Confidentiality We will ensure that confidentiality is maintained throughout this entire process by not disclosing your identity in any way without your consent, unless required by law. All documents will be identified only by code number and kept in a locked filing cabinet. Participants will not be identified by name in any reports of the completed study. During the Zoom interview, it is suggested that you log in with a nickname or a numerical identifier (this can be provided to you) to ensure confidentiality. While having your camera on is not a requirement for this study, it is preferred so that an in-person interview is replicated as much as possible. However, you may turn your camera off or mute your microphone at any point during the interview should you feel the need to do so. Also note that any and all data collected will be encrypted and placed into locked filing cabinets. Contact for Information about the Study If you have any further questions or would like more information about this study please contact Marla Buchanan (Principal Investigator) at marla.buchanan@ubc.ca or Mark Kerr (Co-investigator) at markerr@student.ubc.ca. Phone numbers are also available at the top of this page for further inquiry via telephone. Contact for Complaints If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598. 61 Consent Taking part in this study is entirely up to you. You have the right to refuse to participate in this study. If you decide to take part, you may choose to pull out of the study at any time without giving a reason and without any negative impact on your employment. Your signature below indicates that you have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study. ____________________________ _______________________ Participant Signature Date ___________________________________________________ Printed Name of the Participant signing above Thank you for your willingness to participate in this study.
Thesis/Dissertation
eng
Counselling Psychology
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Therapeutic enactment : a case study of the experience of a Canadian military veteran
Text