Dramatherapy As Treatment For Military Veterans With Post Traumatic Stress Disorder (Ptsd)

In 1980 the American Psychiatric Association (APA) recognised Post-Traumatic Stress Disorder (PTSD). The APA added PTSD to the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) nosologic classification scheme (Friedman 2016). It was first recognised by the APA through the efforts of many professionals in collaboration with veterans from the Vietnam War who had been suffering from PTSD (James & Johnson 1996, p.383). The concept of PTSD was that the cause of it was actually outside of the individual (i.e., a traumatic event) rather than an inherent individual weakness (i.e., a traumatic neurosis) and that the key to understanding the scientific basis of PTSD was the concept of ‘trauma’ (Friedman 2016). In the initial DSM-III trauma was conceptualised as a catastrophic stressor that was outside the range of normal human experience. The framers of PTSD diagnosis saw events such as rape, torture, war, natural disasters and human made disasters as traumatic events. These traumatic events were seen very differently from the painful stressors that constituted normal vicissitudes such as divorce, failure, rejection, and serious illnesses (Friedman 2016).

There are many symptoms and treatments for dealing with PTSD. The major symptoms of PTSD are (1) re-experiencing symptoms, such as flashbacks, intrusive memories and dissociative experiences; (2) avoidance symptoms such as numbing, isolation and avoidance of reminders of the traumatic event; and (3) hyperarousal symptoms such as sleep disturbance, anxiety, anger, impulsivity and startle responses (James & Johnson 1996, p.383) Treating PTSD can consist of taking medication, usually the same medication that is taken to treat anxiety and depression. The medication taken are antidepressants SSRIs (selective serotonin re-uptake inhibitors and SNRIs (serotonin-norepinephrine re-uptake inhibitors. These medications help affect how you feel. They affect the level of naturally occurring chemicals in the brain called serotonin/norepinephrine (U.S. Department Of Veteran Affairs 2017). Rather than taking medication, a much preferred method to treating PTSD are through different types of psychotherapies. Types of psychotherapies with the strongest evidence in treating PTSD are Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Eye-Movement Desensitisation and Reprocessing (EMDR). There are other types of psychotherapies that are recommended for treating PTSD but the four types of psychotherapies mentioned above are highly recommended in treating PTSD (U.S. Department Of Veteran Affairs 2017). Another type of psychotherapy used to treat PTSD is dramatherapy. Along with other types of psychotherapy, dramatherapy has helped in treating military veterans with PTSD.

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Dramatherapy is defined as the “utilisation of dramatic methods in group situations, usually for the purposes of promoting healing intrinsic to the art of theatre, developing skills of improvisation and creative thinking, expanding the repertoire of roles with the inclusion of body movement and other aesthetic dimensions” (Kedem-Tahar & Felix-Kellerman 1996, pp.28-29). In the United States 23 military veterans take their only lives every day. This exceeds the number of deaths from combat. Additionally, there is a higher rate of military veterans suffering from PTSD compared to the rest of the general population in the US (Ali & Wolfret 2016, p.58). A percentage of 11-20% of US veterans who served in Operations Iraqi Freedom (OIF) and Enduring Freedom (OEF) suffer from PTSD, compared to the 7-8% of the US general population who suffer from PTSD this is quite a huge comparison (U.S. Department Of Veteran Affairs 2016).

In Australia, from the findings of the 2010 ADF Mental Health Prevalence and Wellbeing Study, it was estimated that 90% of Australian Defence Force (ADF) members have experienced at least 1 traumatic event in their life. Of the 90%, it is estimated that at least 8.3% of ADF members have suffered from PTSD compared to the 5.2% of the greater Australian public who have suffered from PTSD, with ADF males having a greater rate of experiencing PTSD than the rest of the Australian public (Australian Government, Department of Defence). Even with an increase in the national and global awareness of PTSD in veterans, a troubling clinical and epidemiological trend poses great challenges to addressing PTSD. The most concerning challenge is the over-reliance on medication to help treat PTSD symptoms (Ali & Wolfret 2016, p.58). With veterans relying more on medication everyday to cope with their PTSD, a more structured treatment model must be developed and implemented in treating military veterans deal with PTSD.

In the United States, one such program is DE-CRUIT, a relatively new theatre based treatment program. DE-CRUIT is a program designed specifically to help military veterans returning from active service in transitioning back into their community. The Veterans Center for the Performing Arts (VCPA) developed the DE-CRUIT program as part of its mission to support veterans who deal with PTSD and reintegrates them back into civilian life through their scientific model.

When joining the military, in order for soldiers to perform their primary function of fighting in combat, the military uses a systematic process that prepares their soldiers to behave in a certain way, to learn to kill the enemy in combat, to go to war, to be numbed to the violence around them, and their compassion for the enemy completely removed. At the end of their military service there is no training for veterans to undo what has been drilled into their brains and to be put back into civilian life. DE-CRUIT denotes the process of de-programming soldiers in order to allow them to overcome the practical and psychological limitations that soldiers were immersed in during their military life (Ali & Wolfert 2016, p.59).

The DE-CRUIT program uses routinised techniques derived from principles of classical actor training such as experiential analysis, symbolic representation and spoken verse. The program uses these techniques to transform military camaraderie into camaraderie among treatment group members to communalise the process of healing from the trauma of war (The DE-CRUIT Scientific Model 2016). The model combines these techniques with Cognitive Processing Therapy (CPT) and Narrative Therapy. There are 3 components of this model, each component an extension of existing evidence based-treatment principles that are often use with military veterans. The components are Unit Cohesion, Communalisation of Trauma, and Therapeutic Embodiment (The DE-CRUIT Scientific Model 2016).

Unit Cohesion is a military concept defined as the bonding of soldiers as a way to sustain their will and commitment to each other, to the unit and to the mission. Unit Cohesion is essential to military effectiveness (MacCoun & Hix 2010, p.137). When the soldier returns home from duty, they do so without their unit around them and often feel untethered. DE-CRUIT adopts this notion of cohesion as a mechanism to foster bonding among group members and creates a sense of connection grounded in the participating veterans shared expression of trauma and in their shared goal of adopting the routines of the DE-CRUIT method (The DE-CRUIT Scientific Model 2016). Routines include breathing exercises, practice in finding and using one’s voice and accessing the symbolic expression of trauma through dramatic verse, reciting dramatic verse reflects the therapeutic notion of feeling safe which is a key technique in trauma therapy (The DE-CRUIT Scientific Model 2016). Working together gives a sense of safety and cohesion, and much like in active service, being a cohered unit allows for members to feel safe and supported in their time of healing. The DE-CRUIT program additionally employs camaraderie in collectively identifying strategies for overcoming cognitive stuck points that hinder veterans post-traumatic growth, a process that serves to communalise the experience of trauma (Ali & Wolfret 2016, p.61).

Communalisation of Trauma. CPT and narrative therapy include techniques that encourage trauma survivors to relate their stories of trauma. The DE-CRUIT program expands these techniques into multi-session group process that encompasses progressive phases of narration and sharing. Veterans in the program write a first-person monologue that describes their experiences of trauma and then relinquish their monologues that are than learned, rehearsed and performed by another member of the program, thus creating a communal narration of trauma (The DE-CRUIT Scientific Model 2016). Through this method it allows for veterans to see their own actions and encounters in a way that is similar to the simulation described by Keith Oatley’s theory of psychological benefits of simulated narration, where the fictional representation of human encounters and actions, presented through literature and theatre, provides a deep and immersive simulative experience (Ali & Wolfret 2016, p.59).

Therapeutic Embodiment is a key element in the DE-CRUIT program that focuses on rhythm, embodiment, and breath in the reading, reciting, and performing of dramatic verse (The DE-CRUIT Scientific Model 2016). This focus is derived in part from scientific supported relaxation and breathing techniques used in psychotherapy for trauma. (The DE-CRUIT Scientific Model 2016). The DE-CRUIT program utilises relaxation techniques and integrates them into a structure that mimics the routines and rituals of military training while also subverting those routines into patterns of emotional self-awareness as opposed to violence-oriented patterns of aggression (The DE-CRUIT Scientific Model 2016). Through this veterans work together to fully inhabit the spoken verse in monologues, progressively immersing themselves in the patterns of breathing, movement, and rhythm that are needed to fully master the execution of various texts (The DE-CRUIT Scientific Model 2016).

DE-CRUIT members attend 10 2-hour weekly sessions. Before the start of their first meeting, each veteran attends a meeting with the program facilitator to become familiar with the goals of the program (Ali & Wolfret 2016, p.61) Veterans sign up for the DE-CRUIT program through the VCPA which is connected to an extensive, diverse network of of veterans organisations. All ages and genders are welcomed to attend the program, with each session having anywhere from 3-12 members. From previous studies documenting the therapeutic benefits of veterans working together, all veterans from any era are welcomed to participate (Ali & Wolfret 2016, p.62). The program is run by either 1 or 2 facilitators depending on the size of the group, the facilitators are veterans themselves and experts with the experience in participating and delivering the DE-CRUIT treatment (Ali & Wolfret 2016, p.62). Throughout the 10 sessions, the program structure is aimed at creating a deliberate and gradual transition from open exploration of the sources and ongoing effects of trauma in the veterans lives to communalised sharing of trauma narratives through fellow group members (Ali & Wolfret 2016, p.62). The ten sessions are structured as followed:

In sessions 1 and 2 veterans learn about some of the experiences commonly associated with traumatic stress, flashbacks, nightmares and hyper-vigilance. Veterans begin to identify their own traumatic experiences and cognitive stuck points connected to their military related trauma. They start to learn the programs relaxation techniques and breathing exercises (Ali & Wolfret 2016, p.62).

In sessions 3 and 4 veterans come together to explore the representation of war related trauma through monologues and verses. Veterans engage in personal experiential analysis of various passages which they examine line-by-line and write their own personal reflections and then discuss as a group. Relaxation techniques are breathing exercises are continued to be developed (Ali & Wolfret 2016, p.62).

In session 5 veterans are given a monologue to examine together and each veteran is assigned a monologue to learn, rehearse and perform at the last session. Each monologue selected for each veteran is matched to their own past experiences and traumas that they have encountered such that the chosen monologue reflects their experiences (Ali & Wolfret 2016, p.62).

In sessions 6 through 8 each veteran writes their own first-person trauma monologue derived from a military related trauma they have encountered. At the end of session 8 each veteran passes their written monologue to a member in the group and then that member has to learn, rehearse the monologue (Ali & Wolfret 2016, p.62).

In session 9 veterans work together to rehearse the monologues. This session is key in terms of the cohesion and camaraderie in the veterans support of each other as they invoke their deepest selves and their truest voices in performing (Ali & Wolfret 2016, p.62).

In the final session the veterans perform their monologues (Ali & Wolfret 2016, p.62).

Another dramatherapy program for military veterans is the Veterans Bedside Network (VBN). VBN members each week try to lift the spirits of hospitalised veterans and inspire them to be stars of their own radio production. The VBN is a non-for-profit organisation that has been around for 58 years, it has dedicated volunteers who conduct a dramatherapy program in veteran hospitals.

Dramatherapy is a better treating method for dealing with PTSD than taking medications. Whereas medications affect the way military veterans feel, dramatherapy uses theatre based techniques to help military veterans deal with various issues once they return home from active duty. DE-CRUIT is a program that uses routinised techniques derived from the principles of classical actor training. The program uses different techniques to transform military camaraderie into camaraderie among treatment group members to communalise the process of healing from the trauma of war (The DE-CRUIT Scientific Model 2016). The model combines these techniques with Cognitive Processing Therapy (CPT) and Narrative Therapy. Three components to this model are Unit Cohesion, Communalisation of Trauma, and Therapeutic Embodiment. Each of these components are an extension of existing evidence based-treatment principles that are often used with military veterans.

References

Friedman, M.J. (2016). PTSD: National Center for PTSD. PTSD History and Overview. Accessed: May 15, 2018 https://www.ptsd.va.gov/professional/PTSD-overview/ptsd-overview.asp

James, M. & Johnson, D.R. (1996). Drama therapy in the treatment of combat-related post-traumatic stress disorder. The Arts in Psychotherapy, 23(5), pp.383-395. Accessed May 18, 2018

U.S. Department Of Veteran Affairs (2017). PTSD: National Center for PTSD. Treatment of PTSD. Accessed: May 15, 2018 https://www.ptsd.va.gov/public/treatment/therapy-med/treatment-ptsd.asp

Australian Government. Department of Defence (ADF) Post Traumatic Stress Disorder Accessed May 15, 2018 http://www.defence.gov.au/health/healthportal/PTSD.asp

Kedem-Tahar, E. and Felix-Kellermann, P. (1996). Psychodrama and drama therapy: A comparison. The Arts in Psychotherapy, 23(1), pp.27-36. Accessed May 16, 2018

Ali, A. and Wolfert, S. (2016). Theatre as a treatment for posttraumatic stress in military veterans: Exploring the psychotherapeutic potential of mimetic induction. The Arts in Psychotherapy, 50, pp.58-65. Accessed May 19, 2018

U.S. Department Of Veteran Affairs (2016) PTSD: National Center for PTSD. How Common is PTSD. Accessed May 19, 2018 https://www.ptsd.va.gov/public/ptsd-overview/basics/how-common-is-ptsd.asp

The DE-CRUIT Scientific Model 2016. Accessed May 19, 2018 https://www.decruit.org/2016/03/de-cruit-scientific-model/

MacCoun, R.J. & Hix, W.M. (2010) Unit Cohesion and Military Performance, in Sexual Orientation and U.S. Military Personnel Policy: An Update of RAND’s 1993 Study, RAND Corporation, Santa Monica, pp.137-165 Accessed May 19, 2018