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Combat Veterans' Perspectives on a Dramatherapy Journey: A

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Combat Veterans' Perspectives on a Dramatherapy Journey: A ANGLIA RUSKIN UNIVERSITY THE THEATRE OF WAR, THE DRAMA OF LIFE COMBAT VETERANS’ PERSPECTIVES ON A DRAMATHERAPY JOURNEY A PHENOMENOLOGICAL MIXED METHODS CASE STUDY LINDA C. WINN A thesis submitted in partial fulfilment of the requirements of Anglia Ruskin University for the degree of Doctor of Philosophy Submitted 2016 i !"#$%&'()*(+($,-! Very many thanks go to Dr Ditty Dokter and Professor Helen Odell-Miller. Without their support, encouragement and wise counsel I would have abandoned this journey when the storm-winds blew. I am indebted to my family and friends for their love and kindness when I have been preoccupied with my research. There have been many times during this period we have laughed together and cried together. We have celebrated new life and had to say goodbye too soon to others. I thank my grandchildren for being there to bring me back to earth. There have been many people who have assisted me since the 1980s when I began working with veterans. I feel truly blessed and want to thank them all, unfortunately space and word limits preclude that. I shall just name a few: Surgeon Captain Morgan O’Connell, RN, for inviting me on to the PTSD course at Royal Naval Hospital Haslar, and his support and humour over the years; Alida Gersie for her initial generosity of time and recommendation that set me on this path; Sue Jennings for her interest, enthusiasm and willingness to share her knowledge; Kim Dent-Brown for making figures appear easy; Di Gammage for her thoughtful clinical supervision; my friends in our Action Learning Set, all proving life-long learning can be fun; Janey Fisher who has only joined me in recent months but whose copyediting skills and proof-reading was always good humoured and kept me on course for this last stretch of the journey. I thank Faber and Faber and Simon Armitage for permission to use extracts from his version of Homer’s Odyssey (2010), the text that became our guidebook. There are three people, combat veterans, without whom this study would not have happened: Alan, Jack and Chris (participant chosen pseudonyms). I thank them beyond measure for trusting me enough to embark on this journey with me. At times we made new discoveries, at others there were storm clouds on the horizon, but they all held fast, looking out for one another. They shared generously both time and their stories as we travelled together. Their motivation was to discover whether other veterans suffering from the effects of trauma or having difficulty returning home, could be helped through dramatherapy. I hope I have achieved my aim of ensuring their voices are heard clearly throughout this research. ii I am honoured to be able to do this work with veterans and families and thank others I have met along the way and have taught me so much. My research is dedicated to the memory of those whose journey in this life is over. May they find peace and those they leave behind be comforted as they travel on, buoyed by courage, hope and love. Linda C. Winn August 2016 ! iii !"#$%&'$(! THE THEATRE OF WAR, THE DRAMA OF LIFE COMBAT VETERANS’ PERSPECTIVES ON A DRAMATHERAPY JOURNEY A PHENOMENOLOGICAL MIXED METHODS CASE STUDY LINDA C. WINN AUGUST 2016 A review of academic literature revealed a dearth of published research concerning whether dramatherapy might help UK combat veterans recover from Post Traumatic Stress Disorder (PTSD). Furthermore no published research sought to capture veterans’ perspectives during dramatherapy in the UK. My research questions addressed the gap in the research literature: What is the participant’s perspective on the use of dramatherapy in helping British combat veterans a) to recover from PTSD? and b) to adjust to civilian life? The research design was a phenomenological mixed methods case study. The qualitative measures were arts-based. Interpretative Phenomenological Analysis (IPA) was used to examine the transcripts of the dramatherapy sessions. The quantitative measures were the Clinical Outcomes Routine Evaluation (CORE) -34 and CORE-10; Short Warwick Edinburgh Mental Well-being Scale (SWEMWBS) and the PTSD Checklist – Military (PCL-M). The multiple methods synthesis raised questions and gave new insights rather than confirming results. The participants were 3 male veterans from the same region of the UK. I was the researcher/dramatherapist. The aim of the research was to achieve an in-depth study underpinned by a participant-centred approach. iv The research theme was journeying towards recovery. The choice of play-text, an excerpt from The Odyssey, reflected this. The initial 5 dramatherapy sessions were individual and the remaining 3 were group sessions. The IPA indicated that the participants’ perspectives were that dramatherapy might help other veterans towards recovery from PTS. Furthermore dramatherapy might help in their adjustment to civilian life. The use of , imagination and role rehearsal and assisted in reframing of their personal stories. The participants found the use of a novel method developed by myself, from Turner’s Model of Crisis (TMOC) (Turner, 1967) particularly helpful in moving through traumatic memories, utilising metaphor and a problem-solving approach. This led to embodiment of reprised positive military roles in overcoming obstacles on their journeys. They used this method in other situations arising outside of the research and recommended it as potentially having a positive impact on other veterans, seeking recovery. They remained in the clinically significant scoring for PTSD. However, they identified the framework of dramatherapy methods resulted in an increase in confidence, creativity and ability to manage conflict. This was supported by the IPA results. Key words: veteran, PTSD, dramatherapy, IPA, mixed methods, embodiment, metaphor, role ! ! v Table of Contents List of diagrams and tables viii List of appendices xi Copyright xii Chapter 1 Where shall we go? Thesis Introduction and Overview 1.1 Introduction 1 1.2 The context of the research 2 1.3 The type of study 3 1.4 The focus for this study 4 1.5 The research questions 4 1.6 The purpose of the study 5 1.7 Operational definitions and key terms 6 1.8 Significance of the study 7 1.9 Delimiters and limitations 8 1.10 My personal journey to the start of this study 10 1.11 Summary 11 Chapter 2 Mapping the Territory 2.1 Introduction 13 2.2 The literature review 13 2.3 Military mental health 15 2.4 PTSD diagnosis and treatment recommendations 18 2.5 Arts therapies, combat and trauma 19 2.6 Conclusion 30 33 Chapter 3 The guidebook: Research Methods and Study Design 3.1 Introduction 33 3.2 The research questions 33 3.3 The study design 34 3.4 The context 42 3.5 Participant selection 43 3.6 Data collection 44 vi 3.7 The rationale for the Interpretative Phenomenological Analysis (IPA) 48 3.8 Ethics and consent 52 3.9 Summary 53 Chapter 4 Tools for the journey: Dramatherapy Methods 4.1 Introduction 54 4.2 The participants 54 4.3 Treatment structure and clinical rationale 55 4.4 Key dramatherapy procedures 58 4.5 Summary 66 Chapter 5 Signposts: Analysis and Interpretation of the Evidence 5.1 Introduction 67 5.2 Qualitative data results 68 5.3 IPA 72 5.4 Quantitative data results 135 5.5 Overview of findings 142 Chapter 6 The scenery: Synthesis of Findings 6.1 Introduction 145 6.2 What is the participant’s perspective on the use of dramatherapy in helping British combat veterans to recover from PTSD? 145 6.3 What is the participant’s perspective on the use of dramatherapy in helping veterans to adjust to civilian life? 154 6.4 The veterans’ perceptions of the usefulness of dramatherapy methods 163 162 6.5 Participants’ perspectives on hindering aspects of dramatherapy 170 6.6 Unexpected findings 171 6.7 Summary of results 175 Chapter 7 Homeward bound: Summary of the Study 7.1 Answering the research questions 177 vii 7.2 The contribution to knowledge 181 7.3 Critique of the methodology 185 7.4 Limitations of the study 192 7.5 Recommendations for clinical practice 194 7.6 Recommendations for further research 195 7.7 Personal reflections 196 7.8 The end of the journey … 201 References 202 Appendices 241 viii List of Diagrams, Figures and Tables Diagrams and figures Figure 2.1 Therapeutic elements of Creative Arts Therapies and CBT 20 Figure 2.2 Art psychotherapy levels of evidence 21 Figure 2.3 Johnson, Landy and Winn’s modes of working with psychological trauma 28 Figure 3.1 Five misunderstandings about case study research 40 Figure 3.2 Research question pathway 41 Figure 3.3 SWEMWBS scoring guide 46 Figure 4.1 Participant details 54 Figure 4.2 6PSM 58 Figure 4.3 BASIC Ph assessment scale 59 Figure 4.4 6PSM: The seven levels of assessment 60 Figure 4.5 Examples of communiwells created by the participants 61 Figure 4.6 Diagrammatic form of Turner’s Model of Crisis 62 Figure 5.1 Alan’s scoring on 6PSM 69 Figure 5.2 Jack’s scoring on 6PSM 70 Figure 5.3 Chris’s scoring on 6PSM 71 Figure 5.4 A comparison of all participant’ scores - BASIC Ph Sessions 1 and 8 72 Figure 5.5 Superordinate themes and subordinate themes 73 ix Figure 5.6 EPR Jennings (2012 pp. 180-182) applied to IPA findings 101 Figure 5.7 Key aspects from dramatherapy sessions revealed by IPA 135 Figure 5.8 CORE-34 test results for Alan 136 Figure 5.9 CORE-10 test results for Alan 136 Figure 5.10 SWEMWBS test results for Alan 137 Figure 5.11 PCL-M test results for Alan 137 Figure 5.12 CORE-34 test results for Jack 138 Figure 5.13 CORE-10 test results for Jack 138 Figure 5.14 SWEMWBS test results for Jack 139 Figure 5.15 PCL-M test results for Jack 139 Figure
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