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Abstract

Background:

Veterans and first responders suffering from posttraumatic stress disorder (PTSD) often report having difficulties with treatment adherence and exhibit high rates of dropout. To address these issues, previous studies have implemented the use of residential retreat programs, in the populations of interest. However, previous studies have mostly utilized trauma-centered therapy methods, which are accompanied by their challenges and trade-offs. To rectify this, the Learn to Live residential retreat program was formulated, which incorporates non-trauma-centered methods to improve PTSD symptom manifestation and management.

Methods:

Twenty-one participants registered for the five-day residential retreat program and attended the first day of the program. The primary objective of the pilot trial was to determine the feasibility of the protocol in terms of retention rates and subjective efficacy of the program. Secondarily, the authors sought to examine the potential impact of the program on PTSD symptom manifestation measured by the PTSD Checklist for DSM-5.

Results:

Of the 21 participants attending the first day of the program, 19 completed all five days. Eighteen participants who finished the program reported finding the program helpful and being willing to recommend the program to others. Similarly, symptoms of PTSD showed statistically significant improvements at a one-month follow-up (V(17) = 152, P < 0.001), with 12 of the 18 participants exhibiting clinically significant improvements.

Conclusion:

This pilot trial provided preliminary evidence for the feasibility and efficacy of the program. This provides the groundwork for future randomized controlled trials to establish the effectiveness of similar programs for improving PTSD symptoms in veterans and first responders.

Introduction

Posttraumatic stress disorder (PTSD) is a highly debilitating condition affecting around 6% of the general population following the occurrence of a traumatic event.¹ However, certain populations, including veterans and first responders, are at an increased risk for developing PTSD, with estimates of prevalence ranging from 5% to 30% across both groups.^2

–5 This observation may be explained by examining the potential risk factors present in the work environments occupied by veterans and first responders. Firstly, both populations are likely to experience multiple potentially traumatic events (PTEs) (e.g., repeated exposure to physical threats, bearing witness to death and destruction, etc.).^6,7 Given that the impact of PTEs is cumulative, those who experience more instances of such events are at a higher risk for developing trauma-related disorders.⁸ Secondly, the social dynamics in the military and the first responder milieu are largely similar and contribute to the maintenance of PTSD. Specifically, a “hero” culture, accompanied by the requirement to be “macho,” is reportedly present in both contexts. Although these attitudes may be adaptive in some ways, such beliefs may instill a sense of reluctance towards therapy initiation in those with PTSD.^9
–11

Lastly, sanctuary trauma (alternatively named “institutional betrayal”) may be especially common in both populations. That is, veterans often express a sense of distrust towards their respective organizations, believing that they have not been adequately supported despite their service.¹² Similarly, qualitative studies investigating first responders' assessment of their organizational support systems reflect a general suspicion toward these systems.^10,13 This lack of trust may also make the prospect of seeking treatment less likely for both populations.

Concerns regarding higher exposure to PTEs and decreased treatment initiation are compounded by previous investigations revealing particularly low levels of treatment adherence and higher rates of treatment dropout in veterans and first responders.^5,14 In other words, even in instances when these individuals seek therapy, they are likely to discontinue treatment before its conclusion. The relatively higher rates of dropout and lower treatment adherence may be explained by the same factors mentioned above. That is, veterans and first responders may discontinue therapy believing that mental health problems can be managed without treatment, or due to a sense of distrust towards mental health providers.^14
–16 Given these observations, it is imperative to examine the efficacy of treatment protocols that can address low treatment adherence and high rates of dropout, in the population of veterans and first responders.

Group Therapy Approaches for PTSD

Initial attempts at treating PTSD, using group therapy, date back to the Vietnam war when returning veterans were encouraged to take part in “rap groups.”¹⁷ Since then, a slew of new treatment approaches have been developed to address individuals' needs, making “rap groups” obsolete. However, group therapy remains a standard option in the treatment of PTSD, with veterans reportedly having favorable opinions towards this modality.^18
–20 Unfortunately, most group therapy modalities have been examined in the veteran population, with results informing treatment for first responders.

Group therapy for PTSD has been formulated in part to mitigate treatment dropout and ameliorate adherence. The group therapy modality offers unique opportunities for treatment, not present in individual therapy. Specifically, the social context, within which group therapy is embedded, allows participants to tackle specific challenges related to PTSD: the presence of individuals possessing similar symptoms allows for the normalization of PTSD symptoms, increases a sense of group cohesion and trust, enables group learning, and improves feelings of self-efficacy. This sense of social connectedness is often hard to generate outside the group therapy context, due to feelings of distrust in the patient population. Moreover, the social structure of civilian life is markedly different from that of a military or first responder unit, making it difficult for veterans and first responders to adjust to daily life. However, in a group therapy setting, most members share similar experiences, which in turn facilitates the formation of social bonds.^{21

–29} These, in turn, may be responsible for decreased dropout rates in group therapy.²⁴

Group therapies could be broadly divided into trauma-focused therapies and non-trauma-focused therapies. As the name suggests, trauma-focused therapies are formulated to help participants process the initial experiences which may have led to the current manifestation of their symptoms. Prevalent trauma-focused therapies include cognitive processing therapy (CPT), prolonged exposure (PE) therapy, and psychodynamic therapies. In CPT, participants are taught to restructure maladaptive cognitive patterns connected with the initial trauma and the manifestation of their symptoms. On the other hand, in PE, participants are told to imagine the initial traumatic experience or are instructed to gradually expose themselves to trauma-related stimuli, so that negative emotions associated with these events can be processed and expunged. Lastly, in psychodynamic therapies, patients and clinicians discuss the traumatic event and how it may be influencing the patients presently.¹⁹ There is some evidence for the effectiveness of CPT, PE, and psychodynamic therapy in the group format.^{17,26,30
–32} Moreover, the Veteran's Affairs/Department of Defense (VA/DOD) consider PE and CPT as the gold standard for PTSD treatment, although in their individualized format.¹⁹

Non-trauma-focused protocols include treatments that address symptoms as they manifest in individuals' day-to-day lives, rather than processing root causes. These treatments include stress inoculation treatment, present-centered therapy (PCT), interpersonal therapy, and adjunct/complementary therapies. In stress inoculation treatment, individuals are asked to reframe the cognitive patterns that lead to the generation of daily stress and symptomatology, similar to PCT, which seeks to increase adaptive responses to daily stressors. On the other hand, interpersonal therapy focuses on improving individuals' relationships. Lastly, adjunct/complementary therapies, such as mindfulness/meditation, animal-assisted therapies, biofeedback, and social rhythm cognitive behavior therapy, have also been offered for those with PTSD.¹⁹ Amongst these treatments, PCT has received the most attention and has been used to compare the effectiveness of non-trauma-focused and trauma-focused group therapies.^32

–36 These studies have generated mixed results. However, previous meta-analytic studies have shown negligible differences between trauma-centered and non-trauma-centered modalities.³⁷

In addition to trauma-focused and non-trauma-focused group therapies, psychoeducation is also often provided in a group format.²¹ Psychoeducational modalities educate individuals about the effectiveness of various treatment protocols and the symptoms of PTSD, with studies revealing preliminary evidence for their efficacy in the veteran population.³⁸ Lastly, biological and non-pharmacological treatments have also been studied, including repetitive transcranial magnetic stimulation, electroconvulsive therapy, and vagal nerve stimulation. However, these treatment modalities do not have adequate research backing and are not recommended by the VA/DOD.¹⁹

Group Therapy in Residential Retreats

In the past decade, interventions examining the effectiveness of residential retreat programs have been on the rise. Residential retreat programs generally involve the administration of standard group treatment modalities delivered in a resort or camp setting. These programs have the potential to be more effective than standard group therapy in terms of decreasing dropout rates and increasing adherence. This proposition is based on the observation that residential retreat programs carry the same advantages as standard group therapy (e.g., facilitating social bonds and the development of trust) while being delivered in a fraction of the time.

There is some evidence for the effectiveness of residential retreat modalities in reducing PTSD symptoms in various populations.^39
–41 However, most previous studies have examined standard trauma-focused treatment modalities in the context of a residential retreat program. Although such an approach may be useful, it carries the risk of re-traumatization (e.g., by remembering index traumas), which may increase treatment dropout and interfere with treatment efficacy. This added risk may not be justified as previous studies have pointed to the comparable efficacy of trauma-centered and non-trauma-centered treatments for PTSD.³⁷

The Valhalla Project Niagara and the Learn to Live Program

The Valhalla Project Niagara was established by Graham Bettes, a police officer and detective with 30 years of service, and Shawn Bennett, a firefighter with 28 years of service, both of whom also served in the Canadian Armed Forces, attaining the rank of Sergeant. The organization was launched in 2020 to spread awareness about PTSD and help affected veterans and first responders better cope with their condition. To aid their efforts, The Valhalla Project Niagara enlisted the help of Ken Beaudette, a paramedic with 22 years of service and experience as a medic in the Canadian Armed Force, and Wendy Walker, a paramedic for 21 years with the Toronto EMS.

In its first two years, the Valhalla Project Niagara launched several programs, including a weekly Jiu-Jitsu class, a weekly support group meeting, and a support dog training program. These programs sought to provide the attending veterans and first responders with a safe and supportive community, in which they could once again regain a sense of belonging and control over their condition. Additionally, the flagship Learn to Live program was launched simultaneously. The Learn to Live program incorporated aspects of the other programs, such as providing peer support, while also aiming to provide veterans and first responders with educational material about PTSD and teaching them skills to help manage their condition.

As the Learn to Live program did not include any active interventions (i.e., index traumas were not addressed), and the program was offered in a group format at a residential retreat, it provided an excellent opportunity to address some of the gaps in the academic literature discussed above. Therefore, the current observational study sought to examine the potential efficacy and feasibility of this residential retreat program, which incorporates non-trauma-centered treatment methods, to address symptoms of PTSD in veterans and first responders.

Methods

Participants

Participants were made aware of the program through the program's website and by using the snowball recruitment method. This study examined data from participants who completed the program in September or October of 2021. Only those individuals with a prior PTSD diagnosis, who were also veterans or first responders, were included. In total, 14 participants comprised the September cohort and 7 participants comprised the October cohort. The study procedures were discussed with these individuals and only those who consented to the study and signed the consent forms were included in the analyses. All procedures related to this study, including participant consent forms, were unconditionally approved by the Veritas Independent Review Board (Ref: 2021-2650-7125-3).

Procedures

The Learn to Live program is a five-day residential retreat program offered by the Valhalla Niagara Project through the Cave Springs Camps at St. Catharines, Ontario. The program incorporates non-trauma-centered methods to address individuals' needs. The modules constituting the program can be broadly grouped into educational modules, cognitive skills demonstration and training, and social cohesion activities. Although the modules remain the same across cohorts, the order in which they are presented is flexible.

The educational modules which comprise the program can be broadly grouped into three separate categories. The first includes a general overview of treatments/medications available for PTSD and a more specific overview of cognitive behavioral therapy. The second category includes education modules about the importance of sleep/lifestyle/diet/exercise. The last category includes educational material about suicide integrated with a session involving suicide survivors (i.e., families of those who have committed suicide). Psychoeducational treatments have been previously recommended by the VA and Department of Defense and are a staple in PTSD treatment.¹⁸ Secondly, the coping skills presented include breathing exercises, mindfulness/meditation, daily gratitude exercises, visualization techniques, and yoga. Previous studies have pointed to the efficacy of such activities in the treatment of PTSD.^42

–48

Lastly, participants also complete several activities as a group, which served to foster social cohesion, but also provide various options for the participants to become engaged and active in their lives after the end of the program. These include outdoor activities (such as hiking), exercise, creative activities (such as painting, mandala drawing, learning to play guitar, etc.), and introspective activities (letter writing and journaling). Such activities are potentially beneficial for those suffering from PTSD.^49

–52

Measures

After obtaining consent, participants were asked to complete a set of questionnaires designed to track their psychological well-being throughout the program. The questionnaire package included background questions, the standard PTSD Checklist for DSM-5 (PCL-5),⁵³ Functional Outcome of Sleep Questionnaire (FOSQ-10),⁵⁴ the Center for Epidemiological Studies Depression scale (CES-D),⁵⁵ and two novel scales formulated by the program directors, namely the Valhalla Symptom Management Questionnaire, and the Five Core Symptoms of PTSD (Core-5) Questionnaire.

The background questions were put together to get an indication of participants' work and life situations before and after their traumatic events. Therefore, these questions ask participants to indicate the number of traumatic events they've experienced, the length of time they were on the job before they experienced the traumatic event, the amount of support they received from their supervisors and family members, etc. The PCL-5 is a standard PTSD checklist devised to screen for the likelihood of having clinical PTSD. As such, it is a staple of PTSD research, and therefore, was also included in the study. In addition, the FOSQ and CES-D were included to assess the degree to which participants' sleep problems affected their daily functioning and the degree to which participants manifested depressive symptoms. The Valhalla Symptom Management Questionnaire was devised to assess participants' challenges with PTSD symptom management in their day-to-day lives. Lastly, the Core-5 scale was formulated to capture internal and external manifestations of participants' symptoms, including the degree of trust, self-efficacy, intimacy, self-esteem, and sense of safety, as these are common facets of symptom manifestation for the PTSD population.

At the end of the five-day retreat, open-ended questions regarding participants' assessment of the program were also administered. Questionnaires were administered again one month after the end of the program.

Data analysis

Paired-samples Wilcoxon-rank tests were performed to determine the degree to which each individual changed on the various questionnaires at time 2. Exploratory Spearman's correlations were also conducted to determine the relationship between change in the various outcome variables and the variables of interest at baseline. Lastly, a robust regression analysis was conducted to determine whether treatment response could be predicted by baseline scores on any of the measures.

Results

Participant characteristics

Twenty of the 21 participants met the clinical threshold for PTSD at the start of the program, indexed by scores on the PCL-5, although all participants had been previously diagnosed with PTSD. All participants who responded to background questionnaires fully stated that they had encountered several traumatic events in their capacity as military personnel or first responders, with some reporting more than 100 traumatic events. Participants reported experiencing their first traumatic event anywhere from their first week at the job to 17 years into their careers. Participants' demographic information is summarized in Table 1.

Table 1.

Participants' Demographic Information

Variable	Number (N = 21)
Age	48 ± 10
Gender (male)	9 (43%)
Ethnicity
Caucasian	19 (90%)
Southeast Asian	1 (5%)
Metis	1 (5%)
Meeting threshold for depression at baseline	19 (95%)^a
Depression prior to first trauma	7 (35%)^a
Anxiety prior to first trauma	5 (25%)^a
Job burn-out prior to first trauma	7 (35%)^a
Nightmares prior to first trauma	3 (15%)^a
Trouble concentrating prior to first trauma	4 (20%)^a
Shift schedule was unreasonable before first trauma	9 (45%)^a
Did not have management support	18 (95%)^b
Had family concerns before traumatic event	9 (45%)^a

One data point missing.

Two data points missing.

Additionally, Spearman's correlation analyses were conducted on the outcome variables at baseline, to determine the relationship between the variables of interest. Results revealed significant correlations between scores on the Core-5 scale and scores on the Valhalla Symptom Management Scale (ρ(17) = 0.53, P < 0.05) and CES-D (ρ(17) = 0.53, P < 0.001). These results are outlined in Table 2.

Table 2.

Spearman's Correlations Between Outcome Variables at Baseline (N = 18)

Variables	PCL-5	Core5	SMS	FOSQ-10	CES-D
PCL-5	1
Core5	0.15	1
SMS	0.37	0.53^*	1
FOSQ-10	0.31	−0.13	0.29	1
CES-D	−0.13	−0.71^***	−0.34	0.23	1

Significant at P < 0.05, ^***Significant at P < 0.001.

CES-D, Center for Epidemiological Studies-Depression Scale; FOSQ, Functional Outcomes of Sleep Questionnaire; PCL-5, PTSD Checklist for DSM-5; SMS, Valhalla Symptom Management Scale.

Program feasibility

To assess the feasibility of the program, participant attendance and dropout rates were tracked. In total, 21 participants attended one or both residential retreat programs offered during September and October of 2021. Of these 21 individuals, 2 dropped out of the program. One individual cited a work-related time conflict, while the second individual reported a perceived lack of program efficacy as a reason for withdrawal. Of those who did not withdraw from the program, 18 individuals were able to participate in all five days of the program, and one individual only attended for four days due to other commitments. Three individuals attended both the September and October cohorts; however, they only completed the questionnaires once in September and at a one-month follow-up.

After the end of the program, participants were asked to indicate whether they had found the program helpful and whether they would recommend it. Nineteen individuals answered this question, including one who withdrew. Of these individuals, 18 reported deriving benefits from and being willing to recommend the program. Participants reported the following benefits: having access to a larger range of activities to manage their symptoms, a more positive outlook on life, a better understanding of their condition, feeling supported, feeling a sense of connectedness, an improved sense of confidence, and a sense of gratitude.

Analysis of change in outcome variables

To determine the potential efficacy of the program, Wilcoxon-ranked tests were conducted to assess change in outcome variables from pre- to post-treatment. Results revealed significant improvements in PCL-5 scores (V(17) = 152, P < 0.001) and Core-5 scores (V(17) = 32, P < 0.05). Moreover, 12 of the 18 participants exhibited clinically significant improvements in PCL-5 scores, defined as a decrease of more than 10 points on the questionnaire. Scores on other variables did not exhibit significant change. To parse out changes in PTSD symptomology, scores on the PCL-5 questionnaire were divided into 4 clusters as revealed by previous factorial analyses. Wilcoxon-ranked tests on the subscales revealed significant improvements in symptoms captured by Clusters B, C, D, and E (V(17) = 152, P < 0.001; V(17) = 89.5, P < 0.01; V(17) = 166, P < 0.001; V(17) = 119, P < 0.001, respectively). Cohen's d estimates revealed a large effect size of the change in PCL-5 total scores and all four cluster scores. Changes in Core-5 scores exhibited a small effect size. These results are outlined in Table 3.

Table 3.

Change in Outcome Variables from Pre to Post-Treatment (N = 18)

Variable	Pre-treatment (M ± SD)	Post-treatment (M ± SD)	ΔPre to post-treatment (V)	Effect size (Cohen's d)
PCL-5	66.7 ± 12.3	50.2 ± 14.0	152^***	1.25
Cluster B	15.6 ± 4.0	11.9 ± 4.7	89.5^**	0.85
Cluster C	7.4 ± 1.1	5.9 ± 1.9	83.5^**	1.0
Cluster D	24.1 ± 4.6	18.3 ± 5.5	166^***	1.15
Cluster E	19.6 ± 3.9	14 ± 4.5	119^***	1.33
Core5	21.1 ± 6.5	22.9 ± 7.3	32^*	0.26
SMS	18.3 ± 4.4	18.5 ± 4.3	51	NA
FOSQ-10	19.2 ± 7.5	16.5 ± 8.4	106	NA
CES-D	37.4 ± 14.3	39.2 ± 12	71	NA

Significant at P < 0.05, ^**Significant at P < 0.01, ^***Significant at P < 0.001.

To determine the relationship between changes in various outcome variables, Spearman's correlations were conducted on change scores. Most importantly, these revealed marginally significant correlations between changes in Core-5 scores, total PCL-5 scores, and PCL-5 cluster B scores (ρ(16) = −0.44, P < 0.10; ρ(16) = −0.41, P < 0.10, respectively). In other words, improved symptomology as indicated by increased Core-5 scores correlated with improved symptomology as assessed by the PCL-5. These results are summarized in Table 4. To determine whether Core-5 scores at baseline could predict change in PCL-5 scores, a robust regression analysis was conducted, which included both baseline Core-5 and PCL-5 total scores as predictors. It was found that Core-5 values could significantly predict PCL-5 changes scores (β = −0.80, P < 0.05). That is, every 0.80-point increase on the Core-5 scale at baseline was associated with a commensurate improvement in PCL-5 scores from pre- to post-treatment.

Table 4.

Spearman's Correlation Between Changes in Outcome Variables

Variables	ΔPCL-5-T	ΔPCL-5-CB	ΔPCL-5-CC	ΔPCL-5-CD	ΔPCL-5-CE	ΔCore5
ΔPCL-5-T	1
ΔPCL-5-CB	NA	1
ΔPCL-5-CC	NA	0.65^**	1
ΔPCL-5-CD	NA	0.63^**	0.80^***	1
ΔPCL-5-CE	NA	0.54^*	0.52^*	0.48^*	1
ΔCore5	−0.44^†	−0.41^†	−0.12	−0.25	−0.32	1

†

Significant at P < 0.10, ^*Significant at P < 0.05, ^**Significant at P < 0.01, ^***Significant at P < 0.001.

Personal Vignettes

The following vignettes were written by previous participants in the Learn to Live program. To ensure anonymity, names and potentially identifying information have been altered. These accounts provide support for the potential efficacy of the program for veterans and first responders with PTSD. Specifically, these suggest that the Learn to Live program, and potentially other similarly structured residential retreat programs, can ameliorate symptoms of PTSD through de-stigmatization of symptoms, instilling a sense of trust, fostering social ties, and teaching symptom management techniques to affected individuals.

Sara, police officer

“I accidentally came across the Valhalla Project Niagara on another first responder's Facebook page. At that point, I was off work for PTSD and had no idea there were any sort of programs like Learn to Live. The program was a breath of fresh air, teaching me about my illness, as well as helping me develop coping skills such as mindfulness meditation and yoga. Because of the program, I have learned to manage my symptoms better in daily life. For instance, when I now go out in public, I will visualize the outing before leaving my house, and plan for any ‘bad’ things that can happen. Even if I have anxiety when outside, I use deep breathing and try to determine why I think the attack is occurring. If I'm unable to control my anxiety, I have exit strategies in place to prevent further anxiety or panic attacks. These coping skills have certainly improved my quality of life.

I think my biggest takeaway from the program was learning that there are other first responders suffering from the same issues. By creating a culture of acceptance and camaraderie, the program ‘normalized’ the behaviors associated with my PTSD that I once found so shameful.”

Rodger, paramedic

“I was diagnosed with complex PTSD in 2017, but I continued to work on and off for 4 years after my diagnosis before I had to leave. The Learn to Live program helped me increase my trust in others, and also my knowledge of the disorder, which then helped me have more control over my PTSD. As a result of this self-growth, my relationships have improved, especially with my wife and children. Moreover, my self-esteem has increased, and I feel more confident in what I'm able to accomplish. When I attended the program as a participant, it gave me hope that there would be a life after a PTSD diagnosis, and one that could be enjoyable. I gained a wealth of information during the program, covering various modalities of treatment, self-care, and other skills that I use frequently. But more importantly, the program connected me with a support network that I still use to this day, and these relationships have grown and continue to grow.”

Patrick, combat veteran

“Coming to the program has helped me get a better handle on my PTSD symptoms. Specifically, applying the techniques taught in the program, such as mindfulness meditation and self-care, has been useful. The issue wasn't that I hadn't been taught these techniques before, but that it was usually demonstrated by instructors without any military experience. Having someone else, who has had the same experiences as me, tell me how to implement these techniques was the key. After completing the program, I have a better idea of what I'm going through and know that life is worth living, despite my PTSD. I enjoy my life more now and have even been able to leave the house more often than before.

Moreover, the program has taught me how to be a peer, and to be there for others. To do this, I had to become a leader again and model the good behaviors that I learned. This peer network that we develop in the program is the most important part. It is a source of support when dealing with day-to-day challenges with our PTSD. It also provides us with the assurance of knowing that someone else is aware of what we are going through and willing to be there for us.”

Discussion

The purpose of the present observational study was to examine the potential efficacy and feasibility of a five-day residential retreat program that implemented non-trauma-centered approaches in a group format. The data revealed preliminary evidence for the feasibility of such an approach. Out of the 21 participants who signed up for the program, and attended the first day of classes, 19 were able to complete all classes. Only one participant reported dropping out due to the perceived lack of efficacy of the program. Of the 19 individuals who completed the feedback questionnaire, 18 reported that they found the program satisfactory and that they had experienced improvements in various facets of their lives. These findings were corroborated by the quantitative analyses conducted, which showed statistically significant improvements in PTSD symptoms and the Core-5 scale. Together these data point to the effectiveness of such approaches for addressing PTSD in veterans and first responders.

The finding that group therapy methods delivered in a residential format can be administered effectively mirrors previous studies which examined the feasibility of trauma-centered treatment methods in this format.^39
–41 Residential retreat programs have been shown to lead to similar improvements in PTSD symptomology when compared to standard individual therapy.⁴⁰ The results from the current research corroborate previous studies, showing a large effect size of the change in PTSD symptomology. Moreover, the present study points to the decreased dropout rate of such a treatment approach for individuals with PTSD. Specifically, the dropout rate in the present study was around 10%, which is far lower than those reported for standard therapy methods reported to be around 20%–30%.^5,14

In contrast to previous research which focused mostly on trauma-centered treatment approaches, the present protocol involved present-centered methods alongside psychoeducation. The few other studies investigating non-trauma-centered approaches in the residential retreat format have shown similarly promising results.^35,56 However, these protocols have not been as comprehensive as the one used in the current study, and/or were not fully based on a retreat format. The use of such methods in a residential group format can be particularly advantageous, as they may decrease dropout rates, increase treatment adherence, and reduce the risk for re-traumatization.

The present data also pointed to the importance of the various interpersonal and psychosocial factors included in the Core-5 questionnaires. Specifically, scores on the Core-5 questionnaire were shown to significantly decrease at one-month follow-up, which points to the potential utility of residential group therapy in improving variables such as trust, intimacy, self-esteem, empowerment, and safety. These propositions are also corroborated by personal vignettes. Moreover, Core-5 scores were also correlated with change in the PCL-5 total score and cluster B symptomology, while pre-treatment Core-5 total scores also predicted change in PCL-5 scores. These observations point to the importance of considering psychosocial and interpersonal variables in the treatment of PTSD.

Limitations

The present findings make important contributions to the PTSD treatment literature. Firstly, these data build on the limited relevant literature to illustrate the feasibility of non-trauma-centered approaches in the residential retreat format. Secondly, the present sample included members of the first responder population, which have largely been neglected in the study of PTSD and PTSD treatment. However, the present study has several limitations. Firstly, the positioning of the study as an observational study with a small sample size means that the efficacy of the treatment can not be adequately judged, and the results could only be preliminary. Secondly, the heterogenous sample which forms the study population restricts the generalization of the results to specific groups. Lastly, symptoms of PTSD were captured using self-report measures, and not verified by clinical assessments. Therefore, improvements observed following the completion of the program may not have been indicative of the actual change in PTSD symptomology.

To overcome these limitations, future studies would do well to implement similar treatment approaches in the context of a randomized controlled trial, with homogenous samples and the aid of clinical diagnostic interviews.

Footnotes

Disclosure Statement

Several of the authors are directors at the Valhalla Project Niagara and have devised the current treatment protocol. The Valhalla Project Niagara is a not-for-profit organization. There are no other conflicts of interest to declare.

Funding Information

The program is supported by private donations. No other funding was received.▪

References

Frans

, Rimmö

, Aberg

, Fredrikson

. Trauma exposure and post-traumatic stress disorder in the general population. Acta Psychiatr Scand, 2005; 111:291–299.

Cusack

, Coleman

, Rappaport

, Sheerin

. Moderation of improvement in self-efficacy following group psychotherapy for PTSD. Psychol Serv, 2019; 16:657–663.

Johnson

, Albright

, Marzolf

, et al. Effects of therapeutic horseback riding on post-traumatic stress disorder in military veterans. Mil Med Res, 2018; 5:3.

Kracen A

, Mastnak

, Loaiza

, Matthieu

. Group therapy among OEF/OIF veterans: Treatment barriers and preferences. Mil Med, 2013; 178:e146–e149.

Haugen

, Evces

, Weiss

. Treating posttraumatic stress disorder in first responders: A systematic review. Clin Psychol Rev, 2012; 32:370–380.

Wisco

, Marx

, Wolf

, et al. Posttraumatic stress disorder in the US veteran population: Results from the national health and resilience in veterans study. J Clin Psychiatry, 2014; 75:1338–1346.

Carleton

, Afifi

, Taillieu

, et al. Exposures to potentially traumatic events among public safety personnel in Canada. Can J Behav Sci, 2019; 51:37–52.

Ogle

, Rubin

, Siegler

. Cumulative exposure to traumatic events in older adults. Aging Ment Health, 2014; 18:316–325.

King's Centre for Military Health Research. A Fifteen Year Report: What Has Been Achieved by Fifteen Years of Research into the Health of the UK Armed Forces?. London: Kings College London, University of London, 2010.

10.

Jenkins

. Veteran Paramedics' Experience of Managing Work-Related Trauma: A Qualitative Study [Doctoral Dissertation, University of Notre Dame Australia]. Macquarie University ResearchOnline, 2020.

11.

Foley

, Massey

. Police officers and post-traumatic stress disorder: Discussing the deficit in research, identification and prevention in England and Wales. Police J Theory Pract Principles, 2018; 92:23–34.

12.

Cournoyer

. Assessment of service members' knowledge and trust of the Department of Veterans Affairs [Master's thesis, Army Command and General Staff

College

, Fort Leavenworth

]. 2015. Online document at: www.dtic.mil Accessed January 10, 2022 .

13.

Carrier

. The experiences of police officers exposed to daily trauma as a course of their employment: A phenomenological study. [Doctor of Philosophy (Counselor Education), Sam Houston University]. Retrieved from Sam Houston State University Library, 2020.

14.

Edwards-Stewart

, Smolenski

, Bush

, et al. Posttraumatic stress disorder treatment dropout among military and veteran populations: A systematic review and meta-analysis. J Trauma Stress, 2021; 34:808–818.

15.

Bowers

, Beidel

, Marks

. Obstacles to mental health treatment: Similarities and differences among first responder groups. J Community Saf Wellbeing, 2022; 7:42–46.

16.

Bryant

. Challenges in treating first responders. In: Bryant RA. ed. Treating PTSD in First Responders: A Guide for Serving Those Who Serve. American Psychological Association,, 2021:143–166.

17.

Koller

, Marmar

, Kanas

. Psychodynamic group treatment of posttraumatic stress disorder in Vietnam veterans. Int J Group Psychother, 1992; 42:225–246.

18.

Department of Veterans Affairs and Department of Defense. VA/DoD clinical practice guideline for the management of post-traumatic stress. 2004. Online document at: www.healthquality.va.gov/ptsd/ptsd_full.pdf

19.

Department of Veterans Affairs and Department of Defense. VA/DoD clinical practice guideline for the management of post-traumatic stress. 2017. Online document at: www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGFinal012418.pdf

20.

Held

, Klassen

, Boley

, et al. Feasibility of a 3-week intensive treatment program for service members and veterans with PTSD. Psychol Trauma, 2020; 12:422–430.

21.

Sloan

, Bovin

, Schnurr

. Review of group treatment for PTSD. J Rehabil Res Dev, 2012; 49:689–701.

22.

Sloan

, Beck

. Group treatment for PTSD. PTSD Res Q, 2016; 27:1050–1835.

23.

Belliveau

, Cook

, McLean

, Lea

. Thawing out: Therapy through theatre with Canadian military veterans. Arts Psychotherapy, 2019; 62:45–51.

24.

Hundt

, Robinson

, Arney

, et al. Veterans' perspectives on benefits and drawbacks of peer support for posttraumatic stress disorder. Mil Med, 2015; 180:851–856.

25.

Lewis HRD. Treating Posttraumatic Stress Disorder Among Aging Veterans: What Works? Electronic Theses, Projects, and Dissertations. 2016. Online document at: https://scholarworks.lib.csusb.edu/etd/350 Accessed January 10, 2022 .

26.

Levi

, Shoval-Zuckerman

, Fruchter

, et al. Benefits of a psychodynamic group therapy (PGT) model for treating veterans with PTSD. J Clin Psychol, 2017; 73:1247–1258.

27.

Schwartze

, Barkowski

, Strauss

, et al. Efficacy of group psychotherapy for posttraumatic stress disorder: Systematic review and meta-analysis of randomized controlled trials. Psychother Res, 2019; 29:415–431.

28.

Castillo

, Chee

, Nason

, et al. Group-delivered cognitive/exposure therapy for PTSD in women veterans: A randomized controlled trial. Psychol Trauma, 2016; 8:404–412.

29.

Cox

, Westwood

, Hoover

, et al. Evaluation of a group intervention for veterans who experienced military-related trauma. Int J Group Psychother, 2014; 64:367–380.

30.

Steenkamp

, Litz

, Hoge

, Marmar

. Psychotherapy for military-related PTSD: A review of randomized clinical trials. JAMA, 2015; 314:489–500.

31.

Morland

, Hynes

, Mackintosh

, et al. Group cognitive processing therapy delivered to veterans via telehealth: A pilot cohort. J Trauma Stress, 2011; 24:465–469.

32.

Ready

, Mascaro

, Wattenberg

, et al. A controlled study of group-based exposure therapy with Vietnam-era veterans. J Loss Trauma, 2018; 23:439–457.

33.

Blake

, Weathers

, Nagy

, et al. The development of a Clinician-Administered PTSD Scale. J Traumatic Stress, 1995; 8:75–90.

34.

Haynes

, Burger

, Kelly

, et al. 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. J Affective Disord, 2020; 277:800–809.

35.

Polusny

, Erbes

, Thuras

, et al. Mindfulness-based stress reduction for posttraumatic stress disorder among veterans: A randomized clinical trial. JAMA, 2015; 314:456–465.

36.

Sloan

, Unger

, Lee

, Beck

. A randomized controlled trial of group cognitive behavioral treatment for veterans diagnosed with chronic posttraumatic stress disorder. J Trauma Stress, 2018; 31:886–898.

37.

Tran

, Gregor

. The relative efficacy of bona fide psychotherapies for post-traumatic stress disorder: A meta-analytical evaluation of randomized controlled trials. BMC Psychiatry, 2016; 16:1–21.

38.

Stolee

, Hoyt

, Brinton

. Preliminary findings of a four-session psychoeducational group for combat-related posttraumatic stress disorder. Mil Behav Health, 2020; 8:283–291.

39.

Church

, Brooks

. CAM and energy psychology techniques remediate PTSD symptoms in veterans and spouses. Explore, 2014; 10:24–33.

40.

Fredman

, Le

, Macdonald

, et al. A closer examination of relational outcomes from a pilot study of abbreviated, intensive, multi-couple group cognitive-behavioral conjoint therapy for PTSD with military dyads. Family Process, 2021; 60:712–726.

41.

Ward

, Wood

, Young

. Retreat intervention effectiveness for female survivors of child sexual abuse. Res Social Work Pract, 2020; 30:760–769.

42.

Kim

, Schneider

, Bevans

, et al. PTSD symptom reduction with mindfulness-based stretching and deep breathing exercise: Randomized controlled clinical trial of efficacy. J Clin Endocrinol Metab, 2013; 98:2984–2992.

43.

Hilton

, Maher

, Colaiaco

, et al. Meditation for posttraumatic stress: Systematic review and meta-analysis. Psychol Trauma, 2017; 9:453–460.

44.

Kearney

, McDermott

, Malte

, et al. Association of participation in a mindfulness program with measures of PTSD, depression and quality of life in a veteran sample. J Clin Psychol, 2012; 68:101–116.

45.

Richardson

, Gallagher

. Giving thanks is associated with lower PTSD severity: A meta-analytic review. J Happiness Stud, 2021; 2549–2562.

46.

Gallegos

, Crean

, Pigeon

, Heffner

. Meditation and yoga for posttraumatic stress disorder: A meta-analytic review of randomized controlled trials. Clin Psychol rev, 2017; 58:115–124.

47.

Blanaru

, Bloch

, Vadas

, et al. The effects of music relaxation and muscle relaxation techniques on sleep quality and emotional measures among individuals with posttraumatic stress disorder. Mental Illness, 2012; 4:e13.

48.

Jain

, McMahon

, Hasen

, et al. Healing Touch with Guided Imagery for PTSD in returning active duty military: A randomized controlled trial. Mil Med, 2012; 177:1015–1021.

49.

Wheeler

, Cooper

, Andrews

, et al. Outdoor recreational activity experiences improve psychological wellbeing of military veterans with post-traumatic stress disorder: Positive findings from a pilot study and a randomised controlled trial. PLoS One, 2020; 15:e0241763.

50.

Rosenbaum

, Vancampfort

, Steel

, et al. Physical activity in the treatment of Post-traumatic stress disorder: A systematic review and meta-analysis. Psychiatry Res, 2015; 230:130–136.

51.

Schouten

, de Niet

, Knipscheer

, et al. The effectiveness of art therapy in the treatment of traumatized adults: A systematic review on art therapy and trauma. Trauma Violence Abuse, 2015; 16:220–228.

52.

Cook

, Simiola

, McCarthy

, et al. Use of reflective journaling to understand decision making regarding two evidence-based psychotherapies for PTSD: Practice implications. Practice Innovations, 2018; 3:153.

53.

Blevins

, Weathers

, Davis

, et al. The posttraumatic stress disorder checklist for DSM-5 (PCL-5): Development and initial psychometric evaluation. J Traumatic Stress, 2015; 28:489–498.

54.

Chasens

, Ratcliffe

, Weaver

. Development of the FOSQ-10: A short version of the functional outcomes of sleep questionnaire. Sleep, 2009:32:915–919.

55.

Lewinsohn

, Seeley

, Roberts

, Allen

. Center for epidemiologic studies depression scale (CES-D)—As a screening instrument for depression among community-residing older adults. Psychol Aging, 1997; 12:277–287.

56.

Dahlgren

, Martinez

, Méte

, Dutton

. Healing narratives from the holistic healing arts retreat. Traumatology, 2020; 26:40–51.

Examining the Efficacy and Feasibility of a Residential Retreat Program for First Responders and Veterans with Posttraumatic Stress Disorder: A Pilot Study

Abstract

Background:

Methods:

Results:

Conclusion:

Introduction

Group Therapy Approaches for PTSD

Group Therapy in Residential Retreats

The Valhalla Project Niagara and the Learn to Live Program

Methods

Participants

Procedures

Measures

Data analysis

Results

Participant characteristics

Program feasibility

Analysis of change in outcome variables

Personal Vignettes

Sara, police officer

Rodger, paramedic

Patrick, combat veteran

Discussion

Limitations

Footnotes

Disclosure Statement

Funding Information

References