The mySELF group: Recreation- and art-based group therapy as adjunct treatment for posttraumatic stress disorder

Abstract

An emerging body of literature demonstrates the benefits of recreation and creative arts therapies as adjunct treatment for service members and Veterans diagnosed with posttraumatic stress disorder (PTSD) and other mental health conditions. The my Social life, Expression, Leisure, and Food (mySELF) group was created as an adjunct therapy option for clients receiving treatment at an operational stress injury clinic for military and Royal Canadian Mounted Police with service-related mental health conditions. This 12-week group was run by a multidisciplinary team that included psychology, nursing, therapeutic recreation, Veteran arts, nutrition services, and music therapy. Facilitators provided a variety of recreation and leisure opportunities, such as woodworking, Tai Chi, and guitar. To date, 41 clients have completed the mySELF program, and 36 provided pre- and post-questionnaire data. Most had a diagnosis of PTSD and had been in treatment for an average of 3.0 (SD = 2.8 y). Pre-, post-, and follow-up (four months post-group) testing revealed significant improvements in leisure attitudes, environmental quality of life, depression, anxiety, stress, and PTSD symptoms. These promising preliminary results suggest that recreation and art can enhance mental health treatment outcomes for military members and police.

Lay Summary

Military personnel and Veterans receiving psychotherapy for mental health diagnoses such as posttraumatic stress disorder (PTSD) often have only modest symptom improvement. The authors wondered whether participating in a therapeutic recreation and creative arts group along with psychotherapy would aid recovery. A 12-week program called the my Social life, Expression, Leisure and Food (mySELF) group was created that offered therapeutic recreation, art, and music therapy. A total of 36 clients, most with PTSD, who had been receiving psychotherapy for an average of three years completed the program and submitted pre- and post-group questionnaires. The authors examined leisure attitudes, quality of life, and mental health symptoms before, immediately after, and four months after the group. Results showed significant improvements in leisure attitudes, environmental quality of life and depression, anxiety, stress, and PTSD symptoms. These preliminary results suggest that therapeutic recreation, art, and music therapy are beneficial for military personnel, Veterans, and Royal Canadian Mounted Police receiving psychotherapy.

Introduction

Mood disorders such as posttraumatic stress disorder (PTSD), depression, and anxiety are a devastating reality for many military service members, Veterans, and their families. A 2018 Statistics Canada survey concluded that nearly half (44%) of Canadian Veterans discharged after 2002 reported symptoms consistent with depression or an anxiety disorder.¹ Aside from the personal burden associated with mental health conditions, the ripple effects of untreated mental illness are well documented in this population, including increased substance abuse,² systemic family problems,³ incarceration,⁴ unemployment, homelessness,⁵ and suicide.^6,7

Trauma-focused psychotherapies such as cognitive processing therapy (CPT), prolonged exposure (PE), and eye-movement desensitization and reprocessing (EMDR) therapy are recommended first-line treatment options for PTSD.^8,9 Pharmacotherapy is also common and may greatly assist in stabilization and symptom reduction; however, its efficacy appears to be short term without subsequent behavioural intervention.¹⁰ Although trauma-focused therapies such as CPT and PE reduce PTSD symptoms, effects are often modest, particularly among military cohorts. In a review of randomized clinical trials, Steenkamp and Litz found that two-thirds of military patients retained their PTSD diagnosis after CPT or PE treatment.¹¹ Therapies, such as cognitive-behavioural therapy, that are effective at treating depression in the general population have also shown only modest effects with Veterans.¹²

Veterans face several unique barriers that may stall treatment progress and engagement, including lack of social support, stigmatization, isolation, adjustment difficulties, and military culture and milieu that are often at odds with help-seeking behavior.^8,13,14 High rates of comorbidity (notably PTSD and depression) likely contribute to treatment resistance,¹⁵ alongside increased prevalence of somatic symptoms,¹⁶ chronic pain,¹⁷ substance misuse,¹⁸ childhood physical or sexual abuse,¹⁹ and traumatic brain injury.²⁰ Last, military-related PTSD is often complicated by moral injury and dissociative features that do not fit cleanly into manualized protocols.^21,22

Because of the complex nature of the Veteran population and modest treatment effects achieved by trauma-focused psychotherapy alone, the key to improved rehabilitation of service members may involve interlacing first-line therapies with supplementary approaches, including recreation, creative arts, and more overall holistic approaches that address physical, environmental, and spiritual needs.⁸ Although limited research has been conducted on the efficacy of adjunct therapies, a small but growing body of literature suggests that therapeutic recreation, music therapy, and creative arts may be promising complements to existing protocols.

In a study of 11 Veterans with combat-related PTSD, CPT with art therapy led to greater reductions in PTSD and depressive symptoms than CPT alone and to enhanced trauma processing.²³ In a study of 547 Veterans in residential treatment with a diagnosis of depression, anxiety, or PTSD, most participants said they found art therapy sessions useful.²⁴ When asked what they found most interesting or helpful, themes that emerged included sharing among peers and using art to explore feelings. A scoping review of music therapy for military populations found that active music making increased emotional expression and regulation and socialization and decreased loneliness.²⁵ Last, outdoor retreat-style programs and activities such as fly fishing have been shown to decrease hopelessness, guilt, shame, and loneliness and increase expressiveness, attention, affect, tranquility, connectedness, and well-being.^26–29 The authors sought to leverage these potential benefits for their clients.

Methods

mySELF group goals and structure

The my Social life, Expression, Leisure and Food (mySELF) group was created to fill a service gap observed at an operational stress injury (OSI) clinic in London, Ontario, Canada, an establishment funded by Veterans Affairs Canada to assess and treat Canadian Armed Forces personnel, Veterans, and Royal Canadian Mounted Police (RCMP) with service-related mental health conditions. The authors identified that after receiving several years of clinic services (primarily trauma-focused psychotherapy), several clients plateaued, such that their PTSD and depression symptoms improved but not enough to warrant discharge. Because research has shown mental health benefits from engaging in recreation and art, the authors sought a group opportunity to capitalize on these benefits as an adjunct to individual psychotherapy. By doing so, the authors aimed to extend treatment gains, increase awareness of recreation and creative arts benefits, enhance motivation, provide an opportunity to apply skills learned in therapy, address common barriers, enhance quality of life, target anxiety about being in groups of people, and provide awareness of community resources to bridge the gap between treatment and participation in the community. To date, three offerings have been completed (2016–2018).

Clinicians referred eligible clients to the mySELF group. Inclusion criteria included mental health symptom stability and completion, or near completion, of active trauma treatment. There were no diagnostic criteria for participation, however; because clients were receiving treatment at an OSI clinic, all had at least one mental health condition related to military or RCMP experiences.

The integration of this OSI clinic within a Veteran hospital provided a unique opportunity to create a multidisciplinary team involving psychologists, nurses, therapeutic recreation, Veteran arts instructors, a registered dietitian, and music therapists.

The mySELF group ran three-hour sessions for 12 weeks. It provided a myriad of opportunities for recreation and artistic self-expression with a focus on individual needs. Each week began with 30 minutes to socialize and discuss the plan for the day. There were two 45-minute activity time slots, which allowed participants to choose either of the two activities (Table 1), with a break in between. Some activities, such as guitar, required weekly participation, so other activities were offered more than once to allow participants as much choice as possible. Examples of therapeutic opportunities, session structure, and discussion topics are shown in Table 1. Participants could also meet with the registered dietitian to talk about food and nutrition. She also provided everyone with a recipe book of simple meals. After the activities, there was a shared lunch during which participants could socialize. There were also planned discussions on topics such as overcoming barriers and community resources (Table 1).

Table 1.

Group structure, activities, and discussion questions

Time	Activity	Description
10:00–10:30	Coffee Connection	An opportunity for socialization, discussion, and disseminating the plan for the day
10:00–10:30 11:15–11:30 11:30–12:15	Activity 1 Break Activity 2	Art therapy examples: Woodworking Wood burning Copper enameling Clay Silk painting Leather work Book making Stained glass Painting Drawing	Music therapy examples:Guitar Drumming	Recreation therapy examples: Cooking Tai Chi Aqua therapy Golf Gardening Yoga Riding stables Nature hikes Yoga Escape room Bowling Indoor curling Fly fishing
12:15	Lunch	A second opportunity for socialization, as well as debriefing activities and discussing bold moves.
		Discussion topic examples: Recreation Overcoming barriers Achieving flow Benefits of recreation Relaxation “Bold moves” to face fear and anxiety Barriers to recreation Community resources

Participants completed self-report questionnaires at the beginning (pre), end (post), and approximately four months after (follow-up) the mySELF group. Data were entered into a de-identified, password-protected database accessible only to the study analysts (LK and FK). Because this project was for quality improvement, it did not require institutional ethical review under Article 2.5 of the Tri-Council Policy Statement.³⁰

Measures

Leisure attitudes were measured pre- and post-group using the Leisure Attitude Measurement (LAM),³¹ a 36-item questionnaire with three domains: cognitive (e.g., engaging in leisure activities is a wise use of time), affective (e.g., when I am engaged in leisure activities, the time flies), and behavioural (e.g., given a choice, I would increase the amount of time I spend in leisure activities). Responses are measured on a Likert scale ranging from 1 (never true) to 5 (always true) and averaged within domains. Scores of less than 2.5 indicate a need for education. The LAM was not used at follow-up to shorten the questionnaire and instead ask more open-ended questions that could assist in developing future programming.

The authors assessed quality of life (QOL) at all three time points using the World Health Organization Quality of Life-Brief version (WHOQOL-BREF).³² This 26-item measure consists of four domains: physical health, psychological, social relationships, and environmental. Raw scores are transformed to a 0–100 scale on which higher scores indicate higher QOL.

Depression, anxiety, and stress symptoms were measured at all three time points using the Depression Anxiety Stress Scale-21 (DASS21).³³ This 21-item questionnaire consists of three self-report scales; it asks respondents to rate the applicability of items on a Likert scale ranging from 0 (did not apply to me at all) to 3 (applied to me very much, or most of the time). Scores are multiplied by two, and the total score for each scale (7 items each) is summed. Ranges are from 0 to 20 or more, 28 or more, or 34 or more for the Anxiety, Depression, and Stress scales, respectively, where higher scores indicate higher symptom severity.

PTSD symptoms were measured at all three timepoints using the 20-item PTSD Checklist for DSM-5 (PCL-5).^34,35 Because all participants had previously been assessed for PTSD by a clinician and the study was solely interested in symptom changes, Criterion A was not used. PCL-5 items are measured on a scale ranging from 0 (not at all) to 4 (extremely) with a range of 0–80. The cut-off for probable PTSD is 33.

Homegrown questions

Participants were asked homegrown questions about their expectations and evaluations of the group on a scale ranging from 0 (not at all) to 3 (to a great degree). At follow-up, they were asked about their engagement in recreation activities, what prevented them from engaging in recreation activities, and whether mySELF facilitators should encourage participants to try new activities or activities outside of their comfort zones (no or yes).

Facilitator observations

After each session, facilitators met to discuss and reflect on how the day went, share feedback from participants, and plan the next session. This feedback was also disseminated to all clinicians in the clinic via team meetings.

Analysis

Comparisons were made using paired t-tests for the LAM and repeated-measures analysis of variance for the WHOQOL-BREF, DASS21, and PCL-5. If a participant did not answer more than half the items, they were excluded from the analysis for that questionnaire (or its relevant section). Frequencies were analyzed for the homegrown questions. Verbal feedback provided by clients to facilitators, as well as group observations, were summarized.

Preliminary Results

Participants

A total of 48 clients enrolled in the mySELF program (16 clients in 2016, 17 clients in 2017, and 15 clients in 2018). Seven individuals discontinued as a result of distance (n = 2), anxiety (n = 2), physical illness (n = 1), or disengagement from treatment at the OSI clinic (n = 2). Accordingly, a total of 41 clients completed the group. Of the 41 participants, 36 (87.8%) provided pre- and post-group data, and 33 (80.5%) provided data at all three time points. Of the 36 participants who provided pre- and post-group data, most were aged 45–55 years and had been receiving treatment at the OSI clinic for 3.0 years (SD = 2.8, range = 1–9 years). Most were male (n = 33) and diagnosed with PTSD (n = 32) or other trauma- and stressor-related disorders (n = 2), depression (n = 30), anxiety (n = 3), or a combination of these. The majority were Veterans (n = 30), followed by CAF members (n = 3) and RCMP (n = 3).

Measures

A total of 36 participants completed the LAM pre- and post-group. There was a significant improvement in leisure attitudes across all domains (Table 2).

Table 2.

Change in LAM cognitive, affective, and behavioural leisure attitudes from before mySELF group participation (pre) to after participation (post)

Item	Mean (SD)		t-statistic
	Pre	Post
Cognitive	3.79 (0.71)	4.38 (0.55)	5.87
Affective	3.23 (0.76)	4.05 (0.65)	5.41
Behavioural	3.06 (0.79)	3.60 (0.59)	3.89

Note: N = 36 for all items. p < 0.001 for each item.

LAM = Leisure Attitude Measurement.

A total of 33 participants completed the WHOQOL-BREF at all three time points. However, one participant’s responses were dropped for the physical health, psychological, and environment domains because they answered fewer than half the questions. Accordingly, their data are used only for the social relationships domain (N = 33) and not for the other domains (N = 32). Statistically significant improvement was found for the environmental domain. No statistically significant differences found among the physical health, psychological, or social relationships domains (Table 3).

Table 3.

Change in the physical health, psychological, social relationships, and environmental WHOQOL-BREF domains from before (pre), after (post), and 4 months after (follow-up) mySELF group participation

Item	Mean (SD)			F-statistic (df)	p-value
	Pre	Post	Follow-up
Physical health	47.44 (10.40)	50.69 (11.73)	48.00 (9.57)	1.56 (2, 62)	0.22
Psychological	46.75 (13.91)	49.91 (12.94)	48.06 (11.04)	1.34 (2, 62)	0.27
Social relationships	43.15 (25.61)	45.82 (24.44)	48.33 (23.16)	1.43 (2, 64)	0.25
Environmental	60.09 (15.12)	65.75 (12.96)	65.34 (11.44)	4.60 (2, 62)	0.01

Note: N = 33 for the social relationships domain; N = 32 for the physical health, psychological, and environmental domains (1 participant answered fewer than half the questions).

WHOQOL-BREF = World Health Organization Quality of Life-Brief; mySELF = my Social life, Expression, Leisure, and Food.

Scores on the DASS21 showed statistically significant symptom improvement for depression, anxiety, and stress (Table 4). Similarly, there was a significant decrease in PCL-5 PTSD symptoms (Table 5).

Table 4.

Change in DASS21 depression, anxiety, and stress symptoms before (pre), after (post), and 4 months after (follow-up) mySELF group participation

Item	Mean (SD)			F 2, 64	p-value
	Pre	Post	Follow-up
Depression	24.42 (8.88)	19.27 (10.69)	19.94 (10.24)	6.33	< 0.01
Anxiety	22.24 (9.44)	16.48 (11.14)	18.21 (9.87)	9.49	< 0.001
Stress	26.36 (9.96)	20.18 (11.25)	21.76 (10.43)	8.10	< 0.001

Note: N = 33 for all items.

DASS21 = Depression Anxiety Stress Scale-21; mySELF = my Social life, Expression, Leisure, and Food

Table 5.

Change in PCL-5 posttraumatic stress disorder symptoms before (pre), after (post), and 4 months after (follow-up) mySELF group participation

Mean (SD)			F 2, 62	p-value
Pre	Post	Follow-up
47.13 (15.82	42.00 (19.75	42.53 (17.92	4.67	.01

Note: N = 32.

PCL-5 = PTSD Checklist for DSM-5; mySELF = my Social life, Expression, Leisure, and Food.

Homegrown questions

Nearly all participants (97.2%) would recommend the mySELF group to another client, and most (88.9%) indicated an increased desire to develop recreation in their lives. Of the 36 participants who provided post-group data, the vast majority (81%) believed participation offered unique benefits not provided by the rest of their OSI clinic treatment. Of the 33 participants who provided pre-group, post-group, and follow-up data, 78.8% resumed or started new recreation or social activities, and 30.3% resumed or started new relationships. The most common reasons for not engaging in further activities were anxiety (69.7%), motivation or interest (66.7%), and unsure of interests (45.5%). Most (90.9%) felt that mySELF facilitators should encourage participants to try activities outside their comfort zone.

Facilitator observations

Facilitators shared feedback that participants verbally provided during group sessions. Participants spoke of benefiting from the socialization and camaraderie among peers. Guitar participants expressed feeling less isolated and more focused and reported improvement in memory and concentration, decreased anxiety, and more enjoyment overall. Those who participated in aqua therapy indicated a reduction in pain, increased freedom of movement, and a sense of relaxation and security. While attending the Veteran arts studios, several intergenerational connections developed between participants and Veterans Care residents. Pre- and post-session refreshment and lunches provided multiple benefits: healthy nourishment, access to a registered dietitian for consultation, and support for the development of a sense of community among peers. Although there was notable tension in the first few weeks, toward the end of the program participants were much more relaxed, engaged, and willing to share and support each other. Many reported increased confidence, less anxiety, and looking forward to attending the following week.

Although an initial aim of the group was to better bridge the transition between mental health treatment and community engagement, this was challenging for some clients. For example, those who participated in the aqua therapy program found it beneficial, yet existing community programs were geared toward older adults and generally had large numbers of women participants, which may not resonate with middle-aged men. Likewise, participants enjoyed guitar and wanted to continue outside of the group, but no such community groups existed. mySELF facilitators helped arrange for a leader to start and maintain such a group. Since the first mySELF offering, the community Veteran guitar group led by a local volunteer (a former participant) and composed of eight members continues to meet biweekly at the local Legion branch, six years later.

Discussion

The results reveal significant improvements in many important aspects of healthy functioning after mySELF group participation. These findings complement the developing literature on the ability of recreation, music, and art to enhance treatment outcomes for people with PTSD and depression.^{23–25,28,29,36,37} For example, in a small study of Veterans receiving residential treatment for combat-related PTSD, participants voiced that art therapy gave them an opportunity to bond with other Veterans.³⁷ Participants also found socializing with peers to be of high value — and an opportunity not offered through one-on-one therapy. The vast majority of group members endorsed that mySELF offered unique benefits not provided by the rest of their treatment, broadly supporting a more holistic approach to first-line psychotherapies.

On the basis of participant feedback, several more recreation- and art-based groups were created. These extension groups provided more independent and in-depth experiences for clients (i.e., introductory guitar and art-specific interventions). A 12-week group with three-hour sessions called Making Connections was also initiated. Its content was similar to the initial mySELF group, but with a greater focus on bridging community participation. A community-based, month-long weekly fishing group was also created. The guitar group continues to meet; however, other extension group offerings were put on hold as a result of the COVID-19 pandemic. It is hoped that, once hospital restrictions ease, the OSI clinic will re-examine its in-person group offerings. On the basis of facilitator observations from these extension groups, a more sustained, intensive, and personalized intervention may be required to bridge the gap between treatment and community participation, and the development of community resources specific to the interests and needs of the client may need to be explored and supported beforehand.

Limitations

Results from the mySELF group should be interpreted considering the small sample size and potential responder bias, because each participant was receiving psychotherapy at the same clinic at which the mySELF group was offered. Data were collected for program evaluation, and there was no control group; therefore, it is uncertain whether findings are attributable to group participation or a combination of ongoing individual therapy and group participation. However, given that, on average, clients were in therapy for nearly three years, the significant decrease in many symptoms over a short period of time suggests that the group was of considerable benefit. Although participants reported many benefits from the mySELF group, it is not possible to determine whether socializing with peers, engaging in recreation and art, implementing skills learned in therapy, or another factor was most beneficial. Given the small sample size and number of comparisons, post hoc testing was not performed. Accordingly, where the reported group differences lie is unknown.

Conclusion

The nature, content, duration, and stage of treatment for adjunct therapies for Veterans is a promising and much-needed avenue for future research. For participants, the greatest barrier to engaging in recreation was anxiety. Future research may benefit from further exploring the generalizability of anxiety as a barrier to participation using a larger sample size and subsequently investigating how anxiety can be reduced as an obstacle. Opportunities specific to Veterans, such as the mySELF group, are a hopeful solution. That said, the facilitators and participants of this group benefited greatly from residing in a hospital with a Veteran’s Care Program, and thus existing recreation resources and staff members were experienced in Veteran care.Accordingly, the mySELF group may be challenging to replicate in a different setting. Research is needed to determine which components of groups such as mySELF offer the most potential to aid recovery. The authors believe a major contribution of recreation is the aspect of doing something, offering clients an opportunity beyond that achieved in an office setting. Therapeutic recreation and other creative arts through opportunities such as the mySELF group offer a venue to practice skills learned during treatment and maintain treatment gains.

Biographies

Lisa King, MSc, is a research associate and a program evaluation officer at St. Joseph’s Health Care Operational Stress Injury Clinic. She is currently interested in measurement-based care and understanding mental health treatment outcomes for Veterans and Canadian Armed Forces personnel.

Doreen Campbell, BA, BEd, Dip AT, is an art therapist in the London, Ontario, Canada, community, with a focus on the senior population as well as children’s grief. She is honoured to be working with the residents in the Veterans Care Program at Parkwood Institute, St. Joseph’s Health Care, since 2011. She also enjoyed serving on the board of the Ontario Art Therapy Association for several years.

Marie Finkbeiner, BSc in therapeutic recreation, is a therapeutic recreation specialist in the Veterans Care Program at St. Joseph’s Health Care in London, Ontario, Canada.

Jane Gallimore, RN, RSW, CPMHN(C), is a registered nurse at St. Joseph’s Operational Stress Injury Clinic in London, Ontario, Canada.

Jill Kennedy, BA, BMT, is a music therapist working in Veterans care and palliative care at St. Joseph’s Health Care in London, Ontario, Canada.

Emily McCarthy, BMT, is a music therapist in the Veterans Care Program at Parkwood Institute in London, Ontario, Canada.

Felicia Ketcheson, MSc, is a research associate and a program evaluation officer at St. Joseph’s Health Care Operational Stress Injury Clinic in London, Ontario, Canada.

Funding Statement

No funding was received for this article.