Processes and Outcomes of a Communalization of Trauma Approach: Vets & Friends Community-Based Support Groups

Abstract

Aims:

Veterans often experience challenges related to processing traumatic experiences and community reintegration, yet there is a dearth of research on promising community-driven approaches. This paper describes core processes and outcomes of Vets & Friends (V&F), a community-based support program that promotes veteran reintegration by healing trauma and moral injury using a Communalization of Trauma (CoT) approach.

Methods:

We conducted focus groups with 23 V&F group members. A mix of inductive and deductive codes were generated during thematic analysis.

Results:

Critical themes identified included processes such as sharing narratives, connecting emotionally with experiences, feeling heard and accepted by group members, and listening as others shared their experiences. Outcomes included restoration of trust, connection with group members, building skills to manage trauma, and community acceptance and engagement.

Conclusion:

V&F shows promise in meeting veteran specific needs by employing CoT approaches that offer opportunities to restore community trust and acceptance.

Introduction

Reintegration of veterans and rehabilitation of persons who have experienced trauma are community issues. Over 18 million veterans reside in the United States (United States Census Bureau, 2017), and many of them face difficulties returning home, such as: war-related post-traumatic stress disorder (PTSD; Fulton et al., 2015), increased risk of sleep disorders (Martin, 2016), increased suicide/suicide ideation (Bruce, 2010), and physical health issues with comorbid mental health problems such as traumatic brain injury (TBI) and chronic pain (Koblinsky et al., 2014). These challenges can complicate the transition process, impede the ability to obtain education and employment, disrupt the development and maintenance of supportive relationships, and make it difficult to find stable housing (Castro et al., 2014; Kintzle et al., 2016; Levi et al., 2017).

Many veterans do not make use of formal health care services due to structural constraints (e.g., lack of access, poor transportation; Johnson et al., 2010; Washington et al., 2011; Zullig et al., 2012) and social factors (e.g., widespread stigma and misunderstanding; Pedersen et al., 2016; Vander Weg & Cai, 2012). Research suggests that sense of community and belonging is important for successful adaptation and reintegration of veterans and families (Bowen et al., 2003; Huebner et al., 2009), though it is not clear how best to foster or promote it. Community interventions to support veterans may be particularly impactful in promoting social support and community connectedness (Gorman et al., 2018) to combat many of the challenges faced by veterans in transition (e.g., reducing symptoms of PTSD and risk of suicide; Forman & Havas, 1990; Kaplan et al., 2007).

Given the pervasiveness of community reintegration challenges and mental health issues among veterans, support groups led by peers and civilians in the community are a promising means of providing support complementary to other formal mental health care (Christensen & Jacobson, 1994; Durlak, 1979; Keenan et al., 2014; Solomon, 2004; Whiteman et al., 2013). Community psychology has long contributed to research on the empowering effects of peer support in community settings (Hagler et al., 2018; Rappaport et al., 1985; Salem et al., 1988; Van de Ven, 2020). The approach we describe here builds on this literature by adding a focus on supporting veterans through communalization of trauma (CoT).

This paper describes Vets & Friends (V&F), a community-based program that uses a CoT approach to help heal survivors of trauma and moral injury. We sought to answer: What are the outcomes of a CoT group designed to support veterans experiencing trauma and moral injury, and what are the key processes by which these outcomes are achieved? Drawing upon CoT theory deductively as well as V&F interview data inductively, we present processes and outcomes of CoT identified from a qualitative pilot study of V&F groups.

Communalization of Trauma

CoT is a therapeutic practice that promotes recovery from trauma or moral injury by restoring safety, trust and connection to community, which are often lost or severely disrupted as a result of war. Moral injury is a distinctive trauma that occurs when a person perpetrates, fails to prevent, bears witness to, or learns about an act that transgresses ingrained moral beliefs (Litz et al., 2009). It was first described as a betrayal by someone who holds legitimate authority (e.g., a military leader; Shay, 1991) and later expanded to include a second form in which service members perpetrate acts in war that betray their own moral code (Litz et al., 2009). In contrast to posttraumatic stress, the trauma arises not from life threat but from violations of personal ethical and moral standards.

CoT was first described in a book by psychiatrist Jonathan Shay (1995) that highlighted how theater was used in ancient Greece to help warriors heal from trauma by sharing their stories with a broader community. Additional aspects of communal healing approaches were explicated in other books (Herman, 1997; Shay, 2002) and articles (Cilliers et al., 2016; Kingsley, 2007; Munroe, 1996; Spring, 2016). Proponents of CoT approaches note that, in addition to undermining basic assumptions about meaning and justice in the world, war violates the principles of community (e.g., safety, rules of behavior and interrelationships) and distances service members from their home communities (Munroe, 1996). Because this harm is social and interpersonal in nature, recovery from it is also social and interpersonal. Therefore, community plays a critical role in addressing military trauma as “any blow in life will have longer lasting and more serious consequences if there is no opportunity to communalize it” (Shay, 1995, p. 39).

This is in contrast to predominant treatments for PTSD, which imply that trauma in response to war is abnormal and best addressed one-on-one by mental health professionals working in formal healthcare settings (Caplan, 2007). Consistent with the view that posttraumatic stress is a normal, adaptive reaction to unusually stressful circumstances (Burstow, 2005), CoT has the potential to destigmatize war trauma and shift focus from addressing individual “mental illness” to restoring sense of community and trust. Similar to other narrative approaches to treating PTSD, CoT entails sharing the trauma and the emotions linked to it. Constructing personal narratives helps survivors gain mastery over their experiences, distinguish emotions that may be re-experienced together (e.g., anger, grief), and shows the trauma is shareable (Kingsley, 2007; Shay, 2002). Story sharing must occur in a way that is safe for both survivors and listeners. For example, retraumatization is likely if survivors are not safe (e.g., sober and practicing self-care) before they begin to share their experiences (Shay, 2002). In addition, stories need to be constructed and shared over time as this decreases the chances of retraumatizing the survivor and allows listeners adequate time to process, reflect and respond to survivors (Munroe, 1996).

Shay (1995) asserts that trauma narratives are healing only if shared with a trustworthy community, which suggests using group healing modalities. Key functions of a trustworthy community are establishing safety and trust with survivors, validating feelings and experiences, connecting emotionally with survivors, and challenging negative views resulting from trauma (Shay, 1995; Munroe, 1996). Establishing safety aids community members in listening to and accepting survivors’ stories. Further, a group can relate to and process more emotions than a single listener (Munroe, 1996). In this way the community can counter negative thinking (e.g., nobody can be trusted, no orientation to the future) by providing diverse, alternative views. Validation for survivors comes from feeling heard and understood by their community. Survivors feel valued when – after sharing their experiences – they are accepted by and considered a valued member of the community.

There are several interesting logistical aspects of CoT noted in the literature. First, CoT approaches are well suited to non-clinical group settings rather than to formal (individual or group) clinical settings (Munroe, 1996; Spring, 2016; Shay, 2009). Because community requires at least 3 people (Munroe, 1996), CoT is not possible in individual therapy. Further, a therapist who runs a trauma group cannot easily demonstrate basic trust in a community, meaning solo mental health professionals are unable to model or provide the healing components of communities described above. It is an open question, then, how to best run or lead a CoT group. Second, including peers (e.g., fellow service members) and civilians in the trusted community group adds value to the CoT process. Peers help survivors feel less alone and verbalize their experiences (Shay, 1995). In addition, peers can take new, meaningful helping roles as they support other survivors in the process (Munroe, 1996). Involving civilians reduces the distance that often grows between military and civilian community members, fosters shared understanding of war and trauma experiences, and raises awareness among civilians of how to support military members. It is unclear, however, what the most effective ratio of peer to non-peer and civilian to military group members is. Finally, the importance of sharing trauma narratives over time indicates a need for long-term group engagement that allows participants to proceed at their own pace. Not only does this go against prevailing market forces that prefer bounded, structured, short-term therapies, it poses challenges for retaining and engaging group members over extended periods of time. In summary, while CoT is a promising community-based approach to healing military trauma and moral injury, research on it and related programs is scarce. Important practical considerations such as group leadership structure, group member composition and long-term implementation (e.g., session content, sequencing) merit further exploration.

Outside of the US, descriptions of community healing efforts after widespread violence or conflict show that elements central to CoT (e.g., safety, trust, truth-telling, restoring connection to community) feature prominently in reconciliation or restorative justice approaches (Ngwenya, 2018). Further, communalizing trauma has been suggested as useful for different traumatized populations, including peacekeepers (Ray, 2009b), prisoners of war (Stein et al., 2015), and children impacted by conflict (Mercer, 2015). Its utility depends, in part, on how community driven and culturally consonant it is (Mercer, 2015; Schultz et al., 2016), how well it gives voice to experiences that are often ignored or marginalized, and how well traumatic experiences can be cognitively reframed for processing and sharing. Within the U.S., communalizing approaches have been pioneered by Native American and Latino communities (Brave Heart, 1998; Schultz et al., 2016).

Our literature search identified three programs that employed narrative and communal elements of CoT approaches with veterans (Ali et al., 2018; Keenan et al., 2014; Wilson et al., 2009). The first was an empirical study of DE-CRUIT, a program that endeavored to help veterans process trauma through performing Shakespeare’s military monologues and writing narratives which the participants “hand off” to a fellow veteran in the group to memorize and perform to a closed audience of peers and invited family and community members (Ali et al., 2018). At the closing session, veterans discussed how they felt before and after their performance with the audience members, who in turn shared their emotional reactions to the stories. Analyses were not focused on effectiveness of the CoT approach, but instead were aimed at identifying the nature of veteran narratives as they were instructed to monologue “the trauma that most affected them” (p. 11). Authors highlighted the importance of allowing veterans’ stories to “emerge in an organic manner” (through graduated engagement in writing and processing; p. 12) in an environment that feels safe.

The other two programs were described conceptually. One was a professional team-led, clinic-based group therapy approach, which was open to all veterans who had experienced trauma (Keenan et al., 2014). Participants spent their first several meetings developing safety and rapport via collectively engaging in a training on posttraumatic stress and associated symptoms. Veterans then constructed and shared their narratives with group members over time. As a result, participants reported experiences of healing through the compassion, acceptance, validation, and affirmation of fellow group members. Lastly, the Veteran Education Project (VEP) trained veterans to share their stories in schools and public venues through conferences, workshops, and public meetings to alleviate PTSD and promote reintegration (Wilson et al., 2009). Authors discussed four key benefits of sharing trauma stories, including: (1) communalization of trauma with peers may help normalize difficult experiences and foster a sense of connection; (2) potential to transform challenging experiences into learning and growth opportunities (for the self and others); (3) social engagement may serve as a facilitator of validation (particularly where the community acknowledges “the sacrifice and duty involved with their efforts to protect the country along with any complex ethical dilemmas involved,” p. 420); and (4) development of self-awareness, understanding, and knowledge through sharing stories of trauma.

All of these programs asked participants to construct, emotionally connect with, and share narratives of their trauma. Further, they recognized that treatment needs to be paced to address the myriad of complications that veterans experience, and that reconnecting with the self, others, and the community takes time (Ali et al., 2018; Keenan et al., 2014; Wilson et al., 2009). VEP and DE-CRUIT began as small-scale grassroots practices formed by community members to meet specific needs within the community (Ali et al., 2018; Wilson et al., 2009). Community connectedness is a strength of these programs but the variation with which CoT approaches are implemented and studied poses challenges for future research. For example, it is unclear whether and how community members engaged with veterans to establish trust, validate feelings and experiences, connect emotionally, and challenge negative views.

Vets & Friends

V&F is a group-based CoT model in which veterans, family members, friends, and civilians participate to provide support for individuals healing from trauma and moral injury. V&F embraces a nonprofessional, community-based, team-leadership approach, and to date has been implemented in Minnesota and Wisconsin. V&F complements Veterans Health Administration (VHA) services by providing longer-term, low-intensity support to veterans where they live. Four V&F groups have operated to date. Each group had 7 to 12 group members which included current or former military service members, family members (e.g., parents, spouses, children), and nonveteran community members. Participants were usually invited to join by group leaders or other group members, but “walk-ins” and referrals were also welcome. To join, group members must: (1) have experienced trauma or moral injury (e.g., combat), (2) be a friend or loved one of someone who has experienced trauma or moral injury, or (3) be a community member who deeply cares about and desires to learn how to support those who have experienced trauma or moral injury. While trauma and moral injury are not exclusively experienced by military service members, V&F groups intentionally focused on the healing of veterans and their intimates (close family members and friends). Groups met weekly or biweekly for approximately 1.5 hours in community spaces (e.g., churches, community centers). Meetings varied in structure, but often started with a check-in or discussion topic. Examples of topics include PTSD, moral injury, traumatic grief, triggers, substance abuse, self-medication, sleep deprivation, suicide awareness, calming skills, brain chemistry of trauma and TBIs, and making and maintaining meaningful connections. Despite differences in format, each group focused on establishing safety and trust for participants to share their stories of trauma or moral injury with deeply engaged peers and community members.

V&F group leaders worked in teams composed of military and civilian peers who led by example and shared their stories of trauma with group members. Team leaders volunteered their time and came from all walks of life. Some had professional training and backgrounds (e.g., counselors, chaplains) but did not lead groups in formal professional capacities. Group leaders were selected based on (1) participation in V&F retreats or recruitment by other group leaders, (2) demonstrated connection with and investment in their communities, and (3) leadership skills (e.g., ability to listen and accept others’ experiences, emotional maturity, capacity to function in a leadership team). Group leaders worked in teams to facilitate meetings and orchestrate presentations, programs and other outreach activities in the community. They acted as group administrators by conducting outreach to prospective participants, securing meeting spaces, handling communication among group members, preparing group topics for conversation, identifying resources, and navigating challenges as they arose. The team leadership design was intentional as it minimized the potential for burnout through shared responsibilities and allowed for group leadership teams to model both community and trust, consistent with CoT principles. To date, V&F groups are not formally funded but group leaders have been supported by the V&F founders (i.e., retreat trainers) who conduct five-day retreats that train teams to communalize trauma and respond appropriately to PTSD, moral injury, traumatic grief, suicide ideation, cultural diversity, and other trauma-related topics.

Methods

Procedures

A partnership formed in 2015 between Welcome Them Home-Help Them Heal (WTH-HTH; the parent nonprofit group that developed V&F) and the University of Minnesota Medical School, Duluth Campus. Mutual interests in improving the lives of veterans and their families, and reducing veteran mental health disparities drove conversations surrounding effective community-level systems of support and became the foundation of inquiry into the outcomes and processes of V&F. A Community Health Collaborative Grant was awarded to our team by the University of Minnesota Clinical and Translational Science Institute (CTSI). The purpose of the pilot study was to inform training and group leader support procedures to ensure maximal functioning and effectiveness of V&F support groups. In this manuscript, we present outcomes of V&F, with particular attention to its CoT approach and the processes by which these outcomes are achieved.

Drawing upon principles of Community-Based Participatory Research (CBPR; Israel et al., 1998; Minkler & Wallerstein, 2011), we had two Principal Investigators (PI), one from the community and one from the university. The research partnership began shortly after the first V&F training retreat. Since the groups were in the early stages of forming and operating, the timing of the research was opportune for both those developing the program and group leaders. We carefully coordinated research project tasks with outlined V&F work to ensure that research and practice efforts informed each other as the process unfolded, with minimal impact on the function of the groups themselves.

Recruitment and Participants

University staff provided group leaders with informational flyers to distribute to their groups prior to recruitment. Potential participants were contacted by university research staff via email or phone. The informational flyer and email included a brief description of the study, as well as an opportunity to opt out if they did not want to be contacted further. Inclusion criteria were: 18+ years of age, English language proficiency, and participation in V&F as a group leader or group member within the past year.

A total of 23 participants representing four V&F groups took part in focus groups, of which 16 were male and 7 female, 10 were veterans and the remaining 13 nonveterans were spouses, parents of veterans, or community members (see Table 1 for group characteristics and participant demographics). V&F groups 2 and 4 were active at the time of the study. Group 1 ran for approximately 1 year but ended due to logistical issues, such as a long commute to the meeting location for group leaders, local walk-ins occasionally dropping in while intoxicated (presenting potentially unsafe encounters for group participants), and complex relational dynamics between spouses that sometimes dominated group conversations. Group 3 intentionally ran for approximately 12-15 weeks because the group leaders felt that having set start and end dates would increase participation by allowing a natural entry point for new members when the group restarted. Meetings for groups 1, 3, and 4 were held in churches, while group 2 convened at a local community center. Group 1 was primarily a couples group with a fluctuating group size; group 2 was veterans only with the exception of two nonveteran group leaders; group 3 was a mix of veterans and nonveterans; and group 4 was a family-focused group that included spouses and children (children are omitted from typical group size in Table 1). Groups 1 and 2 had an uneven mix of male/female and veteran/nonveteran group leaders, while groups 3 and 4 were evenly split.

Table 1.

V&F Group and Interview Participant Characteristics

		Typical group size	Interview participant demographics
		Total	Total	Male	Female	Veteran	Non- veteran
Group 1	Inactive	10	6	5	1	2	4
Group 2	Active	10	5	5	0	3	2
Group 3	Inactive	7	5	4	1	2	3
Group 4	Active	12	10	5	5	4	6
	Totals	36	23	16	7	10	13

Note. Totals exclude duplicates (i.e., participants who took part in multiple groups).

Design

A total of 7 focus groups were conducted from July to September of 2017. Prior to these, we conducted a focus group with V&F retreat trainers in order to identify desired outcomes and concepts for exploration in subsequent focus groups. The focus group protocol for group leaders and members were then refined to include direct probes about the desired outcomes identified (e.g., group leaders feel prepared and supported, group members feel safe). Overall, the focus group protocol was designed to elicit the range of experiences of group leaders and members. Questions included: how, why and when participants got involved, nature/extent of participation or involvement, examples of positive and negative group dynamics, and areas for improvement. All focus groups were audio-recorded and transcribed word-for-word, and participants were deidentified. In addition to the focus group sessions, the university PI and Research Assistant (RA) observed one meeting for each of the two groups active during the study period. This allowed the team to become familiarized with V&F group formats as they operated in their regular meeting times and places.

Data Analysis

Our team created a “start list” (Miles & Huberman, 1994) of 15 deductive codes developed from CoT elements identified in the literature review. After conducting all interviews, we utilized qualitative coding software (NVivo) to code our data. The start list was comprised of code names, descriptions, and examples of each CoT element from literature text. The university PI and RA coded two half-interviews separately, completed inter-rater reliability testing and discussed development of inductive codes and necessary refinements of deductive codes as well as definitions based upon fit with the data. Codes that received a Kappa value below 0.41 (QSR International, n.d.) were discussed and refined to ensure there were no coding gaps or overlaps. Discrepancies were resolved by the PI and RA separately reviewing instances of coding differences with fit of code definitions. A list of example quotes for each code was developed to offer further clarity for future coding. All subsequent coding was completed by the RA who took part in self-reliability testing and met regularly with the university PI to discuss findings, resulting in a total of 17 codes (see Table 2). Upon completion of the interviews and analysis of the data, the university PI and RA presented preliminary findings to the retreat trainers, group leaders and members, and the WTH-HTH board of directors. The community PI and two active group leaders then offered feedback for further revisions of the study findings presented below.

Table 2.

Data Analysis Coding List

	Code type	Code Name	Definition
			Instances of a participant discussing…
PROCESSES	Sharing personal stories	Sharing narrative	… sharing their story of trauma with others.
		Connecting emotions	… naming or describing the emotions of their trauma and/or its ripple effects.
	Feeling heard and listening	Feeling heard and accepted	… feeling heard by others.
		Listener qualities and demonstration of acceptance	… listening and engaging with another sharing their story.
	Logistical aspects and composition of V&F groups	Preparation	… how they did or did not feel prepared to lead or participate in V&F groups.
		Setting	… the settings in which V&F groups occur.
		Group membership	… members of V&F groups.
		Team leadership	… leadership of V&F groups.
		Timing	… the pacing of participating in and recognizing outcomes of V&F groups.
		Safety	… the safety of their self-practices and surroundings.
		Spirituality	… the role of spirituality in V&F groups.
		Support vs. therapy	… the support model of V&F and distinctions between support and therapy.
		V&F unique value	… differences between V&F groups and other support groups or healthcare experiences.
OUTCOMES	Outcomes	Restoring trust	… restoration of trust in others.
		Connection	… connecting with group members.
		Building skills	… development of skills.
		Community acceptance and engagement	… feeling accepted by their community and/or engaging with their community.

Note. List of codes was expanded from the original 15 (start list) to 21 as additional themes became apparent in the data; list was then reduced to 17 as codes were either merged due to overlap of data or eliminated entirely due to infrequency of use.

Findings

Table 2 outlines and defines 17 codes, aggregated into four broad themes: sharing personal stories, feeling heard and listening, logistical aspects and composition of V&F groups, and outcomes. Below we describe three of these code categories as they relate to processes and outcomes of CoT. Processes (sharing personal stories; feeling heard and listening) are intended to describe the ways V&F enacted CoT practices in their groups, while outcomes highlight the results of participation. Though participants described a variety of logistical aspects of V&F groups, in-depth reporting on these is beyond the scope of this paper.

Processes: Sharing Personal Stories

Sharing Narrative

Participants described how telling their trauma stories could “relieve the burden” of the trauma by creating opportunities to (1) connect with fellow survivors (e.g., veterans) through shared experiences and (2) feel accepted by group members (both veterans and civilians) for their experiences. Group leaders played important roles in modeling sharing and vulnerability, easing conversational flow, and facilitating flexibility in the group format to prioritize group member needs.

Veteran 1: I guess we’re [veterans] kind of taught, trained, to take it and shut up. Put it in a box and throw it away. But that box doesn’t exactly stay shut. I mean, getting out and getting into a group of people that can relate is huge. You’re going to air all kinds of different [stuff]… but who cares, right? At least it’s off your back. You can leave a whole pile of whatever you want to call it here and walk away.

Participants emphasized the importance of survivors sharing their stories in their own language (i.e., including profanity or potentially troubling details). Several even described speaking a “common language” in their group as dialogue flowed naturally through shared experiences. This style of free-flowing conversation fostered interactions some may have found troubling or difficult to navigate.

Veteran 2: The very first night I was there, I was sitting at the end and [another veteran] was right next to me, and [he] was telling me that he had traumatic brain injury. I looked at him and said, ‘Well, you ever think about committing suicide?’ And the whole group goes, ‘Geez.’ And [he] was real gracious. He says, ‘Yes, I have.’ And I go, ‘Oh, boy, that’s tough.’ I says, ‘What do you think about now?’ He says, ‘Well, I’ve gotten better.’ And he says, ‘And, this group has helped me.’ I go, ‘Wow. That’s a pretty big step to climb.’ And [he] didn’t get mad. But I’m very forward. I leave nothing to the imagination, let’s put it that way.

Lastly, participants noted that discussions within groups were not restricted to traumatic experiences and ripple effects. Group participants connected through the sharing of a multitude of life experiences that extended beyond trauma and into positive aspects of everyday life (e.g., hobbies, sports, family, spirituality).

Connecting Emotions

Many participants reported difficulty expressing their feelings. For some, this was linked to stigma surrounding emotionality in military culture. Further, some participants discussed how their emotional responses to memories changed over time as a result of group participation.

Veteran 3: It’s helped my triggers. Being able to share openly and being able to share these things. I now look back, and… talk about my military experience with joy. With some pride that I served my country honorably. That came out of this group, and that’s big because any time you’d talk about military, I had all of my stuff stacked in a corner, and I just wouldn’t touch it. ‘Oh, military ruined my life.’ Now I can go in there and look at the pictures, and, ‘Oh yeah, I remember that.’

Supporting group members who connect emotions with specific traumatic memories was described as sometimes being particularly difficult for V&F group leaders. These nonprofessionals did not necessarily have backgrounds that equipped them to deal with heightened emotional responses (e.g., yelling, cursing, slamming doors) that commonly accompany sharing of traumatic memories.

Civilian 1 (community member and group leader): The night that I remember most was one when we had a big group over a year ago. Totally, without any of us initiating it, they got on the topic of traumatic grief. People went around talking about their traumatic grief. [A veteran] got into his crying episode. He was working for the VA. [This veteran] just burst out crying… there were just these episodes of traumatic grief that people talked about. They went around the room, and it took the better part of an hour. It was just really amazing that one guy was there for the first time. He talked about his acute traumatic grief, where he would just get upset. He was working in an office after coming back from Vietnam, and he said that people, when they saw him getting upset, they would just scatter because he would just haul off and hit people. He didn’t come back after that. I’ve called him a couple of times, but it was just so traumatic for him. He poured all of this out, and he won’t come back from that.

Connecting emotions to traumatic experiences is challenging. Group leaders and group members can find themselves engaged in conversations that are raw and emotionally charged, presenting situations that require patience and skillful group facilitation. Group leaders described needing training and support to navigate particularly intense situations for the safety of the survivor and other group members.

Processes: Feeling Heard and Listening

Feeling Heard and Accepted

Many participants expressed that feeling heard and accepted began with an invitation to participate in V&F. Common experiences amongst survivors allowed participants to share their stories of trauma with a deep level of vulnerability, perhaps for the first time.

Veteran 2: You can say what’s on your mind and what you feel in your heart, and these guys take it at that. They don’t analyze it or put you down, or anything like that. These guys accept who you are… That’s the way that people in the service, they accept you for who you are. You depend on that man next to you. That’s the way I still feel about this group. We’ve got a camaraderie, where we’re all in that, and that’s something that never leaves you.

Several noted that V&F groups allowed participants the freedom to communicate their thoughts and feelings, and to be accepted for their experiences and perspectives. As one veteran described about their fellow group members, “You really believe that these people understand. That’s the big thing for me, is that, here I find somebody that understands.” Feedback from peers, family, or community members was described as validating feelings and experiences by helping to normalize varied responses to trauma, while not making a survivor feel as though someone was trying to “fix them”.

Listener Qualities and Demonstration of Acceptance

By far, participants noted the most important characteristic of a listener was simply being a fellow trauma survivor, loved one of a survivor, or community member who cares deeply about and accepts survivors and their experiences. Participants described a quality listener as being able to hear and not judge, criticize, take personally, or look down upon the person sharing their story. They can set aside their personal differences, maintain confidentiality within the group, and are aware of when to speak and when to simply listen, or as one veteran put it, “If they’re going to let it buck, let it buck.” When a quality listener offers feedback, it promotes personal growth and counters self-deprecating views. The nonprofessional nature of group leadership, participation, and setting allowed for listeners to bring their experiential knowledge to the table without imposing authority.

Civilian 2 (community member and group leader): … in your [authoritative] role, you are supposed to be the authority on morality and the right kind of ethics and all of that, but in that group, you have to let that go because you have to listen… to still be able to speak a message when it’s needed, but not to wince when I hear a bad word, or think, ‘Oh, that person’s horrible for what they did.’

Further noted, participants characterized an invested listener as a “non-anxious presence” who is able to model sharing and vulnerability, capable of feeling with the survivor without being triggered or with the knowledge of how to manage their triggers, and open to being changed and forming new understandings of their own experiences by hearing another person’s story. However, an individual does not need to exhibit all of these qualities to be a good listener. Participants emphasized the importance of being oneself as long as listeners are aware of and continuously working towards a “non-anxious presence” that benefits others in the group.

Outcomes

Restoring Trust

Establishing trust with group members takes time. Many participants expressed having had difficulty initially opening up due to lack of trust within the group. In some instances, it took an individual witnessing a fellow group member share their experiences (and demonstrate vulnerability) to establish trust in the group.

Veteran 3: These are long-term things that we’ve dealt with for a lot of years, and we need a long-term type thing. And for me, that’s what really appealed to me, was that I didn’t feel pressured. It wasn’t in your face kind of, let’s get this guy fixed… this was just a safe place to come, lay it out on the table and not be judged, and kind of work it as we feel it. Once you get comfortable with everybody, it may take a year to get comfortable, seriously for some of us to open up… a lot of guys that are coming in aren’t very trusting and really don’t want to open up that way, so I’ve got a lot of faults and I can share them and go, ‘Hey, it’s alright.’

The low-intensity, long-term nature of V&F allows for trust to develop slowly as veterans come to know one another and learn from their experiences of trauma and healing.

Connection

Through sharing of common experiences, demonstration of respectful listening, and establishment of trust, participants reported forming connections with fellow group members. The level of personal connections formed amongst group members was described as a camaraderie, brotherhood or family, and “radical friendship”. Participants emphasized that these connections were forged from genuine compassion and not an ambition to “fix” survivors. Veterans expressed that it felt particularly powerful to share amongst peers, regardless of branch, era of service, or rank. Further, connections fostered comfort with one another that extended beyond participation in a group, as participants were invited to call each other or meet outside of the group time and setting, whether for leisure or because they were in need of help.

Connections formed amongst veterans and civilians differed between groups. Veterans in the veteran-only group described how civilians cannot understand the depth of camaraderie that veterans share.

Veteran 2: It’s just, I feel like bothers, man… And that’s the way I felt in the service, too. I mean, he depended on you, and you depended on him, and that’s just the way it is. That’s what family does…

Veteran 3: And you try to recreate it, and it’s just, civilians don’t understand the depth of camaraderie or friendship.

Conversely, a veteran in a more mixed group felt he would not be interested in participating in a group without civilians.

Veteran 4: I feel that I could relate to non-vets more than I could to vets, and if this was just about the vets, I don’t think I would be attracted to it as much. I think I could work with both, but I don’t think I could work with just the vets alone.

Of note, we also observed connection amongst military spouses attending V&F groups in support of their partners. Particularly, the presence of other spouses who shared their stories of struggle helped normalize everyday challenges surrounding mental health, family dynamics, workforce problems, and more related to military transition.

Civilian 3 (veteran spouse and group leader): … we have two civilians… what they bring is… kind of a reality check. We were going through all of these things that we wished that our families could be, kind of a vision for our families, and then, she said… ‘Well, I deal with the same issues.’ We’re all like, ‘You do?’ …it was very interesting and really helpful to hear that everybody has these struggles, just to different degrees perhaps, or a different source perhaps, nevertheless, it’s the same journey.

Just as sharing and listening established trust and fostered connection, participants stated that trust and connection in-turn supported their ability to share and listen.

Building Skills

V&F participants reported experiencing incremental improvement in their quality of life through information gleaned from group conversations about specific aspects of trauma and moral injury.

Veteran 3: We got information and we went, ‘Oh, that’s why I’m reactive,’ and understanding that really helped, for me, to understand why I respond to it and not be so self-conscious about it. It’s a brain injury. This is why you do what you do. And then the tools now to adjust my life in ways that can better handle that, so I can respond instead of react. All that stuff was brought up to the table, and it was really nice.

They described learning from each other how to develop as leaders (within the group extending out to the community), navigate systems (e.g., healthcare, veteran services), communicate their needs (e.g., to a doctor, friend, partner), gain awareness of and manage intrusive thoughts or triggers (their own or someone else’s), and advocate for and be a friend to fellow survivors. Importantly, these cumulative improvements were recognized and celebrated amongst group members.

Community Acceptance and Engagement

V&F participants described that being accepted by a community means “being able to be who we are” and in return receive “genuine care.” Veterans are, as one participant put it, “a little gruff sometimes.” Individuals in V&F groups have endeavored to reach isolated veterans in their communities to begin the process of reconnecting, and have also reached out to their larger community to ask for support in healing their trauma. For example, one veteran wrote a letter to his church describing his experiences of trauma and asking for support through prayer.

Veteran 5: And I think that’s [ability to speak freely] a key component though, and that’s part of why I wrote the letter back to my church just on sharing more of my story… I think that’s the transparency, and… it doesn’t have to be a vets issue. This is life issues. And if you can go back and have an honest conversation of, here’s what I struggle with, and here’s how I’m working through it, and here’s the blessing and the hurt and the pain, and all of it together, that’s real life.

Membership within a V&F group sparked a change in how participants engaged with other community members. For example, several participants who previously isolated themselves began to socialize with others in public and developed friendships within and outside of the groups.

Discussion

V&F shows promise in meeting veteran-specific reintegration needs through communalization of trauma. V&F provides a safe space to share and emotionally connect with narratives of trauma amongst a trustworthy group, and supports regaining control over troubling experiences and engaging in community. Similar to other veteran-focused CoT programs, V&F appears to restore trust and sense of connection among participants by creating safe “communities” of group members in which veterans’ traumatic experiences can be shared, heard and accepted. V&F participants described the importance of telling their stories naturally at their own pace (Ali et al., 2018), healing through group acceptance and validation (Keenan et al., 2014), and gaining insight into their struggles that helped them transform painful experiences into growth opportunities (Wilson et al., 2009). This kind of transformation suggests that V&F can support posttraumatic growth, in which trauma survivors develop new understandings of self and relation to others as well as possibilities for the future (Tedeschi et al., 1998). Interventions that help veterans safely re-experience symptoms and enhance social connection appear to promote posttraumatic growth (Tsai et al., 2015; Tsai & Pietrzak, 2017). Participants described learning about trauma as key to helping them normalize and reframe their experiences. Psychoeducation is effective at helping traumatized individuals understand trauma and its effects, as well as where they are in their own healing journey (Brave Heart, 1998; Ray, 2009a). Further, “critical adult education,” in which counselors and clients explore structural causes of trauma, may be helpful at reducing stigma and using strengths-based approaches to healing (Burstow, 2003). V&F appears to be unique in its fostering of connection among veterans and civilians to validate experiences, challenge negative views, and cultivate community acceptance. In addition, V&F is a small-scale grassroots program formed by veterans and non-veterans to meet specific needs within their communities. This may mean it is more acceptable to community members than professionally-led CoT approaches within formal healthcare settings.

CoT offers a long-term, low-intensity approach to healing in a community setting where peers and civilians can demonstrate listening that validates and restores trust in the community, in contrast to formal services which typically take place in clinical settings and are often short-term and individualized (Munroe, 1996; Shay, 1995; Spring, 2016). V&F groups, however, experience similar challenges to other mental health care, including limited availability of resources (e.g., adequate meeting space, opportunities for referrals to formal care) and challenges finding diverse leaders as indicated by the team-based approach (e.g., mixed gender, age, professional and life experiences). Further, V&F groups are not likely to work for all veterans – participants mentioned that recently returned veterans may need time to settle in before processing their experiences. In addition, the nature of long-term support is time-consuming and demanding of participants (particularly group leaders), and requires committed attendance and shared responsibility to the groups, as well as regular training and support of group leaders. A CoT lens may be useful to community psychology in research on community healing and reconciliation processes (Danesh, 2008; Kang et al., 2020).

A strength of this pilot study is the university-community collaboration through all phases of the project, including writing this manuscript. This allowed us to develop our partnership by establishing rapport with key stakeholders in V&F, further ensuring data validity. This study adds value to current literature by further developing upon applied components of CoT in a real-world context, illustrating outcomes of a nonprofessional peer-led community-based support group, and offering insights into rural approaches to combating mental health issues faced by veterans, families, and community members. Limitations of this study include a small sample size, reliance on participant memories for groups not currently operating, and challenges associated with describing an innovative program during its developmental stages from the “ground-up”.

Future research should identify relevant outcome and process measures to capture both impacts and mechanisms of change at different levels of analysis (e.g., individual, group). Our findings suggest assessing posttraumatic growth in the form of restoring trust, sense of community/connectedness, building skills and community engagement as outcomes of CoT. In discussing replicability of V&F groups with program leadership, we decided a “principles-focused evaluation” approach (Patton, 2017) to studying program implementation would best meet both group and evaluation needs. This type of evaluation allows for program formats (e.g., number of sessions) to vary as long as core principles that define and differentiate V&F from other programs (e.g., creating safety, allowing individuals to share at their own pace) are adhered to. In contrast to conventional approaches to “fidelity”, program functions (or principles) are standardized and the specific forms can vary in response to local group needs, values and goals (Hawe et al., 2004). This will advance understanding of V&F as well as similar CoT approaches in veteran and other populations experiencing moral injury and trauma. An informal comparison of ongoing versus disbanded V&F groups suggests that differences were most apparent in life-expectancy of groups, consistency in leadership personnel and approaches, and clear rules surrounding who can participate and how. Finally, more research is needed to understand how best to recruit, train and support group leadership teams in CoT approaches.

Conclusion

Veterans face unique challenges returning home to their communities, including threats to mental health due to trauma experienced while serving. Community-based support groups that utilize CoT approaches – like V&F – have the potential to address these traumas and offer resolutions by creating a safe environment for the restoration of trust and acceptance by community. Findings highlight opportunities for future use of CoT practices in community-based support settings, particularly when utilized in conjunction with formal (professionally-led) care.

DATA AVAILABILITY STATEMENT

Data will not be made available to the public.