Long-Term Group Nature-Assisted Therapy for Veterans Diagnosed with Chronic PTSD

ABSTRACT

Posttraumatic stress disorder (PTSD) is common among veterans. However, many veterans who deal with this condition avoid therapy, and innovative therapeutic solutions are needed. The current article presents a case study of combining nature and group therapy in a long-term, group adventure therapy program for veterans with chronic PTSD. Qualitative data were collected during four focus groups with 10 participants. Thematic content analysis was employed to conceptualize this intervention’s therapeutic components. Three main themes were identified, highlighting how this program enhanced participants’ skills in coping with PTSD avoidance symptoms, because group relations constituted a platform for promoting rehabilitation efforts. Nature was described as a pivotal curative factor, providing added value to this therapeutic model. These findings suggest nature-assisted therapy is a promising supplementary intervention, particularly for clients who fail to gain sufficient improvement via other individual or trauma-focused therapies.

KEYWORDS:

• Group therapy
• PTSD
• veterans
• nature-assisted therapy
• qualitative research

Posttraumatic stress disorder (PTSD) is a well-documented phenomenon with lifetime prevalence rates ranging from 1.3% to 12.2%, depending on country and social background (Karam et al., 2014). The main features of PTSD are intrusive memories of a traumatic event, which lead to avoidance reactions of trauma-related reminders. These reactions are followed by alterations in mood and cognition, a pervasive sense of imminent threat, sleep disturbances, and hypervigilance (Shalev et al., 2017). The PTSD rate is especially high among combat soldiers, generally estimated at 20% (Fulton et al., 2015), and it can develop to a chronic state, estimated to affect between 2% and 15% of all cases (O’Donnell et al., 2020). Substantial rates of depression (around 50%) and other comorbid conditions (Roberts et al., 2020) make coping with the aftermath of combat trauma a major concern for veterans and mental health providers alike (Trivedi et al., 2015).

Various pharmacological and psychological treatments are offered to people with PTSD. However, the recovery percentage is not yet satisfactory (Shalev et al., 2017). Moreover, many veterans diagnosed with PTSD do not seek mental health assistance (Hoge et al., 2014; Mott et al., 2014; Spoont et al., 2016), and many suggested psychological treatments are terminated prematurely (Lewis et al., 2020).

Veterans have mentioned several obstacles that prevent them from seeking mental health assistance. Among them are peers’ and commanders’ devaluations (Hoge et al., 2004), fears of negative stigma (Brown & Bruce, 2016; Mittal et al., 2013), and negative implications for future career development (Brown & Bruce, 2016).

The symptom complexity of PTSD requires the use of varied therapeutic strategies (Cloitre, 2015; Gerger et al., 2014) and flexibility in their application (Van der Kolk, 2014). Given veterans’ reluctance to engage in standard psychological treatments, there is a growing need to develop novel and innovative mental health modalities that better suit this population (Cukor et al., 2009). The current article presents an example of combining several therapeutic factors (group, nature, cognitive, and behavioral interventions) to augment their effects.

Group treatments are associated with improvements in symptoms of PTSD (Schwartze et al., 2019). Group cohesion (Ellis et al., 2014) and interpersonal learning (Yalom & Leszcz, 2005) have been identified as universal healing factors for group interventions that enhance the efficacy of group treatment. These elements are even more relevant for group members who deal with trauma-related avoidance behaviors.

Spending time outdoors and being in contact with nature can enhance mental health (Bettmann et al., 2019; Bird, 2015), because nature has unique healing properties (Berger, 2017) that affect different sensory and nonverbal attributes than talk therapy (Franco et al., 2017). The psychological response to spending time in nature includes feelings of pleasure, sustained attention and interest, “relaxed wakefulness,” and a diminution of stress-related negative emotions, such as anger and anxiety (Maller et al., 2006). Such mindful states allow reflective observation of what is happening inside and outside the individual, similar to what clinicians aim to achieve in therapeutic group interventions. In the case of patients with PTSD, the purpose of observation is to suspend the impulsive response and automatic defense mechanisms. In group therapy for patients with PTSD, this factor has an even greater impact because each participant gets to see this mechanism at work both personally and among group members and practice such skills in real-life situations with other group members (Schwartz Landrum, 2016). Because nature-based therapeutic interventions take place outside of clinics, they may also reduce the negative stigma often associated with psychiatric treatments (Brown & Bruce, 2016; Forsyth et al., 2020).

Nature-assisted therapy (NAT) is a broad term used to describe therapeutic interventions that combine nature’s elements with a therapeutic practice. NAT exists on a continuum (Poulsen et al., 2015) from more extreme and usually short-term interventions (usually a workshop of several days in which participants experience individual and group challenges in the wilderness), to longer-term, less extreme interventions that consist of half-day weekly outings in which participants experience therapeutic interventions in a nature-based environment, such as gardening and fishing (Annerstedt & Währborg, 2011). Different models promote the use of specific natural properties to enhance patients’ well-being. Professional choices are also dependent on the therapist’s theoretical approach and can be defined in various ways (Cooley et al., 2020). For example, therapists can use nature as a setting for talk therapy to promote a conversation, as a tool for psychological projections to promote psychological dynamic movements, or to challenge group members to promote behavioral coping and build psychological strength.

Characteristics shared by all NATs include spending substantial time in nature to enhance curative elements such as the experience of wonder and fascination and the sense of being “away” from daily stresses. Moreover, NAT promotes practicing a different approach to daily problems and the sense of having access to something that is easily in reach, providing a feeling of self-efficacy and satisfaction (Maller et al., 2006).

Combining different therapeutic approaches with nature in therapy can maximize the healing potential of each (Duval & Kaplan, 2014). Accordingly, a common combination of two different therapeutic modalities is of NAT and Adventure-Based Programs (ABP), which were found efficient in helping veterans reintegrate in society by enhancing their sense of coherence and overall well-being (Ewert et al., 2011).

Prior research found that nature-assisted interventions are associated with positive physical and mental health outcomes (Duval & Kaplan, 2014; Greer & Vin-Raviv, 2019), including reduced blood pressure, anger, aggression, and anxiety, along with increased self-esteem and reduced negative stigma (Forsyth et al., 2020), better cognitive abilities, and interpersonal cooperation (Bill, 2017). However, such positive findings still lack a sufficient evidence base and systematic long-term follow-up (Greer & Vin-Raviv, 2019; Hoag et al., 2014). Moreover, most finding are based on short-term therapeutic interventions (Dietrich et al., 2015). The current research aimed to fill this gap by presenting a long-term therapeutic intervention that augments its healing factors’ strengths while implementing it with male veterans. Research regarding men’s experience of change is limited. We aim to expand the knowledge in this field.

Current case study: nature-assisted group intervention for veterans with chronic PTSD

A long-term, open-ended group intervention was provided for veterans dealing with chronic PTSD in an outpatient clinic of a general medical center in Israel. Enlisting in the IDF is mandatory for Jewish men and women and for Druze men, and some Arab-Israeli citizens also choose to enlist on a voluntary basis (Shorer’s own, in press). As most of Israeli citizens are veterans, treating veterans is part of the regular medical service. The group featured three therapeutic factors: a supportive social environment in a therapeutic group setting, nature’s healing properties, and the use of challenging activities.

The group met year-round for a weekly group outing, lasting 2 hours, in outdoor locations around the medical center. Like other nature-assisted therapies (Poulsen et al., 2015), the group consisted of eight to 10 male veterans at any given time. Being a small country, military service in Israel is often relatively close to the soldier’s homes. Moreover, as most of the combat service is taking place among civilian areas, soldiers and veterans deal with many moral dilemmas throughout their service, and the transitions from a mental state of “being a soldier” to a mental state of a civilian is frequent and stressful (Lander et al., 2021). Dealing with PTSD in this context is usually complicated, as the army service is a major issue in the Israeli daily life.

The group was led by two professionals: one mental health therapist and one outdoor facilitator. Group interventions combined aspects of the “softer” type of NAT with “peak” interventions during which participants experienced more extreme challenges. Activities were selected according to group dynamics, combined with theoretical considerations. As such, the group facilitators constantly focused their interventions in accordance with the group’s development and tried to match the right nature-assisted intervention to support and enhance this development. Appropriate trauma-focused interventions for certain stages were chosen. For example, practicing in vivo exposure to stressful situations occurred alongside the need to trust others, challenging situations in terms of the ability to communicate emotions and thoughts, and more. In this framework, participants experienced many kinds of short-term individual and group challenges: hiking, navigating, camping, and challenging group tasks. In addition, four annual “peak” interventions involved three full-day hikes and one overnight stay in nature.

Every group session involved group discussions, both before and after the main activity (Yalom & Leszcz, 2005). These discussions enabled participants to process their emotional and physical experiences and connected them to past and present events in their lives. The discussions were designed to enhance participants’ process of meaning-making, which is an intrinsic part of the healing process.

An important component of this model is masculine camaraderie, or “brotherhood.” On the behavioral level, participants got to practice skills that were previously associated with negative military memories in a safe and therapeutic setting. This was achieved, for example, because to participate in the group, participants left behind their routine and went off to join their “buddies,” where they worked together to achieve a challenging task. On the atmospheric level, a special group vibe developed (e.g., establishment of private and shared humor), resembling the characteristics of a military unit.

Method

This research followed a thematic analysis approach, which is a systematic and rigorous approach to coding and theme development in qualitative research that highlights the process of gathering themes as contextual and subjective (Clark et al., 2015). Thus, this approach is suitable for the study of psychotherapeutic interventions, which are always contextual and subjective experiences.

Participants

The current case study presents findings from the past 3 years of the group’s work, during which we treated 10 military veterans (eight Jewish and two indigenous Muslim Bedouin soldiers), who were 52 years old on average (SD = 9.46) and served between 3 and 23 years (M = 4.5) in various combat positions in the Israel Defense Forces. All participants were diagnosed with chronic PTSD and were married. Half were unemployed at the time of the focus group.

Data collection and analysis

The research was approved by the medical center’s board of ethics, and the participants consented to the use of these materials for this case study. Qualitative data were collected during four focus group meetings. Focus groups of different sizes and settings are a well-documented tool for empirical investigation, providing the opportunity to explore relations among self, other, and context. Thus, they are a good choice for research on sensitive topics and vulnerable populations (Kamberelis & Dimitriadis, 2020). To give voice to participants’ knowledge (Letendre & Rankin Williams, 2014), the participants were asked to reflect on their personal journey in the therapeutic group. The leading questions were: “Please describe your experience of that group intervention. What, in your opinion, are its characteristics, and how do you feel regarding this therapy’s components?” Their responses were recorded and later transcribed verbatim. Participants names and other identifying details were changed to ensure their privacy. Original data were in Hebrew and have been translated for this article.

Thematic analysis (Clark et al., 2015) was used to conceptualize participants’ experiences. In line with this process, the first two authors separately analyzed the data, then compared and discussed their analyses until agreement was reached. Their conceptualizations were then presented to two other professionals (the third author and a NAT provider specialist) for critical reading. Another round of discussion occurred after their critique was received. The final materials were presented to the participants, who reviewed and approved the suggested conceptualizations. This process ensured that acceptable standards of rigor were met (Krueger & Casey, 2015; Tong et al., 2007).

Findings

Findings were conceptualized into three themes, representing the core components that make this therapeutic intervention effective: (a) reaching out to the world, which lies in direct contrast to what individuals with PTSD-related avoidances typically do; (b) belonging: being part of a group and taking advantage of group relationships as a platform for healing; and (c) nature as a curative factor.

Reaching out to the world: “Being in the World”

Sharing of difficulties and coping methods with their peers usually came after many years of social concealment. As such, it constituted a significant step in the participants’ group experience. Moreover, the support and help that group members provided one another had a unique nature. For example, Leroy, 64, who had been coping with PTSD for more than 30 years, described how the group members helped him overcome stigma and stigma-related barriers to treatment:

This group is the only place where I am known not as a PTSD patient, but as myself. The members here know me for my personality and accept me for who I am. And this has great meaning for me. By doing so, the group has given me an extraordinary gift.

In another example, Tom, 52, described his experience and related to the group work as a catalyst for personal change:

I have a problem—I have to be in control all the time. … [For me,] following someone else in complete blindness was very hard … but doing it [during the group activities] taught me to reduce my stress. And I could never have imagined doing such a thing, but actually—I really enjoyed it!

Tom found the group offered the right environment to test his coping skills, and he was pleasantly surprised to rediscover his developmental potential, because he was able to accomplish much more than he previously believed. In another example, Mussa, 38, a Bedouin who had served for 16 years in the Israel Defense Forces, said the following:

I was on this hike with the group where the anemones were in full bloom, and I felt I was really breathing. … It made me feel good, and it came after a very long time where I have not had such feelings at all. So, I wanted to share that feeling with my kids. The week after that I brought them there. We sat there and felt good. And although when I hang out with the kids, it gets hard for me after a few minutes—I still managed to do it.

Mussa illuminated how skills learned during group activities can be generalized to life outside the group as a new, meaningful form of learning. His success in sharing this positive experience with his family led to a growing feeling of self-value, a significant quality that seems to be severely damaged in veterans coping with PTSD. His words emphasize how such interventions can help stop PTSD’s vicious cycle, which is critical for engaging traumatized veterans in rehabilitation programs.

Belonging: being part of a group

Psychological trauma involves an experience of emotional flooding that cannot be contained in the context in which it is experienced (Storolow, 2007). Reflecting on the healing process, Jack, 48, who had been coping with chronic PTSD since his mandatory service 30 years prior, illuminated how participating in the group made him realize the need to accept his condition and pushed him to adopt different coping methods. Reflecting on a navigation task in which he and his friends had to meet the challenge of finding their way in a forest, he said:

We have to face and internalize our condition and struggle back. Look forward at all times. Even when everything seems difficult and impossible. And I do not know about you guys, but as for me, the group empowers me and provides me with strength to keep doing this.

The empowerment he described seemed to stem from the group, which provided a noncritical and unmediated source of support. Like Jack, the other participants explained that the group provides a therapeutic environment and antidote to their posttraumatic experience by promoting a sense of “brotherhood” – the very same feeling of partnership and belonging that was severely damaged during and after their trauma.

Because the group intervention involved movement, both concrete and metaphorical, participants became energized by the group spirit, which seemed to fuel them and helped them get past their individual apathy. This trend seems to be at the heart of the group’s therapeutic power. Gabi, 49, elaborated on how the group’s therapeutic effects can influence participants’ lives beyond the group meetings:

When you feel bad, call someone from the group, because they are the ones who will understand you. Please do not fear you are a burden on me. Because when you turn to me for help, you are actually strengthening me as well, as you give me an opportunity to feel valuable.

Gabi emphasized the meaningful benefits that participants gain from being in relationships with one another. Based on his words, these informal interactions seemed to provide participants with opportunities to feel self-worth, rather than feeling weak and criticized for their illness. In another example, Mark, 47, who served as a medical first-responder for many years, referred to another group member who was coping with a life-threatening physical disease. Mark’s words emphasize the participants’ strengths in mutually supporting and empowering each other:

In the midst of Hanukkah [the Jewish holiday of lights], each of us is like a small light and all of us together form a bigger and stronger one. Gather our blessings as a strong light’s beam and push away the disease with great force and intensity, so no darkness remains.

These examples attest to the group’s power as a continuous support system. It served as a secure base that promoted participants’ resilience, strengthening them as they coped with various daily challenges. Leroy shared his experience of overcoming an avoidance that had been going on for many years, providing an example of the group’s contribution to his ability to face the outside world in a more active way:

It is now 44 years since the war, and it is the first time I am participating in the memorial ceremony in my village, where many soldiers are buried, including my classmate who fought on the same front as I did. And although this is a personal achievement, I must tell you guys how big your contribution is in helping me to restore my inner strength and to achieve this goal!

Such positive experiences seemed to fuel the group’s ongoing work, reinforcing other participants’ efforts to cope with PTSD and other stress-related symptoms. The group environment, which combined interrelational therapeutic work with concrete behavioral activities, seemed to create a synergetic process that empowered participants’ personal strengths.

Nature as a curative factor

While outdoors, participants often experienced the healing properties of being in contact with nature. This was achieved, for example, as they practiced a mindful walk in nature, away from their daily life hassles. A new way of coping emerged, as Tom, 52, described:

We go out and see how nature regenerates itself. This gives us the sense that within ourselves, something was also cut off and blocked for a period of time, but this does not mean we are going to lose our hope. … We have lost our confidence, but here we can start to regain it.

Tom used nature as a metaphor for his life and compared the changes he observed in the outdoors to changes he has experienced in light of the trauma he endured. Other participants also described nature as a therapeutic component. Being in touch with nature (e.g., observing the life cycle of flowers or watching leaves or water flowing downstream) seemed to help them accept the changes that occurred in their lives as a natural process. This attitude stands in sharp contrast with their stagnant state when they first entered this group therapy.

Reflecting on this issue, Leroy talked about the shift in his self-efficacy as he felt a sense of vividness arise from within while being outdoors with his peers: “For many years I’ve been like the living dead. … Now, when I go to Harod Spring or to any other spot outside, I feel that I am alive again!” This experience of renewed vigor while being in nature with his peers supported an active stand against the illness, as described by most group participants.

Discussion

A group is often described as a whole that is greater than the sum of its parts (Foulkes, 1983). This description seems apt for the current case example, regarding not only the human resources of the group but also its therapeutic components: group, challenge activities, and nature. Participants indicated an improved ability to cope with PTSD’s presence in their lives, highlighting growth that seemed to be possible as a result of higher levels of psychological mindedness and the reduction of the use of emotional suppression in a synergetic group process.

This group’s therapeutic approach addressed the consequences of trauma in an indirect way, different from trauma-focused therapies, which directly address PTSD symptoms. Participants’ posttraumatic conditions were manipulated through exposure to associated stress and anxiety-provoking components. Nature served as a kind of a bypass, providing a platform for influencing posttraumatic stress via indirect exposures, while the other two therapeutic components were naturally activated. In this framework, numerous nonverbal, emotional, body, and mind experiences were elicited. Because the group occurred throughout the year, participants had the chance to practice every skill for a few weeks, ensuring prolonged in vivo exposure to nature and the other healing components. Thus, the conditions for participants to master the skills of overcoming provoked discomfort – connected to or created by the behavioral tasks that took place during the group’s meetings – were maximized.

These sensory-based experiences enhanced regulation abilities, which seemed to be badly damaged in these traumatized veterans. At the same time, the nature-assisted activities provided many opportunities for spontaneous exposure to numerous activating stimuli (noises, meetings strangers, and other incidences that occurred while spending time in the world). In this way, participants coped with emotional issues that arose not only from the present group assignments, but also from past traumatic experiences reflected in the present challenges. Successful coping in the group sessions improved the chances of successful coping in other stress-related arenas and enhanced improvement in mood and functioning far beyond the group meetings.

In the current case study, participants regained mastery over activities typically considered masculine and reminiscent of activities they engaged in during military service (e.g., long hikes, navigating, spending the night in the woods, team challenges). Such experiences seemed to be crucial for the group’s development and the participants’ individual growth. Participants’ recognition of their capabilities helped them build trust in themselves and others and generated hope for movement toward a healthier future. This behavioral process appears to have led to a gradual shift in clients’ cognitions and emotions regarding themselves, others, and the world.

In line with previously described nature-assisted therapeutic interventions (e.g., Bettmann et al., 2019; Poulsen et al., 2016), nature served as a catalyst in the process of change. Being in nature helped participants cope with shame and stigma and enhanced their communication skills, which in turn, aided the sharing of trauma-related content in both verbal and nonverbal ways. By doing so, an indirect emotional processing of traumatic memories took place (Poulsen et al., 2016), leading to an alleviation of stress.

Moreover, nature-assisted therapeutic interventions which combined challenging and adventurous components seemed to reduce feelings of hopelessness and increase positive and empathic responses among participants (Greer & Vin-Raviv, 2019). As previously documented, our participants also developed new coping strategies that seem to support reestablishment of a healthier sense of self and a new trust in the world and others (Poulsen et al., 2016), elements that were damaged among them, similar to many traumatized clients (Dettmer et al., 2015). These interventions seem to work through nonverbal mechanisms, such as behavioral activation, desensitization, and a gradual exposure to anxiety-provoking situations (Gelkopf et al., 2013), as well as cognitive generalization of successes (Poulsen et al., 2016). As participants shared successful experiences, group support played a mutual role, by which both the giver and receiver of feedback were empowered.

Although the effectiveness of group interventions for PTSD has been found to be only moderate (Haagen et al., 2015), being part of a group seems to have the potential to empower individuals and reveal unique personal qualities different from individual psychotherapies (Sloan et al., 2012). Former research had found nonspecific treatments for PTSD to be beneficial for symptom reduction (Gerger et al., 2014). Unlike other types of groups, which provide shorter interventions for veterans coping with PTSD (e.g., Gelkopf et al., 2013; Levi et al., 2017), the current study involved a longer-term and open-ended group intervention, which allowed participants to gradually develop their engagement and trust in the group and the therapeutic process (Williams et al., 2014).

This study has several limitations. First, the group featured a relatively small number of participants, and the analysis was based on a single group. The data were systematically collected during the last 3 years of the group at different points. Expanding the data collection is needed. Another limitation is that we could not pinpoint a specific healing factor that promoted change for these participants. Hence, we can only use our clients’ descriptions as a testament to its effectiveness. Further research on combined therapeutic initiatives is needed to improve our ability to address veterans’ needs.

Conclusion and clinical implications

Long-term group work that incorporated spending weekly periods of time in nature was found to be helpful in supporting and promoting traumatized veterans’ rehabilitation efforts. This group intervention is a promising supplementary intervention that is particularly suited to clients who have failed to achieve sufficient improvement via other individual therapies.

Disclosure statement

No potential conflict of interest was reported by the author(s).