High-Intensity Sports for Posttraumatic Stress Disorder and Depression: Feasibility Study of Ocean Therapy With Veterans of Operation Enduring Freedom and Operation Iraqi Freedom

The PTSD Checklist—Military Version.

The PTSD Checklist—Military Version (PCL–M; Weathers, Litz, Herman, Huska, & Keane, 1993) was used to assess PTSD symptomatology. The PCL–M is a 17-item self-report assessment of PTSD symptoms in the categories of intrusion, avoidance, and hyperarousal as described in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV; American Psychiatric Association, 1994). The PCL–M specifically asks about symptoms in response to “stressful military experiences” and is used in screening for PTSD and monitoring symptom change during and after treatment (Bliese et al., 2008; Wilkins, Lang, & Norman, 2011).

Two approaches for scoring the PCL–M, which indicate severity of symptoms, are used: (1) cutpoint scores and (2) the symptom-cluster approach. Total scores can range from 17 to 85, with a cutpoint of 50 (Hoge et al., 2008) or 60 (Dunn, Julian, Formolo, Green, & Chicoine, 2011), indicating a clinically significant level of PTSD symptoms. Using the symptom-cluster approach, a clinically significant level of PTSD symptoms is indicated if a servicemember reports at least a moderate degree of bother for one or more intrusion symptoms, at least three avoidance symptoms, and at least two hyperarousal symptoms (Brewin, 2005, as cited in Tanielian & Jaycox, 2008). The PCL–M has been shown to have adequate internal consistency (rs = .75–.80), test–retest reliability (r = .80), and convergent validity (κ = .64) in Vietnam veterans and provides a relatively conservative indication of change in PTSD symptoms (Wilkins et al., 2011).

Major Depression Inventory.

The Major Depression Inventory (MDI; Olsen, Jensen, Noerholm, Martiny, & Bech, 2003) is a self-report measure that is used to assess severity of depressive symptoms. Psychometric studies of the MDI in veterans are limited, but studies in psychiatric outpatients have shown acceptable reliability and validity (Cuijpers, Dekker, Noteboom, Smits, & Peen, 2007). Each of the 12 items is scored on a 6-point scale ranging from 0 to 5, with higher scores indicating greater symptoms. A scoring algorithm is provided for determining the level of depressive symptoms according to DSM–IV criteria. Using the total score (range = 0–50), respondents can be grouped according to severity of symptoms as none, mild, moderate, and severe (Cuijpers et al., 2007; Forsell, 2005).

The Ocean Therapy Components.

Ocean Therapy is based on principles of occupational science and occupational therapy in which participation in meaningful activities within the natural environment (e.g., surfing) is both part of the therapeutic process and a desired outcome (American Occupational Therapy Association, 2008; Gray, 1998; Stoller, Greuel, Cimini, Fowler, & Koomar, 2012). One intention of the intervention is for veterans to develop sufficient skills that they are confident and competent to paddle out, catch a wave, and ride it in to shore. The intervention is also designed to provide a supportive setting in which veterans can reflect on the process and experience of acquiring new skills in a safe but unpredictable environment such as the ocean. For example, examining participants’ responses to situational challenges on the beach, such as getting along with others or dealing with frustration if good waves do not come along, may provide lessons for successful transition to civilian life.

The following sections briefly describe the program structure and the five resiliency themes addressed during the five sessions. In addition, we describe four dimensions of the occupation-based process that link surfing, veterans’ military experiences, and return to civilian life (see Figure 1).

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Figure 1.

Ocean Therapy^TM program components, including the resiliency themes addressed, the surfing skills taught, and the key process elements that evolve and intertwine across the five sessions.

Program Structure.

The program comprises five 4-hr sessions occurring weekly for 5 consecutive weeks. The sessions combine the active experience of surfing with focused group processing and collaborative social participation among civilian volunteers and fellow veterans (Cole, 2005; Fazio, 2008). Each group consists of 25–35 participants, including 10–15 veterans, 15–20 volunteers, a safety and logistics coordinator, and an occupational therapist competent in surf instruction, group processing, ocean lifeguarding, and first aid. The occupational therapist coordinates the organization of each session and facilitates the discussion. All group members, including veteran participants, volunteers, and staff, engage in the discussions to enhance group partnership and trust, key elements that support the success of the surf lesson and foster transition skills.

Each 4-hr session consists of a 45-min introductory presentation and two surf lessons, each of which is followed by a time for reflection and group discussion. The introductory presentation sets the framework for the session, describing the mission of the program and the resiliency theme for that week. It also addresses pragmatic concerns such as the schedule for the day, safety information, and introductions. Next, participants engage in a 15-min stretching session to warm up, before moving to the surfboards for 20 min of on-land instruction and practice. Each of the techniques required to successfully paddle out, stand up, and ride a wave in are taught in the first lesson but are specifically strengthened and developed across the five sessions. Additional content in subsequent weeks includes wave selection, ocean currents and conditions, and surfing etiquette.

Participants are paired with a surf instructor for each 45-min individual surf lesson. This lesson is followed by 20 min of focused group processing led by the occupational therapist in which participants share the sensations and emotions evoked by the experience of surfing and describe how this experience relates to the resiliency theme being addressed during that particular session. Consecutively, surf instructors reinforce participant experiences by providing candid observations of the participants’ accomplishments and challenges during the surf lesson. Participants then identify a surfing skill they can improve, and then work on this skill in the second 45-min surfing lesson. The final portion of the session includes a communal lunch and group discussion in which the occupational therapist helps participants reflect on how the process of learning new surfing skills and experiences while interacting with other veterans and civilians in a somewhat unpredictable environment can be applied to their current life situations.

Resiliency Themes.

Themes of resiliency are used to conceptually frame the intervention (Reyes, 2013). Resiliency has been described as a person’s ability to apply successful coping strategies in response to stressful life situations to resume usual activity engagement and social relationships (Richardson, 2002). Ahmed (2007) suggested that resiliency in response to traumatic events can be facilitated by enhancing positive beliefs and attitudes and supporting creative processes. The following five resiliency themes are addressed across 5 wk in the order listed:

Key Process Elements.

The experiences of the first author (Rogers) over several years engaging veterans with surfing have suggested four key process elements that may enhance the therapeutic experience of this occupational therapy intervention by connecting participants’ surfing experiences to their previous military identity and current challenges they face as they transition to civilian life (Kielhofner, 2008).

The first process element is “getting demo’d”: relating surfing culture to military culture. Concepts used to describe military culture include masculinity, attention to the physical body, discipline, adrenaline, and a mission-centered brotherhood (Greene, Buckman, Dandeker, & Greenberg, 2010). Returning veterans may have difficulty finding a similar culture in civilian life. The surfing culture is defined by many of the same dynamics as military culture: It is a male-dominated sport in which fitness is required to manage in vigorous ocean conditions, and the “mission” of riding a wave can be an intense challenge pairing one’s actions with an unpredictable environment (Fuchs & Schomer, 2007). At its core, surfing is a sport associated with feeling a “rush” or adrenaline surge by dropping down the face of the wave (Diehm & Armatas, 2004). As a veteran participant commented, “In combat, you wait and you wait, and then you engage in an intense adrenaline rush fighting for your life. In surfing, you wait and wait; then you engage in a natural adrenaline rush riding a wave.” Both surfing and military cultures have created specific languages that have many similarities. Surfers use various terms to define the intense and uncontrollable experiences of the sport, including “wiping out,” “blown up,” “demo’d” (demolished), and “what a rush.” Military personnel use similar phrases to describe the violent, uncontrolled experience of combat.

The second process element is creating a new kind of brotherhood: integrating surf instructors and veterans in the program. The designated surf instructors have an extensive background in surfing, surfing instruction, and ocean safety. They come from a variety of professions, social and ethnic backgrounds, and military service appointments. Both program participants and surf instructors have reported developing a sense of kinship or brotherhood with one another over the course of the sessions. Trust is built in the water, where participants rely on the surf instructor to support their skill acquisition and safety in a novel and variable environment. Trust is simultaneously built among participants when they begin to support one another both in the water and on the beach; some eventually make plans to surf together outside of the program. One participant stated, “I never thought I would find another brotherhood like the Marines, but I’ve seen here that surfers are like brothers. . . . It’s like a family.” As a sense of belonging or community develops, participants identify with one another and with the sport.

The third process element is storytelling and storymaking: making sense of experience in ways that create connections with others. Surf instructors have described the emergence of storytelling in the water as veterans begin to recount aspects of their injury and service in the military. This concept of storytelling is common in surf culture; surfers often spend time in the lineup waiting for waves, “talking story” about past surf adventures, or discussing personal issues at home or at work (Ford & Brown, 2006). Veterans have reported a similar experience while on deployment, during which much of their time is spent waiting or recovering from combat, and storytelling emerges as a way to process traumatic events (Adler, Castro, & McGurk, 2009). The use of narrative as a therapeutic tool in processing traumatic events is well documented; narrative functions to re-create a new life history or build an understanding and acceptance of illness or injury (Carless & Douglas, 2008; Mattingly, 1998). In one discussion session, a veteran shared, “I’ve never shared this openly, but my drinking is affecting my daily life. I don’t go outside. Now I look forward to surfing.” During the program, storytelling merges into storymaking (Clark et al., 1996), in which participants and surf instructors extend their life stories by “riding waves” in the present, providing the content for future narratives.

The fourth process element is reframing the mission: promoting competence and self-efficacy. Veterans, who are trained to be effective in an environment in which actions are guided by orders and interactions are governed by rank, may experience disrupted self-efficacy when faced with unstructured and unpredictable civilian environments (Pietrzak et al., 2009). For example, when enrolling in a class on a college campus, directions or procedures may be unclear; the order of actions may not be clearly defined; and the behaviors of other students and staff may appear erratic. Individuals with a high sense of self-efficacy believe in their capability to successfully perform the tasks required to accomplish life goals (Benight & Bandura, 2004). In acquiring surfing skills and witnessing their personal achievement in a novel but supportive environment, program participants are able to renew their belief in their ability to achieve goals and obtain a productive role in civilian life (Kielhofner, 2008). With direction from an occupational therapist, the intervention may support self-efficacy by creating opportunities for autonomy and self-reflection and by fostering trust between participants and instructors. One veteran stated, “I didn’t think I would stand up [on the board], and I did. I wonder what else I can do?”