An Educational Theater-Based Activity to Challenge Cultural Stereotypes about Veterans’ and their Lived Experiences

The media stereotypes military veterans as damaged beings or indestructible heroes, often forming implicit and explicit biases that impact medical and health providers’ capability to connect emotionally with veterans. This educational tool uses interactive theater to challenge veteran stigma, enhance empathy, and increase learners’ ability to talk to veterans about their service. This 90-minute session includes an interactive theater performance where learners recite verbatim veteran interview excerpts. This article contains all the materials necessary to replicate this activity in the appendices. The performance is prefaced with an introduction of the script, how it was developed and directions for engaging in the session. The session is facilitated by faculty knowledgeable in veteran culture and care who led post-performance discussion. Electronic survey data provides quantitative and qualitative assessment of learners’ attitudes, beliefs, and quality of the session. Learner satisfaction revealed satisfaction among all questions asked, which including the following dimensions: instructional format, session content, impact of content. Qualitative results illustrated a newfound awareness of the diversity of military experience, personal bias, and the impact of social stigma on veteran health. Addressing stigma in the vulnerable veteran population is challenging. This one-time intervention called for learners to confront their biases and showed a short-term impact that may improve clinical care of veterans. Future research should address long-term impact on patient care and clinical outcomes.

The ongoing military conflicts in Iraq and Afghanistan have spurred many societal conversations about the effects of war on veterans.Posttraumatic Stress Disorder (PTSD) is often cited in these conversations as a major consequence of the conflicts; a reference that has led to the overgeneralization that many veterans carry a PTSD diagnosis.Many clinicians and veterans find the diagnosis of PTSD to be inadequate and (in some cases) a flawed label to capture the impact of the military experience on the human mind and soul.Tightly linked to the overpathologizing of veterans with PTSD, is the stigma-related concerns that many veterans experience due to the fear of being perceived as psychologically weak.Research has established a strong connection between stigma and a veteran's decision to avoid or delay health care; even when care is accessible and desired (Schreiber & McEnany, 2015).The sequela of this phenomenon leads to untreated symptoms of preventable and curable conditions and can ultimately lead to poor health outcomes and premature death (Keusch et al., 2006).
Overcoming stigma can be especially challenging to veterans as they attempt to reintegrate into the civilian world, and they are inundated with social, economic, and political circumstances that have changed since they began their military commitment.Reintegration into civilian life can also be challenging because of new cultural views brought on by war and traumatic experiences (Caplan, 2011;Finley, 2011;Gutmann & Lutz, 2010;Holyfield, 2011).Often times, veterans' new worldviews conflict with their civilian peers, including health care providers, contributing to suboptimal care.It is therefore critical to educate health care providers who are in training on veterans' lived experiences.This paper reports on an interactive, researchbased theater performance, Tracings of Trauma, performed as an educational session for medical and allied health students.The session addresses veterans' experiences of stigma, posttraumatic stress disorder, and mental health after returning from deployment.We describe the educational objectives, evaluation tool, learner satisfaction data, qualitative results, implementation, and lessons learned to promote and support implementation by other instructors in higher education.All session materials, in the form of a toolkit, are provided in the appendices.
The use of theater has been successfully used as an engaging method of transferring knowledge surrounding complex topics that deal with stigma, vulnerable populations, human emotion, and intense personal experiences.Predominantly, it has been used in public health contexts where there are constraints surrounding health literacy, mass media access, and cultural beliefs (Rossiter et al., 2008).Research-based theatrical performance has addressed the experiences of combat veterans returning home after war, with positive impacts of raising awareness and knowledge of veterans' issues for the general public (Belliveau & Nichols, 2017).Theatrical performances in medical education have successfully been applied to educate learners about patient illness experiences and stigmatized diseases (Lorenz et al., 2004).It has also been used as a tool to reflect on professionalism (Rosenbaum et al., 2005).Research shows that this method results in greater empathy, improved humanistic skills, and new awareness of patient care issues (Shapiro & Hunt, 2003).
Performance-based approaches such as reader's theater and verbatim theater have been used to engage medical learners on topics that may be culturally silenced or sensitive.This is different than professional theatrical performances (mentioned above), in that students take part in scripts and are engaged as amateur actors.For example, "Understanding Partnerships With Patients/Clients in a Team Context Through Verbatim Theater" used verbatim transcripts from patients to promote and explore partnership in clinical encounters (Langlois et al., 2017).In "Teaching Medical Students How to Ask Patients Questions About Identity, Intersectionality, and Resilience" students learn about co-existing stigmatized identities related to sex and gender and use roleplay to practice sensitive clinician-patient conversations (Potter et al., 2016).Sessions teaching veteran-centered care have included humanities-focused content such as documentary film and interactive narrative cases to improve interpersonal clinical communication skills (Lypson et al., 2014(Lypson et al., , 2016)).
To our knowledge, no educational tools have used theater-based approaches to teach learners about the lived experience of veterans and the mental health consequences of war.Tracings of Trauma offers a unique contribution.It uses interactive readers theater to invoke emotions and engage students with veterans' voices in a manner that sensitively broaches topics of trauma, politics, and personal bias.Post-performance discussion offers an opportunity to debrief and highlights how these issues can negatively impact professional practice.The target audience for this interactive theater session includes medical students, physician residents, allied health students, academic fellows, and higher education faculty.The session has also been performed for the public at veteran-related events such as film festivals or veteran art exhibits.
In a political climate where the Global War on Terror continues, relying on an all-voluntary military consisting of less than 5% of the United States population, the vast majority of US citizens are far removed from the impact of war.Veterans' perceived lack of common ground with civilians, rooted in society's disconnect to the effects of war, is an overlooked barrier to compassionate and competent care (Hooyer, 2015).Tracings of Trauma is an interactive teaching tool that addresses this disconnect.It seeks to educate civilian medical and allied health learners on the experience of military training, the diversity of war experiences, and the challenges of coming home to veterans' mental health.The content is research-based and focuses on the intersectionality of veteran voices and identities.The intention is to educate students, physicians, and health service providers on stigma, and to enhance empathy and understanding for their veteran patients and clients.

EDUCATIONAL OBJECTIVES
After competing this 90-minute session students will be able to: 1. describe the varying experiences of veterans from the intersections of race, gender, and socio-economic status 2. identify the stigmas veterans face in transitioning back to civilian life 3. explain the reasons veterans have difficulty talking about their trauma 4. contrast the different meanings veterans attach to their posttraumatic stress disorder diagnosis 5. identify how personal biases can impact their care of veterans

OVERVIEW
This study was approved by the Medical College of Wisconsin Institutional Review Board for the protection of human subjects and ethical conduct of research.We designed Tracings of Trauma to serve as a one-time educational performance to be facilitated in elective courses, special topic curriculums, grand rounds, and faculty development.
Learners are not required to have any prerequisite knowledge or work.In order to facilitate effective discussion and answer questions related to veteran-centered care, facilitators need to have experience and expertise working with the veteran population.Depending on the size of the group, it is helpful to have multiple facilitators familiar with veteran culture for the small group debriefing discussion.We also recommend having at least one veteran in attendance during the performance to answer any questions during the debriefing portion of the experience.

DEVELOPMENT
Veterans collaborated on the development of both the content and evaluation tools.In the research that informed the development of the script, veterans identified three issues that contributed to difficulties transitioning home.First, veterans wanted the performance to challenge existing stereotypes that portrayed them as dangerous or broken.Second, they wanted the session to bridge cultural gaps between military and civilian culture so that civilian providers had a better understanding of training for and going to war.The third was to spread the burden of war by making people aware of the sacrifices that veterans made in their service and the difficulties in returning home.

IMPLEMENTATION
The purpose of this paper is to support implementation of Tracings of Trauma for other educators.We therefore describe in detail the structure and flow of the session from beginning to end.All components of the session are found in the labeled appendices.The session began with the primary facilitator briefly introducing the session, methodology, background, and directions for learner engagement during the performance.This is located on the first page of the script (Appendix A).The facilitator then passed out 55 "fieldnotes" in numerical order (Appendix B).These fieldnotes contain the verbatim excerpts from veteran interviews that learners recited when the primary facilitator, reading from a script, called them out in numbered sequence (Appendix A).The primary facilitator took on the voice of the "researcher narrator" in the script and the learners took on the voices of the veterans, reciting the excerpts in a round-robin format.Passing out the fieldnotes in numerical order allows the performance to be more predictable, making it easier for learners to focus on the content.The full reading of the performance took 25-30 minutes, with 10 minutes for the introduction and passing out of fieldnotes.After the script performance, the facilitator began the debriefing with four discussion questions located at the end of the script.The session can be facilitated during class time, professional development events, and lunch and learns within an hour timeframe, but we found that 75-90 minutes is ideal.
We learned that the best setup for the activity is a circle of 10-18 chairs facing each other, allowing for learners to make eye contact.Tables can create physical barriers that contributed to more separation between learners.The ideal number of learners is 18 or less; this allows for them to connect more deeply to the veterans lived experiences since each learner reads at least three fieldnotes.A facilitator's guide (Appendix D) lists steps for preparation and implementation.

EVALUATION
We developed the evaluation tool using Kirkpatrick's model of program evaluation (Kirkpatrick & Kirkpatrick, 2006).We evaluated learners at three levels: satisfaction, knowledge/attitudes, and behaviors.First, to assess satisfaction, we included survey items related to the learner's overall satisfaction with different features of the session (Level 1).Second, to assess Level 2 (knowledge/attitudes) and Level 3 (Behavior), we included retrospective pre/post items on the survey.The items assessed values related to assumptions about veterans, bridging the cultural divide between veterans and civilians, empathizing with veterans, knowledge gains, and transferability of knowledge to personal action.These were outcomes that veteran collaborators identified as significant.
We administered the survey to learners immediately after the session through SurveyMonkey.The survey required at least 5 minutes (Appendix C).In our experience, learners are very responsive to the open-ended questions, so we allowed closer to 8 minutes for the assessment.We highly recommend using SurveyMonkey or Qualtrics software for analysis.

RESULTS
Tracings of Trauma is an educational intervention that is the subject of previously submitted scholarly work.Briefly, the intervention was delivered five times to 142 learners.These sessions were offered mainly to medical students who made up 60% of the sample, the remainder of learners were students of occupational therapy, social work, and allied health.The majority (70%) of learners indicated that they had participated in previous educational sessions related to veteran healthcare and only 2% of learners identified as veterans.We used Kirkpatrick's model of program evaluation to assess the intervention.Paired-sample t-tests showed statistically significant differences in knowledge, attitudes, and beliefs (Kirkpatrick's Level 2) around all four variables: emotional connection, comfortable conversation, empathy, and assumptions.The variable of connection illustrated the largest effect, characterizing the performance's capacity to evoke shared human emotions among people with very diverse experiences.Learners also reported that they felt more confident talking with veterans about their experiences in the military (Kirkpatrick's Level 3).Notably, the pre-assessment on empathy denoted  high levels of empathy with veterans (m = 3.99), which increased after the intervention (m = 4.37).These results are published in detail elsewhere (Hooyer et al., 2020).
Unique to this submission is our learner satisfaction data and qualitative comments that learners offered to complement their pre/post responses (Kirkpatrick's Level 1 of program evaluation).Both data sources provide additional evidence of effectiveness of the performance as an educational intervention.Selected qualitative comments are displayed in Table 2.When asked, "I think interactive performance is an effective way to educate people about veterans' experiences," 91% of learners responded that they strongly agreed or agreed.Similarly, 88% of learners strongly agreed or agreed with the question "I feel the knowledge I gained will impact my future professional interactions with veterans."Lastly, 89% of learners indicated that the performance had an emotional impact on them.
The qualitative comments provided by learners also provided insight into the performance's effectiveness.When asked about learning acquired, one learner commented: "It was eye opening to learn more about how ashamed or afraid some veterans are to admit that they have served."While reflecting and commenting on how the knowledge they gained will impact their future professional interactions with veterans, two learners offered: I live a much different life than those that have served in the military.I have experienced difficult times and loss, but nothing comparable to their experiences.This gave me an opportunity to hear their voices and hopefully gain just a little more understanding of their lives.
I just think the activity made me feel more comfortable with the idea of what PTSD is to a variety of different people and also just the good and the bad that soldiers experienced from war.
Finally, many learners commented on the emotional impact that they performance had on them.Three profound comments include: • I had goosebumps during many of the quotes.
• The comments made it feel like those individuals were in the room.

SURVEY ITEM QUALITATIVE COMMENTS
I have learned something new about veterans' lives.
-It was eye opening to learn more about how ashamed or afraid some veterans are to admit that they have served.-By reading the comments out loud, the impact was greater, and pushed me to experience what it would be like to be in their shoes.-I think the takeaway from this experience is that everyone reacts differently.Everyone had a different experience and there is no way to make even small assumptions about a veteran's life.-The variety of reactions to military service is impressive and humbling.I think interactive performance is an effective way to educate people about veterans' experiences.
-Hearing things said out loud makes them sink in much more than simply reading them.-I was skeptical of the dissemination method, as I feel like reading quotes can at times become an act of ventriloquy, but I appreciated my groups' effort to respecting the words of the vets.-Sitting through a 20-minute lecture, or even a video might not have been as effective as participating ourselves by reading the field notes.-I was able to speak someone else's words and see their perspective.
That is a good way to feel less of "you" and more of "others." I feel the knowledge I gained will impact my future professional interactions with veterans.
-The performance has given me insight into the thoughts and opinions of some veterans.-I live a much different life than those that have served in the military.I have experienced difficult times and loss, but nothing comparable to their experiences.This gave me an opportunity to hear their voices and hopefully gain just a little more understanding of their lives.-I just think the activity made me feel more comfortable with the idea of what PTSD is to a variety of different people and also just the good and the bad that soldiers experienced from war.
This performance had an emotional impact on me.
-I had goosebumps during many of the quotes.
-The comments made it feel like those individuals were in the room.
-Putting myself in their shoes, just for a little bit, helped me think about their experiences from their own lens.
Table 2 Contains selected responses that learners provided for each pre/post survey item.Selected Qualitative Comments.
• Putting myself in their shoes, just for a little bit, helped me think about their experiences from their own lens.

DISCUSSION
Tracings of Trauma demonstrates that the use of a performance-based approach can be an effective strategy to teach medical and allied health learners about veterans' lived experiences.Through participation, learners experienced improvements in their abilities to connect and empathize with veterans.They also reported an increased sense of comfort in talking with veterans and reduced assumptions about veterans' experiences.These results lead us to encourage other educators to adopt Tracings of Trauma as part of curriculums for non-veteran students in veteran studies, the humanities disciplines, and professional programs of study in counseling education, nursing, and social work.While this study did not report results from performances to the general public, Tracings of Trauma has been implemented during Veterans Day activities, film festivals, church services, and mental health summits.Audience responses during post-performance discussions, focused on an increased awareness and new understanding of the diversity of veteran experiences, as well as enhanced empathy for reintegration difficulties.
The evaluation we provide in the appendix would allow for more robust assessment of the performance's impact on various audiences and learners.
Several key lessons have emerged throughout the development, implementation, and evaluation of this session.First, we learned that it is critically important to have a primary facilitator that is familiar with veteran culture.The content of the performance is emotional and evokes varied reactions and questions from learners.It is important to have an experienced facilitator with content expertise to guide discussion and competently respond to questions.Likewise, it is ideal to have co-facilitators that are also knowledgeable about the veteran and military ethos.For example, two of our co-facilitators were both veterans and psychiatrists.If for example, Tracings of Trauma were to be implemented with counseling education students, it would be beneficial to have a counselor that worked for Veterans Affairs co-facilitating.Second, we recommend that facilitators consider students' level of comfort in participating.Out of all the students who took part in this study only three were military (veteran or active).Some students had previous education in military medicine and culture (medical students) and others had previous modules in military and veteran health (social work students).We experienced a few instances where students did not feel comfortable publicly reading the fieldnotes.It is important to offer a chance for students to listen and not read if that is their preference.The "opt out" option is mindful of the individual's comfort level, but also ensures that those who participate are respectfully giving the narratives the dramatic delivery that is intended.Third, given the emotionally laden content of the performance, the learners' level of emotional maturity should be acknowledged.We recommend offering Tracings of Trauma to learners at more advanced stages of their training.
We also received important feedback from our learners.Their feedback consistently suggested that we need to provide more time for discussion and that we should have veterans in the audience to answer questions regarding appropriate clinical care.At least 20 minutes needs to be allotted for discussion.Last, through student feedback, we discovered that large open spaces could affect acoustics and do not lend to the intimacy of the fieldnotes and the emotional responses these fieldnotes can invoke.We have facilitated this performance with multiple small groups in a large room, which proved to be disruptive since students could hear echoes of fieldnotes in other groups.For grand rounds, we have separated learners into two small rooms, this takes additional time but results in more engagement.

LIMITATIONS
There are a few limitations to note.Veterans did not participate in the sessions evaluated in this report.Including a veteran as a learner or facilitator could create meaningful opportunities for learner engagement and deeper dialogue.However, many learners need time to reflect on the performance's content and their reaction to it.It is possible that having a veteran present may also suppress learners' participation in the debriefing discussion due to a heightened awareness for the need to be culturally sensitive to veterans but uncertain of how to do so.Second, evaluation data was self-reported, and findings may be skewed due to a social desirability effect that may have compelled learners to respond positively to survey questions.Third, Tracings of Trauma represents the spoken words of the veterans that participated in the research that informed the script; thus, potentially limiting generalizability of the veteran experience.However, of important note, a strength of the script is the diversity of veteran perspectives represented in the selected quotes.The script was based off purposeful sampling of veteran research participants for diverse positionality (race, gender, ethnicity, military operational specialty, branch, and deployment).
A competent and empathic health professions workforce is needed to meet the health needs of veterans.
Tracings of Trauma provides a promising short-term intervention to prepare learners otherwise unfamiliar with military culture and the veteran experience to serve veterans.Future research on the performance should consider the long-term impact on behavior and practice and impact on varying audiences.The performance elements outlined in this project may serve as a model to teach about the experiences of different era veterans and coming home, the experiences of military families, and other military work exposures and related health complications (e.g., Agent Orange, Gulf War Illness, multidrug resistant Acinetobacter) that require sensitivity and cultural humility.

ADDITIONAL FILES
The additional files for this article can be found as follows: Appendix A. Facilitator Script Tracing of Trauma.DOI: https://doi.org/10.21061/jvs.v7i1.251.s1• Appendix B. Learner Fieldnotes.DOI: https://doi.org/10.21061/jvs.v7i1.251.s2• Appendix C. Evaluation of Tracings of Trauma.DOI: https://doi.org/10.21061/jvs.v7i1.251.s3• Appendix D. Facilitator's Guide.DOI: https://doi.org/10.21061/jvs.v7i1.251.s4ACKNOWLEDGEMENTS This publication/project was made possible by Grant Number T32 HP10030 from the Health Resources and Services Administration (HRSA), an operating division of the US Department of Health and Human Services.Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Health Resources and Services Administration or the US Department of Health and Human Services.Thank you to Monica Haller of the veterans Book Project, our colleague facilitators Mike McBride, MD (Zablocki VAMC) and Jeff Whittle, MD MPH (Zablocki VAMC), and Jeff Morzinski, PhD (Medical College of Wisconsin) and Linda Meurer, MD MPH (Medical College of Wisconsin) for their valuable feedback and support in developing this intervention.

Table 1
identifies the specific value being assessed, the survey question used to measure change, and the corresponding level from Kirkpatrick represented by the value that is being assessed.

Table 1
Values Assessed by Tracings of Trauma Evaluation with Corresponding Survey Questions.