Office of Research & Development

VA RESEARCH QUARTERLY UPDATE
 

A Chat with Our Experts

From War to Home: Through the Veteran's Lens


Dr. Gala True
Dr. Gala True

Dr. Gala True

From War to Home: Through the Veteran's Lens is a VA traveling exhibit that explores the realities of military service through the words and images of Iraq and Afghanistan War Veterans. The images and stories in the exhibit, which can be seen online, bear witness to the health impacts of military service and deployment during wartime, and reveal the personal views of the men and women behind the lens.

An article in the journal Qualitative Health Research, published online Dec. 8, 2014, explained the research method, called Photovoice, used to assemble the exhibit. It also included some of the stories told by Veterans, and examined the value of the process in helping Veterans identify and overcome barriers to obtaining mental health services.

VARQU spoke to Dr. Gala True, project director for the exhibit, core investigator at VA's Center for Health Equity Research and Promotion (CHERP), and co-director of the qualitative evaluation core of VISN 4's Center for Evaluation of Patient Aligned Care Teams (CEPACT). We discussed the exhibit, those who participated in it, and how that participation has changed the lives of Veterans.

Fallen Soldier Battle Cross, from the From War to Home exhibit.
"Fallen Soldier Battle Cross," from the "From War to Home" exhibit.

"Fallen Soldier Battle Cross," from the "From War to Home" exhibit.

VARQU: Tell us about "From War to Home", and how the exhibit was put together.

True: We gave cameras to Veterans who served in Iraq and Afghanistan, and asked them to take photographs and to contribute others from their personal collections to tell their stories of military service, deployment, and homecoming. We also asked them to identify barriers and facilitators to seeking physical and mental health care after their deployment.

Then we met with each Veteran and reviewed their photos with them, asking them to tell the story behind each photo. Some Veterans contributed up to 60 photos, and others offered more like 10. Using all of the interviews and photographs that had been contributed by 29 Veterans, we developed the exhibit by creating photo narratives—basically pairing photographs with what the Veterans had said about them.

We sought feedback from the Veterans on their individual stories, to make sure we captured their story right, or if they wanted to change or had left out anything. As a group, we also showed Veterans the photo narratives we thought captured the essence of their experiences, and asked them what else they thought should be in the exhibit—what they wanted to add to it, or what they thought was missing. So they had a lot of input into what the exhibit ended up looking like.

An image by Jose G., part of the
An image by Jose G., part of the "Wart to Home" exhibit.

An image by Jose G., part of the "Wart to Home" exhibit.

The overall goal of the exhibit was to represent common themes across Veterans' experiences, but also to illustrate the diversity of the Veterans who serve today and their experiences with war and coming home. The exhibit ended up with four broad themes to tell Veterans' stories: from the time of their deployment, to making the transition home, to seeking care, and to finding strength and resilience to move forward.

VARQU: What do you believe are some of the most powerful items in the exhibit, and why?

It's difficult to pick any one story, because even though I've been doing this for about three years now, I still find each of them very moving.

One piece that really sticks out, not just for me, but also for many who see the exhibit, both Veterans and non-Veterans, is one by Tommy. It's called "Fallen Soldier Battle Cross." The picture is of a fallen soldier battle cross, for a close friend he had served with who was shot by a sniper and killed while they were on patrol. Before they sent the soldier's body home to his family, the other soldiers made a battle cross, which is a ritual arrangement of the soldier's helmet, rifle, dog tags, and boots; some of his personal items; and a photograph of him.

It's put up on a pedestal, and it's something for the soldiers of his unit to look at and to honor him, think about him, and try to say goodbye to him as best they can before his body leaves. One of the reasons I think that photograph is really powerful is because it truly depicts the ritual and culture of the military, and how they honor fallen friends.

Tracy P., a retired lieutenant colonel, and her daughter, from the
Tracy P., a retired lieutenant colonel, and her daughter, from the "War to Home" exhibit.

Tracy P., a retired lieutenant colonel, and her daughter, from the "War to Home" exhibit.

Also, the words Tommy used to talk about the photograph are really powerful, because he talks about what a terrible loss it was to lose this friend, and to have him die right next to him. But he also talks about the loss to the man's family and to the others in the unit, and how everyone had really loved this guy, and he ends it by saying, "If it had been me, it wouldn't have been such a big deal."

I think that that really captures a lot of the themes I hear from Veterans about survivor guilt and the difficulty of processing the surreal experience of losing someone they care about who was right next to them. It depicts how some soldiers, especially younger soldiers who don't have kids, really kind of devalue their own lives during a deployment. They think of others' lives as more important than their own.

Another piece I think is really powerful is by Jose. Jose took a photograph out of the window of his car while he was driving down the highway. You see a long, grey road in front of you, and it's during wintertime so the trees are bare.

Jose used the photograph to talk about how he felt depressed and suicidal after leaving the Navy. He talks about how he would drive down the highway feeling these thoughts of suicide coming into his head, and he was thinking it would be so much easier if he just flipped the car off the side of the road and died.

Many, many Veterans who have seen that piece said they had the same thoughts, especially while driving. But the really powerful part of Jose's piece is how he talks about how, at a moment he was feeling that way, he felt the presence of God in the car with him. He felt as if God had touched his shoulder and said to him, "I'm here with you."

It was a very powerful moment for Jose. He calls it his testimony, which in his Christian faith is the story of how he experienced the divine intervention of God in his life. That moment really turned things around for him. Many of the Veterans who have seen it felt the same way about wanting to die, but they also said they had lost touch with their faith, or their sense of a higher power, because it was difficult to have a sense of faith during a war. So they liked this piece because they liked that Jose could have that feeling, and that it could help him.

Jose is doing really well now, so it is a great piece about how Veterans are not stuck in a moment, which is something many Veterans want to convey. They don't want to be seen as stuck in a moment of depression or PTSD or suicidal thoughts. Instead, their lives are moving and changing. I think that the piece is even greater when you know that now he has a job, and a family, and that he's no longer in that moment. So his photo also shows the resiliency of Veterans and how they move forward.

A third piece is by Tracy, who retired as an Army lieutenant colonel. She's standing with her daughter who had just been commissioned as an officer. Both of them are standing in their full dress uniforms, and looking proud and happy. Tracy has a long quote that goes with the photo, about how when she came home from deployment and served in combat, she had PTSD. She also had issues with sleeplessness and depression when she came home.

But she really was in denial for a long time, and would not seek any help or admit that she was struggling. She talks about how she really felt the need to be strong, because she had been a lieutenant colonel, and didn't want anyone to see her as less than 100 percent mission focused, strong, and resilient.

It finally dawned on her that if she didn't admit that she had problems, with her daughter going into the military, and now she has another daughter going into the military, that she wasn't setting a good example for her daughters—because they would think you would always have to keep a mask of invincibility on, and you should never admit you need help.

She didn't want them to suffer the way she had suffered; she wanted to be able to admit to them that war changes you, and you may need help afterwards. She also talks about how her children were very affected by her going to war and coming home with her struggles, and they were very aware of those struggles. So it's been really helpful for her children that she has sought help, and is doing better. It's been great for her, and healing for her, but it's also been great for her daughters to see that she is willing to get help and has been able to get that help through the VA and other places.

Another reason I think that piece is very powerful is because it shows us a lot about women in the military that we don't usually know—that they serve in combat and the impact it has on them and on their families. It also represents how serving in the military can be a family tradition, how families are affected by one member's service, and how they can help each other move forward after war.

VARQU: Would you explain the Photovoice method and its therapeutic value?

Photovoice is an approach to using visual data in qualitative health research. Participants' photographs, and the description of their photographs, help to facilitate discussion of potentially difficult topics. More importantly, they really allow Veterans to be very engaged in the research project, and to be self-reflective. Being able to look at a picture and to talk about it is an easier way for people to disclose emotions.

The other part of Photovoice is that Veterans themselves become very involved in dissemination and interpretation of the findings of the project, and many of them become advocates. They are involved in the project well beyond the data collection phase; they give talks and presentations with me to health care providers, to medical students, civilian audiences, and to audiences within VA. Through their participation, they advocate not only for their own needs, but also the needs of others in their community. That's very powerful for them.

I've had Veterans tell me that this has really given them a sense of what they want to do next with their lives. Many of the Veterans in the project are going back to school, or are going into education. One Veteran wants to teach math to inner-city kids. He gives a lot of talks with me and it's helping him with his public-speaking skills, and helping him think about how he wants to be an advocate for other Veterans.

There are Veterans in the project who have gone on to become social workers and who use the project's methods in their own work. Participants see the method as a powerful way to give a voice to their own concerns, to the concerns of those they served with, and to help them serve as advocates for other Veterans going forward.

VARQU: Your PhD is in anthropology, and your expertise is in folklore studies. That's an unusual background for a medical investigator. How does your background help you in your work, and how do you use your knowledge to help Veterans?

The orientation I come from in my training is that patients are experts in their own experiences. We need to go to them first to understand what their experiences are and what their unmet needs are. They are very important partners in identifying solutions to problems.

Also, coming from a folklore background, the emphasis in my training was really on how the role of cultural and religious values and people's backgrounds and different identities are so important. They shape how patients think about health, and about seeking and remaining engaged in treatment. You also need to know something about a person's background, experiences, and values in order to understand how they define "health" and what their goals are for recovery, and in the case of Veterans, what their goals are for community reintegration after separation from military service.

Also, I come from a discipline where we value the power of stories. Storytelling is a means of building common knowledge and bridging gaps between people with different experiences or backgrounds. The experience can be beneficial for the storyteller; participants in the Photovoice project say it is cathartic to share their stories with others. And with Photovoice, the Veteran controls what parts of their stories they want to share and with whom.

But there's also something very powerful about stories for the audience. There is a great deal of research recently about the power of stories to convey a message, including new findings about how our brains react to stories, how stories help us build empathy, and remember lessons more vividly. In medical education, there is a growing recognition of how we can use the power of stories to help providers connect better with their patients.

VARQU: Where has the "From War to Home" exhibit been, where is it going, and how can a facility interested in displaying the exhibit learn how to do so?

The exhibit has been to nine different locations, including VA medical centers, international health care conferences, schools of medicine, and a liberal arts campus in California. It's currently (December 2014) at the Bedford (Mass.) VA Medical Center, and that's been a really great experience. The exhibit is installed in the hallways that patients walk through to get to primary care, and the reaction has been so amazing and so positive that they've asked to extend the display for another six weeks.

We've had requests from a number of VAs to host the exhibit. We're still in talks about where it will be going, but one of the things that is really great is that most of these facilities have a Veteran-centered care committee, and these are really great people to work with along with the interior designer and people like that to get the exhibit installed. We're hoping that it will go to as many VA facilities as possible, and we'd love to get the exhibit to Central Office in Washington, DC.

Having the exhibit on display at any VA facility reminds us of who we are serving and why we come to work every day.

People who want to learn how to bring the exhibit to their facility can visit our website (www.va.gov/FromWarToHome/) or email me at Jennifer.True2@va.gov.


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