Hostname: page-component-78c5997874-8bhkd Total loading time: 0 Render date: 2024-11-19T04:20:01.678Z Has data issue: false hasContentIssue false
  • English
  • Français

Adapting CBT to treat depression in Armed Forces Veterans: qualitative study

Published online by Cambridge University Press:  21 March 2019

Paul Farrand ,
Eugene Mullan ,
Kat Rayson ,
Alberta Engelbrecht ,
Karen Mead  and
Neil Greenberg
Paul Farrand*
Affiliation:
Clinical Education, Development and Research (CEDAR), Psychology, Washington Singer Laboratories, University of Exeter, Exeter, UK
Eugene Mullan
Affiliation:
Clinical Education, Development and Research (CEDAR), Psychology, Washington Singer Laboratories, University of Exeter, Exeter, UK
Kat Rayson
Affiliation:
Clinical Education, Development and Research (CEDAR), Psychology, Washington Singer Laboratories, University of Exeter, Exeter, UK
Alberta Engelbrecht
Affiliation:
Clinical Education, Development and Research (CEDAR), Psychology, Washington Singer Laboratories, University of Exeter, Exeter, UK
Karen Mead
Affiliation:
Help for Heroes, Tedworth House, Tidworth, UK
Neil Greenberg
Affiliation:
King’s Centre for Military Health Research, King’s College, Weston Education Centre, London, UK
*
*Corresponding author. Email: [email protected]
Get access Rights & Permissions [Opens in a new window]

Abstract

Background:

The principles of the Armed Forces Covenant state that Armed Forces Veterans should be at no disadvantage resulting from their service compared with a general adult population. However, despite being at increased risk of experiencing common mental health difficulties, evidence indicates that 82% of Armed Forces Veterans receive no treatment, compared with 63% of the general adult population.

Aim:

To gain a better appreciation of factors that inform the type of adaptations to cognitive behavioural therapy (CBT) interventions for depression and mainstream service promotion materials to enhance acceptability for Armed Forces Veterans.

Method:

This is a qualitative study employing a focus group of 12 participants to examine the main impacts of depression on Armed Forces Veterans alongside attitudes towards terminology and visual imagery. Thematic analysis was used to identify themes and sub-themes with rigour established through two researchers independently developing thematic maps to inform a final agreed thematic map.

Results:

A behavioural activation intervention supporting re-engagement with activities to overcome depression had good levels of acceptability when adapted to reflect an Armed Forces culture. Preferences regarding terminology commonly used within CBT adapted for Armed Forces Veterans were identified. Concerns were expressed with respect to using imagery that emphasized physical rather than mental health difficulties.

Conclusions:

There is the need to consider the Armed Forces community as a specific institutional culture when developing CBT approaches with potential to enhance engagement, completion and recovery rates. Results have potential to inform the practice of CBT with Armed Forces Veterans and future research.

Keywords

adaptationsArmed Forces VeteransCBTdepressionqualitative
Type
Main
Information
Behavioural and Cognitive Psychotherapy , Volume 47 , Issue 5 , September 2019 , pp. 530 - 540
Copyright
© British Association for Behavioural and Cognitive Psychotherapies 2019 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Alvarez, J., McLean, C., Harris, A. H. S., Rosen, C. S., Ruzek, J. I. and Kimerling, R. (2011). The comparative effectiveness of cognitive processing therapy for male Armed Forces Veterans treated in a VHA posttraumatic stress disorder residential rehabilitation program. Journal of Consulting and Clinical Psychology, 79, 590–599.CrossRefGoogle Scholar
Bernal, G., Jiménez-Chafey, M. I. and Domenech Rodríguez, M. M. (2009). Cultural adaptation of treatments: a resource for considering culture in evidence-based practice. Professional Psychology: Research and Practice, 40, 361–368.CrossRefGoogle Scholar
Binks, E. and Cambridge, S. (2018). The transition experiences of British Military Veterans. Political Psychology, 39, 125–142.CrossRefGoogle Scholar
Bower, P. and Gilbody, S. (2005). Stepped care in psychological therapies. Access, effectiveness and efficiency: narrative literature review. British Journal of Psychiatry, 186, 11–17.CrossRefGoogle ScholarPubMed
Braun, V. and Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3, 77–101.CrossRefGoogle Scholar
Britt, T. W., Bennett, E. A., Crabtree, M., Haugh, C., Oliver, K., McFadden, A., et al. (2011). The theory of planned behavior and reserve component veteran treatment seeking. Military Psychology, 23, 82–96.CrossRefGoogle Scholar
Bryan, C. J. and Morrow, C. E. (2011). Circumventing mental health stigma by embracing the warrior culture: lessons learned from the Defender’s Edge program. Professional Psychology: Research and Practice, 42, 16–23.CrossRefGoogle Scholar
Castro, F. G., Barrera, M. Jr and Martinez, C. R. (2004). The cultural adaptation of prevention interventions: resolving tensions between fidelity and fit. Prevention Science, 5, 41–45.CrossRefGoogle Scholar
Clark, D. M., Layard, R., Smithies, R., Richards, D. A., Suckling, R. and Wright, B. (2009). Improving access to psychological therapy: initial evaluation of two UK demonstration sites. Behaviour Research and Therapy, 47, 910–920.CrossRefGoogle ScholarPubMed
Clarkson, P., Giebel, C. M. and Challis, D. (2013). Military AF Veterans Improving Access to Psychological Therapies (MV IAPT) Services. Final Report of an Independent Evaluation to Pennine Care NHS Foundation Trust (Discussion Paper: M277). Manchester: Personal Social Services Research Unit.Google Scholar
Cole, R. F. (2014). Understanding military culture: a guide for professional school counsellors. Professional Counsellor, 4, 497–504.CrossRefGoogle Scholar
Coleman, S. J., Stevelink, S. A. M., Hatch, S. L., Denny, J. A. and Greenberg, N. (2017). Stigma-related barriers and facilitators to help seeking for mental health issues in the armed forces: a systematic review and thematic synthesis of qualitative literature. Psychological Medicine, 47, 1880–1892.CrossRefGoogle ScholarPubMed
Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I. and Petticrew, M. (2008). Developing and evaluating complex interventions: the new Medical Research Council guidance. British Medical Journal, 337, 979–983.Google ScholarPubMed
Dent-Brown, K., Ashworth, A., Barkham, M., Connell, J., Gilbody, S., Hardy, G., et al. (2010). An Evaluation of Six Community Mental Health Pilots for AF Veterans of the Armed Forces: A Case Study Series. Report for the Ministry of Defence. Sheffield: University of Sheffield.Google Scholar
Edlund, M. J., Fortney, J. C., Reaves, C. M., Pyne, J. M. and Mittal, D. (2008). Beliefs about depression and depression treatment among depressed veterans. Medical Care, 46, 581–589.CrossRefGoogle ScholarPubMed
Farrand, P., Jeffs, A., Bloomfield, T., Greenberg, N., Watkins, E. and Mullan, E. (2018). Mental health service acceptability for the armed forces veteran community. Occupational Medicine, 68, 391–398.CrossRefGoogle ScholarPubMed
Farrand, P., Pentecost, C., Greaves, C., Taylor, R. S., Warren, F., Green, C., et al. (2014). A written self-help intervention for depressed adults comparing behavioural activation combined with physical activity promotion with a self-help intervention based upon behavioural activation alone: study protocol for a parallel group pilot randomised controlled trial (BAcPAc). Trials, 15, 196. Available at: http://www.trialsjournal.com/content/15/1/196 CrossRefGoogle Scholar
Goodwin, L., Wessely, S., Hotopf, M., Jones, M., Greenberg, N., Rona, R. J., et al. (2014). Are common mental disorders more prevalent in the UK serving military compared to the general working population? Psychological Medicine, 45, 1881–1891.CrossRefGoogle Scholar
Greenberg, N., Lewis, P., Braidwood, A. and Hunt, E. (2018). The Armed Forces and Mental Health: Part 1 – Mental Healthcare in Military Service. Royal College of Psychiatrists CPD Online. Available at: http://www.psychiatrycpd.co.uk/learningmodules/armedforcesandmentalhealth.aspx Google Scholar
Grey, N. (2009). Imagery and psychological threat to the self in PTSD. In L., Stopa (ed), Imagery and the Threatened Self: Perspectives on Mental Imagery and the Self in Cognitive Therapy. London: Routledge.Google Scholar
Hackman, A., Bennett-Levy, J. and Holmes, E. A. (2011). Oxford Guide to Imagery in Cognitive Therapy. Oxford: Oxford University Press.CrossRefGoogle Scholar
Hall, G. C. N., Yip, T. and Zárate, M. A. (2016). On becoming multicultural in a monocultural research world: a conceptual approach to studying ethnocultural diversity. American Psychologist, 71, 40–51.CrossRefGoogle Scholar
Hall, L. K. (2011). The importance of understanding military culture. Social Work in Health Care, 50, 4–18.CrossRefGoogle ScholarPubMed
Hunt, E. J. F., Wessely, S., Jones, N., Rona, R. J. and Greenberg, N. (2014). The mental health of the UK Armed Forces: where facts meet fiction. European Journal of Psychotraumatology, 5, 23617. Available at: https://doi.org/10.3402/ejpt.v5.23617 CrossRefGoogle ScholarPubMed
Improving Access to Psychological Therapies (2009). Veterans: positive practice guide. http://www.iapt.nhs.uk/silo/les/veterans-positive-practice-guide.pdf Google Scholar
Iversen, A. C., Dyson, C., Smith, N., Greenberg, N., Walwyn, R., Unwin, C., et al. (2005). ‘Goodbye and good luck’: the mental health needs and treatment experiences of British ex-service personnel. British Journal of Psychiatry, 186, 480–486.CrossRefGoogle ScholarPubMed
Iversen, A. C. and Greenberg, N. (2009). Mental health of regular and reserve military veterans. Advances in Psychiatric Treatment, 15, 100–106.CrossRefGoogle Scholar
Jacobson, N. S., Martell, C. R. and Dimidjian, S. (2001). Behavioral activation treatment for depression: returning to contextual roots. Clinical Psychology: Science and Practice, 8, 255–270.Google Scholar
Kitzinger, J. (1995). Qualitative research: introducing focus groups. British Medical Journal, 311, 299–302.CrossRefGoogle ScholarPubMed
Kleim, B. and Westphal, M. (2011). Mental health in first responders: a review and recommendation for prevention and intervention strategies. Traumatology, 17, 17–24.CrossRefGoogle Scholar
Langston, V., Gould, M. and Greenberg, N. (2007). Culture: what is its effect on stress in the military? Military Medicine, 172, 931–935.CrossRefGoogle ScholarPubMed
Lasalvia, A., Penta, E., Sartorius, N. and Henderson, S. (2015). Should the label ‘schizophrenia’ be abandoned? Schizophrenia Research, 162, 276–284.CrossRefGoogle ScholarPubMed
Lubian, K., Weich, S., Stansfeld, S., Bebbington, P., Brugha, T., Spiers, N., et al. (2016). Chapter 3: Mental health treatment and services. In McManus, S., Bebbington, P., Jenkins, R. and Brugha, T. (eds), Mental Health and Wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital.Google Scholar
Mays, N. B. and Pope, C. C. (1995). Rigor and qualitative research. British Medical Journal, 311, 109–112.CrossRefGoogle Scholar
Meyer, E. G., Writer, B. W. and Brim, W. (2016). The importance of military cultural competence. Current Psychiatry Reports, 18, 18–26.CrossRefGoogle ScholarPubMed
Ministry of Defence (2011). The Armed Forces Covenant. London: Ministry of Defence.Google Scholar
Murrison, A. (2010). Fighting Fit: A Mental Health Plan for Servicemen and Veterans. Ministry of Defence. Available at: https://www.gov.uk/government/publications/fighting-fit-a-mental-health-plan-for-servicemen-and-veterans--2 Google Scholar
Nedegaard, R. and Zwilling, J. (2017). Promoting military cultural competence among civilian care providers: learning through program development. Social Science, 6, 1–11.CrossRefGoogle Scholar
NHS England (2016). Developing Mental Health Services for Veterans in England. Oxford: NHS England.Google Scholar
Palmer, I. P. (2012). UK extended Medical Assessment Programme for ex-service personnel: the first 150 individuals seen. The Psychiatrist Online, 36, 263–270.CrossRefGoogle Scholar
Richards, D. A. (2010). Behavioural activation. In Bennett-Levy, J., Richards, D. A., Farrand, P., Christensen, H., Griffiths, K. M., Kavanagh, D. J., et al. (eds), Oxford Guide to Low Intensity CBT Interventions, pp. 141–151. Oxford: Oxford University Press.CrossRefGoogle Scholar
Richards, D. A. and Farrand, P. (2010). Choosing self-help books wisely: sorting the wheat from the chaff. In Bennett-Levy, J., Richards, D. A., Farrand, P., Christensen, H., Griffiths, K. M., Kavanagh, D. J., et al. (eds), Oxford Guide to Low Intensity CBT Interventions, pp. 201–208. Oxford: Oxford University Press.CrossRefGoogle Scholar
Royal College of General Practitioners, Royal British Legion and Combat Stress Meeting (2011). The Healthcare Needs of Veterans: A Guide for General Practitioners. Available at: www.combatstress.com/media/21792/gp_guidance_doc_rgcp_rbl_cs_17jan11.pdf Google Scholar
Sharp, M.-L., Fear, N. T., Rona, R. J., Wessely, S., Greenberg, N., Jones, N., et al. (2015). Stigma as a barrier to seeking health care among military personnel with mental health problems. Epidemiological Review, 37, 144–162.CrossRefGoogle ScholarPubMed
Snider, D. M. (1999). An uninformed debate on military culture. Orbis, 43, 11–26.CrossRefGoogle Scholar
Steenkamp, M., Litz, B. T., Gray, M. J., Lebowitz, L., Nash, W., Conoscenti, L., et al. (2011). A brief exposure-based intervention for service members with PTSD. Cognitive Behavioral Practice, 18, 98–107.CrossRefGoogle Scholar
Woodhead, C., Rona, R. J., Iversen, A. C., MacManus, D., Hotopf, M., Dean, K., et al. (2011). Mental health and health service use among post-national service veterans: results from the 2007 Adult Psychiatric Morbidity Survey of England. Psychological Medicine, 41, 363–372.CrossRefGoogle ScholarPubMed
Zinzow, H. M., Britt, T. W., McFadden, A. C., Burnette, C. M. and Gillispie, S. (2012). Connecting active duty and returning AF Veterans to mental health treatment: interventions and treatment adaptations that may reduce barriers to care. Clinical Psychological Review, 32, 741–753.CrossRefGoogle Scholar
Submit a response

Comments

No Comments have been published for this article.