Wellness for Warriors: Developing a Veteran Self-Guided Behavioral Health Workbook with Stakeholders
Veterans provide a niche population that has the potential to benefit from self-guided positive psychology. Approximately 18.5 percent of US service members who have returned from Afghanistan and Iraq have post-traumatic stress disorder or depression, and roughly half of those who need treatment for those conditions seek it (RAND, 2008). The Veteran population experience mental disorders more than the civilian population (Oster et al., 2017). Additionally, Veterans face barriers to seeking and receiving mental health care such as fear of being perceived as weak, fear of trauma related feelings and memories, and lack of understanding of mental health care (United States Government Accountability Office, 2011). Research supports the use of self-guided positive psychology interventions to decrease the symptoms of mental disorders such as depression (Boiler et. al, 2013). These interventions help beyond mental health issues; they can also be used to promote overall well being (Syn & Lyubormisky 2009). Such material tailored for the Veteran population is sparse. The creation of a self-guided resource could not just benefit Veterans experiencing mental health disorders; it could help all Veterans (Chakhssi et. al., 2018). Incorporating positive psychology interventions into a self-guided resource would allow Veterans to be able to access such resources at the comfort of their home discretely, without having to go through the process of contacting anyone else. Placing more emphasis on the use of these interventions could help in bolstering the psychological health of all Veterans, instead of mainly assisting with mental health problems and substance use disorders, which has been the typical focus of Veteran health in the past (Bryan et al., 2012). This paper will outline the processes used in the creation of such a self-guided workbook for Veterans.
Since its creation in 1998, positive psychology has gained widespread attention. Positive psychology is defined as the scientific study of what makes life most worth living (Peterson, 2008); in other words, it is nothing more than the study of ordinary human strengths and virtues. This field of study grew largely from the inequality of study in clinical psychology, which focuses on mental illness (Gable and Haidt, 2005). Instead of focusing on ailments, positive psychology focuses on enhancing wellbeing. The goal of positive psychology is not to replace traditional psychology but rather to complement it (Linley et al., 2006). The subject fully acknowledges the existence of human suffering but seeks to understand the positive aspects in their own right, and not as buffers against the problems and stressors of life (Gable and Haidt, 2005). Interventions using positive psychology can be classified into different categories, with some of these being savoring, gratitude, kindness, promoting positive relationship processes, and creating meaning (Schueller and Parks 2014).
Assimilating positive psychology interventions into self-guided manuals can be beneficial. They are easily accessible and can be used in short periods of free time (Bergsma, 2007). In low resource settings, they can help in reducing treatment gaps for certain mental disorders by providing tools for enhancing wellbeing and thus working towards recovery. In times that can be lost before professional care can be obtained or after the completion of face-to-face therapy, the utilization of self-guided resources can be helpful (Mehrotra et al., 2017; Carter, 2002). Additionally, they provide a strong antidote against learned helplessness (Seligman et al., 1978).
Currently, the typical users of self-guided resources are highly educated, affluent, and typically women. In the context of self-help groups, people who are males, in minority groups, are older and are in the working, lower classes are under-represented (Nayar, Kyobutungi, & Razum, 2004). For example, a major concern is that self-help is not as sought-after in the minority of people who identify as African American (Gutierrez, Ortega, & Suarez, 1990). Similarly, scholars have recognized that self-help is a gendered activity as books and marketing campaigns often target women. This gap in gender could be explained by the motives of both genders: women, when compared to men, are more likely to seek out self-help resources of their own free-will to engage in actions which would produce results to enhance their lifestyles (McLean and Kapell, 2015). Expanding self-help materials for Veterans that incorporate positive psychology would create resources for a population that is typically not targeted.
Creating wellness resources could help with core issues that Veterans face in receiving care. For example, factors such as stigma and cost have proved to be barriers for Veterans being able to receive proper care (Fleming et al., 2016). Stigma is a large reason why people do not reach out to better their wellbeing through counseling for the treatment of their mental health issues. (Vogel, Wade, & Hackler, 2007). Veteran culture has been shown to promote self-reliance, with a certain amount of social stigma related to seeking out help (Harding, 2016). This culture puts emphasis on thoughts that align with masculine roles, and chastise the seeking of help (Nash, Silva, & Litz, 2009). This could serve as an obstacle as Veterans could be reluctant to find ways to better their wellbeing with fears that other people would view them in a negative manner (Campbell et al., 2017). Major financial reasons that cause Veterans to not seek care include not having enough money to see someone professional and not wanting to pay for the cost of travel to a health care facility (Cheney et al., 2018). While Veterans are able to receive reduced costs care, they have to meet specific criteria (“Veteran Affairs”); for some, these costs may be more than they are willing to spend. These factors increase the support of the use of self-guided resources, which require no need to reach out for help and do not cost money.
2.1 Sections of Workbook
Our workbook incorporates the techniques of not only positive psychology but also clinical psychology and health psychology into an easily accessible guide with a Veteran target audience. The workbook contains five sections: Understanding Health, Thoughts, Activities, Sleep, and Eating. The content is organized with the first and last sections being the least stigmatizing (Health and Eating), and the middle sections being more introspective (Thoughts, Activities, and Sleep). Users of the workbook can start anywhere in the workbook to do the activities. An extensive literature review was done to incorporate appropriate interventions.
The section “Understanding Health” focuses on helping Veterans interpret what health means to them and urges them to consider what activities they partake in that make them feel healthy or unhealthy. This process of introspection is the basis of the workbook.
“Thoughts” provides a range of activities that encourage self-compassion. Self-compassion has been shown to increase emotional wellbeing (Bluth & Blanton, 2014). An example activity that incorporates a positive psychology intervention is a gratitude journal. Keeping a gratitude journal has been shown to also increase wellbeing when compared to not keeping a journal at all or keeping a journal regarding day-to-day activities (Emmons & McCullough, 2003).
“Activities” contains exercises and instruction on improving health through various exercises. This section contains a wide variety of activities, ranging from a page to reflect on hobbies to instructions on how to meditate. These activities provide a foundation for Veteran users interested in becoming more active in their daily life.
“Sleeping” has tips on creating a healthier sleep schedule and sleep hygiene. Much of this section contains information, with one exercise that allocates space to write about one’s sleep schedule. Previous research has shown that on average, veterans report deficient amounts of sleep when compared to the general population, hence why a section on sleep could be helpful to some users (National Veteran Sleep Survey, 2018).
The last section is “Eating”. Similarly, this section provides information on how to eat in a better manner. Activities include a recipe makeover of a favorite recipe and a food diary to track what foods the user has eaten in a week. This has the potential to benefit Veterans as higher depressive symptoms are associated with poorer diets in Veterans (Hoerster et al., 2015); providing a space for Veterans to reflect on their eating habits could bring awareness to ways in that they can better their diets.
Six Veteran stakeholders from the area were included in a focus group for input regarding the workbook. Participants came from diverse backgrounds with a diverse age range (40-52), gender (5 female, 1 male), race (African American, Pacific Islander, White), ethnicity (Hispanic), military branch (Navy, Army, and Coast Guard) were present in the focus group. A Marine Veteran (male, Hispanic/white, age 35) was not present in the focus group, but was given the workbook afterwards to review. Additionally, Veterans were from varying eras. Stakeholders were Veterans from Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and the Gulf War. The Veterans had diverse affiliations, with peer support workers, Veteran Service Organization workers, and students. All stakeholders were involved with current Veteran culture.
2.3 Focus-Group Procedure
Participants took part in a two-hour focus group. Each Veteran was given a copy of the manual at the beginning of the session, in addition to being emailed a copy one week before the focus group. They looked through it at their own pace and then were asked questions regarding their opinions of the workbook. Throughout the focus group, a note-taker was present on the phone. After the initial focus group, edits were made to the manual and it was sent again to the stakeholders for input.
3.1 First Glance Feedback
Initially, stakeholders viewed the workbook and disliked the front cover that was included. Our front page incorporated a scenic image. The stakeholders believed that this cover was not relevant to the Veteran experience and would not attract a lot of users. The cover was changed to an image of a member in the Army. The title of the resource was at first “Veteran Wellness Workbook,” but one stakeholder pointed out that the word “workbook” reminded her of school and sounded like she had to complete extra work, leading us to change the title to “Veteran Wellness Guide.”
After an initial flip through of the workbook, a major change that stakeholders proposed was to the graphics. A large majority of the graphics incorporated cartoons along with civilians, but it was proposed that the images be Veteran-centric. Stakeholders urged for more realistic images with references to different service branches. A few pictures had mixed reviews; stakeholders either disliked the images to a great extent or thought they were incredibly relevant. Overall, all images that were given negative feedback for were removed, and new images that were Veteran-focused, realistic, and self-encouraging were added.
3.2 Positive Feedback
The Veteran stakeholders approved of all activities in the workbook, with some emerging as activities they thought would be highly beneficial. A specific activity that was liked by all stakeholders was mindfulness in the “Thoughts” section. On this page, Veterans had a space to write down uncomfortable feelings they had, and then note why they felt this way; this provides them with a space to accept instead of avoid their feelings. All stakeholders agreed that bringing awareness to their feelings could be highly beneficial. One specific example given to us from a stakeholder that we incorporated was that the Veteran held onto his wife’s hand very tightly when in a crowded location, but never noticed it until his wife pointed this out. He then realized that when he was in crowds, he felt anxious.
Similarly, the gratitude journal in the “Thoughts” section was well-liked among stakeholders. Specifically, an aspect of the gratitude journal that stakeholders pointed out was the simple examples that were provided. Instead of providing extreme examples, we provided examples of small things such as “The weather was nice today” and “My coffee tasted better than usual.” Providing small examples lead to a reminder to be that there are many small pleasures in daily life to be appreciative of.
The activity on self-kindness in the “Thoughts” section was well-received. This exercise provides a space to compare how users of the workbook would treat a friend who is feeling badly vs. how they treated themselves when they were feeling this way. Stakeholders believed that this was an interesting perspective and that they would definitely use this activity when the time came. One stakeholder brought to attention that she never thinks about how she treats herself differently than her friends and believed this activity could be incredibly helpful.
Lastly, the meditation guide in the “Activities” section was given strong approval. All stakeholders believed meditation was a tool that could help Veterans obtain a certain level of calmness in their lives. Stakeholders believed the simple directions in the workbook could motivate users to meditate. One of the stakeholders pointed out that because the meditation activity was not very long, it could attract more users to participate as it would not be very tedious.
3.3 Major Changes
One common theme that emerged from this focus group was that all stakeholders believed that adding more concrete examples could be helpful to users of the manual. Revisions made based on group suggestions include organizations that Veterans could contact to volunteer with such as “The Mission Continues.” Likewise, the stakeholders asked for specific resources they could use to improve their mood, lose weight, and even better improve sleep schedule. Changes were made to direct users of the workbook to apps and websites specifically created for Veterans to improve their health and wellbeing, such as the MOVE Weight Management App and Mood Coach App, both resources provided by the VA.
Furthermore, more concrete, Veteran focused examples were asked for. As an illustration, a stakeholder provided the situation of having to learn a new skill at work, and that it is sometimes difficult to take orders without questioning why. Eventually, the stakeholder was able to learn the skill, but initially it was tough. This example was placed in the “Perseverance and Positivity” exercise. Generally, explanations as to why activities and resources could be beneficial were requested. These explanations gave the chance to demystify the exercises and give motivation to complete them. These were the two main changes that were asked for by the stakeholders.
3.4 Input Not Used
As Veteran experiences tend to be emotionally heavy, many stakeholders reported of providing more harsh examples. Stakeholders proposed adding in how to react when a friend commits suicide, but this was not included as it has the chance to trigger users of the manual. Without the assistance of professional help, this could negatively affect some Veterans. Instead, Veteran assistance in form of a 24-hour Veteran phone line, chat line, and emailing site were included. This could connect Veterans to assistance in the case they needed to speak with a professional.
3.5 Following Up
Six months after the focus group, stakeholders were followed up with regarding the utility of the workbook. The feedback received was extremely positive. All of the stakeholders rated the wellness workbook as either useful or very useful and all of the stakeholders said they would definitely recommend it to other Veterans. One of the stakeholders from the study specifically said that working together through the exercises with their son was very helpful as he was currently serving in the military, and the activities had seemed to help with bettering both of their wellness. Another stakeholder reported that they used the meditation activity after recently recovering from knee surgery, and that it had encouraged them to incorporate more activity into life. In general, the Veterans all reported that the workbook led them to think about wellness in their lives to a greater extent.
The current study complied evidence-based psychological interventions for self-guided use to create an appropriate resource for the Veteran population and then did a focus group to make the resource more pertinent to the Veteran experience. As a whole, Veterans reported high levels of need in their community in regards to Veteran-centric wellness resources. We found that Veterans are open to these resources and believe that they could be of benefit to the Veteran community. Veteran stakeholders agreed that they would have used at least some of the activities the “Veteran Wellness Guide” had it been a resource provided to them outside of the focus group. Moreover, the study highlighted the importance of seeking input from the target audience in the process of creating self-guided materials for specific populations. Engaging with Veterans in the process of creating this guide produced a more Veteran-centric guide with example activities that were more catered towards the Veteran experience in addition to being better liked and used to a greater extent.
There are many potential benefits of self-guided wellness materials with positive psychology interventions for the Veteran population as demonstrated by previous studies. Veteran patients have been shown to achieve major improvements in psychological and social functioning after participating in programs that incorporate positive psychology techniques, in addition to reporting more energy, better physical self-care, and improved sleep (Perlman et. al., 2010). The benefits shown by previous studies indicate that shifting from the major focus of assisting in mental health problems and developing more material that aims to reinforce the psychological health of all Veterans can help in many aspects.
The US Veteran Affairs has been incorporating the focus on wellness with the adoption of a program called Whole Health (“Veteran Affairs”). Whole Health is a shift from a health care system focused on disease management to one focused on the physical, emotional, and social wellbeing of a person. Modern medicine often centers on treating symptoms, as opposed to trying to determine the underlying causes of a condition such as mental health, physical health, and eating habits, which is a focus of Whole Health. Specific ways that Whole Health has incorporated these new goals is by providing Veterans with courses in tai chi, yoga, and acupuncture, in addition to trying to collaborate with diverse clinical teams to provide Veterans with health plans to better overall wellbeing. The guide created aligns with the goals of Whole Health.
4.2 Limitations and Future Directions
The limitations of this study should be considered in light of its strengths. One such limitation is due to the qualitative nature of the study. While using a qualitative study provided specific details regarding how to better the Veteran Wellness Guide, a quantitative study regarding the health benefits of using similar resources, such as measuring stress levels before and after using self-guided guides specifically for Veterans, could be highly beneficial. Another limitation from this study is that only Veteran feedback was received due to the Veteran-Centric focus. Future efforts in creating wellness material could be aided by the input from people like family members as they provide a different aspect of life as a Veteran. While the sample of Veteran used was diverse, the proportion of men to women stakeholders was not even, with there being more women. Future studies might consider incorporating more males in this process. It could be beneficial to create similar resources geared towards sub-groups in the Veteran population to incorporate the different experiences these groups could face, such as material specific to genders.
This study indicated that self-guided wellness materials incorporating positive psychology interventions were well received and welcomed by Veterans. The development of these resources has the potential to bolster facets of Veteran lives that are typically overlooked. It is crucial to focus not only on the illnesses that Veterans face but also on how they can thrive in their daily lives through promoting general wellbeing. A focus group comprising of diverse Veteran stakeholders was used to determine how to create the Veteran-centric wellness guide, compiling various exercises from positive psychology, along with health and clinical psychology. Input received from these stakeholders impacted phrasing, images, and examples that would be relatable for Veterans. Future research in the development of self-guided help that addresses specific needs for Veterans could be of great benefit to this underserved population.
Tanielian, T., Jaycox, L. H., Schell, T. L., Marshall, G. N., Burnam, A., Eibner, C., Vaiana, M. E. (2008). Invisible Wounds: Mental Health and Cognitive Care Needs of Americas Returning Veterans. PsycEXTRA Dataset. doi:10.1037/e527722010-001
Oster, C., Morello, A., Venning, A., Redpath, P., & Lawn, S. (2017). The health and wellbeing needs of veterans: A rapid review. BMC Psychiatry,17(1). doi:10.1186/s12888-017-1547-0
GAO-12-12 VA Mental Health: Number of Veterans Receiving ... (n.d.). Retrieved from https://www.gao.gov/assets/590/585743.pdf
Bolier, L., Haverman, M., Westerhof, G. J., Riper, H., Smit, F., & Bohlmeijer, E. (2013). Positive psychology interventions: A meta-analysis of randomized controlled studies. BMC Public Health,13(1). doi:10.1186/1471-2458-13-119
Sin, N. L., & Lyubomirsky, S. (2009). Enhancing well-being and alleviating depressive symptoms with positive psychology interventions: A practice-friendly meta-analysis. Journal of Clinical Psychology,65(5), 467-487. doi:10.1002/jclp.20593
Chakhssi, F., Kraiss, J. T., Sommers-Spijkerman, M., & Bohlmeijer, E. T. (2018, June 27). The effect of positive psychology interventions on well-being and distress in clinical samples with psychiatric or somatic disorders: A systematic review and meta-analysis. Retrieved from https://link.springer.com/article/10.1186/s12888-018-1739-2
Bryan, C. J., Jennings, K. W., Jobes, D. A., & Bradley, J. C. (2012). Understanding and Preventing Military Suicide. Archives of Suicide Research,16(2), 95-110. doi:10.1080/13811118.2012.667321
Peterson, C., Park, N., & Sweeney, P. J. (2008). Group Well-Being: Morale from a Positive Psychology Perspective. Applied Psychology,57(S1), 19-36. doi:10.1111/j.1464-0597.2008.00352.x
Gable, S. L., & Haidt, J. (2005). What (and why) is positive psychology? Review of General Psychology,9(2), 103-110. doi:10.1037/1089-26126.96.36.199
Linley, P. A., Joseph, S., Harrington, S., & Wood, A. M. (2006). Positive psychology: Past, present, and (possible) future. The Journal of Positive Psychology,1(1), 3-16. doi:10.1080/17439760500372796
Schueller, S. M., & Parks, A. C. (2014). The Science of Self-Help. European Psychologist,19(2), 145-155. doi:10.1027/1016-9040/a000181
Bergsma, A. (2007). Do self-help books help? Journal of Happiness Studies,9(3), 341-360. doi:10.1007/s10902-006-9041-2
Mehrotra, S., Kumar, S., Sudhir, P., Rao, G., Thirthalli, J., & Gandotra, A. (2017). Unguided mental health self-help apps: Reflections on challenges through a clinicians lens. Indian Journal of Psychological Medicine,39(5), 707. doi:10.4103/ijpsym.ijpsym_151_17
Carter, J. A. (2002). Integrating science and practice: Reclaiming the science in practice. Journal of Clinical Psychology,58(10), 1285-1290. doi:10.1002/jclp.10112
Abramson, L. Y., Seligman, M. E., & Teasdale, J. D. (1978). Learned helplessness in humans: Critique and reformulation. Journal of Abnormal Psychology,87(1), 49-74. doi:10.1037//0021-843x.87.1.49
Nayar, K., Kyobutungi, C., & Razum, O. (2004). Self-help: What future role in health care for low and middle-income countries? International Journal for Equity in Health,3(1). doi:10.1186/1475-9276-3-1
Gutierrez, L., Ortega, R. M., & Suarez, S. (1990). Self-help and the Latino community. In T. J. Powell (Ed.), Working with self-help (pp. 218-236). Silver Spring, MD: National Association of Social Workers.
Kapell, B. M., & Mclean, S. (2014). Public pedagogy from the learners perspective: Women reading self-help relationship books. Studies in Continuing Education,36(3), 342-357. doi:10.1080/0158037x.2014.916262
Fleming, E., Crawford, E. F., Calhoun, P. S., Kudler, H., & Straits-Troster, K. A. (2016). Veterans Preferences for Receiving Information About VA Services: Is Getting the Information You Want Related to Increased Health Care Utilization? Military Medicine,181(2), 106-110. doi:10.7205/milmed-d-14-00685
Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007). Perceived public stigma and the willingness to seek counseling: The mediating roles of self-stigma and attitudes toward counseling. Journal of Counseling Psychology,54(1), 40-50. doi:10.1037/0022-0188.8.131.52
Harding, S. (2016). Self-Stigma and Veteran Culture. Journal of Transcultural Nursing,28(5), 438-444. doi:10.1177/1043659616676319
Litz, B. T., Stein, N., Delaney, E., Lebowitz, L., Nash, W. P., Silva, C., & Maguen, S. (2009). Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review,29(8), 695-706. doi:10.1016/j.cpr.2009.07.003
Campbell, D. G., Bonner, L. M., Bolkan, C. R., Lanto, A. B., Zivin, K., Waltz, T. J., . . . Chaney, E. F. (2016). Stigma Predicts Treatment Preferences and Care Engagement Among Veterans Affairs Primary Care Patients with Depression. Annals of Behavioral Medicine,50(4), 533-544. doi:10.1007/s12160-016-9780-1
Cheney, A. M., Koenig, C. J., Miller, C. J., Zamora, K., Wright, P., Stanley, R., . . . Pyne, J. M. (2018). Veteran-centered barriers to VA mental healthcare services use. BMC Health Services Research,18(1). doi:10.1186/s12913-018-3346-9
Eligibility For VA Health Care. (n.d.). Retrieved from https://www.va.gov/health-care/eligibility/
Bluth, K., & Blanton, P. W. (2014, October 01). Mindfulness and Self-Compassion: Exploring Pathways to Adolescent Emotional Well-Being. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4198323/
Emmons, R. A., & McCullough, M. E. (n.d.). Counting Blessings Versus Burdens: An Experimental ... Retrieved from https://greatergood.berkeley.edu/pdfs/GratitudePDFs/6Emmons-BlessingsBurdens.pdf
VetAdvisor® Johns Hopkins National Veteran Sleep Survey Results. (n.d.). Retrieved from http://myvetadvisor.com/vetadvisorjohns-hopkins-national-veteran-sleep-survey-results/
Hall, K. S., Hoerster, K. D., & Yancy, W. S. (2015). Post-traumatic stress disorder, physical activity, and eating behaviors. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25595169/
Perlman, L. M., Cohen, J. L., Altiere, M. J., & Brennan, J. (n.d.). A Multidimensional Wellness Group Therapy Program for ... Retrieved from http://psycnet.apa.org/journals/pro/41/2/120.pdf
Whole Health For Life. (2016, February 18). Retrieved from https://www.va.gov/patientcenteredcare/explore/about-whole-health.asp