THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINE Volume 21, Number 7, 2015, pp. 409–421 ª Mary Ann Liebert, Inc. DOI: 10.1089/acm.2014.0324
Challenges to Enrollment and Participation in Mindfulness-Based Stress Reduction Among Veterans: A Qualitative Study Michelle E. Martinez, BA,1 David J. Kearney, MD,2,3 Tracy Simpson, PhD,4,5 Benjamin I. Felleman, MS,1 Nicole Bernardi, BS,1 and George Sayre, PsyD1,6
Abstract
Background: Mindfulness-Based Stress Reduction (MBSR) is associated with reduced depressive symptoms, quality of life improvements, behavioral activation, and increased acceptance among veterans. This study was conducted to increase the reach and impact of a veterans’ MBSR program by identifying barriers to enrollment and participation to inform modifications in program delivery. Objective: Verify or challenge suspected barriers, and identify previously unrecognized barriers, to enrollment and participation in MBSR among veterans. Design: A retrospective qualitative analysis of semistructured interviews. Setting/location: VA Puget Sound Health Care System (Seattle, WA). Subjects: 68 interviewed, and 48 coded and analyzed before reaching saturation. Approach: Content analysis of semistructured interviews. Results: Of the participants who enrolled, most (78%) completed the program and described MBSR positively. Veterans identified insufficient or inaccurate information, scheduling issues, and an aversion to groups as barriers to enrollment. Participants who discontinued the program cited logistics (e.g., scheduling and medical issues), negative reactions to instructors or group members, difficulty understanding the MBSR practice purposes, and struggling to find time for the practices as barriers to completion. Other challenges (cohort dynamics, teacher impact on group structure and focus, instructor lack of military service, and physical and psychological challenges) did not impede participation; we interpreted these as growth-facilitating challenges. Common conditions among veterans (chronic pain, posttraumatic stress disorder, and depression) were not described as barriers to enrollment or completion. Conclusions: Women-only MBSR groups and tele-health MBSR groups could improve accessibility to MBSR for veterans by addressing barriers such as commute anxiety, time restrictions, and an aversion to mixed gender groups among women. Educating MBSR teachers about veteran culture and health challenges faced by veterans, adding psychoeducation materials that relate mindfulness practice to conditions common among veterans, and improving visual aids for mindful movement exercises in the workbook could better accommodate veterans who participate in MBSR. Introduction
M
any veterans face an array of health problems, including posttraumatic stress disorder (PTSD),1–3 depression,4–6 chronic pain,7–9 and substance misuse,4,5,10 that can reduce quality of life across the lifespan. Recently, the VA has begun to advocate patient-centered, integrative treatment
approaches and self-care, in an attempt to address multiple domains of health and well-being.11–14 Although evidence suggests that mindfulness-based interventions (MBIs) are acceptable to veterans,15–21 attrition rates vary considerably (3–40%) among MBIs.22 To better understand veteran participation, research is needed to explore reasons why some decline to enroll, drop out of, or complete these programs.
1
VA Puget Sound Health Care System, Seattle, WA. Departments of 2Medicine and 5Mental Health, VA Puget Sound Health Care System, Seattle, WA. Departments of 3Medicine and 4Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA. 6 Department of Health Services, University of Washington School of Public Health, Seattle, WA.
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Mindfulness has been described as ‘‘paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally’’ (p. 4), and accepting one’s present experience as it is, without trying to control, change, or escape it.23 MBIs are usually taught as a group course by an experienced facilitator, and include both in-class and at-home meditation practice. There is evidence supporting the use of MBIs in the management of a wide range of conditions common among veterans, including anxiety,24–27 depression,24–28 substance misuse,29–31 chronic pain,32–35 fibromyalgia,25,36 chronic fatigue syndrome,37 PTSD,18–21,38,39 and irritable bowel syndrome.16,37,40 Of note, several health-related studies of MBIs have been criticized for lacking active control arms, which considerably limits the ability to determine whether the measured benefit is due to group participation in general, as opposed to mindfulness training specifically.41,42 However, metasynthesis research of seven qualitative MBI studies suggests that certain therapeutic change outcomes appear to be directly related to the mindfulness-specific skills taught in an MBI, for example, understanding mind–body interactions and thought processes; accepting/nonjudging thoughts, feelings, and the self; and refocusing attention to the present moment.43 One of the most extensively validated and widely available MBIs is an 8-week program called Mindfulness-Based Stress Reduction (MBSR).44,45 Initial studies suggest low rates of dropout and a high level of acceptability of MBIs, including MBSR, in veteran populations.17–21 Given the evidence of MBIs for mental and physical health burdens common among veterans, it is important to identify obstacles that limit the accessibility, and thus the impact, of these treatments. Qualitative research methods are well-suited for exploring barriers from the patient’s perspective, because they explicitly address the complex and holistic nature of individual subjective experience.46 Qualitative research on barriers to MBIs
A study47 of civilian women with a history of PTSD who took MBSR identified several initial barriers: lack of experience with meditation, doubts about the effectiveness of the group, viewing the group as a ‘‘chore,’’ interpersonal group dynamics, and negative emotions associated with MBSR practice. Another study gathered data from older adults with chronic lower back pain who participated in a mindfulness meditation group modeled on MBSR and found two barriers to meditation: ‘‘becoming sleepy’’ and ‘‘finding time.’’48 Stankovic explored the experiences of veterans with combatrelated PTSD in an integrative restoration meditation group, and noted the following reasons for dropouts: schedule conflicts, full-time work, personal stressors, and discomfort with the class environment.49 Classroom interruptions (e.g., people walking in) were found to trigger PTSD symptoms for some veterans, which prompted one dropout. Distractions (noise from outside the room or participants), and difficulty getting up and down from the floor were other challenges. In a study of mindfulness-based cognitive therapy for depression, participants talked about struggling with having set their expectations too high, the idea of nonstriving, and finding the appropriate balance between acceptance and change.46 Useful as these findings are, this literature is still in its infancy and does not speak to the specific experiences of veterans and barriers they may encounter as they attempt to
MARTINEZ ET AL.
engage in MBSR. The present study was conducted to better understand the unique challenges that may keep veterans referred to MBSR from enrolling and completing the program at two campuses of a large VA healthcare facility. Materials and Methods
Researchers received IRB approval for this study and obtained informed consent from all study participants. Semistructured interviews were used to explore 68 veterans’ experiences of referral to and participation in an 8-week MBSR course at VA Puget Sound. These are closed courses, consisting of 8 weekly 2.5-hour sessions plus a 7-hour session on a Saturday, which typically enroll 15–25 participants with a male-to-female ratio of approximately 80/20. Most were taking MBSR for the first time, but participants had varying experiences, with meditation or other forms of complementary and alternative medicine. We interviewed 24 decliners (did not attend orientation/declined participation after orientation), 7 dropouts (attended
Challenges to Enrollment and Participation in Mindfulness-Based Stress Reduction Among Veterans: A Qualitative Study Michelle E. Martinez, BA,1 David J. Kearney, MD,2,3 Tracy Simpson, PhD,4,5 Benjamin I. Felleman, MS,1 Nicole Bernardi, BS,1 and George Sayre, PsyD1,6
Abstract
Background: Mindfulness-Based Stress Reduction (MBSR) is associated with reduced depressive symptoms, quality of life improvements, behavioral activation, and increased acceptance among veterans. This study was conducted to increase the reach and impact of a veterans’ MBSR program by identifying barriers to enrollment and participation to inform modifications in program delivery. Objective: Verify or challenge suspected barriers, and identify previously unrecognized barriers, to enrollment and participation in MBSR among veterans. Design: A retrospective qualitative analysis of semistructured interviews. Setting/location: VA Puget Sound Health Care System (Seattle, WA). Subjects: 68 interviewed, and 48 coded and analyzed before reaching saturation. Approach: Content analysis of semistructured interviews. Results: Of the participants who enrolled, most (78%) completed the program and described MBSR positively. Veterans identified insufficient or inaccurate information, scheduling issues, and an aversion to groups as barriers to enrollment. Participants who discontinued the program cited logistics (e.g., scheduling and medical issues), negative reactions to instructors or group members, difficulty understanding the MBSR practice purposes, and struggling to find time for the practices as barriers to completion. Other challenges (cohort dynamics, teacher impact on group structure and focus, instructor lack of military service, and physical and psychological challenges) did not impede participation; we interpreted these as growth-facilitating challenges. Common conditions among veterans (chronic pain, posttraumatic stress disorder, and depression) were not described as barriers to enrollment or completion. Conclusions: Women-only MBSR groups and tele-health MBSR groups could improve accessibility to MBSR for veterans by addressing barriers such as commute anxiety, time restrictions, and an aversion to mixed gender groups among women. Educating MBSR teachers about veteran culture and health challenges faced by veterans, adding psychoeducation materials that relate mindfulness practice to conditions common among veterans, and improving visual aids for mindful movement exercises in the workbook could better accommodate veterans who participate in MBSR. Introduction
M
any veterans face an array of health problems, including posttraumatic stress disorder (PTSD),1–3 depression,4–6 chronic pain,7–9 and substance misuse,4,5,10 that can reduce quality of life across the lifespan. Recently, the VA has begun to advocate patient-centered, integrative treatment
approaches and self-care, in an attempt to address multiple domains of health and well-being.11–14 Although evidence suggests that mindfulness-based interventions (MBIs) are acceptable to veterans,15–21 attrition rates vary considerably (3–40%) among MBIs.22 To better understand veteran participation, research is needed to explore reasons why some decline to enroll, drop out of, or complete these programs.
1
VA Puget Sound Health Care System, Seattle, WA. Departments of 2Medicine and 5Mental Health, VA Puget Sound Health Care System, Seattle, WA. Departments of 3Medicine and 4Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA. 6 Department of Health Services, University of Washington School of Public Health, Seattle, WA.
409
410
Mindfulness has been described as ‘‘paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally’’ (p. 4), and accepting one’s present experience as it is, without trying to control, change, or escape it.23 MBIs are usually taught as a group course by an experienced facilitator, and include both in-class and at-home meditation practice. There is evidence supporting the use of MBIs in the management of a wide range of conditions common among veterans, including anxiety,24–27 depression,24–28 substance misuse,29–31 chronic pain,32–35 fibromyalgia,25,36 chronic fatigue syndrome,37 PTSD,18–21,38,39 and irritable bowel syndrome.16,37,40 Of note, several health-related studies of MBIs have been criticized for lacking active control arms, which considerably limits the ability to determine whether the measured benefit is due to group participation in general, as opposed to mindfulness training specifically.41,42 However, metasynthesis research of seven qualitative MBI studies suggests that certain therapeutic change outcomes appear to be directly related to the mindfulness-specific skills taught in an MBI, for example, understanding mind–body interactions and thought processes; accepting/nonjudging thoughts, feelings, and the self; and refocusing attention to the present moment.43 One of the most extensively validated and widely available MBIs is an 8-week program called Mindfulness-Based Stress Reduction (MBSR).44,45 Initial studies suggest low rates of dropout and a high level of acceptability of MBIs, including MBSR, in veteran populations.17–21 Given the evidence of MBIs for mental and physical health burdens common among veterans, it is important to identify obstacles that limit the accessibility, and thus the impact, of these treatments. Qualitative research methods are well-suited for exploring barriers from the patient’s perspective, because they explicitly address the complex and holistic nature of individual subjective experience.46 Qualitative research on barriers to MBIs
A study47 of civilian women with a history of PTSD who took MBSR identified several initial barriers: lack of experience with meditation, doubts about the effectiveness of the group, viewing the group as a ‘‘chore,’’ interpersonal group dynamics, and negative emotions associated with MBSR practice. Another study gathered data from older adults with chronic lower back pain who participated in a mindfulness meditation group modeled on MBSR and found two barriers to meditation: ‘‘becoming sleepy’’ and ‘‘finding time.’’48 Stankovic explored the experiences of veterans with combatrelated PTSD in an integrative restoration meditation group, and noted the following reasons for dropouts: schedule conflicts, full-time work, personal stressors, and discomfort with the class environment.49 Classroom interruptions (e.g., people walking in) were found to trigger PTSD symptoms for some veterans, which prompted one dropout. Distractions (noise from outside the room or participants), and difficulty getting up and down from the floor were other challenges. In a study of mindfulness-based cognitive therapy for depression, participants talked about struggling with having set their expectations too high, the idea of nonstriving, and finding the appropriate balance between acceptance and change.46 Useful as these findings are, this literature is still in its infancy and does not speak to the specific experiences of veterans and barriers they may encounter as they attempt to
MARTINEZ ET AL.
engage in MBSR. The present study was conducted to better understand the unique challenges that may keep veterans referred to MBSR from enrolling and completing the program at two campuses of a large VA healthcare facility. Materials and Methods
Researchers received IRB approval for this study and obtained informed consent from all study participants. Semistructured interviews were used to explore 68 veterans’ experiences of referral to and participation in an 8-week MBSR course at VA Puget Sound. These are closed courses, consisting of 8 weekly 2.5-hour sessions plus a 7-hour session on a Saturday, which typically enroll 15–25 participants with a male-to-female ratio of approximately 80/20. Most were taking MBSR for the first time, but participants had varying experiences, with meditation or other forms of complementary and alternative medicine. We interviewed 24 decliners (did not attend orientation/declined participation after orientation), 7 dropouts (attended
