Social Science - Sociology Assignment 11
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Community Mental Health Journal (2020) 56:1391–1405 https://doi.org/10.1007/s10597-020-00582-y
ORIGINAL PAPER
Qualitative Study of NAMI Homefront Family Support Program
Morgan Haselden1 · Bartholt Bloomfield‑Clagett2,3 · Suzanne Robinson4 · Teri Brister4 · Samantha E. Jankowski1 · Reanne Rahim1 · Leopoldo J. Cabassa5 · Lisa Dixon1,6
Received: 23 July 2019 / Accepted: 11 February 2020 / Published online: 19 March 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract The National Alliance on Mental Illness’s Homefront program is a 6-week peer-taught program for family members of veterans and active duty soldiers. Homefront is associated with increased empowerment, coping, and knowledge, but little is known about member experiences. This study used telephone interviews to identify program components that are helpful or need improvement, and to compare the online and in-person program formats. Seventeen participants (7 online) and 17 instructors (3 online) were interviewed and qualitative data analysis suggested that the most helpful components were group discussion, lessons on veteran-specific issues, and coping skills workshops. Some suggested expanding Homefront to 8 or 10 weeks. The online program was convenient for those unable to attend otherwise, but participants cited some dissatisfac- tion with the discussion format. Instructors described teaching the program as rewarding and noted learning from the cur- riculum. Understanding the experiences of participants may inform the development of future psychoeducation programs.
Keywords Family · Psychosocial support · Caregiving · Veterans · Trauma · Online intervention
Introduction
Veterans and military personnel face many potential chal- lenges when returning from combat or readjusting to civil- ian life. The significant rates of mental health diagnoses among these populations, including depression, PTSD, and substance use, further complicate this transition (Seal et al. 2009). In turn, families of veterans may experience signifi- cant challenges while trying to provide care to their loved ones. For instance, veterans’ numbing and arousal symptoms of PTSD were predictive of family distress, and veterans’
anger was associated with diminished familial relationships and secondary traumatization of family members (Galovski and Lyons 2004). Another study looking at veterans with serious mental illness found that greater depressive and dis- organized symptoms predicted patient perceptions of poorer communication, problem solving, and greater conflict with families (Haselden et al. 2016). These problems are com- pounded by low utilization of mental health services after returning from deployment (Kehle et al. 2010) and high unemployment rates among veterans ( Makin-Byrd et al. 2011; National Center for Veterans Analysis and Statistics 2018).
Families of veterans may seek out self-help groups or other resources for guidance and support. The National Alliance on Mental Illness (NAMI) created the Homefront program to address the specific issues veteran families face. NAMI Homefront is a 6-session, peer-taught psychoeduca- tion course delivered in-person and online. It was adapted from the NAMI Family-to-Family Education program (FTF), a 12-session program for families of individuals with all mental illnesses (Dixon et al. 2011). Previous studies evaluating the effectiveness of FTF demonstrated that par- ticipation is associated with increased empowerment and knowledge about serious mental illness; improved coping, problem-solving and self-care; and decreased distress and
* Reanne Rahim [email protected]
1 New York State Psychiatric Institute, 1051 Riverside Drive, Box 100, Room 2702, New York, NY 10032, USA
2 New York Presbyterian Hospital, New York, NY, USA 3 Weill Cornell Medical Center, New York, NY, USA 4 NAMI Information, Support & Education, Arlington, VA,
USA 5 Brown School of Social Work, Washington University
in St. Louis, St. Louis, MI, USA 6 Department of Psychiatry, Columbia University, 1051
Riverside Drive, Box 100, Room 2702, New York, NY 10032, USA
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subjective burden (Dixon et al. 2011, 2004; Marcus et al. 2013; Mercado et al. 2016). Studies have also shown that gains are sustained 6 months after the intervention is over, without need for a booster session (Dixon et al. 2004; Luck- sted et al. 2013).
A recent study examined the effects of the NAMI Home- front program and found comparable gains to prior FTF studies (Haselden et al. 2019). The study enrolled 119 par- ticipants from the NAMI Homefront program with approxi- mately half the sample in-person and half online. In-person classes spanned 15 states in all regions of the U.S. While the absence of a control group precludes drawing conclusions about causation, NAMI Homefront was associated with sta- tistically significant improvements of empowerment, cop- ing, psychological distress, family functioning, experience of caregiving and knowledge about mental illness (Haselden et al. 2019). Additionally, there were no statistically signifi- cant differences between the online and in-person formats on study outcomes.
The current study interviewed a subset of participants from the quantitative study described above, as well as a small sample of instructors. Participants and instructors of both in-person and online classes were interviewed. Quali- tative methods provide a deeper understanding of the lived experiences of participants and facilitators and uncover more nuanced insights about the program’s impact and mecha- nisms of change not captured by quantitative methods and structured instruments. The study aimed to gain a better understanding of participants’ and instructors’ experiences in the program, what was helpful or worked well and what could be improved. We also explored nuances of the in-per- son versus online format experiences.
Methods
NAMI Homefront Program Description
In 6 two-and-a-half-hour sessions, program participants receive information about mental illnesses, ways to develop emotional insight into their responses to mental illness, and coping mechanisms including self-care, communica- tion skills, problem-solving strategies and crisis planning. There is an added focus on veteran experiences including information about trauma, PTSD, combat-related behaviors, and the U.S. Department of Veterans Affairs (VA). While the program is 6-sessions and most frequently taught over the course of 6 weeks, instructors have flexibility to teach the course over shorter time periods (e.g. 3 weeks, or 1 week- end) depending on the needs of their class.
Both in-person and online formats of the program com- bine lectures with interactivity. The online program is deliv- ered as a live webinar, with instructors using PowerPoint
to present material, while in-person instructors present the material using white boards or flip charts. The curriculum content is identical in both formats. Online participants may use a microphone or webcam to speak, or type in a com- munal chatbox which instructors narrate. Mirroring the in- person format, the online platform also allows splitting into small groups to facilitate participation in skills workshops.
The program is advertised for family members, support persons, and caregivers of veterans or military service mem- bers with mental health conditions. Such individuals are eli- gible to participate in the program.
Recruitment
Recruitment for the larger quantitative study of 119 par- ticipants occurred at NAMI Homefront classes (in-person and online) offered across the United States between March, 2015 and October, 2017. Program teachers were asked to inform program participants about the study and provide them with a copy of the study flyer. Inclusion criteria were being a family member or support person of a military ser- vice member or of a veteran with mental illness, English speaking, and age 18 years or older. Participants of the quantitative study provided online consent, which included a question that asked if they would give permission to be contacted to learn more about participating in a qualitative interview at a later time. Study participants enrolled from 22 in-person classes (N = 63) and 12 online classes (N = 56). In-person classes spanned 15 states in all U.S. regions. We do not have the total number of class participants who were actually offered quantitative study participation; however, the average class sizes for in-person and online classes were 8 and 12 participants respectively. If we assume that all participants were offered participation, we estimate a study enrollment rate of approximately 36% for in-person classes, and 50% for online classes. We do not have information on the characteristics of program participants who took the class but did not enroll in the quantitative study.
For this qualitative sub-study, a convenience sample, including both in-person and online class participants, was recruited from the quantitative research study between Octo- ber, 2015 and May, 2017. Research staff contacted individu- als who provided permission and informed them about the qualitative study. Interested individuals provided verbal consent over the phone and research staff documented that verbal consent was given.
Of the 119 participants that enrolled in the quantitative study and completed a baseline assessment, 115 provided consent to contact about the qualitative study. Four partici- pants had already completed the research study by the time the qualitative component was added to the study. After the qualitative component was added, research staff contacted the first 38 participants who had completed the post-program
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quantitative assessment to inform them about the qualita- tive study. Of these 38, 17 participated. Of the 21 partici- pants who were contacted but did not participate, 15 did not respond, and 6 responded but were unable to schedule a time for the interview. For the 78 participants who were not contacted, 4 did not complete a post assessment, and 71 completed the post assessment after we had ended recruit- ment for the qualitative study.
The instructors interviewed were also a convenience sample recruited between October, 2015 and October 2017. Seventeen instructors were enrolled in the study. Seven in- person instructors were recruited from a study flyer which NAMI officials distributed to instructors. These instructors contacted the research team and enrolled in the study. Data on the number of instructors reached via the flyer were not systematically collected. Another 9 in-person instructors were recruited by direct communication with the research team after they had assisted with recruitment of participants, and 7 of these instructors participated in the research inter- views (2 expressed interest but did not respond to schedul- ing). Finally, in an attempt to obtain feedback from online instructors, NAMI officials referred 3 instructors that had recently taught the online course. Inclusion criteria for instructors was simply being a trained NAMI Homefront instructor and having taught at least one in-person or online course.
Qualitative Interviews and Quantitative Measures
Interviews were conducted by a trained research assistant (RA) via telephone, audio-recorded, and professionally tran- scribed. RAs cleaned the transcripts by listening to the audio files and correcting any mistakes in the transcripts. The interviews lasted approximately 30–60 min and participants and instructors were compensated $20 for their time. Brief semi-structured interview guides were used for participants and instructors. Participant interviews asked the following: what was most helpful about the program; least helpful; what ways did the program help your ability to cope with the mental health challenges of your service member/vet- eran; what was your “aha” moment; what would you change about the program, or how could it be improved; and would you recommend the course to others. Instructor interviews asked the following: What parts of the class worked well; didn’t work well or could be improved; what topics were most helpful and least helpful; how did teaching the class affect you personally; would you teach the course again. The interview questions were developed in collaboration with NAMI to capture information that would help improve the program. The research team drafted general questions which the NAMI Homefront Program Directors further honed and supplemented with some questions from NAMI’s standard satisfaction questionnaire.
Demographic characteristics of the participants and their veteran relative (participant-reported) were collected at baseline of the quantitative study via an online survey. Gender was the only demographic characteristic collected for instructors (self-report).
Data Analysis
Demographic data were analyzed using SPSS version 25. After the final three interviews, the PI and interviewer dis- cussed the feedback from participants, found no new infor- mation emerged and determined we had reached saturation. Limited resources necessitated that we use a rapid analysis methodology (Hamilton 2013; Sobo et al. 2003) and comple- mentary matrix analysis (Averill 2002) to analyze qualitative data. Rapid analysis methodology is well-suited for mixed- methods studies that are collecting and analyzing quantita- tive and qualitative data concurrently (Hamilton 2013; Sobo et al. 2003). Briefly, this method involved reducing transcript data using a summary template, transferring summary data into a matrix for analyses, and identifying key themes that emerged from the data. After cleaning the transcripts, the research team developed a summary template with each question from the interview corresponding to a section of the template. These sections are referred to as domains. Two domains were added to the summary template due to their frequent discussion during interviews (identified during transcript cleaning). These domains were comments about class length and class format. A third domain was added to record other topics discussed. Summary preparation was completed by three separate readers. Readers copied verba- tim quotes from the transcripts into the summary template domains and briefly summarized the main point of discus- sion (e.g. communication skills workshop). Readers were trained on a sample of four interviews to ensure interrater reliability. Then the remaining transcripts were divided and summarized. For the four transcripts that were used for train- ing, a final summary was created for each by merging the three readers’ individual summaries.
Participant and instructor interviews were analyzed separately, in that order. After all summaries within a sub- sample were completed, all data from the summaries were copied into a matrix with each row being a participant and each column being a domain (e.g. helpful, not helpful etc.). The three readers independently reviewed the matrix and created analytical memos to explain their interpreta- tion of each domain. Readers grouped quotes and noted their interpretation of a theme. The readers then reviewed each other’s analytical memos and met to discuss their interpretations. Interpretations that were shared by more than one reader were considered validated and included in the final analytical memo as a theme. For quotes that the readers’ interpretations differed, they discussed and came
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to a consensus on what the quote reflected. The readers’ analytical memos were then consolidated to create a final analytical memo for participants and instructors.
Data from the final memos were then synthesized to create a narrative. We identified important themes based on salience. For the most part, these themes emerged around different program components. Differing opinions about a component were grouped together for interpreta- tion. For example, a component of the program may have been described as helpful and not helpful by different participants, or as helpful but could be improved. There- fore, within each theme/component below, we describe the positive and/or negative feedback of both participants and instructors. Themes that were expressed by both participants and instructors were grouped together for interpretation.
This protocol was reviewed and approved by the New York State Psychiatric Institutional Review Board. The authors have no known conflicts of interest, and all authors certify responsibility for the manuscript.
Results
Sample
Study participants enrolled from 7 in-person classes (n = 10, 59%) and 3 online classes (n = 7, 41%). In-person classes spanned 7 states (AZ, CA, MO, NE, OK, TN, TX). Thirteen (76%) participants completed the program in 6 weeks (6 in- person participants and all 7 online participants). Two (12%) completed the program in 3 weeks, with two classes per day, and 2 (12%) completed the program in 1 weekend, two classes per day (all in-person participants). The mean (SD) number of classes completed was 5.7(0.7) with a median of 6 classes for the total sample.
Table 1 shows demographic characteristics of partici- pants. The gender and racial/ethnic distribution (n = 16 female, 94%; n = 9 white/Caucasian, 52%) was similar to the quantitative study (Haselden et al. 2019). No participants had an active-duty family member (i.e. all veterans). All the veteran family members were male and their mean(SD) age was 42(13) years.
Table 1 Demographic characteristics of participants
a Participants could report all diagnoses known to them and therefore the denominator for each diagnosis is the total sample. N = 1 was missing
Characteristics In-person class participants (n = 10)
Online class par- ticipants (n = 7)
Total participants (N = 17)
N % n % n %
Age (M ± SD) 47.1(5.1) 38.0(4.1) 44.6(14.8) Gender Female 9 90 7 100 16 94 Male 1 10 0 0 1 6
Race/ethnicity Black/African American 2 20 0 0 2 12 Hispanic or Latino 2 20 0 0 2 12 White/Caucasian 4 40 5 71 9 52 More than 1 race/ethnicity 2 20 0 0 2 12 Prefer not to answer 0 0 2 29 2 12
Relationship to veteran Spouse/partner 6 60 6 86 11 69 Parent 3 30 1 14 4 25 Sibling 1 10 0 0 1 6
Participant report of veteran’s diagnosesa
Post-traumatic stress disorder 7 70 5 71 12 71 Depression and/or anxiety 4 40 7 100 11 65 Bipolar disorder 3 30 2 29 5 29 Traumatic brain injury 2 20 2 29 4 25 Problems with substance use 0 0 2 29 2 12 Schizophrenia or schizoaffective disorder 1 10 0 0 1 6 Personality disorder 0 0 1 14 1 6
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Fourteen (82%) of instructors taught in-person classes and 3 (18%) taught online classes. Fifteen (88%) of instruc- tors were female.
Qualitative Results
We first report a brief summary of the course content par- ticipants and instructors described as helpful. Second, we present four key components of the program that they emphasized. We ordered these components based on our interpretation of significance which was determined by the degree of importance and emotion that participants/instruc- tors expressed. Third, we report the personal impact the program had on participants and instructors. Fourth, we describe differing opinions about course length, and fifth we report feedback unique to the online class format.
Course Content
Both participants and instructors identified group discus- sion, instruction on coping skills, a focus on veteran-specific information, and information on mental health diagnoses more broadly (i.e., an overview of the clinical symptoms associated with different mental illnesses) as most helpful.
Key Component 1: Group Discussion
Participants noted that it was both validating and educational to meet others who were struggling with similar experiences in caring for a loved one with mental illness. Some reported that they did not realize the degree to which their veteran’s symptoms were tied to their military experience until com- municating with others through group discussion. These dis- cussions helped to normalize the participants’ experiences, made them feel less alone in their struggles, and helped them to experience more empathy toward their veteran.
Instructors also reported group discussion as a component of the course that worked well. These instructors commented that the discussions provided a forum for people to share freely and connect, allowing individuals who often feel iso- lated to feel less alone.
In addition, some participants and instructors reported that the lecture-based components of the course contained too much material and that they would have preferred to allow more time for discussion. Participants reported feel- ing overwhelmed at times regarding the amount of material presented and that there was not enough time for questions and discussion.
Key Component 2: Veteran‑Specific Information
Participants noted that information targeted to veterans was helpful. This included information regarding trauma and
PTSD, combat behaviors, adaption to civilian life, and VA resources. Some participants noted that they would have liked further, more targeted information related to under- standing trauma and PTSD in the context of the wars in Iraq and Afghanistan (versus Vietnam), to reintegration into civilian life after combat, and to navigating VA services.
Instructors also noted that information specific to veter- ans and their families worked well or best. Some instructors reported that the information on VA and DoD resources as well as teaching on PTSD could be further streamlined to help participants.
Key Component 3: Coping Skills
Participants reported that the coping skills/workshops taught in the course were helpful, including communication skills, self-care, and crisis planning. Participants felt that the infor- mation on coping skills not only provided pragmatic strate- gies to address challenging interactions with their veterans, but also helped them to better understand their own reactions to their veteran’s mental illness. Some participants reported that more information on self-care, specifically, would be helpful.
Instructors also noted that classes on coping skills (com- munication, self-care, crisis planning) were some of the most helpful components of the course. Instructors commented that these classes helped participants to better apply com- munication skills in daily life through in-class role play, to recognize their own needs as caregivers, and to build support networks to more effectively help themselves and their loved ones. Some instructors felt that more time should have been given to discussion of crisis planning, specifically.
Key Component 4: Mental Health Diagnosis
Some participants reported that information on understand- ing the clinical differences between different mental health diagnoses was helpful. These participants wanted to know how the symptoms their veteran was experiencing differed from those of others with different mental health diagnoses. Some participants reported that information on the neu- robiology of the brain was helpful. Specifically, students spoke positively about the section on the brain as it related to trauma, PTSD, traumatic brain injury, depression and anxiety.
However, some participants commented that there was too much information about mental health diagnoses that were not as common in veteran populations, particularly schizophrenia. These participants noted that having an over- view of mental illness was important but could be briefer. Some participants also commented that the class which focused on the brain was too dense and overwhelming.
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Instructors reported that the overview of clinical symp- toms of different mental health diagnoses was helpful. These instructors noted that families struggle with either not know- ing or not understanding their veteran’s diagnosis, and an overview of different diagnoses provides important psy- choeducation. Like participants, some instructors reported that information on the neurobiology of mental illness was particularly helpful, while others thought this information could be revised or streamlined to make it more interesting to participants.
Personal Impact on Participants
All participants reported that the mental health challenges of the family member/veteran motivated them to take the class. Participants spoke of how they were impacted by one another, and by the lessons on how to cope with the mental health challenges of the veteran. Specifically, students noted the impact of self-care, communication skills, and empathy, and spoke to how these increased or improved since tak- ing the program. Lastly, participants described the positive impact of a better understanding of mental illness and feel- ing less stigmatized about the veteran’s mental health issues.
Personal Impact on Instructors
Instructors noted that teaching the course helped fulfill a desire to help others cope with being a caregiver to a loved one with mental illness. These instructors often commented that they found teaching the class a “rewarding” experience. Some reported that the course reinforced skills, particularly communication skills and self-care, ultimately helping them to improve their interactions with their own loved ones with mental illness, and to tolerate stress associated with caregiv- ing. Some in-person instructors specifically noted that teach- ing the class helped them to process their emotions related to caring for their loved one, which could be triggered by material covered in the course. Two in-person instructors also noted that forming connections with their co-instructors was a valuable experience.
Course Length
Some participants reported that the curriculum covered too much information for the allotted class time. Many of these participants commented that course content should be spread out over additional classes, which would add additional time for group discussion. Some participants also noted that individual class sessions were too long (2.5 h), and recom- mended shorter sessions with more discussion. In contrast, some participants reported that the number of classes was adequate to accommodate the course material, and the pro- gram was already a significant time commitment. Some of
these participants noted that the course might benefit from additional classes, but these should be optional.
Instructors also felt that there was too much material to cover in the time allotted. These instructors noted that classes often ran overtime to allow for additional discus- sion on the topics covered. Many of these instructors recom- mended adding additional sessions to the course.
However, some instructors commented that the course length was adequate. They expressed concerns that increas- ing course length may discourage participants from register- ing due to the increased time commitment.
Two participants and one instructor took/taught the course over 1 weekend. All three did not recommend this structure for future classes. Participants commented that the hours are too long, and the instructor noted that it was “too much content and emotional material to handle” in that short period of time, and commented that group bonding would be better if the course was spread out.
Online Course Format
Convenience
Some online participants noted that the convenience of online classes as compared to in-person classes was impor- tant for their participation in the course. Taking classes online eliminated the transportation time associated with in-person classes as well as decreased the need for child- care for those with children. However, some participants did acknowledge that caring for children while taking the online classes was often a distraction and did not allow them to par- ticipate fully. Two participants noted that in-person classes were not offered in their area and few resources would have been available to them had they not participated in the online course. However, three online participants noted that the timing of the classes (early evening) still posed challenges with their schedules, particularly for those with young fami- lies, and recommended making online classes available at other times of the day.
Group Discussion
Many online participants noted differences between group discussion in an online versus in-person format. Two par- ticipants noted that the online class was able to be open and honest with each other, with one participant noting that the anonymity of an online class may have increased her comfort with sharing personal information. While three participants reported that the text-based platform for communication hindered group discussion. These participants commented that an inability to hear the emotions in other participants’ voices reduced the ability to empathize and connect with others. One participant noted that the use of headsets by
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all participants to enable voice communication would likely alleviate these concerns.
Instructors also expressed differing opinions about the experience of group discussion in the online classes. One instructor commented that the “warmth” of group discussion was diminished with the online format, noting that facilitat- ing online group discussion requires much skill and effort by instructors to call on participants and encourage them to par- ticipate. Online instructors reported that the online classes did have meaningful discussion and engagement, though again with more effort on the part of instructors. Instruc- tors were pleased with the tools to overcome engagement barriers, including breaking into small groups and using other teaching materials, like quizzes, to prompt discussion. One instructor noted that the text-based platform may have helped participants communicate more succinctly.
Technical difficulties
Online participants noted technical difficulties as things that were not helpful or least helpful. These difficulties primarily included trouble with audio and video components of the online platform. One participant noted that allowing the plat- form to be used on a phone or tablet device would also be helpful. Online instructors echoed participants’ comments about difficulties with the audio and video components of the online platform. See Table 2 for exemplary quotes from participant and instructor samples.
Discussion
This study found a general consensus among instructors and participants regarding the most helpful components of the NAMI Homefront program. First, participants and instruc- tors noted that group discussion about shared experiences is one of the most valuable components of the course, often providing participants with a sense of community and under- standing that they previously lacked. Second, participants and instructors emphasized that the general information about veterans and psychoeducation were critical. Partici- pants want a balance of information that is well targeted to their specific circumstances (i.e., trauma/PTSD), but also want to understand “the lay of the land” (i.e., overview of clinical mental health diagnoses and corresponding symp- toms). Finally, participants and instructors highlighted the skills workshops as very useful in helping improve coping with the mental health challenges of their veteran and feel empowered to improve their interpersonal relationships. Altogether, this feedback suggests the NAMI Homefront program has a similar impact as other family-based peer support programs (Drapalski et al. 2009).
Participants consistently reported the importance of the group atmosphere and discussion format. The interviews underscored the hardships that military families experience when veterans return from war—feeling in the dark about what is happening with their loved ones, feeling scared, alone and hopeless. These feelings may be exacerbated by other factors that have been reported in the literature such as low utilization of mental health services (Kehle et al. 2010) and high unemployment rates among veterans (Makin-Byrd et al. 2011; National Center for Veterans Analysis and Sta- tistics 2018). At the same time, the interviews suggested how effectively the peer atmosphere mitigates these feel- ings. Understanding that others were undergoing similar experiences was validating and liberating for families. The larger quantitative study of 119 participants showed that the program led to significant improvements in empower- ment, coping, psychological distress, family functioning, and experience of caregiving (Haselden et al. 2019). While the program includes targeted workshops to improve these dimensions, this feedback from the qualitative interviews suggests that the peer support significantly contributes to outcomes. These reactions from participants also highlighted the potential impact of stigma towards mental illness in the military community and the perceived pressure on families to cope with their veteran’s experiences on their own. This finding is consistent with prior research, which has empha- sized how stigma is a barrier to veterans receiving mental health care (Kim et al. 2010). Stigma was not measured in the quantitative study and thus cannot be compared.
Homefront’s provision of general and of veteran-specific information contributed to the program’s value. Previous research identifying mechanisms of risk for military families highlighted an incomplete understanding of the impact of deployment and combat operational stress, and inaccurate developmental expectations among family members of vet- erans (Saltzman et al. 2011). Participants noted that discus- sion of how combat-related experiences manifest when sol- diers return home—that a veteran’s new behaviors including isolation, hypervigilance, and desires such as being deployed again may be rooted in prior combat experiences—was helpful. Such discussion has the potential to broaden fam- ily members’ understanding of issues and may reduce risk. Research has also shown symptoms of PTSD in veterans to be associated with secondary traumatization of family members (Galovski and Lyons 2004), partner psychological distress, depression and suicidal ideation (Manguno-Mire et al. 2007). There is a huge gap in educating military fami- lies about the experiences of war and what to expect from the transition to civilian life. Many family members spoke about having few resources or knowledge about how to han- dle these changes. It is possible that the lack of support and knowledge further exacerbates secondary traumatization and psychological distress experienced by some veteran families
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su pp
or t f
ro m
pe
op le
w ho
h av
e th
at u
nd er
st an
di ng
, t ha
t w as
p ro
ba bl
y ke
y ov
er e
ve ry
th in
g el
se .”
(in -p
er so
n in
str uc
to r)
“W el
l, th
er e
ar e
bu ilt
-in p
oi nt
s w he
re w
e en
co ur
ag e
di sc
us si
on a
nd it
is
fo cu
se d
di sc
us si
on . A
nd th
e di
sc us
si on
s w he
n th
ey ’re
v er
y fo
cu se
d lik
e th
at it
a llo
w ed
p eo
pl e
in o
ur g
ro up
to fi
nd c
om m
on al
ity b
et w
ee n
ea ch
o th
er
an d
th at
w as
I th
in k
ve ry
e m
po w
er in
g, b
ec au
se m
os t o
f t he
m h
ad e
xp re
ss ed
fe
el in
g is
ol at
ed . E
ve n
th ou
gh th
ey w
er e
su re
th er
e w
er e
ot he
r p eo
pl e
ou t
th er
e lik
e th
em , t
he y
di d
no t h
av e
a lo
t o f o
pp or
tu ni
ty to
ta lk
a bo
ut th
e m
or e
di ffi
cu lt
th in
gs th
at w
er e
go in
g on
w ith
th ei
r s er
vi ce
m em
be rs
.” (in
-p er
so n
in str
uc to
r) W
an te
d m
or e
“I th
in k
it co
ul d
be ne
fit fr
om b
ei ng
li ke
a c
ou pl
e of
w ee
ks lo
ng er
, a nd
ju st
to
ki nd
o f s
pr ea
d ou
t t he
m at
er ia
l a nd
a llo
w fo
r s om
e ad
di tio
na l d
is cu
ss io
n. ”
(o nl
in e
pa rti
ci pa
nt )
“[ th
e cl
as s o
n th
e br
ai n]
h ad
th e
m os
t i nf
or m
at io
n, a
nd it
w as
re al
ly o
ve r-
w he
lm in
g to
o, b
ec au
se it
w as
ju st
ja m
p ac
ke d
w ith
re ad
in g
ab ou
t w ha
t w en
t on
a nd
n ot
a lo
t o f t
im e
to st
op a
nd a
sk q
ue sti
on s a
nd ta
lk a
bo ut
it m
or e
in
de pt
h. ”
(in -p
er so
n pa
rti ci
pa nt
)
“I th
in k
ju st
th e
ex pe
ct at
io n
to fl
y th
ro ug
h ev
er yt
hi ng
so q
ui ck
ly w
he n
w e’
d lik
e to
sl ow
d ow
n an
d ha
ve b
et te
r d is
cu ss
io ns
a nd
b et
te r,
m or
e fr
ui tfu
l t im
e on
e ac
h to
pi c.
Y ou
k no
w I
fe el
li ke
w e
ru sh
ed so
m e
of th
e to
pi cs
, b ut
it c
ou ld
al
so b
e lik
e an
8 -w
ee k
cl as
s, lik
e ex
pa nd
in g
m or
e on
so m
e of
th e
ill ne
ss es
, ex
pa nd
in g
m or
e on
th e
br ai
n, e
xp an
di ng
m or
e on
c om
m un
ic at
io n
an d
ba r-
rie rs
a nd
b ou
nd ar
ie s a
nd c
ris is
. I th
in k
w e
co ul
d do
a li
ttl e
bi t b
et te
r j ob
ex
pa nd
in g
so m
e of
th os
e. I
th in
k it’
s j us
t a li
ttl e
bi t r
us he
d in
th e
6 w
ee ks
.” (in
-p er
so n
in str
uc to
r) “I
th ou
gh t i
t w as
a de
qu at
e fo
r m os
t c la
ss es
, b ut
I no
tic ed
a nd
I w
ro te
it d
ow n
in c
la ss
tw o
an d
cl as
s n um
be r fi
ve . I
w as
v er
y co
ns tra
in ed
o n
tim e,
b ec
au se
th
er e
w as
so m
uc h
in fo
rm at
io n
be in
g pr
ov id
ed th
at it
w as
— I f
el t l
ik e
w e
co ul
dn ’t
di sc
us s,
w e
co ul
dn ’t—
yo u
kn ow
, w e
co ul
dn ’t
re al
ly g
et in
to w
ha t
th is
m ea
nt fo
r e ac
h in
di vi
du al
, b ec
au se
it w
as so
fu ll
of in
fo rm
at io
n in
th os
e cl
as se
s. I d
on ’t
be lie
ve it
w as
a de
qu at
e fo
r t ho
se tw
o. ”
(in -p
er so
n in
str uc
to r)
Ve te
ra n-
sp ec
ifi c
in fo
rm at
io n
H el
pf ul
“F ro
m a
c on
te nt
st an
dp oi
nt , I
th in
k on
e of
th e
m os
t h el
pf ul
p ie
ce s f
or m
e is
I d
on ’t
ha ve
a lo
t o f k
no w
le dg
e an
d ex
pe rie
nc e
ab ou
t v et
er an
s i n
m en
ta l
ill ne
ss a
nd th
e VA
a nd
a ny
th in
g lik
e th
at . S
o I t
hi nk
ju st
th e
co nt
en t i
n ge
n- er
al g
av e
m e
a lo
t o f i
ns ig
ht in
to k
in d
of w
ha t I
w as
e xp
er ie
nc in
g. ”
(o nl
in e
pa rti
ci pa
nt )
“W ha
t w as
u ni
qu e
w as
in th
e H
om ef
ro nt
p ro
gr am
, [ w
e ta
lk ed
a bo
ut ] w
he n
yo u
ar e
in th
e m
ili ta
ry li
ke h
av in
g, y
ou k
no w
b ei
ng a
bl e
to st
ay aw
ak e
an d
vi gi
la nt
, a nd
a ng
ry o
fte n,
it ’s
w ha
t k ee
ps y
ou a
liv e.
A t h
om e,
th at
c an
m ak
e yo
u, y
ou k
no w
, a nx
io us
a nd
p ar
an oi
d an
d ag
gr es
si ve
. A nd
so se
ei ng
th os
e co
rr el
at io
ns fr
om li
ke th
is w
as th
e or
ig in
al b
eh av
io r,
th is
w as
th e
le ar
ne d
be ha
vi or
a nd
th is
is w
ha t t
ha t l
oo ks
li ke
a t h
om e,
th at
w as
o ne
o f t
he m
os t
un iq
ue th
in gs
th at
w as
u se
fu l f
or m
e.” (o
nl in
e pa
rti ci
pa nt
)
“I th
in k
an yt
hi ng
th at
’s d
ire ct
ly re
la te
d to
th e
un iq
ue e
xp er
ie nc
e be
in g
m ili
ta ry
fa
m ily
m em
be rs
w as
m os
t p ow
er fu
l.” (i
n- pe
rs on
in str
uc to
r) “I
th in
k th
e em
ph as
is o
n th
e PT
SD w
as g
oo d.
E ve
ry o
ne o
f t he
m th
at I
ha d,
th
ei r l
ov ed
o ne
w as
su ffe
rin g
so m
e ty
pe o
f P TS
D .”
(in -p
er so
n in
str uc
to r)
1399Community Mental Health Journal (2020) 56:1391–1405
1 3
Ta bl
e 2
(c on
tin ue
d)
Th em
e Pa
rti ci
pa nt
s In
str uc
to rs
W an
te d
m or
e “I
fe el
th at
th er
e co
ul d
ha ve
b ee
n m
or e
co nv
er sa
tio ns
o n
th e
af te
rm at
h of
in
te gr
at io
n. A
nd th
e se
pa ra
tio n
fro m
se rv
ic e
in to
c iv
ili an
li fe
is d
iffi cu
lt fo
r th
e fa
m ily
a s w
el l a
s t he
se rv
ic e
m em
be r,
an d
I f el
t i t w
as to
uc he
d on
v er
y br
ie fly
… in
o ur
fa m
ily th
at se
pa ra
tio n
an d
m ov
e in
to c
iv ili
an li
fe w
as a
tra
um a
in it
se lf.
A nd
th at
w as
n’ t r
ea lly
to uc
he d
on ”
(o nl
in e
pa rti
ci pa
nt )
“I w
is h
th at
th er
e ha
d be
en m
or e
ab ou
t t he
V A
st ru
ct ur
e as
w el
l a s o
rg an
iz a-
tio ns
o ut
si de
o f t
he V
A st
ru ct
ur e
be ca
us e
no t e
ve ry
se rv
ic e
m em
be r q
ua li-
fie s f
or V
A c
ar e”
(o nl
in e
pa rti
ci pa
nt )
“I a
ls o
th in
k th
er e
sh ou
ld b
e a
se ct
io n
fo r s
om e
ki nd
o f i
nf or
m at
io n
ab ou
t w ha
t it’
s l ik
e to
b e
a m
ili ta
ry fa
m ily
a nd
b e
liv in
g aw
ay fr
om th
ei r s
up po
rt sy
ste m
, an
d a
lo t a
re in
is ol
at io
n or
li vi
ng in
a fo
re ig
n co
un try
a nd
d ea
lin g
w ith
m en
- ta
l h ea
lth c
ha lle
ng es
. T he
y do
n’ t r
ea lly
g o
in to
th at
in a
ny o
f t he
c ha
pt er
s a t
al l.
A nd
th at
’s w
ha t t
he m
ili ta
ry is
a ll
ab ou
t. Th
e fr
eq ue
nt m
ov in
g, th
ey d
on ’t
ta lk
a bo
ut th
at .”
(i n-
pe rs
on in
str uc
to r)
C op
in g
sk ill
s C
om m
un ic
at io
n “E
sp ec
ia lly
th e
“I ”
st at
em en
ts in
p ar
tic ul
ar , w
er e
I w ou
ld sa
y pr
ob ab
ly th
e m
os t h
el pf
ul th
in g
to m
e is
le ar
ni ng
to in
co rp
or at
e th
at in
to d
ai ly
li fe
w he
n de
al in
g w
ith so
m eo
ne th
at h
as m
en ta
l i lln
es s.”
(i n-
pe rs
on p
ar tic
ip an
t)
“A nd
th e
co m
m un
ic at
io n
w or
ks ho
ps w
er e
an ot
he r b
ig o
ne , t
ha t w
as , t
ha t
se em
ed to
b e
ex tre
m el
y he
lp fu
l b ec
au se
th en
th e
ne xt
c la
ss w
he n
ev er
yo ne
ca
m e
ba ck
th ey
’re li
ke , "
I w en
t h om
e an
d I t
rie d
th is
, a nd
I tri
ed th
at a
nd
I g ot
a d
iff er
en t r
es po
ns e,
" a nd
so it
w as
c oo
l t o
se e
th em
g oi
ng h
om e
an d
ac tu
al ly
tr yi
ng w
ha t t
he y’
re b
ei ng
ta ug
ht .”
(in -p
er so
n in
str uc
to r)
S el
f- ca
re (H
el pf
ul )
“I th
in k
it he
lp ed
m e
to se
e th
at I’
m o
ka y,
th at
I’ m
n or
m al
, t ha
t I d
on ’t
– th
at
I h av
e to
ta ke
c ar
e of
m ys
el f.
Th at
w as
h ug
e. I
do n’
t w an
t t o
ge t t
o th
e po
in t
w he
re I’
m su
ffe rin
g m
en ta
lly .”
(in -p
er so
n pa
rti ci
pa nt
)
“A nd
th en
w e
re al
ly st
ar te
d ge
tti ng
in to
se lf-
ca re
, h ow
y ou
c an
su rv
iv e
th is
a nd
ta
ke c
ar e
of y
ou rs
el f,
th at
is w
ha t t
he y
se em
to b
e m
os t i
nt er
es te
d in
in b
ot h
cl as
se s.”
(i n-
pe rs
on in
str uc
to r)
S el
f- ca
re (W
an te
d m
or e)
“I th
in k
m or
e of
th e
se lf-
ca re
. I th
in k
it w
as ju
st ge
ne ra
l l ik
e, “
M ak
e su
re y
ou
ta ke
ti m
e fo
r y ou
rs el
ve s,"
a nd
– b
ut I
fe el
li ke
th at
e sp
ec ia
lly sh
ou ld
h av
e a
lo t m
or e
di sc
us si
on , i
n ta
lk in
g ab
ou t l
ea rn
in g
to sa
y I w
on ’t
in ste
ad o
f I
ca n’
t, an
d be
in g
ve ry
c le
ar a
bo ut
b ou
nd ar
y se
tti ng
.” (in
-p er
so n
pa rti
ci pa
nt )
“I m
ea n
I t hi
nk w
ha t p
ro ba
bl y
ne ed
s t o
be d
on e
is d
o a
si de
-b y-
si de
c om
pa ri-
so n
an d
se e
w ha
t t he
y cu
t o ut
[f ro
m F
am ily
-to -F
am ily
]. A
nd th
er e’
s s om
e re
al g
oo d
stu ff,
li ke
th ey
h ad
so m
e re
al ly
g oo
d stu
ff on
se lf-
ca re
in th
e N
A M
I Fa
m ily
-to -F
am ily
c ou
rs e
th at
th ey
sh or
tc ha
ng ed
I th
in k,
o r r
ed uc
ed , s
o an
y- w
ay .”
(in -p
er so
n pa
rti ci
pa nt
) C
ris is
-p la
nn in
g (H
el pf
ul )
“T he
c ris
is p
la n
ha nd
ou t w
as g
oo d
… Ju
st to
h av
e a
pl an
in p
la ce
so th
at
w he
n so
m et
hi ng
d oe
s h ap
pe n,
b ec
au se
it ’s
h ap
pe ne
d to
m y
fa m
ily , y
ou
do n’
t h av
e to
sc ra
m bl
e to
fi gu
re so
m et
hi ng
o ut
, y ou
’v e
al re
ad y
ta lk
ed a
bo ut
it
w ith
y ou
r v et
er an
, a nd
y ou
c an
ju st
fo llo
w th
os e
pr oc
ed ur
es .”
(in -p
er so
n pa
rti ci
pa nt
)
“I w
ou ld
sa y
on e
th in
g w
as b
ig a
nd th
at –
a nd
th er
e’ s p
ro ba
bl y
no t e
no ug
h on
th at
– is
th e
cr is
is p
la n
an d
un de
rs ta
nd in
g ho
w to
h an
dl e
a cr
is is
a nd
b e
re ad
y fo
r i t.
I w ou
ld sa
y th
at ’s
p ro
ba bl
y on
e of
th e
m os
t b en
efi ci
al to
p eo
pl e,
be
ca us
e th
at ’s
p re
tty sc
ar y,
th at
u nk
no w
n, b
ut to
k no
w h
ow to
h el
p th
at p
er -
so n
th e
be st,
w ou
ld b
e ve
ry , v
er y
im po
rta nt
.” (in
-p er
so n
in str
uc to
r) C
ris is
-p la
nn in
g (W
an te
d m
or e)
N /A
“T he
re is
n’ t a
lo t o
f t im
e fo
r p eo
pl e
in th
e cl
as s t
o ac
tu al
ly g
o th
ro ug
h th
e cr
is is
pl
an …
w e
ta lk
ed a
bo ut
it v
er y
br ie
fly a
nd w
e sa
y, y
ou k
no w
, t he
b es
t t im
e to
pl
an fo
r c ris
is is
n ot
w he
n yo
u’ re
in c
ris is
. A nd
, y ou
k no
w , g
et so
m e
of th
e stu
ff on
p ap
er n
ow w
hi le
th in
gs a
re o
ka y
an d
th en
h av
e it
av ai
la bl
e. A
nd th
en
w e
do n’
t r ea
lly to
uc h
on a
ny o
f t he
to pi
cs in
it …
S o
to b
re ak
th os
e pi
ec es
do
w n
… a
nd k
in d
of h
el pi
ng th
em w
or k
th ro
ug h
th at
p la
n. ”
(o nl
in e
in str
uc -
to r)
M en
ta l h
ea lth
d ia
gn os
es H
el pf
ul “I
th in
k it
w as
th e
kn ow
le dg
e th
at th
is is
a ll
re al
ly a
re al
th in
g, …
. l ite
ra lly
, th
e lis
t o f…
sy m
pt om
s t ha
t h e
ha s o
r m ay
h av
e of
m en
ta l i
lln es
s. A
nd it
di
dn ’t
ju st
co ve
r P TS
D , w
hi ch
I th
ou gh
t w as
g oo
d… Yo
u ki
nd o
f h av
e a
w el
l-r ou
nd ed
v ie
w o
f m en
ta l i
lln es
s a nd
n ot
ju st
on e
sp ec
ifi c
ar ea
.” (in
- pe
rs on
p ar
tic ip
an t)
“I m
ea n
ju st
ev en
li ke
th e
sy m
pt om
s w er
e ve
ry h
el pf
ul o
f t ry
in g
to re
co gn
iz e,
th
ey g
o th
ro ug
h th
is , t
he il
ln es
se s a
nd th
e sy
m pt
om s f
or th
em . B
ec au
se th
at ’s
a
bi g
pr ob
le m
, p eo
pl e
sti ll
str ug
gl e
w ith
w ha
t i s t
he a
ct ua
l d ia
gn os
is .”
(in -
pe rs
on in
str uc
to r)
1400 Community Mental Health Journal (2020) 56:1391–1405
1 3
Ta bl
e 2
(c on
tin ue
d)
Th em
e Pa
rti ci
pa nt
s In
str uc
to rs
W an
te d
le ss
o n
sc hi
zo ph
re ni
a an
d m
or e
on tr
au m
a/ PT
SD “I
g ue
ss it
’s g
oo d
to h
av e,
li ke
, a b
rie f o
ve rv
ie w
, b ut
I th
in k
th at
sh ou
ld h
av e
be en
a li
ttl e
br ie
fe r.”
(o nl
in e
pa rti
ci pa
nt )
“M ay
be so
m e
of th
e di
ag no
se s I
d on
’t th
in k
co m
e in
to p
la y
w ith
m ay
be th
e tra
um a
of v
et er
an s c
om in
g ho
m e
or m
ili ta
ry m
em be
rs c
om in
g ho
m e
…
w he
n yo
u’ re
ta lk
in g
to th
e m
ili ta
ry /v
et er
an c
om m
un ity
, s ur
e [s
ch iz
op hr
e- ni
a] m
ay c
om e
up e
ve ry
n ow
a nd
th en
. B ut
I th
in k
fo r t
he m
os t p
ar t,
it’ s n
ot
go in
g to
b e
a di
ag no
si s t
ha t i
s h ap
pe ni
ng in
th at
c om
m un
ity .”
(in -p
er so
n pa
rti ci
pa nt
)
“T he
o th
er th
in g
th at
d id
n’ t w
or k
w el
l, th
ey g
av e
a lo
t o f e
xa m
pl es
a nd
c as
e stu
di es
a nd
w ha
tn ot
, a nd
th ey
u se
d sc
hi zo
ph re
ni a
as a
n ex
am pl
e as
o pp
os ed
to
P TS
D w
hi ch
th ey
c ou
ld re
la te
a lo
t m or
e to
. S o
th at
w as
, y ou
k no
w ,
an yt
im e
I t ur
ne d
ar ou
nd th
e ex
am pl
e w
as so
m et
hi ng
w ith
sc hi
zo ph
re ni
a.”
(in -p
er so
n in
str uc
to r)
B ra
in b
io lo
gy H
el pf
ul “B
ut it
w as
a ct
ua lly
v er
y in
fo rm
at io
na l,
be ca
us e
it w
en t m
or e
in d
ep th
a bo
ut
PT SD
a nd
w ha
t v et
er an
s g o
th ro
ug h,
a nd
w en
t a lo
t t hr
ou gh
li ke
th e
br ai
n pr
oc es
s… th
at w
as th
e m
os t i
nt er
es tin
g pa
rt to
m e
w as
w ha
t p ar
ts o
f t he
br
ai n
ca us
es y
ou k
no w
, d ep
re ss
io n
or a
nx ie
ty .”
(o nl
in e
pa rti
ci pa
nt )
“L ea
rn in
g th
e fa
ct th
at th
at m
y hu
sb an
d ac
tu al
ly h
as p
hy si
ca l d
am ag
e to
h is
br
ai n,
w as
o ne
th in
g I h
ad n
ev er
e ve
r d re
am ed
w as
tr ue
. I ju
st fig
ur ed
it
w as
a ll
m en
ta l a
nd I
ne ve
r i m
ag in
ed a
nd d
id n’
t k no
w , i
t g av
e m
e a
lo t m
or e
em pa
th y
fo r h
im to
re al
iz e
th at
h e’
s a ct
ua lly
su ffe
rin g
ph ys
io lo
gi ca
lly a
nd
no t j
us t m
en ta
lly .”
(in -p
er so
n pa
rti ci
pa nt
)
“T he
y lik
e le
ar ni
ng a
bo ut
th e
bi ol
og y
of th
e br
ai n.
” (in
-p er
so n
in str
uc to
r) “R
ea lly
h el
pf ul
w as
ta lk
in g
ab ou
t w ha
t h ap
pe ns
in th
e br
ai n.
” (in
-p er
so n
in str
uc to
r)
C ou
ld b
e re
vi se
d/ str
ea m
lin ed
“[ Th
e cl
as s o
n th
e br
ai n]
h ad
th e
m os
t i nf
or m
at io
n, a
nd it
w as
re al
ly o
ve r-
w he
lm in
g to
o, b
ec au
se it
w as
ju st
ja m
p ac
ke d
w ith
re ad
in g
ab ou
t w ha
t w en
t on
a nd
n ot
a lo
t o f t
im e
to st
op a
nd a
sk q
ue sti
on s a
nd ta
lk a
bo ut
it m
or e
in
de pt
h. ”
(in -p
er so
n pa
rti ci
pa nt
) “T
he c
la ss
th at
fo cu
se d
on li
ke n
eu ro
tra ns
m itt
er s a
nd b
ra in
c he
m ist
ry a
nd
m ed
ic at
io n,
ju st
fe lt
a lit
tle d
au nt
in g,
a nd
w as
m or
e lik
e in
fo rm
at io
n gi
vi ng
th
an d
is cu
ss io
n ba
se d.
” (o
nl in
e pa
rti ci
pa nt
)
“I th
in k
th at
th e
bi ol
og y
of m
en ta
l h ea
lth c
on di
tio ns
is d
iffi cu
lt to
m ak
e it
in te
re sti
ng . T
o m
e, th
at is
m y
fa vo
rit e
cl as
s, bu
t i t i
s n ot
a lw
ay s t
he fa
vo rit
e of
th
es e
pa rti
ci pa
nt s.”
(o nl
in e
in str
uc to
r) “I
w ou
ld p
ro ba
bl y
re du
ce th
e di
sc us
si on
o n
th e
br ai
n …
y ou
st ar
t t o
ge t p
re tty
te
ch ni
ca l a
nd I
do n’
t k no
w w
ha t k
in d
of p
os iti
ve im
pa ct
y ou
h av
e, b
ec au
se
so m
e of
th e
pe op
le y
ou lo
ok o
ut th
er e
in y
ou r a
ud ie
nc e
an d
yo u’
re re
ad in
g it
an d
yo u
ca n
te ll
yo u’
re lo
si ng
th em
.” (in
-p er
so n
in str
uc to
r) Pe
rs on
al im
pa ct
“I t j
us t g
av e
m e
a ne
w p
er sp
ec tiv
e on
[h is
d ia
gn os
es ] a
nd h
ow th
ey a
ffe ct
th
em . P
lu s,
th at
g av
e m
e an
o pp
or tu
ni ty
to si
t i n
a gr
ou p
of p
eo pl
e w
he re
th
ey w
er e
ab le
to ta
lk a
bo ut
h ow
it im
pa ct
s t he
m …
it d
efi ni
te ly
g av
e m
e a
ne w
p er
sp ec
tiv e
on a
pp ro
ac h
an d
un de
rs ta
nd in
g of
w ha
t’s re
al ly
g oi
ng o
n. ”
(o nl
in e
pa rti
ci pa
nt )
“T hi
s i s s
o hu
ge , s
ay in
g yo
u kn
ow , i
t’s o
ka y
to b
e an
gr y,
it ’s
o ka
y to
h av
e gr
ie f …
I th
in k
it he
lp ed
m e
to se
e th
at I’
m o
ka y,
th at
I’ m
n or
m al
, t ha
t I
do n’
t – th
at I
ha ve
to ta
ke c
ar e
of m
ys el
f. Th
at w
as h
ug e.
I do
n’ t w
an t t
o ge
t to
th e
po in
t w he
re I’
m su
ffe rin
g m
en ta
lly a
nd , y
ou k
no w
, t ha
t w ill
m ak
e m
y ki
ds su
ffe r m
en ta
lly . S
o, I’
ve le
ar ne
d th
at I
re al
ly n
ee de
d to
g ua
rd a
ga in
st th
at a
nd k
ee p
m ys
el f p
ro te
ct ed
a s m
uc h
as I
co ul
d. ”
(in -p
er so
n pa
rti ci
pa nt
) “[
M y
hu sb
an d]
d oe
s n ot
ic e
I d on
’t fr
ea k
ou t a
s f as
t a nd
a s b
ad a
s I u
se d
to
be ca
us e
I h av
e ta
ke n
th at
c la
ss a
nd I
ha ve
re ad
u p
on m
or e
w ay
s t o
he lp
h im
an
d ho
w I
ne ed
to c
al m
d ow
n an
d ok
ay , t
hi nk
a nd
u se
th is
te ch
ni qu
e in
ste ad
of
b lo
w in
g up
a nd
b ei
ng li
ke w
hy d
id y
ou d
o th
at ?”
(o nl
in e
pa rti
ci pa
nt )
“E ve
ry ti
m e
I t ea
ch th
e cl
as s I
th in
k I g
ro w.
I th
in k
I c on
ne ct
to o
th er
s w el
l. I
th in
k it
hu m
bl ed
m e
an d
re m
in ds
m e
th at
I’ m
n ot
a lo
ne in
m y
ow n
jo ur
ne y
to o.
A nd
it a
ls o
en co
ur ag
es m
e to
st ay
d oi
ng th
e go
od w
or k
th at
I do
, b ec
au se
I a
m a
so ci
al w
or ke
r. So
it re
fr es
he s m
e in
w hy
I do
w ha
t I d
o, e
sp ec
ia lly
w
he n
I c an
su pp
or t t
he se
fa m
ili es
a nd
h el
pi ng
th ei
r v et
er an
s l iv
e a
be tte
r l ife
. B
ec au
se th
at is
k in
d of
w ha
t i t’s
a ll
ab ou
t.” (i
n- pe
rs on
in str
uc to
r) “I
fo un
d it
ve ry
re w
ar di
ng . I
th in
k I g
et m
or e
ou t o
f i t t
ha n
th ey
d o.
I m
ak e
ne w
fr ie
nd s a
nd th
ey h
el p
m e,
I he
lp th
em …
I kn
ow w
ha t I
fe lt
lik e
se ve
n or
ei
gh t y
ea rs
a go
. A nd
I’ m
st ill
in it
b ut
n ot
a s b
ad a
nd I’
m ju
st –
m y
w ife
a nd
I ar
e ju
st try
in g
to h
el p
ot he
r f ol
ks to
o. ”
(in -p
er so
n in
str uc
to r)
“I ’v
e le
ar ne
d a
lo t a
bo ut
h ow
to c
om m
un ic
at e,
h ow
to h
av e
em pa
th y
fo r m
y da
ug ht
er a
nd h
ow to
se lf-
ca re
. I fa
ll ba
ck to
th os
e th
re e.
S o
it gi
ve s m
e a
be t-
te r u
nd er
st an
di ng
o f w
ha t s
he is
g oi
ng th
ro ug
h. ”
(in -p
er so
n in
str uc
to r)
1401Community Mental Health Journal (2020) 56:1391–1405
1 3
Ta bl
e 2
(c on
tin ue
d)
Th em
e Pa
rti ci
pa nt
s In
str uc
to rs
C ou
rs e
le ng
th T
oo d
en se
; e xt
en d
“I f i
t w as
a li
ttl e
m or
e su
pp or
t, I w
ou ld
h av
e go
ne 1
0 w
ee ks
, e as
y. I
w ou
ld
ha ve
g on
e, y
ou k
no w
, s ix
o r—
I w ou
ld h
av e
go ne
8 o
r 1 0
or 1
2 if
I k ne
w
th at
th er
e w
ou ld
b e
a lit
tle m
or e
tim e
to a
bs or
b an
d a
lit tle
m or
e tim
e to
ta
lk …
T ha
t w as
a lo
t t o
ta ke
in in
tw o
an d
a ha
lf ho
ur s …
it w
as a
li ttl
e bi
t lo
ng .”
(in -p
er so
n pa
rti ci
pa nt
) “I
w ou
ld sa
y, h
av in
g it
sp re
ad o
ut to
b ei
ng a
n 8
to 1
0 w
ee ks
’ t im
el in
e an
d ha
vi ng
li ke
sl ig
ht ly
le ss
c on
te nt
in e
ac h
on e
pa rti
cu la
rly a
ro un
d th
e m
ed ic
at io
ns a
nd th
e di
so rd
er s a
nd li
ke sp
re ad
in g
th at
o ut
a li
ttl e
m or
e an
d th
en in
co rp
or at
in g
ad di
tio na
l t im
e fo
r d is
cu ss
io n
in e
ac h
cl as
s.” (o
nl in
e pa
rti ci
pa nt
)
“Y ou
k no
w , i
t’s a
lo t o
f m at
er ia
l a nd
w e
ac tu
al ly
h ad
to g
o on
e m
or e
cl as
s t o
fit it
a ll
in . B
ec au
se w
e ju
st, w
he n
pe op
le w
ou ld
g et
to a
d is
cu ss
io n
po in
t, yo
u kn
ow , a
nd [t
he in
str uc
to r m
an ua
l] sa
y[ s]
le t t
he m
d is
cu ss
it fo
r o ne
, t w
o m
in ut
es a
nd w
e’ re
li ke
, r ig
ht , w
e ju
st co
ul dn
’t cu
t p eo
pl e
off .”
(in -p
er so
n in
str uc
to r)
A de
qu at
e “S
ix w
ee ks
is a
g oo
d le
ng th
o f t
im e
… M
ay be
p er
ha ps
6 w
ee ks
, a nd
th en
ad
di ng
2 w
ee ks
fo r a
ny on
e w
ho w
an ts
to d
o it,
b ut
th at
re al
ly tr
ul y
w ou
ld b
e a
m ea
su re
m en
t o f t
im e
to w
ar ds
th e
fa ci
lit at
or s”
(o nl
in e
pa rti
ci pa
nt )
“I ju
st di
dn ’t
w an
t i t t
o en
d be
ca us
e of
a ll
th e
in fo
rm at
io n
th at
th ey
w er
e gi
v- in
g us
, b ut
it d
id n’
t s ee
m li
ke it
w as
— 6
w ee
ks w
as y
ou k
no w
, I ’m
a ss
um in
g if
it w
as lo
ng er
I’ d
ap pr
ec ia
te th
at to
o. It
w as
ju st
al l t
he in
fo rm
at io
n th
at w
e ne
ed ed
in th
e 6
w ee
ks so
.” (in
-p er
so n
pa rti
ci pa
nt )
“I th
in k
it’ s a
g oo
d in
tro du
ct io
n, so
m et
im es
th e
12 -w
ee k
pr og
ra m
fo r F
am ily
- to
-F am
ily c
an se
em o
ve rw
he lm
in g.
I th
in k
it ha
s, I m
ea n,
e ve
ry b
it of
th e
in fo
rm at
io n
th at
is , i
s c rit
ic al
, b ut
th is
is a
g oo
d st
ar t f
or p
eo pl
e an
d I t
hi nk
ha
vi ng
ta ke
n th
is c
la ss
, s om
e pe
op le
th en
m ay
c ho
os e
pa rti
cu la
rly if
th ey
h ad
a
go od
e xp
er ie
nc e
to g
o ah
ea d
an d
ta ke
th e
Fa m
ily -to
-F am
ily c
la ss
a s w
el l.”
(in
-p er
so n
in str
uc to
r)
O nl
in e
cl as
s f or
m at
C on
ve ni
en t
“I li
ve in
su ch
a sm
al l t
ow n
th at
th er
e’ s n
ot a
lo t o
ffe re
d he
re a
t t he
V A
. I
ha ve
to tr
av el
a lm
os t t
w o
ho ur
s a w
ay , a
nd e
ve ry
th in
g is
d ur
in g
th e
w ee
k,
w el
l, th
at ’s
ju st
no t f
ea si
bl e
fo r m
e w
ith fi
ve k
id s a
nd a
fu llt
im e
jo b
an d
so , I
m
ea n
I l ik
e th
e on
lin e
stu ff.
” (o
nl in
e pa
rti ci
pa nt
) “I
t w as
c on
ve ni
en t,
be ca
us e
I h av
e ki
ds . S
o yo
u kn
ow , m
y ki
ds a
re h
om e,
a nd
I d
on ’t
ha ve
to w
or ry
a bo
ut th
at .”
(o nl
in e
pa rti
ci pa
nt )
N /A
S om
e in
co nv
en ie
nc ie
s “T
he y
ou ng
er g
en er
at io
n …
w e
ha ve
c hi
ld re
n in
th e
ho us
e, w
e sti
ll ha
ve so
m e
of th
os e
th at
w he
n yo
u ha
ve a
m ee
tin g
fro m
5 :0
0 to
7 :0
0, it
is ri
gh t i
n th
e m
id dl
e of
y ou
r t im
e.” (o
nl in
e pa
rti ci
pa nt
) “D
ur in
g th
e cl
as se
s, I a
ct ua
lly h
ad to
ta ke
c ar
e of
m y
ba by
a t t
he sa
m e
tim e,
an
d so
I w
as tr
yi ng
to p
ar tic
ip at
e, w
hi le
I w
as tr
yi ng
to g
iv e
a ba
th to
m y
ba by
, a nd
so I
w as
n’ t a
bl e
to fu
lly p
ar tic
ip at
e as
m uc
h as
I w
an te
d to
.” (o
nl in
e pa
rti ci
pa nt
)
N /A
D is
cu ss
io n
fo rm
at : a
de qu
at e
“Y ea
h, I
th in
k th
at e
ve ry
bo dy
w as
su rp
ris in
gl y
op en
a bo
ut th
ei r s
itu at
io n,
w
hi ch
w as
re al
ly h
el pf
ul .”
(o nl
in e
pa rti
ci pa
nt )
“I f y
ou ’re
li ke
in a
c ha
t r oo
m , y
ou se
e ev
er yb
od y’
s q ue
sti on
s o r c
on ve
rs a-
tio ns
li ke
so m
e th
at c
ou ld
n’ t g
et th
ei r m
ic ro
ph on
es to
w or
k. T
he y
w ou
ld
ju st
w rit
e do
w n
w ha
t t he
y ne
ed ed
to sa
y. A
nd th
en it
w ou
ld p
op up
o n
th e
bi g
sc re
en . Y
ou k
no w
, t ha
t w or
ke d
ou t r
ea lly
g re
at , b
ec au
se li
ke th
er e
w er
e pl
en ty
o f t
im es
I di
dn ’t—
m y
ta bl
et w
as b
ro ke
, s o
I’d u
se m
y ph
on e,
so th
e ca
m er
a an
d lig
ht in
g on
m y
ph on
e w
er en
’t th
e gr
ea te
st, so
I— lo
ts o
f t im
es
I j us
t u se
d th
e ch
at b
ox to
te ll
w ha
t I n
ee de
d to
te ll
th em
.” (o
nl in
e pa
rti ci
- pa
nt )
“I f t
he in
str uc
to r i
s e ng
ag in
g an
d qu
es tio
ni ng
a nd
g iv
in g
tim e
fo r p
eo pl
e to
fo
rm ul
at e
th ou
gh ts
a nd
d oe
sn ’t
ge t n
er vo
us in
th at
q ui
et ti
m e,
it –
y ou
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nl in
e in
str uc
to r)
1402 Community Mental Health Journal (2020) 56:1391–1405
1 3
(Galovski and Lyons 2004; Manguno-Mire et al. 2007). It is notable that the larger quantitative study showed a decrease in family member psychological distress post-intervention and at 3-month follow-up (Haselden et al. 2019). These qual- itative results highlight how a combination of education and opportunity to unpack the trauma they have experienced was emotionally liberating. Furthermore, this study found that a better understanding of trauma and what a veteran experi- ences led to transformative attitudes about mental health, such as greater empathy and viewing mental health disorders as similar to other medical conditions. It is possible that a better understanding of trauma, in combination with peer support, is an effective mechanism for decreasing stigma about mental illness in the military community.
Equally important to participants was learning the sci- ence and the brain biology of trauma, PTSD, traumatic brain injury, depression and anxiety. Many families associ- ated their veteran’s behavior changes with conscious choices and noted that the psychoeducation component helped them have more empathy and patience with their veteran family member. This is in line with prior research which identified mechanisms of resilience enhancement in military families, such as providing psychoeducation and developmental guid- ance, enhancing family awareness and understanding, and improving family empathy and communication (Saltzman et al. 2011). However, participants and instructors did have suggestions for improving the content and delivery of the program. First, they noted that information and examples on serious mental illnesses such as schizophrenia could be shortened, as well as information about the brain and medi- cations. This is understandable considering prior research has reported depression, PTSD and anxiety disorders to be the most prevalent mental health diagnoses in veterans (Stecker et al. 2010). Participants seemed to favor reallo- cating time to more trauma/PTSD- and veteran-focused content or allotted discussion time. Second, some partici- pants suggested that the class that addresses the science and brain biology be split into two classes while adding skills workshops and additional discussion time to maximize engagement.
The interviews with participants and instructors provided a deeper understanding of how the program led to improved outcomes on coping, distress and family functioning. Par- ticipants and instructors spoke about how they applied what they learned from the communication and problem-solving skills workshop, and the confidence it gave them to improve their relationship with their loved one. This is in line with the larger quantitative findings of improved coping, fam- ily functioning and problem solving (Haselden et al. 2019). This response is encouraging and could have an important impact on veteran families. A prior study found symptoms of depression in veterans was associated with perceptions of poorer communication, problem solving and greater family Ta
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(o nl
in e
in str
uc to
r)
1403Community Mental Health Journal (2020) 56:1391–1405
1 3
conflict (Haselden et al. 2016). The NAMI Homefront pro- gram could be an important resource for such families. The self-care workshop evoked relief from families who appreciated the need to take care of themselves in order for them to be able to care for their veteran. This finding may also be reflected in the quantitative study results regarding decreased psychological distress (Haselden et al. 2019). The crisis planning workshop was also important to participants and helped them feel better prepared to handle future crisis. However, individuals and instructors noted that the self- care and crisis planning workshops were relatively brief and could be expanded to provide more concrete suggestions and allow for more dialogue.
Participants and instructors also provided valuable feed- back about program length, particularly advocating for extending the program. While the 6-week format of the pro- gram has shown to be effective at improving outcomes post program and at 3-month follow-up (Haselden et al. 2019), both participants and instructors noted that there was too much information packed into the classes. The amount of information given in 2.5 hours was overwhelming at times for participants, and instructors felt it was an unrealistic expectation to cover the amount of material in the allotted time. Furthermore, this prevented groups from being able to have more open dialogue and time to delve further into the information provided. It was suggested that the course be expanded to an 8- or 10-week program, spreading the material out and building in more time for discussion. Brief family education programs have been described as lasting anywhere from 6 to 10 weeks (Drapalski et al. 2009). While there is obvious appeal to an abbreviated 6-week format, the program could be significantly enhanced by extending the length of the program, and still be considered a brief intervention. Alternatively, there could be an optional 1–2 classes offered at the end of the program.
The study also provided a better understanding of the nuances between the in-person and online formats, specifi- cally the efficacy of the modified online format. Feedback about the online format highlighted the challenges of utiliz- ing technology when participants present with a wide range of previous user experience. Overall, the feedback about the online format is in line with prior literature on telehealth interventions. This includes the findings that technical dif- ficulties, such as securing audio and visual connection, are common (Banbury et al. 2018). In addition, participants found the at-home setting to be convenient, although increas- ing the odds of environmental distractions such as cooking dinner or caring for family members (Banbury et al. 2018). Furthermore, prior studies looking specifically at videocon- ferencing for health interventions suggest that the NAMI Homefront online program could benefit from requiring all participants to partake in videoconferencing; these studies suggest that videoconferencing would improve the bonding
experience and more closely replicate an in-person program (Banbury et al. 2018; Wasilewski et al. 2017). A system- atic review of 15 studies reported that videoconferencing, with the help of good IT support, is a feasible intervention model, with the majority of studies reporting few techni- cal problems (Banbury et al. 2018). Acceptability of vide- oconferencing is high, which was attributed to being able to see and hear other individuals in the group, meeting people with similar experiences, sharing personal experiences, and receiving emotional support from the group (Banbury et al. 2018). Comparison studies showed videoconferencing to be similar to face-to-face programs and significantly better than text-based forum (Banbury et al. 2018). In addition to improving the personal connection via audio and video, it is possible that requiring participants to partake in vide- oconferencing will make it easier for instructors to engage participants and for participants to feel more comfortable speaking up. Requiring participants of the online classes to partake in videoconferencing may be challenging, and require additional resources, such as providing participants with web-cameras and headsets which was common in prior studies (Banbury et al. 2018; Wasilewski et al. 2017). How- ever, the feedback from these qualitative interviews and the prior literature suggest that this modification could maxi- mize engagement and better emulate the benefits of face- to-face interactions. Nonetheless, there was an appreciation amongst participants and instructors for the online option as it allowed the program to reach families that would not have been able to access the program otherwise.
Finally, this study was able to gather information on the experiences of NAMI Homefront instructors, of both in-per- son and online formats. The instructor feedback highlighted that teaching the curriculum is just as powerful and valuable an experience as it is for participants. NAMI utilizes a peer model in its programs, in which courses are taught by lay volunteers with lived experience of caregiving for a loved one with mental illness. These volunteers receive additional training and certification to teach NAMI courses. As such, instructors note that they continue to learn from and find meaning in the Homefront curriculum. Instructors often noted that they find teaching the class rewarding by helping others navigate caregiving stressors which they have also experienced, bonding with their students in the process and gaining a sense of community.
This study has several limitations. The small con- venience samples of NAMI Homefront participants and instructors limits the generalizability of study findings. It is unknown if individuals who responded to our calls and agreed to participate differ from those who did not. Addi- tionally, 71 participants from the larger quantitative study were enrolled after we had reached saturation of qualita- tive feedback and ended recruitment for qualitative partici- pants. While the curriculum remained constant across the
1404 Community Mental Health Journal (2020) 56:1391–1405
1 3
study, and we do not have reason to believe there would be systematic differences in earlier versus later classes or participants, we acknowledge that it is possible that different samples of participants may have looked differ- ent and that this feedback may not be representative of the whole sample. The phone-based interviews may have caused interviewers to miss participants’ non-verbal cues or expressions which may have been best detected via in-person interviews. Qualitative data analysis relies on subjective decisions. To minimize bias in this analytical process, we used multiple strategies (e.g., use of multiple coders, team meetings) to ensure the trustworthiness and rigor of our analysis.
Despite these limitations, this study explored the expe- riences of in-person and online NAMI Homefront par- ticipants and instructors, and highlights common themes. Through semi-structured qualitative interviews, research- ers were able to ascertain that participants found the peer atmosphere, coping-skills workshops, and veteran-spe- cific mental health information most helpful, and felt that more time was needed for open discussion. Extending the program to 8 or 10 weeks would be a more realistic and comfortable pace to deliver the content and allow more time for discussion. It is important to acknowledge the emphasis that participants and instructors placed on group discussion and sharing of personal stories; however, it is also important to remember that the group discussion builds off of the psychoeducation and skills workshops. Prior research on caregiver interventions has indicated that multicomponent interventions that provide a range of sup- port services generate a larger effect and have been found to reduce caregiver burden in comparison to single-com- ponent interventions (Wasilewski et al. 2017). Thus, it is likely that the psychoeducation, skills workshops, and peer support/group discussion collectively make NAMI Home- front an effective resource. Moreover, while the online format offered convenience to those with tight schedules or in areas with limited resources, there was a loss of rela- tionship-building and bonding between participants due to the digital format. Prior research and participant feed- back suggest that requiring online participants to engage in videoconferencing would mitigate this problem. Finally, researchers also interviewed NAMI Homefront instruc- tors and found that while teaching classes was a fulfilling and informative experience for them, they mirrored many of the concerns program participants had. Study findings can be used to further streamline the NAMI Homefront program to better address the needs of veteran families.
Funding This study was funded by a grant from the National Alliance on Mental Illness to the Research Foundation for Mental Hygiene.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflicts of interest.
Ethical Approval All procedures performed in this study were in accordance with the ethical standards of the NYSPI Institutional Review Board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
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- Qualitative Study of NAMI Homefront Family Support Program
- Abstract
- Introduction
- Methods
- NAMI Homefront Program Description
- Recruitment
- Qualitative Interviews and Quantitative Measures
- Data Analysis
- Results
- Sample
- Qualitative Results
- Course Content
- Key Component 1: Group Discussion
- Key Component 2: Veteran-Specific Information
- Key Component 3: Coping Skills
- Key Component 4: Mental Health Diagnosis
- Personal Impact on Participants
- Personal Impact on Instructors
- Course Length
- Online Course Format
- Convenience
- Group Discussion
- Technical difficulties
- Discussion
- References
