Implementation of effective health services entails addressing barriers at multiple levels in the process of translating research to meaningful health care outcomes. Various theories and models identify factors that facilitate or hinder implementation of empirical findings in clinical practice (1). Implementation models stress both examining health outcomes and conducting real-time, formative evaluation of implementation processes and contextual factors that influence program effectiveness and sustainability (1,2).
Adaptation of existing evidence-based interventions must be followed by careful evaluation of the adaptation’s acceptability and impact and by solicitation of recommendations for further improvements in tailoring the intervention for special populations. Focus groups can provide real-time, formative-evaluation data to guide improvements in implementation of clinical innovations.
Veterans who sustained a traumatic brain injury (TBI) during combat while serving in Operation Enduring Freedom (OEF) or Operation Iraqi Freedom (OIF) and their family caregivers have found limited supportive and psychoeducational resources (3,4). We adapted multifamily group treatment, an evidence-based family psychoeducational intervention developed by McFarlane and others for persons with serious mental illness (5–7), to address the needs of TBI survivors and their families. In a companion article, Perlick and others (8) report on an evaluation of the feasibility of implementation and initial efficacy of multifamily group treatment for TBI. The evaluation focused on three issues: systems or stakeholder factors influencing buy-in, impact of group composition, and adaptations needed to optimize treatment responsiveness.
In this article, we report the results of focus groups of veterans and family members conducted at the conclusion of the multifamily group that addressed the above issues from the unique perspective afforded by qualitative methods. Specifically, we asked participants about their treatment experience and the acceptability and perceived efficacy of the intervention. This study had two aims—to examine acceptability and perceived outcomes among OEF/OIF veterans with TBI and families who participated in an initial trial of a psychoeducational multifamily group treatment for TBI and to obtain participants’ views and ideas for improving the intervention and its delivery, including engagement of veterans and families.
All participants enrolled in the multifamily group study for TBI were eligible to participate in a focus group. Details about the eligibility and recruitment for this open trial are described in the companion article (8). Briefly, veterans and family members were referred by specialists in polytrauma or rehabilitation medicine or by multidisciplinary TBI diagnostic teams at the U.S. Department of Veterans Affairs (VA) medical centers in Bronx, New York, and Durham, North Carolina. Inclusion criteria included clinical diagnosis of TBI, including a positive screen for TBI (9) confirmed by medical record review and classification recommendations (10); Mini-Mental State Examination score ≥20 (scoring range 0 to 30, with higher scores indicating better cognitive function); and a family member who agreed to participate in the study.
Veterans or family members exhibiting active psychosis or a severe substance use disorder were excluded. All provided written informed consent to participate in the intervention and postintervention focus groups. The study protocol was approved by institutional review boards at both medical centers.
The intervention comprised two or three individual family meetings with a clinician (“joinings”), an educational workshop on TBI and family guidelines, and nine months of bimonthly psychoeducational group meetings focused on problem solving and communication skills building.
Between August 2010 and March 2011, after the study intervention had concluded, we conducted three 90-minute focus groups of four to six participants each. Groups were conducted by the study clinicians, using a moderator’s guide developed by the study team and adapted from prior studies (7). Participants were asked about their experiences before and during group treatment (for example, “What were some of the problems you were struggling with when you joined this group? In what ways did you personally benefit from the group?”) and views about aspects of treatment that were helpful or that could be improved to optimize the intervention (for example, “How would you improve the multifamily group experience?”) [A list of all focus group questions is available online as a data supplement to this article.] The facilitator briefly summarized responses at the end of each focus group, and all focus groups were audiorecorded and transcribed verbatim by research assistants.
Transcribed focus group data were analyzed by using methods informed by qualitative content analysis (11,12), which is widely used to interpret text data through systematic coding and identification of content themes or patterns (11–13). Two investigators with complementary skills served as primary coders. One author (JMG) has expertise in qualitative methods, and one author (JLS) has specialized knowledge of trauma. First, coders independently read each transcript and noted initial impressions of the data. Next, each reread transcripts and developed line-by-line coding. Coders then compared codes and jointly developed a preliminary coding scheme and operationalized codes. After independently coding each transcript, coders debriefed and revised the coding scheme.
Through consensus and consultation with another content expert in multifamily group treatment who conducted two of the focus groups (KST), codes were grouped into themes appearing across all three groups. Microsoft Word cut and paste functions were used to organize coded data. Five major themes emerged from the analyses, and illustrative quotations, edited for clarity and anonymity, are provided to characterize each theme.
Focus group participants included eight veterans and eight family members. Two family members and two veterans who had completed fewer than four multifamily group treatment sessions were unable to be contacted due to relocation or severe medical problems. Two actively participating veterans were unable to attend the scheduled focus groups and were interviewed by phone. Their responses were not included in the analyses because we did not have permission to record these calls; however, the views expressed during the calls were consistent with themes obtained from focus groups.
All veteran participants had served in the Army and sustained a blast injury. Two were female, five were African American, one was Hispanic, and two were Caucasian. The mean±SD age was 34.5±8.0. Participating family members included six female spouses, one mother, and one sister. Three family members were African American, two were Hispanic, and three were Caucasian; their mean age was 37.9±12.1.
Multiple codes emerged from the qualitative analyses and were grouped into five major themes. The themes with exemplar quotes are listed in Table 1. The first four themes reflected what participants valued about their experience; the fifth theme, suggestions for improvements, more directly informed implementation.
Table 1Themes identified by veterans and families during focus groups about multifamily group treatment for traumatic brain injury
| Add to My POL
|Exploring common struggles and reducing isolation||“Just coming here was like a first step and bringing it out in the open . . . instead of living like “the Cleavers”—you know, everything is happy and keep everything hush hush. . . . Bringing things up in front of other couples . . ., that's a first big step.” (veteran)|
|Building skills to cope with traumatic brain injury (TBI) and related problems||“You talked about a cooling-off period, before talking about something heated. A code word or what not, and I use that . . . things to avoid conflict, like the whiteboard. It's hanging up and I think that's a way of avoiding certain conflicts. . . . Scheduling issues . . . [were] a source of conflict a lot of times, and the fact that I would forget and get upset.” (veteran)|
|Restoring relationships through communication and understanding||“Well just coming here and being able to say something, you know, about an issue—because I know at home I shut down, because I don’t want to go there.” (spouse)|
|Increasing understanding of the interconnection between TBI and posttraumatic stress disorder (PTSD)||“I learned how to cope with my husband's TBI, learned . . . about the dynamics of PTSD and TBI and how to deal with him personally.” (spouse)|
|Improving the multifamily group treatment experience and increasing engagement||“Better tracking methods for our lists and stuff. I would keep mine for the first couple of days and then halfway through the week I don't know where it ends up. It's just a matter I guess of creating it on e-mail or something to where we can access it if we lose it. (veteran)|
Exploring common struggles and reducing isolation.
Nearly all focus group members reported finding benefit in multifamily group treatment through discussion of common struggles. Participants reported that groups helped normalize their experiences and reduced feelings of isolation. The common experience of living with a loved one with TBI or of having been a soldier was described as creating a sense of “connection.” Members stated that they appreciated receiving and giving social support during group sessions and had enhanced their social networks through new friendships. The following quotes reflected participants’ views about common struggles and how multifamily group reduced feelings of isolation:
“One of the comforting things is knowing that there are people that could relate to you, because . . . just being a veteran and knowing that person’s a veteran.”
“You just have a connection that’s instant. Not everyone in the world has walked in those boots . . . and seen death. . . . If there’s a veteran that’s sitting across the table . . . [they] know that’s not an easy walk.”
The theme of exploring common struggles and reducing isolation also influenced perceptions of the impact of group composition on outcomes. One veteran from an all-couples group noted that she had enrolled to learn from other couples that included veterans. Spouses from a group that included extended family speculated that adult children who joined but missed many sessions may have felt they had “too little in common” with the married veterans. Separate groups for spouses and other family members were suggested.
Building skills to cope with TBI and related problems.
Group members expressed that living with TBI is complex and stressful, and many reported learning how to work through problems from hearing how other group members dealt with similar issues. As one veteran stated, “I’m just listening—it doesn’t even have to be your own personal problem. Nine times out of ten you can relate to the problem, you can benefit in some way from just hearing it.”
Both family and veteran group members reported learning skills from each other (for example, problem-solving techniques and goal setting) and received specific guidance for dealing with memory issues (for example, getting a voice recorder, taking notes, using a whiteboard, and creating routine). In the words of one veteran, “The different perspectives on how to handle problems [helped], because when you hear from other people and their perspective, you kind of walk away with—okay, that’s something really different, I could try that. You got some tools to put in your toolkit . . . that you could use later on if that particular problem arises.”
Restoring relationships through communication and understanding.
Living with TBI can have devastating effects on interpersonal relationships through anger dysregulation, communication difficulties, and lack of understanding. As one veteran stated, “Before this, I’d just rather not talk to you. Like if I’m going through something, I’m just not going to talk to you.” TBI-affected veterans and family members commonly reported that multifamily group sessions provided a protected place to work on difficult interpersonal issues.
Participants in all focus groups expressed a desire to communicate more effectively with loved ones. As one veteran stated, “We did need to learn how to communicate . . . not what we thought communication is, because we had our own definition of communication, but really understanding what it means to have effective communication.”
Program education about TBI increased family members’ understanding of and compassion for veterans, while providing a safe place to speak openly with loved ones about difficulties they experienced during combat and rehabilitation. As one veteran stated: “I think one of the reasons that we’re stressing the fact that education is important and that our spouses understand what we’ve been through and where we’re coming from is that it helps us rehabilitate. It really does.”
Veterans also learned how their problems with memory, organization and planning, and avoidance and hyperarousal symptoms related to posttraumatic stress disorder (PTSD) had an impact on their loved ones’ lives. Conversely, family members learned that some personality changes among veterans were symptomatic of TBI or PTSD and were not an attempt to shut family members out or an unwillingness to communicate. Learning that veterans’ apparent lack of interest in the relationship or lashing out in anger were common symptoms of TBI and PTSD restored self-esteem to family members who had previously viewed these behaviors as signs of personal rejection.
Education about TBI and comorbid PTSD also helped foster patience. As one family member said, “It takes patience, and the more educated we get the more patient we are. You know, because if you don’t understand the situation then you are going to come off . . . like, ‘She’s trying to fight me right now.’ You’re just making my life a little harder, but that’s not the case.”
Increasing understanding of interconnection between TBI and PTSD.
Many participating veterans (N=7, 88%) also had symptoms or a diagnosis of PTSD. Veterans and family members talked about symptoms of PTSD and TBI without distinction between the conditions. Participants reported that the group experience helped foster understanding of both disorders. As one family member stated, “I learned how to cope with my husband’s TBI, learned more about his problem [and] about the dynamics of PTSD and TBI, and [learned] how to deal with him personally.”
The problem-solving sessions, which helped caregivers deal with TBI sequelae, generalized to PTSD issues, “I was struggling with what I was going through with my daughter having posttraumatic stress [disorder]. I didn’t know how to deal with it. It [group] helped me to understand and taught me how to be more supportive and recognize what’s going on and how to deal with that because I didn’t know how to deal with it. So this has really helped me and has brought all of us closer.”
Improving the experience of multifamily group treatment for TBI and increasing engagement.
Overall, participants reported that the multifamily group intervention was helpful and filled a unique need for education and support of veterans with TBI and their families. Some veterans reported that implementation of the intervention demonstrated VA’s commitment to veterans with TBI. As one veteran stated: “People saying that they’re here for you means nothing. . . . Show me that you really care. . . . Show me that you’re going to put programs like this in place so that people have a place to go—that’s showing me you care.”
When asked what they would do to improve the program and engage families, participants suggested several changes to the group sessions’ structure and content and recommended increased ability to have contact between sessions. Suggestions for improvement stressed maintaining connections via check-in phone calls between sessions and continuing the program posttreatment on a monthly basis as well as use of alumni to recruit or mentor new members. The need and desire for information and education were other important “buy-in” factors for both veterans and family members. Participants suggested enhancing the educational aspect of the intervention by including more formal didactic presentations by topical experts, providing more help in tracking completion of homework assignments, and offering “refresher courses.” Specific suggestions are summarized in a box on the next page.
Suggestions by veterans and family members to improve and increase engagement in multifamily group treatment
Suggestions for improvement
Provide more flexibility of structured time allotments for socializing and problem solving.
Create time for breakout sessions with only veterans or only family members to promote discussion of issues specific to each.
Focus on common problems, such as memory, and have all families work on their own plan (rather than focus on one family’s problem).
Post problem-solving solutions and reminders online or in e-mails.
Extend didactics beyond initial workshops—occasionally bring in guest speakers to address topics such as medications or rehabilitation.
Allow more than one family member to enroll so that someone is always available to come with the veteran and more family members understand TBI issues.
Build in more contact between sessions through check-in phone calls or e-mails.
Suggestions to increase engagement of veterans and families
Provide more flexibility in enrollment to allow for open groups, rolling enrollment.
Invite multifamily group treatment alumni to new groups to help initiate new people, share lessons learned, and maintain involvement posttreatment.
Advertise guest speakers to bring in families.
Set up guidelines for adding more family members; protect confidentiality.
Reach out directly to family members instead of relying on the veteran to seek help.
Advertise with posters, flyers, and other materials. Use alumni for testimonials and outreach.
Arrange for check-in phone calls and ways to continue support after treatment.
“Reflecting and debriefing” before, during, and after implementation are considered essential components of the implementation process (1). This study added a significant dimension to evaluation efforts to adapt and implement evidence-based interventions for combat veterans with TBI and their families. Participants’ reflections about the value of their multifamily group experience provided important information about treatment acceptability and perceived helpfulness.
Group members’ suggestions for improvement and increased engagement addressed our second research question about how to further improve and tailor a psychoeducational TBI intervention and engage OEF/OIF veterans. These qualitative findings provided a unique perspective on how the intervention helped veterans and families cope with the emotional scars of deployment and the challenges of reintegration. Because group members developed camaraderie through months of conjoint work, the tone of the focus group sessions was reflective and was not encumbered by social evaluation concerns that may limit self-disclosure in pretreatment assessments.
With respect to the intervention’s acceptability and perceived outcomes, both veteran and family participants described powerful experiences of connecting with a wider social network and reconnecting with their loved ones, which reduced isolation, increased empathy, and improved communication. Similar results have been reported in couples’ treatment for PTSD (14,15), family psychoeducation interventions for veterans with PTSD (16,17), and novel studies engaging spouses and family members through Web-based interventions and telemedicine (18,19). The results also parallelled the impact of family interventions for schizophrenia, which have been found to increase knowledge and empathy and decrease stigma and family burden (20).
The positive individual and collective experience of study participants, coupled with results from assessments over the course of the study (for example, significant reduction in veterans’ anger expression, increase in veterans’ social support and occupational activity, and increased empowerment and decreased burden among family members ), lent credibility to intervention sustainability and suggested that this treatment approach warrants further investigation.
Future investigations might benefit from group members' suggestions to increase treatment acceptability and buy-in, in addition to prior reports on customizing multifamily group treatment for this population (6,7,21). Veterans with TBI and their families continue to maintain busy work and school schedules, often while caring for young children or other family members. Clinical leadership needs to engage in plans to facilitate peer support and to deliver information to injured veterans and their families about TBI, comorbid PTSD, and expanded options for family-inclusive, evidence-based treatment (21). In addition, researchers and administrators need to balance the evidence base established for longer interventions with access problems identified by veterans, families, and stakeholders. Suggestions for a more flexible intervention structure that would permit, for example, open enrollment, shorter treatment duration, and expanded didactics may be useful.
Although this intervention was designed for veterans with TBI, preliminary qualitative and quantitative results suggested it may also be helpful as a family-based intervention for persons with co-occurring PTSD. TBI and PTSD share a common subset of symptoms, and the extent to which these disorders are distinct among injured and traumatized military personnel and veterans is the subject of debate (22). We suggest that the practical, problem-solving approach that formed the core of each multifamily group session may have therapeutic benefits for the functional problems common to both disorders.
Given the large numbers of OEF/OIF veterans with comorbid PTSD and TBI, this treatment approach merits careful consideration by future investigations. Our project experience, as reflected in this article and the companion article (8), illustrated the value of incorporating a process evaluation early in the evaluation of the efficacy of a new or adapted intervention, in order to assess and address emergent implementation issues.
The results of this study may have limited generalizability because of a small sample size, use of an all-Army veteran sample, regional recruitment in the eastern United States, and limited participation by nonspouse family members. Our tentative conclusions must be further qualified by the inability to contact and interview all treatment participants. However, even in this small sample, two women who had been injured in combat participated, and the unique perspectives of a soldier’s mother and sister were part of the family members’ qualitative data. Although all participants lived in the eastern United States, there was considerable variability in ethnicity and contrasting cultures among participants in New York City and North Carolina. It is unknown whether patients with moderate or severe TBI would benefit from this psychoeducational intervention because all of the veteran participants were characterized as having mild TBI.
Veterans with TBI and their family members reported that the information and skills learned in the multifamily group intervention helped the veterans’ rehabilitation and the family members’ ability to understand and support the veteran. Participants provided helpful suggestions on how to make multifamily group more effective and to increase treatment uptake and engagement in treatment among veterans. Together with the preliminary quantitative outcomes reported in a companion article in this issue (8), this article supports continued efforts to develop and evaluate multifamily group treatment for veterans with TBI in a randomized clinical trial. Further, comparison of helpfulness and acceptability of other modes of family psychoeducation for TBI, such as Web-based support and couples’ interventions, will be helpful in guiding future efforts.
This study was supported by an award (W81XWH-08-2-0054) from the U.S. Department of Defense to Dr. Perlick, by the Mental Illness Research, Education and Clinical Centers in Veterans Integrated Service Networks 3 and 6, and by a Veterans Affairs Research Career Development Award to Dr. Strauss. The authors are grateful for the assistance of Joy Close, M.S.W., Caitlyn Campbell, B.S., Meenal Misal, B.A., and Caroline Holman, B.A., and appreciate the courage and sacrifice of the injured veterans and their families who participated in this study.
The authors report no competing interests.