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.
Discussion
“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 [
8]), 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.
Acknowledgments and disclosures
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.