Evaluation of a Veterans Health Administration Whole Health for Mental Health Course for Clinicians

Abstract

Objectives:

Veterans experience mental health disorders at higher rates than their civilian counterparts and also experience multiple barriers to mental health services. The Veterans Health Administration (VA) has implemented a Whole Health approach to make health care more person-focused and oriented toward promotion of health-sustaining behavior. We conducted an evaluation to investigate the effects of a Whole Health for Mental Health (WHMH) course for clinicians that focuses on shifting the perspective to a system of care in which mental health is incorporated as a core part of whole-person care.

Design:

We collected surveys before the course, immediately after the course, and at a 2-month follow-up.

Settings/Location:

The course was implemented in non-clinical settings in two VA medical centers (one in the Northeast and one in the Mountain West).

Subjects:

Our sample consisted of VA staff who enrolled in WHMH and completed a pre- and post-survey (n = 100) and follow-up survey (n = 99).

Intervention:

The WHMH is a 2-day face-to-face course that covers multiple aspects of mental health through a Whole Health lens. The course includes evidence-based practices within each aspect of mental health. The course also emphasizes implementation of Whole Health in clinicians' lives, their practice, and the health care system.

Outcome measures:

Attitudes were measured at pre-, post-, and follow-up assessments. The WHMH behaviors were measured at pre- and follow-up assessments.

Results:

There were statistically significant, large changes toward improvement from pre-test to post-test for all attitudes examined. These changes remained significant at follow-up, and the magnitude of change remained at least medium to large. Statistically significant, medium magnitude or larger improvements were found at follow-up for four of the five WHMH behavior outcomes examined.

Conclusions:

Our results suggest that clinicians can increase their attitudes and use of Whole Health concepts and both conventional and complementary approaches related to mental health issues.

Introduction

The Veterans Health Administration (VHA, hereafter “VA”) serves 9 million Veterans enrolled in its health care program.¹ Veterans experience mental health disorders, including substance use disorders, posttraumatic stress, and traumatic brain injury at disproportionate rates compared with their civilian counterparts.² For example, a study using 2012 data from a representative sample of U.S. adults showed lifetime Post-traumatic Stress Disorder rates for Veterans of 13.4% (women) and 7.7% (men) compared with civilians whose rates were 8.0% (women) and 3.4% (men).³ Another study found a 1-year prevalence of any substance use disorder among Veterans of 32.9% compared with 28.6% among civilians (for lifetime substance use disorder, the rates were 52.5% and 42.1%, respectively).⁴ Veterans also experience many barriers to receiving mental health services; these can include worry and concern about what others think; financial, personal, and physical obstacles; difficulties in navigating VA benefits and health care services; and a lack of trust in the clinical encounter.⁵

The VA established the Office of Patient Centered Care and Cultural Transformation (OPCC&CT) in 2011 to lead patient-centered care efforts.^6,7 A key initiative of OPCC&CT has been development of a Whole Health System that seeks to “make healthcare more person-focused, relationship-based, and oriented toward promotion of health-sustaining behavior.”⁸ The Whole Health System includes three key elements: (1) the Pathway (through which Veterans are oriented to Whole Health and empowered to find purpose); (2) Well-Being programs that support Veterans gaining new self-care skills and provide complementary and coaching services; and (3) clinical care, including traditional and complementary services.⁹

The VA staff encourage Veterans to look at their life and health through the Circle of Health (Fig. 1), focusing on what matters most to them and building a personalized care plan accordingly.¹⁰ The circle highlights mindful awareness as the centerpiece critical for healing, as well as eight components of self-care. Concentric circles moving outward represent professional care by conventional and complementary means, and the fundamental importance of community, which takes social and structural determinants of health into account. The eight components of self-care within the circle are important and interconnected, and all of them can serve as starting points for a clinical conversation.⁶

FIG. 1.

Circle of Health.

The OPCC&CT has deployed various Whole Health courses for VA staff to better understand and implement Whole Health to lead system transformation. The Whole Health for Mental Health (WHMH) course that is the focus of this evaluation was designed to support VA clinicians and staff to better deploy the Whole Health System as it relates to mental health and emotional well-being, with the goal being improved health care for Veterans.

Prior evaluations of VA Whole Health courses have shown positive effects on clinicians' and other health care professionals' attitudes and self-reported behavior, including the use of Whole Health concepts and integrative medicine strategies.^11,12 For example, a study of a 2.5 days clinical course focused on integrative medicine, complementary health, and patient-centered care strategies delivered to staff at 15 VA facilities showed positive effects on attitudes toward using complementary/integrative approaches and on self-reported use of these approaches at the 2-month follow-up.¹¹ However, this is the first study of a Whole Health course for clinicians focusing on mental health.

We evaluated the effects of a WHMH pilot course on health care professionals who participated in the course at two VA medical centers in 2019. We used an intervention-group-only design for this study. The Institutional Review Board of the Pacific Institute for Research and Evaluation (PIRE) reviewed the study protocols and deemed the study exempt from human subjects review. A primary goal of the evaluation was to assess whether participating clinicians and other staff would change their attitudes and self-reported behaviors around key Whole Health concepts and both conventional and complementary approaches for mental health issues.

Methods

WHMH course

The WHMH is a 2-day face-to-face course co-created by VA and the University of Wisconsin Integrative Health leaders for any VA clinician or other staff working with people who have mental health challenges or who want to prevent these conditions. Pilot courses were taught by four faculty: a psychiatrist/family medicine physician and a psychologist (both Whole Health National Education Champions selected by the VA based on their research, clinical, and educational expertise and background in Whole Health-related topics), an integrative medicine physician, and a behavioral health faculty member from the University of Wisconsin.

The WHMH course was built on innovative approaches being used by clinicians to support both mental health and health in general, including positive psychology,^13,14 the recovery model,^14,15 psychotherapeutic approaches,^16,17 and the contributions of both conventional care and complementary/integrative health.^18,19 These approaches and the course are grounded in mind–body science. Some of the groundwork for understanding mind–body interactions was established by pioneering studies beginning in the 1930s.^20,21 Mind–body science has subsequently influenced many approaches that acknowledge the role of the mind in health, including the polyvagal theory²² and mindfulness science.^23,24 The course explores how Whole Health can support mental health care in the VA, including by shifting the perspective away from mind–body dualism and toward a system of care in which mental health is incorporated as a core aspect of whole-person care. Participants learn about resources that can inform “whole mental health,” and they explore how to overcome the stigma that often surrounds mental health conditions and their treatment. The course is taught using didactic material with group discussions, skill-building experiences, demonstrations, and patient vignettes. It focuses on the prevention of mental health problems as well as their treatment. Connections are highlighted between mental health and Circle of Health components, including mindful awareness and eight aspects of self-care.

The course begins with an exploration of mind–body connections and issues that inhibit effective, whole-person mental health care. Such issues may arise because of differing perspectives (stigma, lack of awareness, or understanding of the potential role of complementary approaches) or paradigms (reliance on drugs and a molecular model of mental health that loses sight of the individual, failure to think of mental health from a prevention, or self-care perspective). Participants are informed that the course will not focus on mental health pathology and treatment, but rather aspects of mental health through a Whole Health lens. Content delivered in the second half of day 1 and the first half of day 2 is organized into five aspects of mental health using examples of phenomena, modalities, and diagnostic groups for each aspect: (1) Thinking and Cognition (meditation, memory, psychosis), (2) Emotions (emotions and health, depression, gratitude), (3) Behaviors and Choices (engagement, habits, and addiction), (4) Peace and Ease (stress, anxiety, trauma), and (5) Vitality and Wholeness (meaning and purpose). A Whole Health approach is incorporated with evidence-based practices into all aspects of mental health. The final portion of the course focuses on parallel implementation of Whole Health in participants' own lives, their clinical practices, and the health care system in general. Course content, thus, recognizes the importance of self-care for clinicians and staff members as well as patients. Care of the caregiver is important, given that mental health providers often experience compassion fatigue and professional burnout.^25,26 The VA system, in particular, may bring additional strain to providers, due to high rates of mental health diagnoses among returning Veterans, increased suicide risk among Veterans, and other factors.²⁷

Participants

Participants were 134 VA health care professionals who participated in the WHMH pilot courses (one in the Northeast and one in the Mountain West) in 2019 and completed a pre-test.

Table 1 presents participant characteristics. Three quarters (75%) of the sample was female and more than three quarters reported their race as White (76%), followed by Black (10%), and Asian (8%). There were a few Hispanics (4%) in the sample. Participants were in their mid-forties on average (M = 47.34, range: 25–70). Participants had worked in their current position for about 10 years on average (M = 9.77, range: 0–40). Fifteen percent were Veterans (15%). The top three observed occupations comprised 60% of the sample: social workers (26%), psychologists (20%), and registered/licensed vocational nurses (14%). Examining both self-report data and registration data, 57 (or 43%) of participants either had a mental health-related occupation or worked for a VA unit that directly addresses mental health issues. The great majority (92%) of participants indicated that the training was not mandatory for them.

Table 1.

Participant Characteristics (N = 134)

	n	%
Gender
Female	101	75
Male	33	25
Hispanic ethnicity	6	4
Race
Asian	11	8
Black	14	10
White	102	76
Other	5	4
Veteran	20	15
Occupation (n = 132)
Social worker	34	26
Psychologist	26	20
Registered nurse/licensed vocational nurse	19	14
Physician	9	7
Voc./Rec./physical therapist	9	7
Whole health coach	8	6
Nurse practitioner	7	5
Psychiatrist	6	5
Peer support specialist	3	2
Clinical pharmacist	2	2
Registered dietitian	2	2
Health systems specialist	2	2
Other	5	4

	Mean	SD
Age (n = 128)	47.34	10.90
Tenure (n = 131)	9.77	8.12

Sample size is 134, unless noted otherwise.

SD, standard deviation.

Recruitment and data collection

Participants from the two VA medical centers volunteered or were asked to participate in the course. Participants were sent e-mails with links to a web-based pre-course survey. Those who did not complete the web survey were asked to complete a survey onsite before the course. Participants were asked to complete post-course surveys onsite after the course. Two months later, participants were sent follow-up survey links via e-mail. The pre-course survey had a total of 66 items (9 participant characteristics items, 27 attitudinal outcome items, and 30 behavior outcomes). The post-survey had a total of 65 items (27 attitudinal outcome items and 38 items that included training feedback and details on implementation plans that were part of the course). The follow-up survey had a total of 72 items (27 attitudinal outcome items, 30 behavior outcomes, and 15 items about implementation plans that were part of the course). Reminder e-mails were also sent to encourage completion of the follow-up survey. Of the 134 participants who completed pre-course surveys, 100 (or 75%) provided usable data at post-survey and 99 (or 74%) provided usable data at follow-up (2.5–3 months after the course). Examining start and end times for those who completed the pre-course survey on the same day, it took participants an average of 23.87 (standard deviation = 24.84) min to complete the survey.

Measures

Measures included attitudes, WHMH behaviors, and participant characteristics. Except where noted later, all attitude and WHMH behavior measures were developed by the lead author in partnership with the course developers to align with the purpose of the course. Please see Supplemental Data for more details on these measures.

Attitudes

Pre-, post-, and follow-up data were collected for the following measures of attitudes.

Openness to use complementary/integrative health for patient care (adapted from Hsiao et al.’ Awareness and Openness to Working with Practitioners from Other Paradigms scale.²⁸) (6 items; α_time1 = 0.87),

Self-efficacy to use complementary/integrative health for self-care (3 items; α_time1 = 0.96),

Self-efficacy to discuss Circle of Health components related to mental health (10 items; α_time1 = 0.94),

Self-efficacy to work with Veterans on five aspects of mental health (5 items; α_time1 = 0.89),

Self-efficacy to connect mental health concerns and other illnesses (3 items; α_time1 = 0.91)

Response options for all attitude outcomes were “strongly disagree,” “disagree,” “agree,” and “strongly agree.”

WHMH behaviors

Pre- and follow-up data were collected for the following WHMH behaviors:

Use of complementary/integrative health for patient care (5 items; α_time1 = 0.94),

Work with Veterans on five aspects of mental health (5 items; α_time1 = 0.91),

Discussion of Circle of Health components and mental health (10 items; α_time1 = 0.91),

Use of complementary/integrative health for self-care (3 items; α_time1 = 0.89), and

Use of self-care strategies (adapted from the Professional Self-Care Scale²⁹) (7 items; α_time1 = 0.76).

Response options for the first three WHMH behavior outcomes were “none of the patients,” “some of the patients,” “most of the patients,” and “all of the patients.” Response options for the use of complementary/integrative health for self-care were “none of the time,” “some of the time,” “most of the time,” and “all of the time.” Response options for the use of self-care strategies were “strongly disagree,” “disagree,” “agree,” and “strongly agree.”

Participant characteristics

At baseline, participants reported their age, gender, race, ethnicity, occupational roles, Veteran status, length of tenure in the VA, current position title, and whether the course was mandatory for them.

Data analysis

The collected data represent repeated measures data, where multiple observations are nested within participants. Random intercept mixed-model regressions, sometimes referred to as hierarchical linear models, were used to analyze these data. This method, in contrast to repeated-measures analysis of variance, allows for all cases to be analyzed even if a participant does not have all repeated measurements.³⁰ Posing the intercept as the random effect adjusts model estimates for non-independence arising due to multiple observations being nested within the same individual. The data for these analyses assumed normally distributed continuous outcomes. All models were fit by using the lme4 and lmerTest libraries in R.^31,32 We regressed outcomes on a fixed contrast representing time (pre- vs. post-test or pre-test vs. follow-up) in separate analyses and a dummy variable representing the implementation site. We also explored whether the participant being a mental health worker moderated this relationship by adding a dummy variable representing being a mental health worker and the orthogonal interaction of this variable with time. No interaction terms indicating moderation were statistically significant (p < 0.05), so these analyses are not discussed further. The effect size r was calculated for all models based on t and Satterthwaite degrees of freedom by using the formula reported in Cohen.³³

Differential attrition can lead to groups at post-test and follow-up that differ from the pre-test sample. We examined this possibility by regressing study attrition at post-test and follow-up (in separate analyses) on participant demographic characteristics (presented previously) using probit regression models. The omnibus mode tests for post-test; χ² (9) = 5.63, p = 0.776; and follow-up; χ² (9) = 8.70, p = 0.465; attrition failed to reach statistical significance and there was no evidence of significant (p < 0.05) predictors in either model. Therefore, no statistical corrections (e.g., a Heckman selectivity adjustment³⁴) were applied in our models to mitigate selectivity biases.

Results

Table 2 shows change in outcomes from pre- to post- and follow-up.

Table 2.

Change Over Time in Targeted Whole Health for Mental Health Course Outcomes

	Means (SD)			Pre. vs. post		Pre. vs. follow-up
	Pre-test (n = 134)	Post-test (n = 100)	Follow-up (n = 99)	t	r	t	r
Attitudes
Openness to use complementary/integrative health for patient care	3.14 (0.46)	3.51 (0.44)	3.47 (0.42)	6.90^**	0.55	7.41^**	0.59
Self-efficacy to use complementary/integrative health for self-care	3.18 (0.56)	3.60 (0.44)	3.50 (0.46)	6.73^**	0.54	5.62^**	0.49
Self-efficacy to discuss Circle of Health components related to mental health	3.11 (0.67)	3.55 (0.43)	3.37 (0.56)	6.39^**	0.56	4.16^**	0.38
Self-efficacy to work with Veterans on five aspects of mental health	3.19 (0.61)	3.60 (0.48)	3.52 (0.49)	7.13^**	0.58	6.10^**	0.53
Self-efficacy to connect mental health concerns and other illnesses	2.87 (0.68)	3.37 (0.52)	3.27 (0.52)	6.29^**	0.52	5.95^**	0.50
WHMH behaviors
Use of complementary/integrative health for patient care	2.49 (0.72)	—	2.67 (0.58)	—	—	3.11^*	0.30
Work with Veterans on five aspects of mental health	2.60 (0.82)	—	2.76 (0.79)	—	—	1.98	0.20
Discussion of Circle of Health components and mental health	2.38 (0.76)	—	2.68 (0.68)	—	—	5.97^**	0.53
Use of complementary/integrative health for self-care	2.47 (0.80)	—	2.76 (0.66)	—	—	4.93^**	0.45
Use of self-care strategies	3.11 (0.46)	—	3.26 (0.42)	—	—	3.93^**	0.37

Satterthwaite degrees of freedom range between 91 and 106.

p < 0.01, ^** p < 0.001.

SD, standard deviation; WHMH, Whole Health for Mental Health.

Attitudes

Participants reported increases in openness to use complementary/integrative health for patient care, self-efficacy to use complementary/integrative health for self-care, self-efficacy to discuss Circle of Health components related to mental health, self-efficacy to work with Veterans on five aspects of mental health, and self-efficacy to connect mental health concerns and other illnesses. The magnitude of improvement toward more agreement between pre- and post-test for all attitudes examined was large and statistically significant, with effect sizes ranging from 0.52 to 0.58. These changes remained statistically significant between pre-test and follow-up, where the magnitude of change remained at least medium to large. Effect sizes ranged from 0.38 to 0.59.

WHMH behaviors

Statistically significant improvements, which were medium in magnitude or larger, were found for four of the five WHMH behavior outcomes examined (use of complementary/integrative health for patient care, discussion of Circle of Health components and mental health, use of complementary/integrative health for self-care, and use of self-care strategies). Effect sizes ranged from 0.30 to 0.53. The finding for working with Veterans on five aspects of mental health was in the expected direction; however, it failed to achieve a conventional level of significance (p = 0.051).

Discussion

This study assessed change in attitudes and behaviors among VA health care professionals who participated in a pilot course focused on applying Whole Health concepts and the use of both conventional and complementary approaches to mental health. The course emphasized the self-care and prevention of mental health issues, which is consistent with the orientation of VA Whole Health in the VA toward promotion of health-sustaining behavior. Attitudinal outcomes included openness to using complementary/integrative health for patient care, and self-efficacy to: use complementary/integrative health for self-care; discuss Circle of Health components; work with Veterans on five aspects of mental health; and connect mental health concerns to other illnesses. The WHMH behavior outcomes included the use of complementary/integrative health for patient care, work with Veterans on five aspects of mental health, discussion of Circle of Health components, use of complementary/integrative health for self-care, and use of self-care strategies.

This results showed that the pilot course had large effects in the desired direction on all attitudinal outcomes measured and that these improvements were sustained at follow-up with medium-to-large effects. In addition, improvements at follow-up for four of five WHMH behavior outcomes had effects that were medium in magnitude or larger and in the desired direction.

It is notable that there were effects on outcomes related to attitudes toward and use of complementary/integrative health both for self and Veteran, the Circle of Health, and self-care strategies. As previously noted, the course emphasized the contributions of both conventional care and complementary/integrative health, and the connections between mental health and each Circle of Health component, including mindful awareness and eight aspects of self-care. In addition, the course recognized the importance of self-care on the part of clinicians and other staff as well as on the part of the patient/client. The results found in attitudes and behaviors around complementary/integrative health and the Circle of Health, and those found in behaviors around self-care suggest that course participants showed gains in each of the core content areas of the course. For the WHMH behavior outcome that failed to achieve a conventional level of significance in change from pre- to follow-up (Work with Veterans on five aspects of mental health), it is possible that the response categories, which asked about how many Veterans (none to all) the participant worked with on each aspect of mental health, were not constructed to capture behavior appropriately. It might have been more appropriate to have asked how many times the participant had worked with Veterans on these aspects of mental health, since the Veterans worked with might not have exhibited a need for work on multiple aspects of mental health.

Improvements in the outcomes found in the current study provide early evidence that VA clinicians and others can increase their use of Whole Health concepts and both conventional and complementary approaches to mental health issues. These improvements align with the VA's patient-centered care and the integration of mental health into all of the care approaches as addressed in the VA's modernization approach. The attitudes and WHMH behaviors assessed, while certainly circumscribed and with content limits, are also consistent with mind–body science as noted in the Introduction section. It will be important to continue to track findings where possible to determine how the attitude and behavior changes are conserved or not and what the effects are on patient care outcomes and staff satisfaction and/or elements of job burnout.

Our evaluation expands the relatively limited literature on the Whole Health educational courses for clinicians who work with Veterans, and it is the first to assess the results of a mental health focused Whole Health course. Clinicians are central to the Whole Health System and can play an important role in addressing treatment needs and barriers faced by Veterans, including those with mental health issues. In addition, given the fact that Veterans largely use civilian medical care facilities,³ should there be effects on patient care within the VA, such results could inform approaches to improving mental health care for Veterans more broadly.

Limitations

The limitations of this study include that it lacked a comparison group, making it hard to rule out alternative explanations for effects, the follow-up assessment period was relatively short, and most participants self-selected into the course, thereby reducing generalizability. Although the study lacked a comparison group, the strong and consistent pattern of positive findings make it implausible that these findings were due to chance or external factors. While we acknowledge that the present study includes a substantial number of statistical significance tests (15), we far exceeded the one significant result we would expect by chance alone at a 5% Type I error rate, which makes it implausible that our results are due to chance alone. Finally, although social desirability is a potential alternative explanation for our study findings, we believe this is not the case, as the pattern of findings remained strong even at follow-up, where this threat to validity would have presumably abated.

Conclusions

Although further study is needed, WHMH appears to have the potential to increase the targeted outcomes among VA professionals who work with Veteran patients struggling with, or desiring to prevent, mental health issues. The results of this evaluation of the WHMH course suggest that the course can provide VA professionals with tools and resources to assist Veterans in taking a Whole Health approach to their mental health. Further study is needed of whether the course has effects on clinical and patient outcomes. Such courses can be an important part of the transformational efforts within the VA to help make health care more person-centered, relationship-focused, and conducive to health-sustaining behavior.

Footnotes

Acknowledgments

The authors gratefully acknowledge the contributions of the VA's Office of Patient-Centered Care and Cultural Transformation for their guidance with the development and implementation of the WHMH course and its evaluation. Special thanks are due to Cody Schale, PhD, at the Leavenworth VA and Julia Yates, MCSW, LCSW who were co-creators of the course as well as faculty members.

Authors' Contributions

A.R. and M.H. led the development of the course curriculum. D.C. and S.S. designed the study and developed the survey instrument. S.S. analyzed the data. All authors wrote or edited the article.

Disclaimer

The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, or the United States Government.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by the VA OPCC&CT (VA777-12-C-0002; Rychener, Principal Investigator).

Supplementary Material

Supplementary Data

References

U.S. Department of Veterans Affairs. About VHA. Online document at: https://www.va.gov/health/aboutvha.asp, accessed June 1, 2021 .

Olenick

, Flowers

, Diaz

. US veterans and their unique issues: Enhancing health care professional awareness. Adv Med Educ Pract, 2015; 6:635–639.

Lehavot

, Katon

, Chen

, et al. Post-traumatic stress disorder by gender and veteran status. Am J Prev Med, 2018; 54:e1–e9.

Boden

, Hoggatt

. Substance use disorders among veterans in a nationally representative sample: Prevalence and associated functioning and treatment utilization. J Stud Alcohol Drugs, 2018; 79:853–861.

Cheney

, Koenig

, Miller

, et al. Veteran-centered barriers to VA mental healthcare services use. BMC Health Serv Res, 2018; 18:1–14.

Krejci

, Carter

, Gaudet

. Whole health: The vision and implementation of personalized, proactive, patient-driven health care for veterans. Med Care, 2014; 52:S5–S8.

Gaudet

, Kligler

. Whole health in the whole system of the Veterans Administration: How will we know we have reached this future state?. J Altern Complement Med, 2019; 25:S7–S11.

Purcell

, Zamora

, Bertenthal

, et al. How VA whole health coaching can impact veterans' health and quality of life: A mixed-methods pilot program evaluation. Glob Adv Health Med, 2021; 10.

U.S. Department of Veterans Affairs. Implementing a whole health system: Patient and team perspectives. Online document at: https://www.va.gov/WHOLEHEALTHLIBRARY/overviews/implementing-a-whole-health-system.asp, accessed August 24, 2021 .

10.

U.S. Department of Veterans Affairs. Whole Health: The Circle of Health. Online document at: https://www.va.gov/WHOLEHEALTH/circle-of-health, accessed June 2, 2021 .

11.

Atwood

, Shamblen

, Gaudet

, et al. Impact of a clinical educational effort in driving transformation in health care. Fam Med, 2016; 48:711–719.

12.

Collins

, Shamblen

, Atwood

, et al. Evaluation of a health coaching course for providers and staff in Veterans Health Affairs medical facilities. J Prim Care Community Health, 2015; 6:250–255.

13.

Haun

, Paykel

, Alman

, et al. A complementary and integrative health group-based program pilot demonstrates positive health outcomes with female Veterans. Explore (NY), 2020; 16:85–89.

14.

Resnick

, Rosenheck

. Recovery and positive psychology: Parallel themes and potential synergies. Psychiatr Serv, 2006; 57:120–122.

15.

Peebles

, Mabe

, Fenley

, et al. Immersing practitioners in the recovery model: An educational program evaluation. Community Ment Health J, 2009; 45:239–245.

16.

Cuijpers

, van Straten

, Andersson

, van Oppen

. Psychotherapy for depression in adults: A meta-analysis of comparative outcome studies. J Consult Clin Psychol, 2008; 76:909–922.

17.

Lang

, Schnurr

, Jain

, et al. Randomized controlled trial of acceptance and commitment therapy for distress and impairment in OEF/OIF/OND veterans. Psychol Trauma, 2017; 9:74–84.

18.

Haefner

. Complementary and integrative health practices for depression. J Psychosoc Nurs Ment Health Serv, 2017; 55:22–33.

19.

Liu

, Chang

, Reddy

, et al. Improving patient-centered care: A cross-sectional survey of prior use and interest in complementary and integrative health approaches among hospitalized oncology patients. J Altern Complement Med, 2016; 22:160–165.

20.

Selye

. Syndrome produced by diverse nocuous agents. Nature, 1936; 138:32.

21.

Selye

. Stress without distress. In: Serban

, ed. Psychopathology of Human Adaptation. Boston, MA: Springer, 1976:137–146.

22.

Porges

. The Polyvagal Theory. New York, NY: W.W. Norton & Company, Inc., 2011.

23.

Davidson

, Kasniak

. Conceptual and methodological issues in research on mindfulness and meditation. Am Psychol, 2015; 7:581–592.

24.

Wielgosz

, Goldberg

, Kral

TRA

, et al. Mindfulness meditation and psychopathology. Annu Rev Clin Psychol, 2019; 15:285–316.

25.

Newell

, MacNeil

. A comparative analysis of burnout and professional quality of life in clinical mental health providers and health care administrators. J Workplace Behav Health, 2011; 26:25–43.

26.

Garcia

, McGeary

, Finley

, et al. Burnout among psychiatrists in the Veterans Health Administration. Burn Res, 2015; 2:108–114.

27.

Salyers

, Rollins

, Kelly

, et al. Job satisfaction and burnout among VA and community mental health workers. Adm Policy Ment Health, 2013; 40:69–75.

28.

Hsiao

, Hays

, Ryan

, et al. A self-report measure of clinicians' orientation toward integrative medicine. Health Serv Res, 2005; 40:1553–1569.

29.

Galiana

, Oliver

, Sansó N, Benito E. Validation of a new instrument for self-care in Spanish palliative care professionals nationwide. Span J Psychol, 2015; 18:E67.

30.

Raudenbush

, Bryk

. Hierarchical Linear Models (2nd ed.). Thousand Oaks, CA: Sage, 2002.

31.

Bates

, Maechler

, Bolker

, et al. Linear mixed-effects models using ‘Eigen’ and S4 (v. 1.1–21). Online document at: https://cran.r-project.org/web/packages/lme4, accessed October 22, 2019 .

32.

Kuznetsova

, Brockhoff

, Bojesen-Christensen

. lmerTest: Tests in linear mixed effects models (v. 3.1-0). Online document at: https://cran.r-project.org/web/packages/lmerTest, accessed October 22, 2019 .

33.

Cohen

. Statistical Power Analysis for the Behavioral Sciences (2nd ed.). Hillsdale, NJ: Erlbaum, 1988.

34.

Heckman

. The common structure of statistical models of truncation, sample selection and limited dependent variables and a simple estimator for such models. Ann Econ Soc Meas, 1976; 5:475–492.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.02 MB