The experiences of veterans with mental health problems participating in an occupational therapy and resilience workshop intervention: an exploratory study

Abstract

Introduction

Occupational therapy has long had a strong presence in military mental healthcare. Today’s veterans have complex needs and can face challenges reintegrating into civilian life. This exploratory study investigated whether veterans receiving mental health treatment who participated in a bespoke occupational therapy and resilience workshop intervention improved their perceived participation in everyday life.

Method

An interpretivist hermeneutic phenomenological approach was used to explore veterans’ perspectives. Ten participants took part in two semistructured focus groups. Thematic analysis was used to identify and analyse patterns within the data.

Findings

Most participants developed occupational goals and started to make lifestyle changes; participants developed an appreciation of the value of occupation; participants developed insight into their recovery journeys; and value was placed on the ‘healing power’ of the group.

Conclusion

This exploratory study provides preliminary evidence to suggest occupational therapy was influential in helping participants understand the impact of occupation on health and start making lifestyle changes. Participants also reflected on their recovery journeys. The benefits of doing this within a group environment appear to have been particularly therapeutic. Original occupational therapy research in this specialism is sparse. This novel study provides insight that can further discussion and enhance understanding about what the profession can offer this client group.

Keywords

Occupational therapy veterans mental health recovery resilience identity

Introduction

From the founding of the profession, occupational therapists have worked with veterans experiencing mental ill health and have continued to have a presence in military healthcare. The official title ‘occupational therapy’ became cemented at the same time as an upsurge in the recruitment of therapists to support the large numbers of ‘shell shocked’ service personnel returning from the First World War (Laws, 2011).

While the transition from military to civilian life has never been easy, it is acknowledged that today’s veterans have unique and complex needs (Plach and Sells, 2013). Increased survival rates from injuries, multiple lengthy deployments with potential recurrent exposure to trauma are some of the reasons why the aftermath of service can have such multifaceted challenges. There is a significant number of veterans who experience ‘invisible injuries’ including post-traumatic stress disorder (PTSD), depression and anxiety, affecting function and quality of life (Cogan, 2014; Fox et al., 2019). It is also recognised that the transition itself is more than a loss of role (Cogan, 2014) and can be challenging even without illness or disability (Demers, 2011).

Occupational therapy is considered ideally placed to assist in creating a meaningful life after service by supporting veterans to ‘build social support … connectedness with [the] community, enable practical skills for lifestyle management, and restore hope’ (Murtagh, 2014: 329). Although occupational therapy can have a transformative impact, treatment is largely not evidence based due to a paucity of research in this practice area (Cogan, 2014).

Setting

Combat Stress is a military mental health charity which provides free specialist clinical treatment to ex-service personnel across the United Kingdom (UK) (Combat Stress, 2019a) (Figure 1). Occupational therapists were at the forefront of the charity when it was established in 1919.

Figure 1.

Veterans basket weaving at Combat Stress. (Photograph included for its historical representation. The authors do not wish to reinforce dated professional stereotypes and recommend Laws (2011) for an interesting historical analysis of therapeutic work and occupation.)

In 2016, Combat Stress developed a bespoke series of ‘occupational therapy and resilience workshops’ aiming to improve participation in everyday life. Since then, the intervention has been delivered across the UK by the charity’s community occupational therapists. The workshops offer:

A safe environment to discover new skills, problem solve difficulties and build a toolbox of skills, encouraging you to play an active part in your daily life with friends and family (Combat Stress, 2019c).

Resilience is about being able to adapt positively to life situations despite adversity (Hart et al., 2016). It encompasses behaviours, thoughts, actions and skills that can be developed (Lopez, 2011: 33). In the workshops, a resilience framework is integrated with core occupational therapy concepts. Meichenbaum (2012) advocates that resilience can play a part in ameliorating the negative impacts of trauma in military populations. A randomised controlled trial (RCT) found that resilience-orientated treatment provided multifaceted benefits for veterans with PTSD (Kent et al., 2011). Engagement in meaningful daily activity can also boost resilience (Eakman et al., 2016).

Workshop sessions are related to the resilience ‘fitness’ areas of Meichenbaum (2012) and use experiential activities, psychoeducation, discussion and reflection to encourage contemplation on occupational identity and participation, with the aim of driving motivation to develop sustainable occupations (Combat Stress, 2019c; Parkinson, 2014) (Table 1). Where possible guest speakers from relevant local organisations attend sessions to promote their projects and foster integration with community activities; for example, supported volunteer/work agencies and sports initiatives. This is dependent on resources available to each geographical area.

Table 1.

Combat stress workshops.

Workshop session (4.5 hours)	Topic, main content and examples of experiential activities included.N.B. One experiential activity is offered per session, chosen by the therapist. Groups verbally reflect after completion of the activities.
1	Introduction to mental health, occupational therapy and resilience• Group introductions, hopes and expectations, team building activities and group rules• Military mental health, PTSD, anxiety, depression• Stress vulnerability model • Occupational therapy, resilience and post traumatic growth
2	Lifestyle and occupation • Sleep education and sleep hygiene• Food and mood • Physical activity and exerciseActivity: group walk monitoring heart rate, cricket ball games, badminton
3	Emotion and occupation• Recognising emotions• Relaxation and mindfulness • Links between activities and emotionsActivity: photography, pottery, tai chi
4	Interpersonal skills and occupation• Assertiveness • Relationship skills• Altruistic activities and volunteering Activity: skill share, proudest moment presentations, cake decorating
5	Thinking skills and occupation• Problem-solving • Self-belief• Optimistic thinkingActivity: community ‘treasure hunt’, geocaching, quiz
6	Behaviour and occupation• Balance and routine• Avoidance• Activity schedulingActivity: yoga, creative writing, memorial walk
7	Identity and occupation • Spiritual activities• Values and activities• Post traumatic growth Activity: group meal, collage making, creating wildflower seed bombs

PTSD: post-traumatic stress disorder.

Literature review

Numerous commentaries and discussion pieces have explored the context and history of occupational therapy and veterans’ mental health; however, there is a clear paucity of research evidence. In a review of the literature, no RCTs or systematic reviews were found. The 2014 American Journal of Occupational Therapy military special issue expresses:

Much work remains to be done in establishing the impact of occupational therapy on recovery, resilience, and reintegration … and the transition to civilian life (Radomski and Brininger, 2014: 379).

Veteran challenges

Veterans face unique occupational challenges, the most prevalent being associated with relationships, education and physical health (Plach and Sells, 2013). Navigating the transition from military to civilian life is considered a ‘dramatic’ shift as veterans move from the structure of the ‘military machine’ into unstructured civilian life (Wood et al., 2017: 193).

Cogan (2014) asserts that occupational therapists are well placed to support this life transition, due to their focus on supporting daily living skills and the development of healthy habits, roles and routines. Cogan (2014), drawing on the findings of Clark et al. (1997), recommends that a specific manualised recovery focussed programme is developed that supports community integration and the development of a meaningful life after transition.

A further issue highlighted is the necessity for veterans to develop resilience. Eakman et al. (2016) found that veterans with PTSD had the lowest levels of both engagement in meaningful activities and resilience. It is suggested that developing resilience should be a fundamental focus of the occupational therapy intervention for people experiencing PTSD (Lopez, 2011) and for all veterans (Murtagh, 2014).

Occupations and occupational therapy

The transformational and therapeutic impact of occupation on both physical and mental health is well documented (Clark et al., 1997; Creek, 2003). Two pieces of original research appraised specific activities that hold therapeutic potential for veterans. Rogers et al. (2014) conducted a feasibility study evaluating an occupational therapy surfing intervention and deduced that high intensity sports showed promise as an effective and meaningful intervention. Classen et al. (2014) conducted a pilot study that indicated that an occupational therapy driving intervention was efficacious. Driving is considered a fundamental activity of daily living offering independence and freedom. It is a pertinent intervention for veterans as driving skills can be compromised by military training as well any impairments.

Speicher et al. (2014) found improvements in occupational outcomes as well as reductions in PTSD and depression scores for veterans who participated in a residential treatment programme. While the results were promising, it is difficult to appraise the unique occupational therapy contribution as the programme consisted of psychoeducation groups, as well as individual occupational therapy and psychological trauma therapy. However, clinically significant improvements in occupational performance and satisfaction were seen across Canadian occupational performance measure scores (Law et al., 2005).

An unpublished masters-level study by Colfer (2016) identified the value of occupational engagement in re-establishing identity post-transition from military to civilian life for veterans with PTSD. Participants opted to engage in active physical leisure activities, emulating a core part of military life. The importance of maintaining elements of a military identity through engagement in specific occupations was further validated by the significance participants placed on maintaining social contact with other veterans ‘who understood’ (Colfer, 2016: 54).

Rationale

The paucity of occupational therapy research evidence in this specialism is an issue echoed in the literature and it is suggested that the profession has a societal duty to act on this (Kashiwa et al., 2017; Radomski and Brininger, 2014). In the UK, several organisations (Kings College London, Forces in Mind, Combat Stress) have published veterans’ mental health research, but none has studied the impact of occupational therapy.

Due to the number of military personnel involved in recent international conflicts, demand for treatment is expected to rise considerably over the next decades (Radomski and Brininger, 2014). While there is widespread recognition that veterans face occupational challenges and that occupational therapy has an important role to play, evidence-based treatment is largely lacking (Kashiwa et al., 2017). Existing research also tends to utilise psychological and not occupation focussed outcome measures (Cogan, 2014). Cogan (2014) further stipulates that lack of research may result in other professions developing interventions that are better suited to occupational therapy, diminishing the future presence of the profession.

The aim of this preliminary study was to explore the impact of a specific occupational therapy intervention carried out within a UK veterans’ mental health charity, Combat Stress. The following research question was developed: ‘How does engagement with the intervention of “occupational therapy and resilience workshops” affect perceived participation in everyday life for military veterans receiving mental health treatment?’

Method

Theoretical assumptions

The research was a hermeneutic phenomenological qualitative study, falling within the epistemology of the interpretivist paradigm. A defining feature of interpretivism is the belief that there are multiple standpoints on reality, with the highest value being placed on the lived experience. The task of the researchers was to create and uncover meaning by gaining understanding from the participants’ ‘insider perspective’ (Finlay, 2000). Interpretivism recognises the influence of the investigators (Braun and Clarke, 2006), which was particularly pertinent as the lead researcher was at the time of the study an occupational therapist employed by Combat Stress.

Phenomenology aims to uncover the ‘real life’ meaning people give to a phenomenon and is a complex and creative pursuit of striving to ‘make the invisible visible’ (Finlay, 2000: 580). It was appreciated that the experience of taking part in the workshops would be unique for each participant (Laverty, 2003). There are key differences between hermeneutic phenomenology and phenomenology. Hermeneutic phenomenology is time specific and ‘interpretative’ as opposed to ‘descriptive’. It acknowledges that any meaning made is influenced by the researcher and his or her consciousness, with understanding and interpretation being deemed inseparable (Laverty, 2003).

Sampling and recruitment

A non-probability purposive sampling method was used to target information-rich veterans from two Combat Stress workshop groups. All members of selected groups were invited to participate in a one-off face-to-face focus group following their final workshop session. Written informed consent was obtained. There were 10 participants in total (three in the first group and seven in the second). All participants were Combat Stress clients, aged over 18 years, had served in the British Armed Forces and had military-related mental health problems (commonly PTSD, depression and anxiety) (Combat Stress, 2019a). There were no exclusion criteria. Demographic data were not collected as they were not deemed explicitly relevant to the research question.

Data collection

Data were collected through two face-to-face semistructured focus groups (conducted in December 2018 and March 2019). The groups were held in private rooms in city centre community buildings and followed a short break at the end of the final workshop session. Discussions ran for 45 minutes and were audio recorded.

Two weeks prior to data collection, all veterans from the two specified workshops were invited to participate in the study by gatekeepers (the occupational therapists leading the specific workshop). The first author acted as the focus group moderator. A guide of open-ended interview questions was prepared asking participants what they found most pertinent about the workshops, what changes (if any) to daily life they made as a result of the workshops, whether any goals had been set and what occupational therapy meant to them as individuals.

Group discussions naturally involve participants influencing each other and can be considered incongruent with phenomenology with its traditional focus on individuals’ experiences. For this reason, when approaching group discussions in a phenomenological way, it is necessary for the rationale to be made explicit (Bradbury-Jones et al., 2009). Focus groups were deemed appropriate for this study as a hermeneutic methodology was employed. Interpretation was an important and inherent part of the process and essentially the overarching aim was not to achieve an ‘uncontaminated’ individual description of the phenomenon. Focus groups can ‘add’ perspective as discussions are intensified by different outlooks (Bradbury-Jones et al., 2009).

Data analysis

Data were analysed using a six-phase guide for completing thematic analysis (Braun and Clarke, 2006). Audio recordings of the groups were first transcribed verbatim, with areas of interest noted. The dataset was then manually reviewed several times with meaningful chunks of data highlighted and coded. The process was ‘data driven’, as all data were considered relevant and there were no predetermined areas of interest. The initial codes were refined before being brought together to develop broader preliminary themes, which were reviewed and considered as to their meaning and relationships. Analysis was concluded when it was judged that there were insightful key themes that were distinct from one another and well supported by the data (Braun and Clarke, 2006). The final stage of the analysis was writing up a narrative account of what the themes represented. It was accepted that conclusions drawn were tentative interpretations of an exploratory nature (Finlay, 2000). In keeping with the philosophy of hermeneutic phenomenology, thematic analysis was used not just as a ‘tool’ but was approached in a deeply reflective way. It was appreciated that the development of themes evolved from a combination of researchers’ presuppositions and values in combination with the realities of the participants (expressed through their language) (Ho et al., 2017).

Ethical considerations

Ethical approval was gained from Cardiff University School of Healthcare Sciences Research Ethics Committee. To avoid participants becoming clients of the first author, they were recruited from other regional areas. Measures were taken to store data securely and each participant was given a pseudonym. A reflexive journal was kept which prompted thoughtful discussions between the researchers. Enabling the ‘problem’ of subjectivity to become an opportunity, it contributed to a richer analysis (Braun and Clarke, 2013).

Findings

The findings are presented in the context of the four key themes that emerged from the analysis (Table 2). Pertinent verbatim quotes are included. Participant names are pseudonyms.

Table 2.

Key themes.

Theme
1. ‘It’s given us the tools, it’s just a case of doing’: occupational changes
2. Insight into occupational therapy
3. ‘I can see more of a way forward’: acknowledging recovery
4. The healing power of the group

‘It’s given us the tools, it’s just a case of doing’: occupational changes

Most participants described occupational changes implemented and/or goals they had developed since attending the workshops, indicating the beginnings of positive change to participation in daily life. Jon summarised:

It’s given us the tools, it’s just a case of doing [the meaningful activities identified], getting used to it and bringing that into everyday life.

Changes to physical health and fitness activities were frequently cited and included making positive dietary changes and being more physically active. Peter’s summary reflected what many participants shared:

I’m now trying to take an interest in my health and stuff. I’m definitely doing more exercise and getting out the house every day, making an effort to be healthy.

Several participants expressed wanting to overcome feelings of social isolation. It has been acknowledged that community engagement for veterans is pivotal, with withdrawal a real risk due to struggles trusting the civilian community (Brewer and Herron, 2018). Ben’s main goal was:

… trying to get out every day. Making an effort to do something outside the house.

Brian felt the workshops had:

… helped me relate to people better.

Employment-related goals were cited by approximately half the participants. Gaining meaningful employment is considered a powerful way for people with mental health problems to achieve social inclusion (Parkinson, 2014). Justin revealed he had developed his confidence in his existing job:

I’m starting to think about moving into management. I used to get anxious at work but now I’m over that … I can take the next step up.

Changes to participation within family life was another occupational area mentioned by four participants, pertinent as family roles are considered fundamental to occupational satisfaction (Parkinson, 2014). The literature suggests that interpersonal challenges are prevalent among the veteran community (Plach and Sells, 2013), and that often for veterans to achieve a settled family life a level of civilian cultural awareness needs to be developed (Brewer and Herron, 2018).

Two participants described actively trying to do more shared activities with their wives to improve their relationships. For Gary, his main goal was specifically to attend a family party, having lost confidence for many years to attend any social events. More broadly, he explained:

I want to involve my family more. I’m getting more involved in pretty much everything at home … and that’s been good.

Each workshop includes an experiential activity linked to that week’s topic to allow the participants to experience first hand the value of activity, with the aim of inspiring long-term occupational engagement. Discussions indicated the ‘doing’ of these activities was appreciated and enjoyed. One group spoke very favourably about their pottery activity, Clive reflected:

… the pottery itself like, it was all consuming. You had to concentrate so hard. It was grounding and calming [and] good for the senses.

The group revealed they were making plans to establish their own weekly pottery group, indicating that the experiential activity had led to a potential creative and social occupation.

Some participants, however, did not fully grasp the purpose of the activities; rather than reinforcing the value of occupation, they were considered as ‘… helping to break it up’, ‘… getting everyone to muck in … for a bit of a change’.

Insight into occupational therapy

Initially, participants seemed hesitant to discuss what occupational therapy meant to them, but with probing did express interesting insights, with most participants seeming to have a sound appreciation of the links between occupational engagement and health, reverberating with the core belief of occupational therapy philosophy (Creek, 2003). Reference was made to developing an appreciation of ‘what gives you a quality of life’ and how changes to daily activities can be influential by ‘[giving] life back a little [and] some normality’. There were indications that some participants grasped that for occupations to be transformative, they need to align with individuals’ interests and values.

Justin relayed his understanding as:

You have your psychologist and your psychiatrist who diagnose what’s wrong. And the occupational therapists give you the toolbox to help actually adapt and adjust … the practical skills.

Steve felt the purpose of the workshops was to:

Help you organise your life better … tools to help us live our daily lives and have routines.

Several participants reflected on the balance of their lifestyles in the past, present and future, making clear links with the premise of occupational balance (Creek, 2003). Jon illustrated:

I’ve been trying to get the balance back in my life. I was practically living at work like. I’m trying to get it so I work then I come home …. And start doing different things with myself, instead of being a hermit …. It’s not good for you. Trying to get out and do different things. I’ve been taking [my wife] out and one thing and another.

‘I can see more of a way forward’: acknowledging recovery

The focus group questions did not explicitly reference ‘recovery’, but participants themselves geared the conversation towards discussing feeling more in control, accepting, self-aware and hopeful for the future. This natural development of recovery-related conversations may have occurred as the framework has such strong parallels with occupational therapy philosophy (Cole, 2018).

Recovery begins with acceptance of mental illness (Cole, 2018). One participant explained having left the army over 30 years ago but only just ‘clocking on’ that he had been experiencing mental health challenges.

Improvements in mental health were widely reported. For example, Gary shared:

I’m sleeping better now than I was at any time…. Now if I do get anxious, I can usually clear my head within hours instead of days.

Other participants described having improved mood, feeling more positive, less irritable and having a better control of anger.

Hope and optimism for the future were also apparent across both groups, with an acknowledgement of positive change despite still experiencing symptoms. Mark felt able to:

…focus on the parts of life that are important and positive rather than being dragged back by the negatives.

Dave went on to explain:

I found it’s made me aware of what actually the problems are with me. Don’t get me wrong, they can’t erase my memory and cure me, but they certainly can give me the tools and skills to help myself be better. To have a meaningful life anyway …

Believing that you can experience mental illness and still lead a fulfilling life is at the core of the recovery concept. Other important tenets are that it is self-directed and a lifelong process (Cole, 2018), notions that both groups alluded to, affirming ‘it’s up to us to pick which tools we are going to use’ and planning to ‘take it nice and steady’.

Steve reflected:

I can see more of a way forward now than I could at the start. There is still a long way to go. When you look at some of things that [the occupational therapist] talked about you can relate to it. There is a way forward and it’s just a case of finding that particular way.

The healing power of the group

Similarly to recovery, no direct questions were asked about group membership; however, it featured heavily in both focus groups. The data clearly revealed that the group environment was influential, with inter-personal learning, connectedness and emotional support being undoubtedly valued; factors recognised as integral to the ‘healing power of groups’ (Yalom and Leszcz, 2005).

It was apparent that both groups had a strong sense of solidarity, with references made to ‘instant connections’ and ‘strong bonds’ due to the shared military backgrounds. Many references were made to feeling comfortable, at ease, and safe within the ‘non-judgemental’ space.

Steve explained:

It’s people that are like minded, from similar backgrounds with similar problems … the mindset and camaraderie [mean] they can relate to each other. There’s common ground … in terms of relationships, it’s helpful being in an environment like that.

Dave felt:

The camaraderie was as important as the subjects that were covered because it gives you substance…. You learn as much from what everyone else is saying as much as what’s actually covered in the course.

Group members spoke about missing their ‘military family’ after leaving the services and that being part of a purposeful group with other veterans seemed to alleviate some of this loss. Gary described:

You put a group of people together on a table who have mostly never met each other before and you find out a lot of the things you are suffering and your reactions are actually typical instead of just you. You don’t feel so isolated.

Clive added:

You look round here and people go ‘yeah, I’ve been there’. That means a lot.

Another element of the environment that appears to have added therapeutic value was the sense of fun. Participants spoke enthusiastically, describing the atmosphere as lively and enjoyable. Frequent mention was made to how ‘forces’ humour’ and ‘banter’ emerged naturally but were important for bonding and feeling part of a team. Jon affirmed:

We all clicked into each other’s humour straight away. As soon as we started, everyone’s humour came out and it was a really good laugh.

The experiential activity included in each session may have played a role in developing the ‘enjoyable’ atmosphere. Examples of the experiential activities include photography, creative writing, tai chi (see Table 1). Group leadership theory recommends that facilitators promote enthusiasm and interaction to drive motivation for change, with the use of activity and learning new skills being recognised ways of achieving this (Cole, 2018).

Brian described looking forward to experiential activities:

[The occupational therapist] used to keep it under wraps. She wouldn’t tell us until the time had come. We’d be all like ‘what is it, what is it?’ and like bang! ‘This is what we are doing’.

Discussion and implications

This preliminary study explored the experiences of veterans with mental health problems participating in an occupational therapy and resilience workshop intervention. The main findings were that most participants had developed occupational goals as well as an appreciation of the value of occupation on health. They also expressed increased insight into their recovery journeys and felt more optimistic about their futures. Being part of a group of like-minded others coming together to support ‘change’ appeared to have had the biggest impact on wellbeing.

Inspiring change

The findings of this exploratory study provide preliminary evidence of the benefits of occupational therapy and resilience workshops for a particular group of military veterans with mental health problems. These benefits include improved participation in everyday life through the development of occupational goals and by increased engagement in a variety of daily activities; core indicators of good health from an occupational therapy perspective (Creek, 2003; Fox et al., 2019).

The findings also indicate that the workshops enabled veterans to develop an understanding of the links between occupation and health, a valuable prerequisite for ‘inspiring change’:

… the complex task of communicating the benefits of occupational participation might seem straightforward …. However, the challenge of enabling people to recognise the beneficial impact that occupational and social participation can play in their own lives is not easy, especially when people have first-hand experience of being marginalised (Parkinson, 2014: viii).

Existing research has shown that occupational therapy interventions based on education around core concepts of occupational science have shown potential for improving mental health and functioning (Fox et al., 2019).

Identity

Physical health and fitness activities were the most frequently cited priorities for change, which is congruent with existing research suggesting these activities can hold great value for this client group (Plach and Sells, 2013; Rogers et al., 2014). As exercise is a core part of military life, engaging in fitness activities as a veteran could contribute towards maintaining a sense of military identity (Colfer, 2016). Research offering a deeper insight into this would be valuable and could provide a starting place for making practice recommendations.

Significant value was placed on the ‘power’ of being part of the group, an unexpected outcome but one which appears to have had a profound impact for these participants. Possibly, this relates to a yearning to maintain some aspects of military identity alongside the benefits to wellbeing that being ‘socially connected’ within a group offers (Cole, 2018). Being a member of a homogenous military-related group may be particularly meaningful for veterans due to the deep-rooted sense of family the military offers prior to discharge (Wood et al., 2017).

Demers (2011) explored veteran reintegration and championed the need for ‘socially supportive transition groups’; something the workshops may have offered in part. In our study, the ‘power’ of group membership appears to relate to the fact participants were among people with similar past experiences. The communal ‘doing’ of experiential activities and the development of individual goals within the ‘team’ environment appeared to contribute to the overall sense of ‘seeing more of a way forward’. Further research could explore the role of occupational therapy in facilitating these outcomes as compared to non-therapy-specific or self-run workshops.

From an occupational science perspective, Christiansen (1999: 547) deemed that occupations are ‘the principal means through which people develop and express their personal identities’. As identity is thought to play such a fundamental role in whether individuals can smoothly navigate the transition from military to civilian life (Brewer and Herron, 2018) more in-depth research is needed to explore the role of occupation on group and individual identity with this client group.

Resilience and recovery

Resilience underpinned the design and delivery of the intervention but was not investigated fully in the focus groups due to the predominant focus on occupation. On reflection, further in-depth inquiry into resilience and its interaction with occupational engagement would have been valuable.

Resilience has applications to many varied disciplines including genetics, psychology and ecology. The theory behind it has evolved and become more nuanced over time, going beyond the notion that is an internal set of traits held by an individual, to being understood as a more complex and multifaceted set of systems which consider the interaction of the individual with their environment and society (Ungar, 2018). Focusing entirely on individual characteristics is considered reductive and has been contested within the literature (Hart et al. 2016). The use of a resilience framework within occupational therapy is an ‘emerging’ area, with a theoretical practice model yet to be developed (Eakman et al., 2016). It is beyond the scope of this paper to explore in depth resilience-orientated practice in occupational therapy; however, it is noteworthy that the findings in this study did point to resilience enhancing factors external to the individual (e.g. support from others and participation in occupations). The authors feel these ideas are of interest to the profession and warrant further investigation.

Mental health recovery was another area of interest that emerged from the analysis. The aims of the workshops were not overtly related to recovery; however, participants linked occupational therapy to their recovery journeys when describing a wide range of mental health improvements and optimism about their futures. The principles of recovery align closely with occupational therapy philosophy, both having an inherent focus on strengths and empowerment above symptoms (Cole, 2018). However, the authors were unable to find existing research exploring recovery and occupational therapy with this client group.

Limitations

This was a small-scale study investigating a novel area of research. The purpose of the study was to uncover issues for further investigation rather than to make generalisations.

The desired number of participants in the first focus group was not achieved; however, groups with as few as three members can be considered enough to allow for rich discussion (Braun and Clarke, 2013). To increase credibility, ‘member checking’ was attempted in the form of written requests asking for validation and feedback on the synthesised analysed data (Birt et al., 2016); however, no participants responded.

The systematic review completed by Fox et al. (2019) concludes that occupational therapists working with clients with anxiety-related disorders should use interventions that promote participation in daily life, and that this type of treatment can have long-term gains. A longitudinal arm to this study could have provided further insight; for example, following participants up after several months, having allowed time for any occupational changes to become truly embedded and recognised. Methodological triangulation could also have been employed to include interpreting a quantitative resilience outcome scale.

Researcher bias is a further significant issue to note. The first author at the time of conducting the research was employed by Combat Stress (the charity from which the sample was obtained) and had experience in facilitating the workshops, as well as having had a role in their development. This information was shared with participants and both positive and negative comments were encouraged. No attempts to eliminate this integral bias were made; instead her role in interpretation was considered explicitly via the use of an analytical reflexive diary and through in-depth discussions with the other contributors (Laverty, 2003).

Conclusion

The study suggests that the intervention was influential in helping the participants to understand the impact of occupation on health, set occupational goals and start making positive lifestyle changes. Participants also reflected on their recovery journey. The therapeutic benefit of doing this within the homogenous military-related group environment appears to have been meaningful for the participants. When reflecting on the findings as a whole, it is tentatively suggested that the ‘power’ of the group membership could extend beyond the social support element offered by being among other veterans. The coming together, the communal ‘doing’ of experiential activities and the development of individual goals within the ‘team’ environment could collectively account for the overall sense of ‘seeing more of a way forward’.

Original research evaluating occupational therapy practice in this specialism is sparse. This novel study provides insight that can further discussion and enhance understanding about what the profession can offer this client group.

Key findings

The workshop intervention supported positive effects for the veterans’ mental health and encouraged occupational participation in daily life.

Group-based occupational therapy was valued and demonstrated therapeutic effects for the veterans.

What the study has added

This preliminary study has provided insight into veterans’ experiences of a specific mental health occupational therapy intervention, contributing to the sparse evidence base and demonstrating the potential benefits of occupation and group work.

Footnotes

Acknowledgements

The researchers would like to thank wholeheartedly the participants who took part in the research for sharing their experiences so openly and honestly. Gratitude is also extended to Combat Stress, the Elizabeth Casson Trust and the Royal College of Occupational Therapists Wales Region for supporting the project.

Research ethics

Ethical approval was granted by the School of Healthcare Sciences Research Ethics Committee, Cardiff University (September 2018).

Consent

All participants provided written informed consent.

Declaration of conflicting interests

The first author was at the time the research was conducted an employee of Combat Stress. There are no other conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support directly for the research, authorship and/or publication of this article.

Contributorship

Hannah Vaughan-Horrocks researched the literature, applied for ethical approval and collected and interpreted data. Both Carly Reagon and Alison Seymour contributed to the methodology and methods. Hannah Vaughan-Horrocks wrote the first draft of the manuscript. All authors contributed to the analysis and synthesis of data and reviewed and edited the manuscript before approving the final version.

ORCID iDs

Hannah Vaughan-Horrocks

Carly Reagon

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