Amanda Smith

Assignment: Annotation of a Qualitative Research Article

Submit: Annotation of a Qualitative Research Article

This week, you will submit the annotation of a qualitative research article on a topic of your interest. Narrative, ethnographic, grounded theory, case study, and phenomenology are examples of types of research designs or approaches used in qualitative research.

An annotation consists of three separate paragraphs that cover three respective components: summary, analysis, and application. These three components convey the relevance and value of the source. As such, an annotation demonstrates your critical thinking about, and authority on, the source topic. This week’s annotation is a precursor to the annotated bibliography assignment due in Week 10.

An annotated bibliography is a document containing selected sources accompanied by a respective annotation of each source. In preparation for your own future research, an annotated bibliography provides a background for understanding a portion of the existing literature on a particular topic. It is also a useful first step in gathering sources in preparation for writing a subsequent literature review as part of a dissertation.

Please review the assignment instructions below and click on the underlined words for information about how to craft each component of an annotation.

Please use the document “Annotated Bibliography Template with Example” for additional guidance.

It is recommended that you use the grading rubric as a self-evaluation tool before submitting your assignment.   

By Day 7

· Article is attached

· Before you read the full article and begin your annotation, locate the methodology section in the article to be sure that the article describes a qualitative study. Confirm that one of the types of qualitative research designs or approaches, such as narrative, ethnographic, grounded theory, case study, or phenomenology, was used in the study

· Annotate one qualitative research article from a peer-reviewed journal on a topic of your interest.

· Provide the 

reference list entry

 for this article in APA Style followed by a three-paragraph annotation that includes: a summary, an analysis, An application as illustrated in this example

· A 

summary

For each source listed, you will begin with a summary of the information you found in that specific source. The summary section gives your reader an overview of the important information from that source. Remember that you are focusing on a source’s method and results, not paraphrasing the article’s argument or evidence.

The questions below can help you produce an appropriate, scholarly summary:

· What is the topic of the source?

· What actions did the author perform within the study and why?

· What were the methods of the author?

· What was the theoretical basis for the study?

· What were the conclusions of the study?

Remember, a summary should be similar to an abstract of a source and written in past tense (e.g. “The authors found that…” or “The studies showed…”), but it should not be the source’s abstract. Each summary should be written in your own words.

· An 

analysis

Critique/Analysis

After each summary, your annotations should include a critique or analysis of each source. In this section, you will want to focus on the strengths of the article or the study (the things that would make your reader want to read this source), but do not be afraid to address any deficiencies or areas that need improvement. The idea of a critique is that you act as a critic—addressing both the good and the bad.

In your critique/analysis, you will want to answer some or all of the following questions (taken from the

KAM Guidebook

):

· Was the research question well framed and significant?

· How well did the authors relate the research question to the existing body of knowledge?

· Did the article make an original contribution to the existing body of knowledge?

· Was the theoretical framework for the study adequate and appropriate?

· Has the researcher communicated clearly and fully?

· Was the research method appropriate?

· Is there a better way to find answers to the research question?

· Was the sample size sufficient?

· Were there adequate controls for researcher bias?

· Is the research replicable?

· What were the limitations in this study?

· How generalizable are the findings?

· Are the conclusions justified by the results?

· Did the writer take into account differing social and cultural contexts?

· An 

application

 as illustrated in this 

example

Finally, the last part of each annotation should justify the source’s use and address how the source might fit into your own research. Consider a few questions:

· How is this source different than others in the same field or on the same topic?

· How does this source inform your future research?

· Does this article fill a gap in the literature?

· How would you be able to apply this method to your area of focus or project?

· Is the article universal?

First person may be appropriate to use in an application paragraph of the annotated bibliography, but doing so will depend on what aspects of the article you are discussing and faculty preferences. For example, if you are discussing how the article is applicable to your research project, first person may be appropriate. If you are talking about how the article relates to the literature or field as a whole, first person may not be appropriate. In all cases, be sure to follow our guidance on

appropriate use of first person

.

Example

The example annotation below includes the citation, a summary in the first paragraph, the critique/analysis in the second paragraph, and the application in the third paragraph.

Gathman, A. C., & Nessan, C. L. (1997). Fowler’s stages of faith development in an honors science-and-religion seminar. Zygon, 32(3), 407–414. 

https://doi.org/10.1111/0591-2385.00099

The authors described the construction and rationale of an honors course in science and religion that was pedagogically based on Lawson’s learning cycle model. In Lawson’s model, the student writes a short paper on a subject before a presentation of the material and then writes a longer paper reevaluating and supporting his or her views. Using content analysis, the authors compared the students’ answers in the first and second essays, evaluating them based on Fowler’s stages of development. The authors presented examples of student writing with their analysis of the students’ faith stages. The results demonstrated development in stages 2 through 5.

The authors made no mention of how to support spiritual development in the course. There was no correlation between grades and level of faith development. Instead, they were interested in the interface between religion and science, teaching material on ways of knowing, creation myths, evolutionary theory, and ethics. They exposed students to Fowler’s ideas but did not relate the faith development theory to student work in the classroom. There appears to have been no effort to modify the course content based on the predominant stage of development, and it is probably a credit to their teaching that they were able to conduct the course with such diversity in student faith development. However, since Fowler’s work is based largely within a Western Christian setting, some attention to differences in faith among class members would have been a useful addition to the study. 

Fowler’s work would seem to lend itself to research of this sort, but this model is the only example found in recent literature. This study demonstrates the best use of the model, which is assessment. While the theory claimed high predictive ability, the change process that the authors chronicled is so slow and idiosyncratic that it would be difficult to design and implement research that had as its goal measurement of movement in a faith development continuum.

· Format your annotation in Times New Roman, 12-point font, double-spaced. A separate References list page is not needed for this assignment.

· Submit your annotation.

MAIN

Adapting CBT to treat depression in Armed Forces
Veterans: qualitative study

Paul Farrand1,*, Eugene Mullan1, Kat Rayson1, Alberta Engelbrecht1, Karen Mead2 and
Neil Greenberg3

1Clinical Education, Development and Research (CEDAR), Psychology, Washington Singer Laboratories, University of Exeter,
Exeter, UK, 2Help for Heroes, Tedworth House, Tidworth, UK and 3King’s Centre for Military Health Research, King’s
College, Weston Education Centre, London, UK
*Corresponding author. Email: p.a.farrand@exeter.ac.uk

(Received 27 September 2018; accepted 11 December 2018; first published online 21 March 2019)

Abstract
Background: The principles of the Armed Forces Covenant state that Armed Forces Veterans should be at
no disadvantage resulting from their service compared with a general adult population. However, despite
being at increased risk of experiencing common mental health difficulties, evidence indicates that 82% of
Armed Forces Veterans receive no treatment, compared with 63% of the general adult population.
Aim: To gain a better appreciation of factors that inform the type of adaptations to cognitive behavioural
therapy (CBT) interventions for depression and mainstream service promotion materials to enhance
acceptability for Armed Forces Veterans.
Method: This is a qualitative study employing a focus group of 12 participants to examine the main
impacts of depression on Armed Forces Veterans alongside attitudes towards terminology and visual imagery.
Thematic analysis was used to identify themes and sub-themes with rigour established through two researchers
independently developing thematic maps to inform a final agreed thematic map.
Results: A behavioural activation intervention supporting re-engagement with activities to overcome
depression had good levels of acceptability when adapted to reflect an Armed Forces culture. Preferences
regarding terminology commonly used within CBT adapted for Armed Forces Veterans were identified.
Concerns were expressed with respect to using imagery that emphasized physical rather than mental health
difficulties.
Conclusions: There is the need to consider the Armed Forces community as a specific institutional culture
when developing CBT approaches with potential to enhance engagement, completion and recovery rates.
Results have potential to inform the practice of CBT with Armed Forces Veterans and future research.

Keywords: adaptations; Armed Forces Veterans; CBT; depression; qualitative

Introduction
The prevalence of mental health problems amongst UK Armed Forces (AF) Veterans is equivalent
to (Iversen and Greenberg, 2009; NHS England, 2016) or greater (Goodwin et al., 2014) than that
of the general adult population. The prevalence of depression and anxiety disorders in both
populations exceeds that for post-traumatic stress disorder (PTSD) (Hunt et al., 2014). To deliver
the Armed Forces Covenant (Ministry of Defence, 2011) and ensure AF Veterans are not at a
disadvantage to accessing evidence-based psychological therapies compared with a general adult
population, 12 AF Veteran specific mental health services (Murrison, 2010) alongside six pilot
statutory services adopting varied delivery models to accommodate AF Veterans (Dent-Brown
et al., 2010) were established. Protocols for one pilot service (Clarkson et al., 2013) were informed
by those established for the Improving Access to Psychological Therapies (IAPT) programme
© British Association for Behavioural and Cognitive Psychotherapies 2019

Behavioural and Cognitive Psychotherapy (2019), 47, 530–540
doi:10.1017/S1352465819000171

mailto:p.a.farrand@exeter.ac.uk

https://doi.org/10.1017/S1352465819000171

(Clark et al., 2009). Despite increased service provision, however, estimates indicate that 82% of
AF Veterans with mental health problems still receive no treatment (Woodhead et al., 2011)
compared with 63% of the general adult population (Lubian et al., 2016).

This rate is partly dependent on a significant number of help-seeking barriers faced by the AF
population (Coleman et al., 2017). Barriers include external factors related to service delivery such
as unclear referral protocols (Dent-Brown et al., 2010), alongside internal factors associated with
beliefs and attitudes held towards service provision. These factors include beliefs that mental
health problems can be handled by oneself (Britt et al., 2011), NHS mental health service providers
being untrustworthy, lack of confidence (Edlund et al., 2008) and stigma (Sharp et al., 2015).
However, the lowest levels of acceptability are associated with not feeling understood by NHS
services perceived as having little understanding about the experiences and common difficulties
associated with the Armed Forces (Coleman et al., 2017), alongside poor levels of knowledge about
AF culture (Clarkson et al., 2013).

Addressing these barriers has promoted interest in enhancing the cultural competency of
professionals working with AF Veterans (Improving Access to Psychological Therapies, 2009;
Meyer et al., 2016; Royal College of General Practitioners, Royal British Legion and Combat
Stress, 2011) with training programmes developed in the UK (Greenberg et al., 2018) and
USA for health (Nedegaard and Zwilling, 2017) and education settings (Cole, 2014).

Attention has also focused on ensuring language used to name services and interventions
is considered less stigmatizing and more sensitive to an AF context (Zinzow et al., 2012); for
example, naming a mental health service for serving personnel the ‘Defenders Edge’ Program
(Bryan and Morrow, 2011), a CBT psychological therapies service provided by an AF
Veterans charity ‘Hidden Wounds’ (Farrand et al., 2018) and a brief exposure-based PTSD
intervention, ‘Adaptive Disclosure’ (Steenkamp et al., 2011).

However, little attention has directly focused on culturally adapting psychological therapies
and mainstream service delivery for AF Veterans (Farrand et al., 2018; Zinzow et al., 2012).
This has resulted in the delivery of evidence-based psychological interventions and mainstream
services remaining largely the same as those for civilians (Steenkamp et al., 2011), potentially
serving to maintain the AF Veteran mental health treatment gap (Woodhead et al., 2011).
Failing to culturally adapt psychological therapies and enhance the ecological validity of service
delivery is surprising given benefits of adapting psychological therapies for specific populations
(Hall et al., 2016). Although predominantly focused on research into ethnically diverse cultures
(Bernal et al., 2009), culturally adapting psychological therapies has been identified to result in
greater engagement with larger effect sizes (Hall et al., 2016). Ensuring interventions represent
a ‘good fit’ to the specific context may be especially important for AF Veterans given attention
to detail (Palmer, 2012) represents a cultural norm.

This qualitative study seeks to understand the main impacts of depression alongside attitudes
towards language and imagery to inform the practice of CBT for AF Veterans (Hunt et al., 2014)
and stimulate further research. Enhancing cultural awareness and adapting CBT may help to
reduce the current treatment gap faced by AF Veterans (Iversen et al., 2005) and improve access
to an evidence-based psychological therapy.

Method
Setting

The study was based within ‘Hidden Wounds’, a Step 2 CBT psychological therapies service for
the treatment of common mental health difficulties experienced by British AF Veterans, family
members and family members of serving personnel (Farrand et al., 2018). The service is provided
by the UK charity ‘Help for Heroes’, with research undertaken in a recovery centre located in
Southern England.

Behavioural and Cognitive Psychotherapy 531

Design

A focus group methodology (Kitzinger, 1995) was adopted to gain an appreciation of the
main ways that depression has an impact on the lives of AF Veterans, attitudes towards CBT
terminology, and satisfaction with visual imagery commonly adopted within CBT self-help
interventions (Richards and Farrand, 2010) or promote mental health services.

Recruitment

Advertisements introducing the study and inclusion/exclusion criteria were placed on a closed
Help for Heroes ‘Facebook’ page. AF Veterans willing to consider participation were encouraged
to contact a researcher to receive a study information pack detailing ethical rights. To maximize
different perspectives, a purposive sample consisting of the first 12 participants drawn from three
groups associated with the ‘Hidden Wounds’ service were invited to participate and asked to sign
and return a consent form.

Participants

Participants were five male AF Veteran (four Army, one Air Force) service users, three Psychological
Wellbeing Practitioners (PWPs) (one male, two female) and four non-clinical welfare staff
(one male, three female).

Procedure

Focus group aims and ground rules were discussed prior to participants introducing themselves. A
background to CBT was then provided with a topic guide, informed by previous research, examining
adaptations to psychological therapies for an AF population (Alvarez et al., 2011; Palmer, 2012;
Steenkamp et al., 2011; Zinzow et al., 2012) directing subsequent discussion. Section 1 of the focus
group was structured to enable participants to discuss the impact of depression on activities
commonly undertaken by AF Veterans and recognize activities felt to be amongst the first to be
avoided with depression. Participants were divided into three subgroups consisting of at least
one participant from each group in Section 2. A list of commonly adopted terms used within
CBT was then presented (Table 3; column 1). Participants were asked to discuss the acceptability
of each term and generate alternatives if felt to have greater acceptability. Finally, 22 Help for Heroes
stock photographic images focusing on AF Veterans and family members engaging in a number of
everyday activities were individually presented. Participants were asked to consider the suitability
of using each photographic image within a CBT self-help intervention or to promote mainstream
mental health services. Participants rejoined the main focus group at the end of Section 2 where the
collated list of acceptable terms and suitable photographic images identified during Section 2 were
re-presented. Participants were asked to further discuss their attitudes and highlight reasons behind
any disagreement or when consensus could not be reached. The focus group was led by P.F., who is
experienced in focus group facilitation, with K.R. and A.E. acting as scribes.

Analysis

Informed by a model of behavioural activation (Richards, 2010), activities identified during Phase
I of the focus group were separately categorized by two researchers into ‘Routine’ (regular and
important life routines making people comfortable in their surroundings), ‘Pleasurable’ (resulting
in enjoyment and leading to people feeling positive about themselves) and ‘Necessary’ (important
and required to be done to avoid aversive consequences). Analysis of data obtained during Phases
II and III was informed by an inductive approach with thematic analysis (Braun and Clarke, 2006)

532 Paul Farrand et al.

used to identify emerging themes and sub-themes. Following data familiarization, items were
labelled to generate initial codes with rigour (Mays and Pope, 1995) established through two
researchers separately aggregating similar coded groupings to derive sub-themes. These were
compared, with a final agreed thematic map created following discussion and refinement. To
inform final analysis of the data, a title capturing core data features was created for each sub-theme
with representative data extracts identified.

Results
Themes and sub-themes were derived from the three main sections covered by the topic guide
(Table 1).

Table 1. Themes and sub-themes with representative quotes

Themes Sub-themes Representative quotes

Impact of depression
on activities
undertaken
by AF Veterans

Enhancing intervention
acceptability by focusing
on activity

‘When I was at my lowest, it was really hard like. I knew I
should be doing things but didn’t feel up to it. I was
offered the chance to just talk to someone about it, but
I didn’t want that, it would’ve been hard. But something
showing ways to cope is great, it focuses and sort of
prioritizes the things I want to get back to doing.’
(AF Veteran – Air Force)

Benefits of promoting
group-based activity

‘I worry about being forgotten about, that I’m not part
of the machine, that I’ve lost my Army family.
Promoting activities undertaken as part of a group
could really help’(AF Veteran – Army)

Acceptable language
for AF Veterans

Straightforward terminology ‘Simple, basic terms that avoids jargon and actually
helps describe what they mean are the best.’
(AF Veteran – Army)

Language promoting active
engagement

‘Armed Forces Veterans don’t like to be seen as helpless,
so adopting terms that indicates they are actively
engaged with a CBT approach can be really helpful.’
(PWP)

Non-stigmatizing terms ‘At times it can be really difficult, because terms such as
“therapy” and “mental health” which are used all the
time are, from my experience, seen by the Veterans as
being really stigmatizing, and are best avoided.’ (PWP)

Potential to cause distress ‘Especially with some of the squaddies, it’s not unusual for
them to have, well not the best of school days. So,
saying stuff like “homework” could take ‘em right back
there, you know.’ (AF Veteran – Army)

Characteristics of
acceptable
imagery

Enhancing acceptability ‘Personally, I think the photographs of people
doing things in groups are the best, it reminds
me of a team, like I was in, in the Army.’
(AF Veteran – Army)

Imagery as metaphor “I like [photograph], to me it represents the road to
recovery, the journey ahead or going in the right
direction.’ (AF Veteran – Army)

Inappropriate emphasis on
physical injury

‘Too much emphasis on prosthetics – there is an over
representation that [AF Veteran] support services are
all about physical injury, but they’re about emotional
and everyday problems also.’ (non-clinical staff
member)

Considerations regarding
photographic imagery

‘It’s good that their back is to the camera as it makes it
more anonymous, but anyone who served with that
Vet is still likely to know who it is.’
(AF Veteran – Army)

Behavioural and Cognitive Psychotherapy 533

Theme 1: Impact of Depression on Activities Undertaken by AF Veterans
The main impacts of depression associated with reducing activity and behavioural avoidance are
consistent with the phenomenology of depression in the general population. Two sub-themes
highlighted how focusing an intervention on increasing activities commonly undertaken by
AF Veterans, in particular activity undertaken as part of a wider group, could enhance the
acceptability of CBT.

Sub-theme 1: Enhancing intervention acceptability by focusing on activity
All participants highlighted that no longer engaging in activities was a key symptom of depression
experienced by AF Veterans. Given the increased priority placed on activity when serving, engaging
in fewer activities with depression was considered to have considerable impact. The acceptability of
CBT interventions was felt to be enhanced if they focused on, or made reference to, types of activity
AF Veterans commonly engaged in (Table 2). Whilst participants highlighted engaging in all types of
activities when not experiencing depression, ‘Necessary’ activities such as going to work, paying bills
or looking for work were identified as being among the first to be avoided with depression.

Sub-theme 2: Benefits of promoting group-based activity
To re-establish a sense of belonging and connectedness to others perceived as being lost when
leaving the Armed Forces, all participant groups highlighted the value of promoting group-based
activities as part of any CBT intervention. Working as part of a team was something identified as
being synonymous with Armed Forces life.

Theme 2: Acceptable Language
Reported by PWPs, welfare staff alongside two Army and Air Force Veteran service users, a strong
association was perceived to exist between the terms ‘Army’ and ‘Military’. This resulted in a
preference being expressed for initial use of the collective noun ‘Armed Forces’, until the specific
service had been established from which point that should be adopted. Four sub-themes emerged
with respect to the acceptability of language adopted within CBT (Table 3).

Sub-theme 1: Straightforward terminology
There was an awareness that at times technical terms could not be avoided. However, participants
expressed a preference for terms that better described what they were referring to and helped to
promote understanding whenever possible. For example, ‘understanding difficulties’ had much
greater acceptability than ‘formulation’ that was identified as ‘technical jargon’ requiring further
unnecessary discussion to describe meaning that could provide a source of confusion.

Table 2. Types of activities associated with AF Veterans

Engaged in without depression First to be avoided with depression

Pleasurable Necessary Routine Pleasurable Necessary Routine

Family
activities

Gardening
Going to the

cinema

Running
Seeing friends

or other AF
Veterans

Social media

Team sports

Getting up,
out of bed

Going to work
Learning new

skills
Looking for

work
Maintaining

house
Paying bills

Dog walking

Gym
Noisy activities

‘3 S’s in the morning’

(personal hygiene)
Sleep pattern

Running
Seeing friends
or other AF
Veterans
Team sports
Getting up,
out of bed

Learning new
skills

Looking for work
Maintaining

house
Paying bills
Gym
Noisy activities

534 Paul Farrand et al.

Table 3. Acceptability of common CBT terms with alternatives

Commonly
used term

Main comments
(with quotes

where appropriate) Alternatives

Military Considered to represent the Army,
rather than the Air Force or Navy

Armed Forces (however, when
possible refer to specific service)

Straightforward terminology
Client/
service user

Did not reflect the role of someone
receiving help for a problem

Patient, beneficiary, individual,
AF Veteran

Diagnosis Unacceptable unless accompanied by information
to help the person understand the wider
meaning: ‘Diagnosis is a label and can feel like
being pigeonholed, but if education is also given
then it’s OK.’ (AF Veteran – Army)

Problem, outcome, identification

Formulation Dislike of technical terms requiring knowledge to
understand: ‘Formulation too technical, better to
use terms that clearly indicate what they mean.’
(AF Veteran – Army)

Understanding difficulties

Language promoting active engagement
Interventions Alternatives reflecting more of an active approach

to getting on top of psychological difficulties
was preferred

Self-help, ways to cope, coping
mechanisms

Issues Associated with pity and inactivity, whereas
alternatives represented something that needed
to be actively addressed

Challenges, problems, difficulties

Treatment Felt to: ‘ : : : sound like something being done to
you.’ (AF Veteran – Air Force). Preference for
term to clearly represent what treatment
consisted of

Self-help programme, support

Non-stigmatizing terms
Anxiety Directly describe how someone was feeling Feeling anxious, stressed
Depression Strong preference to avoid when used to describe

someone generally, except when directly used
to describe their feeling

Feeling down, feeling low

Mental
health
problem

Term and related terminology identified as ‘ : : : too
stigmatizing.’ (PWP) and better avoided to
engage an Armed Forces population

Emotional problem, psychological
problem, psychological difficulty

Therapist Stigmatizing term implying the person receiving
treatment was passive. ‘Practitioner’ felt to
better represent the need for the patient
receiving treatment to be active in the process.
The focus on ‘wellbeing’ was viewed as having
positive characteristics

Psychological Wellbeing Practitioner,
Emotional Wellbeing Practitioner

Therapy Stigmatizing Support sessions

Potential to cause distress
Assessment Negative reaction as it may be associated with

failure: ‘It reminds me of school and that I could
fail an assessment.’ (AF Veteran – Army).
Alternatives were felt to better describe the aim
and general characteristics of assessment sessions

Discussion, feedback, consultation,
appraisal, shared understanding,
initial contact, chat

Discharge Potential to raise distress if discharged early from
serving: ‘Discharge sounds too much like being
forced to leave the Army and should be seen
as potentially upsetting during a difficult time.’
(AF Veteran – Army)

Next steps

Homework More of an ‘active’ term; however, brought back
thoughts of unhappy school days

Finding out for yourself

Behavioural and Cognitive Psychotherapy 535

Sub-theme 2: Language promoting active engagement
Participants highlighted preference for terms that reflected active engagement with treatment.
Terms associated with ‘self-help’ or promoting ‘ways to cope’ were especially well received.

Sub-theme 3: Non-stigmatizing terms.
Considerable attention was directed towards terms identified as being highly stigmatizing and
could prevent help-seeking. On many occasions these were terms such as ‘therapy’, ‘therapist’
and ‘mental health’ commonly associated with psychological therapies and adopted within mental
health services.

Sub-theme 4: Potential to cause distress
There was a preference to avoid terms that may be easily related to negative life events. For example,
although representing activity, ‘homework’ was felt to have the potential to be associated with
unhappy school days with ‘discharge’ associated with having to leave the Armed Forces too early.

Theme 3: Characteristics of Acceptable Visual Imagery
Four sub-themes emerged regarding the acceptability of visual imagery for inclusion in CBT
self-help interventions and promote mental health services that accommodated AF Veterans.
However, some concerns were also highlighted regarding the use of photographic images.

Sub-theme 1: Images enhancing engagement
Participants from all groups expressed a strong preference towards using visual images represent-
ing physical activities, small construction exercises or groups. Such imagery was preferred to that
depicting people engaging in passive and solitary activities such as painting, yoga or other forms
of relaxation. However, there was a lack of agreement with little consensus regarding the use
of photographs representing relationships and family status. In particular, three welfare staff
participants felt the use of photographs depicting families may serve to exclude AF Veterans
without children, although this was not raised by the Veterans themselves. This issue was further
explored with a compromise reached to adopt images representing the wider ‘Armed Forces family’,
in addition to those representing traditional families. Additionally, whilst it was recognized that not
all members of the Armed Forces had tattoos, they were identified as synonymous with the Armed
Forces and may represent a quick way to help engage AF Veterans.

Sub-theme 2: Visual imagery as metaphor
Especially amongst AF Veterans and welfare staff, photographic imagery reflecting outdoor
activities and people in natural surroundings was identified as having the highest levels of
acceptability. AF Veterans also identified some of these images as having the potential to promote
acceptable metaphors. Many images of groups in general were identified as metaphors representing
group cohesion and ‘esprit de corps’. For example, a group working together on a construction
exercise was felt to represent ‘rebuilding lives’.

Sub-theme 3: Inappropriate emphasis on physical injury
Lower levels of acceptability were associated with an over-emphasis on images used by AF Veteran
specific services regarding physically injured Veterans, especially amputees from more recent
conflicts. Solely focusing on physical injury was felt to exclude those experiencing mental health
difficulties and reduce help-seeking. Adequately representing all AF Veterans in imagery, regardless
of the mental or physical difficulty being experienced, age or rank was stressed as important.

Sub-theme 4: Considerations regarding photographic imagery
Two Army AF Veteran service users highlighted the need to consider the nature of the photo-
graphic images used with members of the AF community. For example, a photograph of sunlight

536 Paul Farrand et al.

shining through leaves into an enclosed shaded wooded area was felt to have potential to ‘trigger a
flashback’ associated with PTSD (AF Veteran – Army). Additionally, concern across all groups
was raised regarding the potential to compromise the confidentiality of Veterans appearing in
photographic images. Solutions identified an increased use of illustrations to replace close shots
of Veterans, or for scenes that could raise concerns.

Discussion
Results of this focus group are helpful in beginning to identify acceptable characteristics of CBT
for depression in AF Veterans, with potential to inform current practice and future research.
Appreciating the specific impact of depression on activities representing common features of
Armed Forces life appeared to be especially helpful in promoting engagement with CBT.
Additionally, adapting CBT practice with consideration to the use of language and imagery
emphasizing group-based activities with potential to represent metaphors consistent with features
of AF culture is particularly suited to an AF Veteran population.

The acceptability of CBT for treating depression in AF Veterans is enhanced by adopting
interventions that place emphasis on overcoming behavioural avoidance. This emphasis could
be accommodated by CBT interventions such as behavioural activation (Richards, 2010), with
certain models also promoting physical activity to improve both mental and physical health
outcomes (Farrand et al., 2014).

Within a general adult population, depression is commonly recognized as first causing
significant disruption to ‘Routine’ activities (Jacobson et al., 2001). However, whilst being aware
of limitations associated with classifying activities for others within an idiographic model of
behavioural activation (Richards, 2010), ‘Necessary’ activities were predominantly identified in
this study as being amongst the first to be avoided by AF Veterans. This is of particular concern
given that failing to complete these activities can have significant negative impacts and represent
an especially important consideration during the transition of AF Veterans into civilian life (Binks
and Cambridge, 2018). Although most AF Veterans cope well with this transition (Iversen and
Greenberg, 2009), there is a significant minority who experience difficulties (Iversen et al., 2005).
With an emphasis on supporting engagement with ‘Necessary’ in addition to ‘Routine’ and
‘Pleasurable’ activities, behavioural activation may represent a suitable CBT intervention to
overcome depression in AF Veterans experiencing difficulties such as finding employment and
housing during transition back into civilian life.

Ensuring language is consistent with characteristics of the AF culture was also identified as
important to inform the practice of CBT and intervention development. This result suggests that,
as far as possible, CBT terminology should be self-explanatory, emphasize active engagement in
treatment and ideally be straightforward, thereby avoiding jargon. Additionally, terms such as
therapist or therapy have potential to create stigma and making use of alternatives may increase
engagement. Reducing stigma is especially important in the AF Veteran population given a
significant deleterious impact on help-seeking (Sharp et al., 2015). Greater consideration given
to language has also been shown to reduce stigma associated with mental health in other settings,
for example with respect to the label ‘schizophrenia’ (Lasalvia et al., 2015).

Adopting metaphors and analogy commonly used within the Armed Forces (Zinzow et al., 2012)
was further recognized as one way to enhance understanding. For example, adopting the phrase ‘test
and adjust’, representing controlled breathing and taking aim with a long-barrelled weapon may
have utility if adopted as analogous to ‘Recording and Testing Out Automatic Thoughts’ and
‘Constructing Realistic and Balanced Thoughts’. Furthermore, unless known in advance, engage-
ment was felt to be enhanced by initially adopting the term ‘Armed Forces’ at the beginning of
assessment but making reference to the specific service during subsequent sessions. This potentially
helped to reinforce an Armed Forces norm associated with attention to detail (Hall, 2011).

Imagery was also identified as having potential to promote engagement and enhance the
delivery of CBT. In particular, several visual images were identified as representing metaphors

Behavioural and Cognitive Psychotherapy 537

for features of AF culture associated with group cohesion and ‘esprit de corps’. For example, an
image of a group of walkers hiking along a path was identified as representing the ‘road to
recovery’. Furthermore, the use of mental imagery to support high-intensity CBT techniques
(Hackman et al., 2011), such as reliving or re-scripting in the treatment of PTSD (Grey,
2009), may highlight imagery as being particularly suitable when working with AF Veterans.
However, consideration should also be given to characteristics associated with the visual images
adopted. In particular, greater effort should be taken to enhance inclusivity by ensuring images
better captured the diverse nature of difficulties and personal characteristics of all AF Veterans.
Several visual images presented in our study focused on younger physically injured AF Veterans
from recent conflicts who were often amputees. However, focusing on this imagery alone has
potential to reinforce beliefs that such difficulties take priority over mental health. This might
inadvertently reduce help-seeking for mental health difficulties.

Overall, acknowledging the AF community as representing a specific institutional culture
emphasizing trust and loyalty as core values, norms associated with discipline, attention to detail,
cohesion, ‘esprit de corps’, professional ethos, alongside placing importance on ceremonial displays
(Snider, 1999) represents the potential to enhance the acceptability of CBT for AF Veterans.
Furthermore, enhancing cultural competence in the CBT workforce at both Steps 2 and 3 within
a Stepped Care service delivery model (Bower and Gilbody, 2005) may be especially important in
achieving service access rates specified by the Armed Forces Covenant (Ministry of Defence, 2011).

Working effectively with AF Veterans, serving personnel or family members (Hall, 2011)
should therefore inform proposals to direct greater attention within health and social care settings
towards distinct features of the Armed Forces (Sharp et al., 2015; Zinzow et al., 2012). This is
especially important with respect to mental health given that the AF culture may shape attitudes
and opinions that serve as a barrier to treatment seeking and engagement (Langston et al., 2007).
Furthermore, the Armed Forces having a distinct institutional culture highlights the importance of
considering other emergency first responders (for example paramedics, police, firefighters) as also
having their own culture (Kleim and Westphal, 2011).

This study has several limitations associated with generalizing results from a single focus group,
particularly accounting for AF Veterans varying by service, age, rank, discharge type in addition to
family members. However, based within the Pre-clinical and Phase I of the MRC framework
(Craig et al., 2008), study results have the potential to inform further research to examine
necessary adaptations across groups of AF Veterans. Furthermore, as adapted interventions risk
losing their link to the evidence base justifying adoption (Castro et al., 2004), there remains a need
for ongoing research to examine effectiveness of interventions adapted for groups of AF Veterans.
Enhancing the cultural competence of the CBT workforce with respect to the Armed Forces, in
addition to culturally adapting the delivery of CBT more generally, may enable statutory mental
health services to better accommodate the specific needs of AF Veterans and family members to
encourage uptake of mental health services by those who need them.

Acknowledgements. The authors would like to thank the focus group participants and all staff within ‘Help for Heroes’ who
helped facilitate the recruitment process.

Conflicts of interest. Paul Farrand, Kat Rayson, Alberta Engelbrecht and Neil Greenberg have no conflicts of interest with
respect to this publication. Karen Mead is an employee of Help for Heroes. However, she had no involvement in any aspect of
the study associated with data collection, analysis, interpretation, reporting or the decision to submit the article for
publication.

Ethical statement. The authors have abided by the Ethical Principles of Psychologists and Code of Conduct as set out by the
APA. Following research approval granted by ‘Help for Heroes’, ethical approval was granted by the University of Exeter
psychology research ethics committee.

Financial support. The study was funded by ‘Help for Heroes’ as part of a wider research programme.

538 Paul Farrand et al.

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Cite this article: Farrand P, Mullan E, Rayson K, Engelbrecht A, Mead K, and Greenberg N (2019). Adapting CBT to treat
depression in Armed Forces Veterans: qualitative study. Behavioural and Cognitive Psychotherapy 47, 530–540. https://
doi.org/10.1017/S1352465819000171

540 Paul Farrand et al.

https://www.gov.uk/government/publications/fighting-fit-a-mental-health-plan-for-servicemen-and-veterans–2

http://www.combatstress.com/media/21792/gp_guidance_doc_rgcp_rbl_cs_17jan11

http://www.combatstress.com/media/21792/gp_guidance_doc_rgcp_rbl_cs_17jan11

https://doi.org/10.1017/S1352465819000171

https://doi.org/10.1017/S1352465819000171

© British Association for Behavioural and Cognitive
Psychotherapies 2019

• Adapting CBT to treat depression in Armed Forces Veterans: qualitative study

Introduction
Method
Setting
Design
Recruitment
Participants
Procedure
Analysis
Results
Discussion
References

1

8

Annotated Bibliography

Author Name

Walden University

RSCH 8110/7110/6110: Research Theory, Design, and Methods

Instructor Name

Due Date

Annotated Bibliography

A
utism researchers continue to grapple with activities that best serve the purpose of fostering positive interpersonal relationships for children with autism. Children have benefited from therapy sessions that provide ongoing activities to aid their ability to engage in healthy social interactions. However, less is known about how K–12 schools might implement programs for this group of individuals to provide additional opportunities for growth, or even if and how school programs would be of assistance in the end. There is a gap, then, in understanding the possibilities of implementing such programs in schools to foster the social and mental health of children with autism. The six articles I selected for this assignment present research on different types of therapeutic programs that have been used to promote social interactions in children with autism.

Annotated Bibliography

Wi
mpory, D. C., & Nash, S. (1999). Musical interaction therapy – therapeutic play for children with autism. Child Language and Teaching Therapy, 15(1), 17–28.

https://doi.org/10.1177/026565909901500103

Wi
mpory and Nash provided a case study for implementing music interaction therapy as part of play therapy aimed at cultivating communication skills in infants with autism spectrum disorder (ASD). The researchers based their argument on films taken of play-based therapy sessions that introduced music interaction therapy. To assess the success of music play, Wimpory and Nash filmed the follow-up play-based interaction between the parent and the child. The follow-up interactions revealed that 20 months after the introduction of music play, the child developed prolonged playful interaction with both the psychologist and the parent. The follow-up films also revealed that the child initiated spontaneously pretend play during these later sessions. After the introduction of music, the child began to develop appropriate language skills.

Si
nce the publication date for this case study is 1999, the results are dated. Although this study found that music interaction therapy is useful, emerging research in the field has undoubtedly changed in the time since this article was published. Wimpory and Nash wrote this article for a specific audience, including psychologists and researchers working with infants diagnosed with ASD. Their focus means that others beyond these fields may not find the findings applicable to their work.

I
am interested in the role of music in therapy to foster social and mental health in children with ASD. Therefore, Wimpory and Nash’s research is useful to me for background information on the implementation of music into play-based therapy in infants with ASD. Wimpory and Nash presented a basis for this technique and outlined its initial development. Therefore, their case study can be useful to my research when paired with more recent research on the topic.

Conclusion

For the Week 10 Application assignment, include a one-paragraph conclusion that presents a 

synthesis

 of the six articles you annotated.

�An introduction paragraph is a helpful addition to your annotated bibliography to tell your reader about your topic of interest and the general context of your topic.

An introduction paragraph is not required for the Week 6 and Week 8 Application assignments.

An introduction paragraph is required for the Week 10 Application assignment; this single paragraph should provide context for why you selected the six research articles that you did.

�Each APA style-formatted reference entry should be followed by a three-paragraph annotation that includes (a) a summary of the source, (b) an analysis of the source, and (c) an application of the source.

�The first paragraph of the annotation is a � HYPERLINK “https://academicguides.waldenu.edu/writingcenter/assignments/annotatedbibliographies/summary” ��summary� of the source.

The summary should present the (a) main findings of the study, (b) primary method(s) of the study, and (c) theoretical or conceptual basis of the study.

�The second paragraph of the annotation is an � HYPERLINK “https://academicguides.waldenu.edu/writingcenter/assignments/annotatedbibliographies/critique” ��analysis� of the source.

The analysis should explain the strengths and limitations of the source.

�The third paragraph of the annotation is an � HYPERLINK “https://academicguides.waldenu.edu/writingcenter/assignments/annotatedbibliographies/application” ��application� of the source.

The application should (a) justify how the source is applicable to your research interest, (b) describe how the source’s method is applicable to your research interest, and (c) indicate how the source might help to guide your future research on the topic.

In this paragraph, it is acceptable to use the � HYPERLINK “https://academicguides.waldenu.edu/writingcenter/scholarlyvoice/first” ��first person� (I, me, my) in your writing.

��A conclusion is not required for the Week 6 and Week 8 Application assignments.

A conclusion is required for the Week 10 Application assignment; this single paragraph should present a � HYPERLINK “http://academicguides.waldenu.edu/writingcenter/evidence/synthesis” ��synthesis� of the six research articles you annotated.