Supporting Community Engagement for Veterans After Psychiatric Hospitalization: Perspectives From Clinical, Personal, and Community Supporters

Abstract

Recently psychiatrically hospitalized Veterans are at elevated risk for suicide soon after discharge. Social connectedness is a robust protective factor against suicide; however, many Veterans have limited sources of social support and well-being. Promoting engagement in community activities may help increase social connectedness, but there is limited research on the barriers and facilitators experienced by mental health providers, community organizations, and Veterans’ loved ones to support such efforts. The current study collected qualitative data via interviews with 29 participants from these three groups in different regions of the United States. Interviews focused on participants’ experiences with organizational- and systems-level factors impacting current implementation of strategies for supporting Veteran engagement in community activities. Data were analyzed using templated summarization and matrix analysis. Participants generally valued community engagement for this high-risk population and identified barriers related to mental health challenges and lack of central coordination of activities. Mental health administrators and policy makers invested in increasing social connectedness among high-risk Veteran groups should consider leveraging existing community networks to address identified barriers to community engagement.

Background

Over the past 20 years, United States Military Veterans have been at elevated risk of death by suicide compared with the general population. As acute suicide risk is often dynamic and time-limited, suicide prevention best practices emphasize the importance of enhanced care support during key risk periods. One such risk period is following inpatient psychiatric hospitalization. Veterans are at elevated risk of dying by suicide in the days and weeks following psychiatric hospitalization extending out to 90 days post-hospital discharge. Although there are some promising interventions highlighted in past systematic review research, effectiveness remains heterogeneous across studies with limited evidence for prevention of future suicide attempts and death (Tyler et al., 2019). In addition, past qualitative research with Veterans highlights the need for more holistic and collaborative approaches to decrease suicide risk (Riblet et al., 2019).

One domain requiring further attention is that of social connectedness. Joiner posits within the Interpersonal Psychological Theory of Suicide that primary drivers of suicidal ideation, a notable risk factor for suicide attempt and death, include thwarted belongingness (e.g., feeling like someone does not belong in society) and perceived burdensomeness (e.g., feeling like a burden on others), both of which are markers of decreased social connectedness. Meta-analytic research finds that these constructs are robustly associated with suicidal ideation (Chu et al., 2017). Thus, increasing feelings of belonging and decreasing perceptions of burdensomeness may decrease suicidal ideation and suicide-related behaviors. In addition, having social connections is associated with greater effectiveness of suicide safety planning, a gold standard intervention for those at moderate-to-high risk for suicide (Chalker et al., 2023). However, past studies find recently psychiatrically hospitalized Veterans often report few existing social connections and limited knowledge of how to develop new ones despite acknowledging their importance (Chen et al., 2022).

The Consolidated Framework for Implementation Research (CFIR) posits that patient-, provider-, and organizational-level factors, such as perceived need for an intervention or available resources for implementation, impact the degree to which an intervention can be successfully deployed within a given healthcare setting (Damschroder et al., 2022). Of particular importance is receiving feedback from healthcare staff and other partners who will be directly implementing a given intervention. In light of past identification of systems-level challenges by Veterans, successful interventions for increasing social connectedness would likely require organizational- and provider-focused strategies as well. However, there remains limited literature on what organizational- and provider-level aspects are most important for facilitating social connectedness-based interventions. The goal of the current study was to identify barriers and facilitators affecting the development of new social connections in the community through community activities (e.g., recreational classes, volunteering) henceforth referred to as “community engagement”. We explored these barriers from the perspective of healthcare providers, community organizations, and Veterans’ loved ones (e.g., Veteran’s friends) with the goal of informing future strategies to improve practices for community engagement.

Methods

Participants

We recruited Veterans’ family members and friends, VA health care staff (with a focus on mental health staff), and representatives from local and national Veteran-serving community organizations to participate in the study. We used a purposive sampling approach that intentionally selected participants across these different roles within three different VA healthcare systems catchment areas (Midwest, West, & South) to increase representation of diverse community contexts (e.g., rurality, unique community programming). VA providers were identified in collaboration with research and clinical partners at each site. Community and Veteran participants were identified through nomination by VA staff, community-based consultants, and research collaborators. Snowball sampling via nomination by participants was also employed. All individuals nominated were eligible for participation if they served in any of our identified Veteran support roles and resided and/or provided activities in any of our three selected regions. Our goal was to have 3–5 participants of each role (e.g., Veteran loved one, VA staff) for each site with a planned sample of 27–45 interviews across sites. Veteran and community participants were compensated $30 for their participation. VA employees were not compensated compliant with VA policy.

Data Collection

Participants were interviewed via telephone as part of a multi-site, formative evaluation for a pilot intervention to improve social connectedness for Veterans after psychiatric hospitalization. The interview guide was designed to elucidate perceived mechanisms of successful community engagement, with the goal of informing implementation strategies. Questions asked for perspectives on community engagement focused on specific constructs from the Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2022). Two study team members (AA and BB) conducted and recorded the interviews. Questions were adapted as needed based on participant roles (e.g., Veteran loved one versus VA healthcare staff).

Analysis

We analyzed interview data using a hybrid inductive-deductive approach to develop codes and findings, aided by the framework method to organize data and facilitate comparing and contrasting across cases and roles (Gale et al., 2013). Six members of the research team (AL, BR, CB, JC, JC, RT) reviewed either de-identified interview transcripts or audio recordings. As a first step, the team developed together a coding scheme including both deductive codes from the CFIR and inductive codes generated through consensus discussion on the most salient concepts for understanding perceived barriers and facilitators to community engagement (Damschroder et al., 2022). Once a coding schema was established, at least one member of the team reviewed each transcript and coded interview content using the framework method, with the team’s qualitative methodologist performing review of the coding. The framework method organizes textual data (including summaries and memos as well as direct quotes from transcripts) into a templated matrix where data for codes is entered in columns and coding by participant can be read across a single row. This method, used extensively in health services research, has been argued to work well as a systematic tool for coding among multidisciplinary team members with varying levels of qualitative data analytic training or familiarity, but does not eliminate the need for qualitative expertise (Gale et al., 2013). After all transcripts were coded, four members of the author team, which includes health services researchers with training in philosophy, psychology, public health, and sociology, reviewed the data matrix and through iterative discussion developed findings focused on participants’ views on barriers and facilitators to community engagement. Reviewers returned to the full transcripts as needed to place data coded in the matrix back in narrative context. This iterative approach to analysis, using both inductive and deductive elements to interpret the data, was consistent with many rapid qualitative analytic techniques used in contexts such as the current study where a new health service is under development (Hamilton & Finley, 2019; Vindrola-Padros & Johnson, 2020).

Results

Between April 2020 and July 2021, we interviewed 29 participants across three sites. Participants included Veterans’ family members and friends (n = 5), VA healthcare staff (n = 15), and representatives from Veteran-serving community organizations (n = 9). Interviews generally lasted up to one hour. Our analysis looked for patterns of variation in the participant responses by role; these findings hold across the participant groups in our sample. However, in relation to desired resources, VA staff and community partners emphasized coordination and staffing. Veteran family and friends instead prioritized having more information and options for engagement. Across all roles, participants commonly viewed community engagement as valuable for its potential to decrease social isolation and to improve mental health. Specifically, they felt community engagement could generate a sense of belonging and/or purpose, counter internalized stigma, and provide positive distraction from potentially harmful thoughts or urges. For example, a Veteran Friend noted, “For those people that don’t really have the necessary support from family or friends, if you’re able to go to these organizations, they kind of make you feel welcome and offer you the support and the guidance that you may need or be lacking. So, I think that would, kind of, help them out during their transition period, especially when they don’t have those things.”

While participants felt most Veterans could benefit from community engagement, Veterans’ other priority needs and capacity for engagement were seen as potential barriers to community engagement in the immediate post-discharge period

Multiple participants expressed the view that community engagement might not benefit all Veterans equally, even if they were equally able to participate. Veterans with less existing social support were seen as a group more likely to benefit because of the greater impact on their isolation. At the same time, a smaller number of participants observed that for Veterans with other highly pressing needs, community engagement could be inappropriate. For example, some felt Veterans had to address basic needs such as housing and food security before working on community engagement. One VA Inpatient Nurse shared, “There are practical challenges… that can supersede community involvement. That can overwhelm the Veteran in worrying about where they’re going to sleep the next day, or where they’re going to get meals for the next week. Those practical needs, unfortunately, can overshadow their community involvement in seeking support, seeking a group to be part of.”

Some participants raised concerns that Veterans’ capacity to engage, influenced by mental health functioning or increased PTSD symptoms more specifically, could make post-discharge community engagement a poor fit for the well-being of the Veteran, other participants, and community organization staff. For example, one Veteran Friend said, “I’m just speculating. What if a Vet came to the yoga class drunk or on drugs and his PTSD was triggered? I mean, it probably can be a complete disaster. I know what that looks like, and it’s terrifying.” Others felt that community engagement activities could be tailored to accommodate a broad range of needs while maintaining safety. For example, one Community Organizer shared, “There really aren’t too many reasons [not to recommend community engagement], unless they are very toxic. …. We’re very accommodating to a certain extent, trying to help them out. If they’re disrupting our community too much, then we have removed folks in the past.”

Active, coordinated, and Veteran-centric outreach around engagement was felt to facilitate post-discharge community engagement

Many of the qualities participants felt supported Veteran community engagement post-discharge were evident in existing practices; they just wanted such practices to be more widely deployed or better resourced. For example, being Veteran-centered and attentive to logistics were good practices believed by participants to support community engagement. “Veteran-centric,” for participants, meant things like individualizing outreach and engagement opportunities to match Veteran interests, as well as recognizing they may prefer activities with other Veterans such as a “Veterans-only class”. Tailoring outreach to match Veteran interests not only made it more likely to “succeed” in getting a Veteran to engage, but was also seen as likely to enhance the sense of purpose already noted as a potential benefit of engagement. Participants also highlighted the need to be attentive to logistics such as arranging necessary supports (e.g., transportation to activities). They also often suggested offering a wide range of informational resources, in a variety of accessible formats, and making sure Veterans knew where to find them. Being able to do these things well requires staff time and other resources, which participants often wished were more available. For example, one Community Organization staff member said, “If there was a VA staff [where]…that person becomes a conduit to other—they know the community very well, they know the Veteran organizations really well, they know other peer support programs really well, and they would know where to put that Vet in.”

Active outreach and follow-up was generally named as a facilitator, and the critical role of active, sustained outreach was even more strongly voiced when participants were asked about what would be helpful. One Community Organization staff member noted, “It’s basically just reaching out to them. We’ll get Veterans coming in who are, you know, the quiet type….They lurk a little bit, but once they get to know a few folks, it really does kind of take off from there.” Participants desired more coordinated, “warm” hand-offs during and immediately after hospitalization, including linkages to potential community supports, as well as more staffing resources (peer supports and social workers) to support community engagement. As noted earlier, VA and community organization staff more often emphasized the need for increased staffing to coordinate engagement efforts, while Veteran family and friends more often commented on the desire for information, guidance, and options for engagement. Several participants also tied in the desire for more resources with wanting to ensure that Veterans’ basic needs were being met, precipitated by the aforementioned belief that meeting Veterans’ basic needs was a prerequisite for maximizing benefit from community engagement.

Discussion

This exploratory research on barriers and facilitators to supporting community engagement among Veterans provides insights from the perspectives of Veterans’ loved ones, community organization staff, and VA healthcare providers. One notable observation from our study, with implications for intervention development, is that some participants across roles (VA providers, community organizations, and Veterans’ loved ones) shared concerns around Veterans’ ability and fit for engaging in community activities, citing conflicting needs (e.g., securing stable housing) and mental health symptoms as barriers. While such comments may reflect actual experiences, we observed that participants more often shared hypothetical situations to voice concerns (e.g., Veteran may be using substances) which were not based in their experiences. It is possible that participants in our sample were influenced by societal mental health stigma beliefs which remain pervasive despite concerted mental health awareness efforts. A recent study shows relatively unchanged beliefs regarding social exclusion for those with mental health challenges as well as increased perceptions of dangerousness for those with schizophrenia since 1996 (Pescosolido et al., 2021). Societal stigma beliefs may also explain the limited effectiveness seen for patient-directed interventions for increasing social support (Beckers et al., 2023). This model of stigma builds upon past literature showing limited associations between mental health severity and functioning over time as well as identification of mediating factors, such as social skills, which are modifiable with support (Bowie et al., 2010; Essau et al., 2014; McLeod et al., 2016). Mental health administrators and policy makers wishing to facilitate increased community engagement among recently psychiatrically hospitalized Veterans may wish to consider psychoeducational interventions to challenge stigmatizing beliefs.

Past research suggests Veteran community engagement is facilitated by more centralized coordination of available activities, having welcoming, low-stigma environments, and coping support (Chen et al., 2022). This study aligns with those findings and additionally highlights the importance of active and ongoing coordination of community activities, including information on available activities and how to access them (Chen et al., 2022). Programs designed for helping Veterans engage in community activities following psychiatric hospitalization may wish to consider employing multiple sources and types of support for maximizing success. Collaborating with community non-profits, such as the National Alliance for Mental Illness, can facilitate access to a range of supports for community activities. Mental health administrators and providers may consider leveraging existing community networks for promoting community engagement to support Veteran well-being following inpatient psychiatric hospitalization in light of limited inpatient staff capacity.

Our study had several limitations. Our sample was relatively smaller and restricted to three, specific regions and specific roles, and may have limited generalizability to other contexts. In addition, the study was conducted to inform the development of community engagement interventions, and thus participants may have been more enthusiastic regarding promoting community engagement secondary to self-selection biases. Although our interviews focused on Veteran populations, many of the barriers and facilitators described are likely common across those experiencing mental health challenges.

Despite these limitations, our study adds to the field’s understanding of barriers and facilitators to community engagement among recently psychiatrically hospitalized Veterans. Future studies identifying optimal strategies for challenging stigma, increasing robust coordination of outreach and engagement efforts are needed to support this high-risk group and support their beneficial participation to increase social connectedness and foster mental health recovery.

Data Availability

Data may be requested through official processes subject to local and Federal policies.