Videoconference mind-body group therapy in a public mental health setting: a pilot study

Brief Report

Introduction

Increasing access to mental health care for underserved communities is a critical public health need. One potential avenue for improving access to mental health care is telemedicine using videoconferencing. Videoconference has been shown in many studies to be effective and acceptable in mental health populations, with outcomes that are consistently comparable to in-person treatment, resulting in high satisfaction for both patients and providers (Germain, Marchand, Bouchard, Drouin & Guay, 2009; Fortney et al., 2007; Sheeran et al., 2011). Several promising studies indicate that videoconference is a viable and effective means of delivering group psychotherapy. Research exploring its efficacy for alcohol-use disorders (Frueh, Henderson & Myrick, 2005), PTSD (Morland et al., 2010; Morland et al., 2014) and depression (Khatri, Marziali, Tchernikov & Shepherd, 2014) have seen positive results. Analysis of individual and group psychotherapy processes concluded that, while videoconference group therapy may differ from in-person groups in subtle ways, it still represents a viable and effective means of delivery for psychotherapy (Greene et al., 2010).

The use of videoconferencing has increased markedly in recent years, with a large-scale study by Deen, Godleski and Fortney (2010) examining the use of telemedicine by the Veteran’s Health Administration, showing group psychotherapy delivered via videoconference has increased by 178% over a 5-year period, to over 5000 visits yearly in 2010. The evidence is mounting that group therapy can be effectively delivered via videoconference.

One emerging form of group therapy is mixed-modality mind-body groups. Mind-body medicine is defined as “Techniques designed to enhance the mind’s capacity to affect bodily function and symptoms” (National Center for Complementary and Alternative Medicine (NCCAM), 2009). Mixed-modality mind-body groups, which offer a variety of therapeutic techniques within a single therapy program, similar to the program offered in the current project, have been shown to be effective for a number of psychiatric diagnoses, including psychosis and other serious mental illnesses (Starkey, Deleone & Flannery, 1995; Lukoff, Wallace, Liberman & Burke, 1986; Glueck & Stroebel, 1975). Research is especially promising in the use of such groups for PTSD (Gordon, Staples, Blyta, Bytyqi & Wilson, 2008; Staples, Abdel Attai & Gordon, 2011). These results for mixed-modality mind-body groups are very encouraging.

Several small studies have now explored whether single-modality or mixed-modality mind-body groups maintain their effectiveness when presented using a videoconference format, rather than in-person, as studied in the above papers.

Tan et al. (Tan et al., 2013) looked at combined videoconference group therapy and heart rate variability biofeedback training program for rural women veterans diagnosed with chronic pain and comorbid depression and/or PTSD. The program was acceptable and easy to administer and resulted in significant decreases in pain unpleasantness, pain interference, depressive symptoms, PTSD symptoms and sleep disturbance, with improvements that were maintained at the 6-week follow-up.

In a small study by Absenger [unpublished data; Saybrook University 2012], a mind-body skills instruction program very similar to the current program was presented both in-person and via videoconference. The participants and the facilitator found both in-person and videoconference-delivered mind-body skills groups very satisfactory.

The purpose of our present study is to determine whether utilizing videoconference for the delivery of “The 7 Foundations of Health and Happiness Group Program” (7FHH) is feasible and effective. 7FHH is a mixed-modality mind-body group that teaches skills such as meditation, breath exercises, relaxation, imagery and movement, along with mindful eating, journaling, empathy practice, life balance, art and behavior change, with a sharing of emotions and experiences in a small group setting (6–10 participants). The 7FHH group provides a setting for the development of increased self-awareness and self-discovery, along with the mastery of skills that are useful for personal health and wellness. To our knowledge, this is the first such group to be offered with this technology to a rural, public mental health population.

We examined two hypotheses related to this group:

Hypothesis 1: Quality of life measures will improve over the 8-week group when compared to wait-listed controls.

Hypothesis 2: General measures of health will improve over the 8-week group when compared to wait-listed controls.

Methods

Study overview

We conducted a pilot study using a nonrandomized, supportive care interventional design with a wait list control on a sample of nine people with chronic mental illness, using an MBM program based on the 7 Foundations of Health and Happiness. We explored a self-reported quality-of-life indicator, using the Arizona Integrative Outcomes Scale (AIOS) (Bell, Cunningham, Caspi, Meek & Ferro, 2004) and the overall mental, physical and spiritual health measures using the Mental, Physical and Spiritual Well-being Scale (MPS) (Vella-Brodrick & Allen, 1995). We also utilized an open-ended questionnaire to collect qualitative data surrounding the experience of the research participants. Primary data collection points were at Weeks 0 and 8, with a secondary data collection point at Week 12. The primary investigator was a psychiatrist certified in MBM with over 10 years of telemedicine experience, who was approved to offer a videoconference MBM group at a public mental health clinic where she served on staff. Ethics approval was granted by the Saybrook University Ethics Committee.

Participants and recruitment

Eligible participants included any adult (18 years and older) client, of any gender, enrolled in services at the Spanish Peaks Behavioral Health Center.

Inclusion criteria specified that participants must be an enrolled client at the Spanish Peaks Behavioral Health Center (a public mental health agency in Southeastern Colorado, serving a largely low-income and/or chronically ill population) with approval of the client’s primary therapist and/or case manager for enrollment in the group. Exclusion criterion was inability to speak or understand English. The program was designed to be used with a mixed-diagnosis group, so there were no exclusion criteria in regards to type of disorder, severity or treatment history (Table 1).
Table 1

Demographic characteristics of enrolled study participants in the videoconference study

Demographic characteristics

Number of participants (N = 9)

Female (%)

Male (%)

Gender

6 (66.7%)

3 (33%)

Ethnicity

 Caucasian

2 (22.2%)

2 (22.2%)

 Native American

1 (11.1%)

 

 Hispanic

3 (33.3%)

1 (11.1%)

Main language spoken at home

 Spanish

 

1 (11.1%)

 English

6 (66.7%)

2 (22.2%)

Education

 High school graduate

3 (33.3%)

 

 Some higher education

2 (22.2%)

3 (33.3%)

 College graduate (BA/BS)

1 (11.1%)

 

Employment status

 Disabled

5 (55.6%)

2 (22.2%)

 Unemployed

1 (11.1%)

 

 Employed, full time

 

1 (11.1%)

Marital status

 Married

1 (11.1%)

 

 Divorced

1 (11.1%)

 

 Single

2 (22.2%)

2 (22.2%)

 Separated

2 (22.2%)

1 (11.1%)

Living arrangement

 With romantic partner

1 (11.1%)

 

 With children

2 (22.2%)

 

 Living alone

2 (22.2%)

2 (22.2%)

 Residential facility

 

1 (11.1%)

 Living with parents or family

1 (11.1%)

 

Legal status

 Voluntary

6 (66.7%)

1 (11.1%)

 Involuntary/conditional

 

2 (22.2%)

Our treatment group of three patients was drawn from the Spanish Peaks Behavioral Health Center clinic in Pueblo, Colorado, and our wait list control of six was drawn from their clinic in Trinidad, Colorado (during 2014). To recruit, staff posted flyers at the clinics and emailed flyers to all staff for direct referrals. The flyer did not mention a study, as patients were offered the option to elect to join the group and not participate in the study, although none selected this option. The opportunity to participate in the research project was presented by the clinic RN when patients called to enroll.

Location and equipment

All sessions took place with the patients sitting in the group therapy room at the respective Spanish Peaks Behavioral Health Center clinic where the patients already received services. The facilitator was located off-site.

We utilized Zoom, a secure, encrypted video conferencing service (http://www.zoom.us/), to connect the two sites. For videoconferencing, the far site (the facilitator’s location) was equipped with a Microsoft LifeCam 1080p HD webcam. The originating sites (the clinic—patients’ location) also used standard webcams with a USB microphone. The facilitator could see the group as a whole throughout the session, as no individual zoom-lens capacity was available during the session.

Outcome measures

The primary outcome measure was the Mental, Physical and Spiritual Well-Being Scale. Secondary outcome measures included change in self-rated global sense of spiritual, social, mental, emotional and physical well-being, as measured by the Arizona Integrative Outcomes Scale (AIOS). We also collected qualitative data utilizing two investigator-developed questionnaires, pre- and post-, and assessed a sample of anonymized pre- and postprogram drawings that research participants produced. These qualitative data will be reported in a later paper. We collected data at baseline (Session 1) and again at Session 8. Secondary analysis was based on additional measurements at 4 weeks after conclusion of the group.

Treatment procedures

Recruitment for Group 1 ran on March–June, 2014 and for Group 2 on July–September, 2014. The recruitment for the second group was started 1 month after the initiation of the first group’s active treatment period, such that the time between the second group members’ acceptance and the beginning of the second active treatment group would serve as a wait list period, providing a control for this study. We utilized the “7 Foundations of Health and Happiness” group program, a curriculum focusing weekly on one of the 7 Foundations (Rest/Relaxation, Movement, Nutrition, Self, Relationships, Work, Meaning), with a final week on Behavior Change.

Each group received a total of eight MBM videoconference sessions. For both groups, the eight sessions were nonconsecutive due to scheduling limitations at the clinic site, and each group took 11 weeks to complete, though the weeks “off” did not match between groups. The treatment group sessions were held between June 6 and August 22, 2014 and the wait list group sessions were held between September 5 and November 21, 2014.

The primary investigator facilitated both groups. Given this dual relationship, all data were de-identified prior to passing on to coresearchers for analysis. The coresearchers were not involved in providing the therapy group in any way.

Videoconference orientation

The first 15 min of the initial group session was spent holding a videoconference orientation covering the following topics:
  • Principal investigator introduction and purpose of study.

  • Brief review of informed consent.

  • Question and answer pertaining informed consent.

  • Participants signed consent forms, completed the Mental, Physical and Spiritual Well-being Scale and Arizona Integrative Outcomes Scale and were officially enrolled in the study.

  • All submitted consent forms received a participant number, for privacy purposes.

Cost of participation

Group members participating in the study vs. those electing not to participate had no additional costs beyond the cost of the group itself. The group treatment program did have associated fees. At the time of this study, the Spanish Peaks Behavioral Health Center billed insurance or patients $129 per session for all the therapy groups, with a sliding scale available down to $10 minimum for those with limited incomes. Each participant received a free hard copy of the book, 7 Foundations of Health and Happiness: Building a Bridge to Balance (Heermann, 2013) for home practice.

Data collection, analysis and reporting

Data were collected at baseline and at Week 8, with secondary data collected at Week 12. Data were collected from the wait list group at the time of their enrollment, as well as at the above data points for their own group. A repeated measures ANOVA was utilized to analyze the quantitative data, comparing the wait list period to the active intervention period. Data analyses were performed using IBM® SPSS® Statistics Software Version 22. No power analysis was conducted, as this was an exploratory pilot study, and we sought to recruit as many participants as possible throughout 2014.

Results

Characteristics

Nine people participated in the pilot study, with three in the treatment group and six in the wait list group, with a wait list period varying from 3 to 16 days (depending on the date of recruitment). Six of the nine participants were female (by chance, all members of Group 2), while the average mean age of the sample was 46 (±9.3 years). Reflecting the severity of their mental illnesses, only one of the group members was employed, with seven on disability pension and one unemployed; and only one was married/partnered. Three of the participants (all male, by chance all in Group 1) were enrolled in the agency’s forensic program, meaning they were at some point committed to the state hospital due to criminal behavior arising from their serious mental illness. These clients were only on release “conditionally”, meaning clients are court-ordered to all recommended treatment or else be returned to the hospital, though the court order did not include our experimental sessions (Table 2).
Table 2

Primary diagnoses of research participants

Group

Study ID

Diagnoses

Group 1 diagnoses

S11

Schizoaffective disorder—depressed type, in medication remission

S12

Major depressive disorder, recurrent and mild (history of severe with psychotic features); Asperger’s disorder; learning disorder not otherwise specified; rule-out of dysthymia; rule-out bipolar disorder Type II

S13

Bipolar disorder Type I, most recent episode manic—severe with psychotic features, partial remission; generalized anxiety disorder

Group 2 diagnoses

S21

Bipolar disorder Type I, most recent episode depressed, with psychotic features; panic disorder with agoraphobia, in good medication remission; cognitive disorder, not otherwise specified; post-traumatic stress disorder

S22

Bipolar disorder Type I—most recent episode mixed with psychotic features; rule-out schizoaffective disorder; post-traumatic stress disorder; generalized anxiety disorder; obsessive compulsive disorder; trichotillomania; impulse control disorder not otherwise specified—skin picking; binge eating disorder;

S23

Major depressive disorder—recurrent, moderate; insomnia—unspecified; anxiety state—not otherwise specified

S24

Major depressive disorder—recurrent, severe, with psychotic features; depressive disorder not otherwise specified—history of postpartum depression; post-traumatic stress disorder

S25

Schizoaffective disorder—bipolar II type; borderline personality disorder; post-traumatic stress disorder; insomnia; cannabis abuse—early remission; alcohol dependence—early remission; cocaine abuse in full sustained remission

S26

Major depressive disorder—recurrent, moderate; anxiety disorder not otherwise specified; rule-out generalized anxiety disorder

Efficacy

Outcomes on the three subscales of the MPS—Mental, Physical, and Spiritual—revealed a significant effect for Time in the program improving subjective well-being on the Mental (p = 0.004) and Physical subscales (p > 0.001) for the active group, whereas there were no significant improvements on the Spiritual scale (p > 0.05). No significant Group X Time effect was found for the benefit of the active intervention compared to the wait list control period was found on any MPS subscale (data not shown; p values > 0.05). See Table 3 for data. Results on the AIOS showed that the wait list group went from a baseline mean of 0.41 (±0.12 SD) to 0.51 (±0.50 SD) at the end of wait list period, compared to 0.50 (±0.18 SD) rising to 0.61 (±0.23 SD) during the active intervention. No significant effect was found for a change over Time, nor for any Group X Time interaction.
Table 3

Results on MPS subscales for wait list and active treatment periods

Subscale

Baseline

Endpoint

Mental

Wait list

27.33 (+2.4 SE)

32.00 (+2.6 SE)

Active treatment

28.44 (+2.42 SE)

31.00 (+2.23 SE)

Physical

Wait list

24.17 (+2.99 SE)

30.17 (+1.93 SE)

Active treatment

28.33 (+2.44 SE)

33.33 (+1.93 SE)

Spiritual

Wait list

35.00 (+4.11 SE)

37.83 (+3.58 SE)

Active treatment

34.56 (+3.35 SE)

35.89 (+2.93 SE)

No significance found between wait list and active treatment. Significant effect found for Time for the Mental (p = XXX) and Physical (p = XXX) subscales for the active group

Acceptability

Although the detailed qualitative data from the self-report questionnaire and the patient drawings are not reported here, a summary of some consistent themes that arose from participant comments include several features. First, they felt the 7FHH program provided practical information on how to deal with stress. They also reported it improved their communication and relationships with loved ones, which in turn contributed to quality of life. Additionally, they commented positively on the cohesive and supportive group atmosphere of the program.

The participants’ reactions to the videoconference technology ranged from several patients who reported initial reservations, which were resolved over the course of the group (i.e. “At first it was strange to use telemedicine but I got used to it and liked it in the end.” “At first I was not used to talking to you over the computer. I do enjoy it now…”), to other patients who specifically praised the use of technology, saying, “I felt like we were a part of today’s technology. I believe technology is our future and we should embrace it and utilize it when we can. It makes me seem important to be a part of this.” Only two participants expressed a preference for in-person therapy and these were still satisfied with the group overall. As a whole, all participants found the group program very satisfactory. When asked if the telemedicine therapy experience felt “real”, all replied “yes”, and when queried whether it felt like a safe place to receive treatment, all patients but one answered “yes”. Regarding whether they felt telemedicine therapy was beneficial, every patient felt that it was. When asked if they enjoyed their experience of telemedicine therapy, again the responses were a unanimous “yes”.

The facilitator also found the group program very satisfactory. Some modifications to standard in-person groups were needed, most notably recommending both a solid safety plan involving on-site staff, as well as a recommendation to enroll no more than six people per group, to allow sufficient eye contact and to ensure participant speech is audible. However, with a good technology set-up (including, at a minimum, high-speed internet, a high-definition webcam and a free-standing microphone for the originating site), the group was noted to function similarly to an in-person group in most ways. The facilitator commented favorably about both groups’ commitment to the group process and their willingness to tolerate minor scheduling or technology issues that arose. Our facilitator noted a lack of dropouts in both groups, which is highly unusual in her experience running other types of groups in various clinical settings.

Discussion

While this was only a pilot study, and confidence in results needs to be tempered, several positive elements were revealed, specifically the high acceptability for both participants and facilitator, as well as participants’ subjective improvements in stress management, relationships and quality of life.

However, because of the small, nonheterogeneous sampling of this study, results cannot be generalized to a larger population. Because of the reasons described above, it also now appears that this may not have been a realistic design expectation, as nine participants per group would likely have created other problems due to the facility set-up and technology limitations, such that, had we been more successful in our recruitment, a larger group size may have actually interfered with the effects. For future studies, we would recommend holding at least two groups for each arm of the study to maximize the effects of the group while attaining adequate power.

Due to its nature as an unfunded project completed within a public and nonacademic mental health agency, other issues arose that may impact the generalizability of these results.

First, the control group (six female voluntary patients living in or near a rural town of ~9000 people, 188 miles from the nearest town >50,000, all patients of facilitator) and the study group (three male forensic patients of other psychiatrists, living in a city of ~108,000, none prior patients of facilitator) may not be comparable populations. This difference arose by chance as a result of accepting all eligible patients. A randomized treatment design with a more robust referral system would mitigate this source of bias for future studies.

Additionally, the “wait list” period between recruitment and the beginning of active treatment for our wait list control ended up being quite short, due to circumstances beyond our control. Consequently, the change in scores between baseline and the first group (from T0 to T1) was likely to be minimal.

One final possible confound is the direct submission of qualitative data to the facilitator. This may have increased the chance that participants’ qualitative comments would be skewed toward pleasing the facilitator. Ideally, we would have had the cofacilitator de-identify the questionnaires prior to sending. Unfortunately, this was not feasible without funding to underwrite the additional staff time that would have required. However, we had no dropouts in either group, which is highly unusual, in the nonforensic population especially. So, despite the potential for this procedure to introduce bias, we believe the positive reports were legitimate expressions of the participants’ thoughts about the group process.

Conclusion

Videoconference as a delivery mechanism for group therapy is very much in the preliminary stages of acceptance and implementation. Very few such groups are described in the literature (Germain et al., 2009; Fortney et al., 2007; Sheeran et al., 2011; Frueh et al., 2005; Morland et al., 2010; Morland et al., 2014; Khatri et al., 2014; Greene et al., 2010; Deen et al., 2010; National Center for Complementary and Alternative Medicine (NCCAM), 2009). The 7FHH was a pilot project designed to investigate the efficacy and feasibility of mind-body skills group delivered via videoconference. Although we are unable to comment definitively on the efficacy of this approach, modest benefits (Time effect only) were revealed for improving perceived mental and physical well-being for group therapy delivered via videoconference. The participants and facilitator indicate that group therapy delivered in this way is quite similar to an in-person group model. Furthermore, all involved viewed the videoconferencing group as an acceptable, positive, growth-creating and supportive experience. The 7 Foundations of Health and Happiness project contributes to the evidence-based practice of telemedicine, potentially improving access to mental health care for underserved communities.

Notes

Acknowledgements

Dr. Jerome Sarris is supported by a CR Roper Fellowship.

The authors would like to thank the leadership and staff of Health Solutions (formerly the Spanish Peaks Behavioral Health Centers) for their support and assistance. Special thanks go to James Hill RN and Chantelle Santistevan RN for their skillful co-facilitation of the groups and for their work in data collection.

The authors would also like to thank Travis Heermann, M.A., of the University of Nebraska at Omaha, College of Arts and Sciences, for his assistance in editing this manuscript.

Compliance with ethical standards

Ethics approval was granted by Saybrook University's Institutional Review Board.

Disclosures

JS has received either presentation honoraria, travel support, clinical trial grants or book royalties from Integria Healthcare & MediHerb, Pfizer, Taki Mai, Bioceuticals & Blackmores, Soho-Flordis, Healthworld, HealthEd, Elsevier, Chaminade University, International Society for Affective Disorders, Complementary Medicines Australia, ANS, Society for Medicinal Plant and Natural Product Research, Omega-3 Centre the National Health and Medical Research Council, CR Roper Fellowship.

Conflicts of interest

No specific conflicts identified.

References

  1. Bell, I. R., Cunningham, V., Caspi, O., Meek, P., & Ferro, L. (2004). Development and validation of a new global well-being outcomes rating scale for integrative medicine research. BMC Complementary and Alternative Medicine, 4, 1.CrossRefPubMedPubMedCentralGoogle Scholar
  2. Deen, T. L., Godleski, L., & Fortney, J. C. (2010). A description of telemental health services provided by the Veterans Health Administration in 2006–2010. Psychiatric Services. doi:10.1176/appi.ps.201100458.Google Scholar
  3. Fortney, J. C., Pyne, J. M., Edlund, M. J., Williams, D. K., Robinson, D. E., Mittal, D., & Henderson, K. L. (2007). A randomized trial of telemedicine-based collaborative care for depression. Journal of General Internal Medicine, 22(8), 1086–1093.CrossRefPubMedPubMedCentralGoogle Scholar
  4. Frueh, B. C., Henderson, S., & Myrick, H. (2005). Telehealth service delivery for persons with alcoholism. Journal of Telemedicine and Telecare, 11(7), 372–375.CrossRefPubMedGoogle Scholar
  5. Germain, V., Marchand, A., Bouchard, S., Drouin, M. S., & Guay, S. (2009). Effectiveness of cognitive behavioural therapy administered by videoconference for posttraumatic stress disorder. Cognitive Behavior Therapy, 38(1), 42–53.CrossRefGoogle Scholar
  6. Glueck, B. C., & Stroebel, C. F. (1975). Biofeedback and meditation and the treatment of psychiatric illness. Comprehensive Psychology, 16(4), 303–321.CrossRefGoogle Scholar
  7. Gordon, J. S., Staples, J. K., Blyta, A., Bytyqi, M., & Wilson, A. T. (2008). Treatment of posttraumatic stress disorder in postwar kosovar adolescents using mind-body skills groups: a randomized controlled trial. Journal of Clinical Psychiatry, 69(9), 1469–1476.CrossRefPubMedGoogle Scholar
  8. Greene, C. J., Morland, L. A., Macdonald, A., Frueh, B. C., Grubbs, K. M., & Rosen, C. S. (2010). How does tele-mental health affect group therapy process? Secondary analysis of a noninferiority trial. Journal of Consulting and Clinical Psychology. doi:10.1037/a0020158.PubMedGoogle Scholar
  9. Heermann, C. (2013). 7 foundations of health and happiness: building a bridge to balance. Denver, CO: SynerGenius Press.Google Scholar
  10. Khatri, N., Marziali, E., Tchernikov, I., & Shepherd, N. (2014). Comparing telehealth-based and clinic-based group cognitive behavioral therapy for adults with depression and anxiety: a pilot study. Clinical Interventions in Aging. doi:10.2147/CIA.S57832.PubMedPubMedCentralGoogle Scholar
  11. Lukoff, D., Wallace, C. J., Liberman, R. P., & Burke, K. (1986). A holistic program for chronic schizophrenic patients. Schizophrenia Bulletin, 12(2), 274–282.CrossRefPubMedGoogle Scholar
  12. Morland, L. A., Greene, C. J., Rosen, C. S., Foy, D., Reilly, P., Shore, J., He, Q., & Frueh, B. C. (2010). Telemedicine for anger management therapy in a rural population of combat veterans with posttraumatic stress disorder: a randomized noninferiority trial. The Journal of Clinical Psychiatry. doi:10.4088/JCP.09m05604blu.PubMedGoogle Scholar
  13. Morland, L. A., Mackintosh, M. A., Greene, C. J., Rosen, C. S., Chard, K. M., Resick, P., & Frueh, B. C. (2014). Cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: a randomized noninferiority clinical trial. The Journal of Clinical Psychiatry. doi:10.4088/JCP.13m08842.PubMedGoogle Scholar
  14. National Center for Complementary and Alternative Medicine (NCCAM). (2009). CAM basics: what is CAM? National Center for Complementary and Alternative Medicine (NCCAM). http://nccam.nih.gov/health/whatiscam/overview.htm. [Accessed 2009 Apr 14].
  15. Sheeran, T., Rabinowitz, T., Lotterman, J., Reilly, C. F., Brown, S., Donehower, P., Ellsworth, E., Amour, J. L., & Bruce, M. L. (2011). Feasibility and impact of telemonitor-based depression care management for geriatric homecare patients. Telemed J E Health. doi:10.1089/tmj.2011.0011.PubMedPubMedCentralGoogle Scholar
  16. Staples, J. K., Abdel Attai, J. A., & Gordon, J. S. (2011). Mind-body skills groups for posttraumatic stress disorder and depression symptoms in Palestinian children and adolescents in Gaza. International Journal of Stress Management, 18(3), 246–262.CrossRefGoogle Scholar
  17. Starkey, D., Deleone, H., & Flannery Jr., R. B. (1995). Stress management for psychiatric patients in a state hospital setting. The American Journal of Orthopsychiatry, 65(3), 446–450.CrossRefPubMedGoogle Scholar
  18. Tan, G., Teo, I., Srivastava, D., Smith, D., Smith, S. L., Williams, W., & Jensen, M. P. (2013). Improving access to care for women veterans suffering from chronic pain and depression associated with trauma. Pain Medicine. doi:10.1111/pme.12131.Google Scholar
  19. Vella-Brodrick, D. A., & Allen, F. C. (1995). Development and psychometric validation of the Mental, Physical, and Spiritual Well-Being Scale. Psychological Reports, 77(2), 659–674.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing 2017

Authors and Affiliations

  1. 1.College of Integrative Medicine and Health SciencesSaybrook UniversityOaklandUSA
  2. 2.Absenger Cancer Education FoundationSpring LakeUSA
  3. 3.Deputy Director of the National Institute of Complementary MedicineCampbelltown NSWAustralia
  4. 4.Professor of Integrative Mental Health at Western Sydney UniversityPenrith NSWAustralia

Personalised recommendations