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 f:	Running head: MINDFULNESS INTERVENTIONS





Mindfulness Interventions in the Training Environment to Treat and Prevent Depression, Lower Suicide Rates and Improve Resilience in the Military and Veteran Communities: A Review of Programs Offering Success Exemplars  




Kate Hendricks Thomas, PhD, E-RYT 200
kthomas@csuniv.edu
(843) 863-7247
Charleston Southern University, Department of Health Promotion

Sarah Plummer Taylor, RYT 500
 HYPERLINK "mailto:sarah@sempersarah.com" sarah@sempersarah.com 
(760)969-3216
University of Denver, School of Social Work
The suicide numbers among active duty military personnel eclipsed the number of combat deaths in 2011 (Hoge, 2012).  Before the wars in Iraq and Afghanistan, the incidence of suicide in active duty US service members was consistently 25% lower than in the civilian population (Department of Defense, 2013).  Currently military and veteran suicide rates exceed those found in the general population, with 22 per day being the most conservative estimates by the Veteran�s Administration.  The reasons for this are multi-faceted, with the question looming as to whether repeated ground combat tours have a deleterious effect on resilience and overall mental health.  Operational tempo in the last ten years has exceeded all previous expectations and metrics; frequent trips to Iraq and Afghanistan are commonplace for this community.  Military deployment to a war zone elevates the risk of long-term physical, psychological, and social problems and reduces overall health status (Spelman, Hunt, Seal, & Burgo-Black, 2012).  
While clinical health services exist for soldiers and Marines with existing mental health conditions like posttraumatic stress, they are not stemming the rising tide of service suicides. A new approach is required, one that speaks to the participatory, hardworking ethos of military culture.  Programs exist that provide guidance, and a mindfulness-based training protocol may provide the answer (Kitamura, 2013; Seaward, 2004).   
The complexity of diagnosing and treating depression in veterans mirrors that in the civilian population.  Over 19 million people in the United States are reportedly diagnosed with depression.  Many others suffer without diagnosis (Craft, 2002).  The signs and symptoms of depression include loss of energy, motivation, hope and zest for life and an overall feeling of worthlessness (McWilliams, Goodwin, & Cox, 2004).  Prescription medication and psychotherapy are the most common forms of treatment for depression within the US.  Annually, over $53 billion is spent in treating depression with prescription medications such as tricyclics, monoamine oxidase inhibitors or serotonin re-uptake inhibitors (SSRI) (Institute of Medicine, 2011).  Effects are usually not seen before six weeks of drug therapy and may be dependent upon continuing medication.  Psychotherapy is another viable, yet costly, treatment option for dealing with the debilitating effects of depression.  Often referred to as talk therapy, it is usually administered in individual or group psychodynamic or cognitive behavioral form.  Psychotherapy can also be a lengthy and time-consuming process, subject to a host of access issues (Norris, 2003). 
The Department of Defense and Veteran�s Administration have made combatting depression a major priority, specifically because it is a known predictor of suicide (Bossarte, 2013).  Studying mental health is fraught with difficulty, as symptoms manifest on multiple levels and vary greatly from one diagnosed patient to the next.  In the military, understanding mental health is important from two key angles.  Prevention of illness and stress disorders saves the services money and training time, and treatment of conditions accrued during service is an ethical responsibility (Meredith et al., 2011).  Conflicts over the last decade that have been characterized by lengthy and repeated deployments to war zones have rendered service members especially vulnerable to stressors that can impact mental well-being and cause depression of varying degrees (Gironda, Clark, Massengale, & Walker, 2006). A telephone survey of 1,965 service members who recently returned from Iraq highlighted the seriousness of the problem; 14% met criteria for PTS and major depression (Tanielian & Jaycox, 2008).  A larger study the following year showed 36.9% of the 289,000 service members surveyed had some sort of mental health diagnosis (Seal et al., 2009).
Careful study of suicide risk in the military population compared to the general population shows that suicide risk is almost four times higher among young veterans than their non-serving peers, a difference made more statistically significant when analysis controls for age and time in service (Bossarte, 2013).  Internationally, numbers indicate the same.  A British study of recent combat veterans found the risk of suicide to be 2-3 times higher for military members than the general population, with the year immediately following discharge being a particularly risky time (Ilgen et al., 2012).  
A qualitative study published in the American Journal of Public Health aimed to probe more deeply the issue of post-discharge suicide risk in young veterans.  Researchers conducted interviews of recently-discharged troops diagnosed with depression and conducted general surveys of separating service-members who did not have a diagnosis.  Their study demonstrated that a major issue for veterans is reintegration into new roles and the loss of community felt when leaving the military.  Veterans described a sense of burdensomeness and extreme disconnect from civilians.  These feelings linked to a failed sense of belonging and desire for death (Brenner & Barnes, 2012).  Follow-on studies focused specifically on female veterans, and found that descriptions of symptoms and feelings of disconnect were markedly similar, though more pronounced and likely to be of greater severity, potentially due to minority status and the environmental factors that accompany it (Guitierrez et al., 2013). 
Depression in veterans can be categorized as both diagnosed and undiagnosed.  Stress and anxiety are symptoms of depression, and depressive conditions are closely related to trauma and stress-related disorders like Posttraumatic Stress (PTS); the two often co-occur (DSM V, 2013).  Because of frequent deployments and repeated exposure to hostile fire, Improvised Explosive Devices, incoming mortars, and other deployment hazards, the rise of stress injury is rampant in today�s military and veteran communities, but it is not a well-understood phenomenon.  Statistics on PTS in veteran communities are uncertain, with estimates out of the Veteran�s Administration sitting at 15-50% (Coughlin, 2012).   A RAND corporation study recently showed numbers hovering at about 20% (Acosta, Adamson, Farmer, Farris, & Feeney, 2014).   Traumatic Brain Injury is also on the rise, as improved body armor and equipment keep Marines alive through explosions that used to kill (Okie, 2005; Tanielian & Jaycox, 2008).  Diagnosed depression is subject to semantic debate in the military community, and symptom overlap between depressive conditions and stress injuries often leads to misdiagnosis or confusion about co-occurring conditions (Department of Veterans Affairs, 2014).  Professionals discussing the same stress injury symptoms may refer to Posttraumatic Stress (PTS) or the less-popular Posttraumatic Stress Disorder (PTSD), stress reaction, battle fatigue, operational stress, or shell shock (Hoge & Castro, 2012).  These trauma and stress disorder diagnoses are often accompanied by symptoms of depression in varying degrees of severity, and this co-occurrence may or may not be understood, recognized, and diagnosed (DSM V, 2013; Hoge & Castro, 2012).
Symptoms of both stress injury and depression double as essential survival skills in a war zone (Department of Veterans Affairs, 2014).  These survival responses are appropriate in a combat setting, and a warrior understands that they could be needed again in the event of another deployment or a life-threatening situation (Seaward, 2004).   Stress case studies conducted by Dr. Jha of the University of Pennsylvania in 2009 studied long-term cognitive changes in soldiers and Marines post-deployment, looking at how stress reactions enable or impair mission effectiveness.  The fast-moving landscape of the contemporary combat environment trains service members to respond quickly and to spend most of their time in elevated states of alertness.  This stress reactivity carries with it decreases in upper-level cognitive ability and a host of emotional, behavioral, and physiological health problems.  In effect, the deployed soldiers� brains build the capacity for quick reaction over time, which is a function more necessary for survival in Iraq, while experiencing degradation of other mental capacities.  Dr. Jha found that overseas deployment was correlated with memory lapses and focusing problems, a deficit that persisted more than 2 months after arriving home (Jha & Kiyanoga, 2010). 
More than simple diagnosis difficulty, depressed veterans face inexorable stigma when it comes to care-seeking for a possible or confirmed condition.  The influence of culture on behavior cannot be understated.   Culture is an important factor that shapes individual behavior through customized sets of attitudes, beliefs, and values shared by a large population (Shiraev & Levy, 2010).  One�s surrounding social norms play a vital role in shaping the attitudes and beliefs commonly used to delineate and define culture.  In insular and intense communities, normative values can become highly prescriptive and are enforced in a myriad of intangible ways.  Emotional norms become disciplinary tools, rendered more effective in communities with high levels of adherence to hierarchy (Ahmed, 2010).  Especially in military communities that promote competitive individualism, this allows the expectations of others to weigh heavily on warriors� shoulders.  In a descriptive case study published by the Journal of Religious Health, Dr. Mark Malmin provides an in-depth review of warrior culture, using the military and law enforcement communities as his frame of reference.  A former soldier and police officer himself, Malmin approaches his descriptive analysis with an insider�s eye.  Using a review of research consisting primarily of survey data and his own interviews and observations of soldiers and law enforcement personnel, Malmin paints an accurate, vivid picture of the insular culture in which warriors exist.  In so doing, he highlights the power of subculture influence on member perception.  Warrior subculture tends to promote the belief that acknowledging emotional pain is synonymous with weakness and specifically, that asking for help for emotional distress or problems is unacceptable (Malmin, 2013).  
Warrior culture can distort critical thinking and good judgment in cases where warriors suppress emotional pain, fail to apply sound cognitive thinking, acknowledge real health or wellness issues, and intentionally choose not to seek help that might remedy a mental health problem.  If strength is a virtue, becoming a patient is antithetical to being virtuous.  The result of such a firmly entrenched value system is powerful stigma against patient-identity and mental health conditions.  According to social worker and grounded theory researcher Dr. Bren� Brown, warrior culture is opposed to vulnerability and sees outreach as weakness. Yet, vulnerability is in fact key to healing and self-knowledge (Brown, 2012).
Within the military community, much of the issue lies neither in lack of screening for depressive disorders, nor in the medical care available to service members suffering from depression.  Rather, the problem is getting veterans to avail themselves of treatment services.  In one post-deployment study, 42% of screened reserve and National Guard soldiers answered questions in such a way that they were flagged as being in need of evaluations and possible treatment.  However, only half of those soldiers referred sought treatment.  Only 30% of those that sought treatment followed the basic program through the full eight sessions (Coughlin, 2012).
Part of the issue is the stated disconnect combat veterans feel from civilians, even civilian mental health professionals who treat the military population.  Service members and veterans often feel they�re wasting their time dealing with people who can�t relate to their perspective, and may actually feel more comfortable in the war zone (Hoge, 2010).  Another glaring problem surrounding seeking initial help and adhering to a program lies in the stigma that surrounds mental health treatment and care.  This has been confirmed in study after study - when veterans were asked why they avoided even recommended care, stigma was identified as a major barrier (Currier, Holland, & Allen, 2012; Elnitsky et al., 2013; Koo, 2014).  The most important challenges in suicide prevention are stigma surrounding mental illness, negative perceptions of treatment, and other barriers (including confidentiality in the military setting) that result in the majority of service members not accessing care when needed or dropping out prematurely  (Held & Owens, 2013).
Rather than operating from a paradigm of post-incident therapeutic intervention, health programmers who wish to maximize efficacy within the confines of warrior culture must alter the conversation to one of preparation and training pre-incident.  Training in mindfulness focuses on building agency and resilience and can ameliorate the problem of stresses due to deployment both before and after the tour (Ryan, 2012).  Creating a climate of peer-led training at both the unit and individual levels will reduce overall stigma against self-care practices because everyone participates, the program is led by trusted informants, and no one has to take on a patient role to participate.  To train is to actively participate, and this is a wellness concept with which service members are already familiar.  Framing mindfulness training as a way to �prepare your brain� renders palatable a training opportunity designed to create more effective warriors with mental endurance; framing this as promotion of combat fitness, resilience, and mental endurance renders it accessible to the military population (Ryan, 2012).  Creating training protocols that emphasize connection and compassion over disassociation is important to maximize success.
Marines and soldiers are competitive individualists who respond much better to notions of challenge than to victim or patient identities.  By establishing mind fitness as another component of optimal combat readiness, we establish mindfulness training as a crucial component of mission preparedness, and remove the stigma of mindfulness treatments for post-deployment troops who may be struggling with stress illnesses of varying degrees.  The message can become directive; just as Marines and soldiers learn mission essential skills and train their bodies for arduous combat, we must adopt practices designed to train and promote health in the mind.  Turning to agentic notions of self-care, health promoters can modify ancient stress management and mindfulness therapies to help them resonate with this community.  
What is Yoga/Mindfulness?
Defining what is meant in holistic health circles by mindfulness interventions becomes important for this review.  There are many definitions and branded phrases to describe the form of therapeutic mindfulness used to treat Wounded Warriors and promote resilience in service members, but the best descriptions are perhaps the oldest definitions of yoga as a practice of many limbs, reaching far beyond simple physical movements known as asana in yogic lexicon.  Subscribing to such a comprehensive definition of yoga renders the terms �yoga� and �mindfulness� interchangeable.  Mindfulness, according to Jon Kabat-Zinn, is a radical act that allows practitioners to access and integrate all elements of their experience � emotional, social, cognitive, and somatic (Ryan, 2012).  Typically, yoga interventions for the military community involve still, seated meditation, physical movements of varying difficulty levels, and instructional seminars on individual peace, spirituality, and stress management (Libby, Corey, & Desai, 2012).
Yoga means union, and it truly does facilitate the coming together of the human mind, body, and spirit.  Science is beginning to understand what it brings to the body, specifically as it relates to the treatment of trauma.  Yoga never moved into the more traditional standard of care until there was hard evidence behind its touted benefits, an empirical validation process that continues today (Nassif, Norris, Gomez, Karch, & Chapman, 2013).  Bessel van der Kolk�s groundbreaking work on treatments outside current care standards for post-incident trauma highlights the way that trauma rewires the brain.  Specifically, areas related to trust, emotional reaction, and connectivity are damaged in trauma sufferers, and must be reactivated through targeted therapies.  Traditional treatments like medication and talk therapy are inadequate, he argues, because they do not offer the resilience-building of agentic treatments that teach patients how to reclaim and rewire their stress response.  Along with neurofeedback, his work in The Body Keeps Score advocates mindfulness and yoga therapies (van der Kolk, 2014).
Mindfulness practices effectively �bridge the gap� between mental and physical vitality.  To understand why such practices have such transcendent appeal, one needs to understand where they come from and what they mean off the mat.
Yoga originated out of an ancient tradition known as Ayurveda as a method and means of maintaining vital balance, derived from the Sanskrit word for union.  The first written records of yoga�s methodology appear in 200 BC in the Yogasutra of Patanjali (Romas & Sharma, 2010).  Yoga in its infancy was not about movement (asana) as much as it is in contemporary western society.  Postures and the ability to hold a specific position were more about establishing a platform for meditation than actually training the physique. But, the concept of using the physical to access the mental and spiritual rang true then, as today.  In the military community, physical training is something held as important and dear.  Therefore, the physical practice of contemporary yoga provides a strong platform for introducing meditation and stress management concepts. 
What Research Is Being Done Currently on Yoga for Military Personnel?
Mindfulness interventions have been highlighted in community setting studies as effective in reducing stress and anxiety  (Stevens, 2012) and in individual case studies looking at mindfulness and mood recovery (Jouper et al., 2012).  The Department of Defense has seen the validity of yoga in Wounded Warrior recovery programs, and is slowly expanding research partnerships with universities like the Uniformed Services University of Health Sciences and Johns Hopkins.  Studies on Dr. Miller�s yoga nidra protocol (called iRest) at Walter Reed yielded positive qualitative feedback and resulted in a 3-week version being included in the treatment program at the deployment clinic  (Engel et al 2008).  In San Francisco, a qualitative study of 16 veterans with diagnosed PTSD completing an iRest course yielded positive findings  (Stankovic, 2011).  
Some of the research efforts are explicitly clinical, and apply rigorous prospective, mixed-methods models (Libby, 2012).  For example, a recent study in the District of Columbia in partnership with the DC Veteran�s Hospital, American University�s Psychology Department, and the War-Related Illness and Injury Study Center (WRIISC) yielded promising treatment results for mindfulness meditation interventions.  Researchers worked with patient volunteers to advance current understanding of veterans with dual-diagnoses of Traumatic Brain Injury (TBI) and Post-Traumatic Stress (PTS) through the lens of neuroscience.  Looking at brain scans in individuals with these diagnoses and comparing functional MRI results pre- and post- intervention, researchers ascertained whether and when stress hormone levels drop with intervention and compared those results to self-reported pain management.  Meditation may reduce physical symptom complaints and improve emotional functioning in patients suffering from chronic pain (Nassif, et al., 2013). 
Studies demonstrating recovery benefits in the Wounded Warrior community abound (Libby, 2012).  A knowledge gap exists in the use of yoga for resilience training in military settings; important research is being conducted to evaluate existing programs and interventions.  Research conducted to evaluate existing programs and interventions often uses process, impact, and outcome evaluation methods.  Programs aimed at improving resilience and preventing depression abound, but assessment standardization does not (Coughlin, 2012).  Presently, the best evaluations are case study analyses.  These success exemplars provide road maps for success in using mindfulness and yoga training protocols in the military community, not simply in post-trauma treatment settings, but within the bounds of the normal military training environment.  Moving such progressive programs outside the care setting immediately removes treatment stigma, and offers the opportunity to reach with more effect.
Because of military culture insularity and lack of communication between bureaucratic treatment agencies, programs that seek to collaborate, bridge gaps, and use peer leadership meet with real success (Greden, 2010).  Understanding culture and delivering a product specifically targeted to the military is important; allowing for participatory implementation of a given program is vital.  In the military community, the best program implementation cases are found within participatory research frameworks.  Warrior subculture creates a powerful mandate for peer-to-peer outreach.  Any message aimed at decreasing stigma must come from members of the community to be deemed credible.  Recall that a major symptom of service members separating, especially after a combat deployment, is a feeling of disconnect from civilians (Hoge, 2010).  Warrior cultures have their own temperaments, typically exclusive and mistrustful of outsiders with different life experiences (Malmin, 2013).
A 2010 case study highlights one Michigan pilot program�s experience with �buddy-to-buddy� peer support programs.  A team from the University of Michigan and Michigan State worked with the Army National Guard (ANG) to address the constellation of issues facing soldiers returning from a deployment to Iraq.  National Guard soldiers, like all reservists, often face stresses additional to those faced by active duty troops.  Reservists don�t come from as insular of a military community, and may lack support services in civilian community settings.  Particularly because PTS symptoms are very likely to be misread as behavioral deviance, stigma may be even more difficult to overcome in community settings removed from the active duty military component (Greden et al., 2010).  
The primary strength of the Michigan case study was the thorough formative research conducted by the academic team.  They surmised quickly that while the stresses soldiers faced were unique, the clinical resources available to them were noteworthy and present.  Gaps existed in all of the expected areas � soldiers faced inexorable stigma associated with seeking care (Greden et al., 2010).  
Michigan researchers also keenly understood the need for audience-centered communication, and partnered with unit leadership to institute a program that was completely peer-led.  This decision came out of the qualitative research they conducted in the unit prior to thinking about a program.  Interviewees said things like, �if you haven�t been there, you don�t get it� and �other veterans can be trusted.�  The research team considered concepts of warrior culture and sought to design a program that spoke the correct language, using an understanding of social norms to change the culture of treatment avoidance (Greden et al., 2010).  After training 350 peer leaders, (called �Buddy Ones� by the program), one returning unit participated in the program.  Preliminary results were encouraging.  Ninety percent of participants understood program intent, received regular calls and contact from their buddies, and felt comfortable with their trained peer.  More than 20% were referred to formal treatment by their buddy, and they affirmed availing themselves of recommended services.  As a pilot study, the Michigan buddy program is light on long-range evaluation results, but advances greatly the notion that attention to warrior culture, unit-specific language, peer leadership, and insider message delivery can aid in suicide prevention (Greden et al., 2010).  This focus on stigma reduction and improved rates of treatment-seeking is of paramount importance.  
Also honing in on the need for culturally-sensitive training to improve later care-seeking is Dr. Elizabeth Stanley of the Mind Fitness Training Institute.  The Institute�s focus is on training instructors and providing services, but also gets involved in research initiatives (Mind-Fitness Training Institute, 2014).  The protocol developed and researched by Stanley�s team was developed in response to stress case studies conducted by Dr. Jha of the University of Pennsylvania that found demonstrable changes to deployed service members� stress reactivity even when removed from the combat environment (Jha & Kiyanoga, 2010).  
Interestingly, high stress reactivity, naturally occurring adaptation though it may be, hinders the ability of service members to perform complex missions and interact with foreign nationals.  The modern battlefield involves interaction with civilians and allies as a matter of course (Hoge, 2010).  Becoming overly reactive as a response to environment hinders that mission.  For example, soldiers who screened positive for mental health problems were three times more likely to report having engaged in unethical behavior while deployed  (Jha, Stanley, Kiyanoga, Wong, & Gelfand, 2010).  Behaviors ran the gamut from unnecessary property damage to noncombatant injury or harm, all diametrically opposed to the United States� mission of winning hearts and minds.
The Mind-Fitness Training Institute team conducted a specific study on a company of Marines in the fleet during pre-deployment work-ups, seeking to answer the question of whether a mindfulness-based behavioral health intervention could improve the resilience of Marine Corps reservists preparing for a tour in Iraq.  Attempting a mixed-methods approach to the instrumental case study, the researchers studied one unit of 34 reservists.  In addition to the normal training required before heading overseas, these reservists underwent a carefully tailored yoga and mindfulness program designed to improve their ability to manage both chronic and acute traumatic stress (Teng et al., 2013).   
Results were statistically significant in the studied population, demonstrating that adherence to intervention protocol for 15-minutes each day exponentially improved working memory capacity (Teng et al., 2013).  Working memory capacity contributes to emotional regulation as well as upper-level cognitive functioning (Seaward, 2004).  
Most of these reservists had already deployed once before or worked in civilian occupations like law enforcement that could be classified as high-stress.   Researchers cogently made the point that using the small detachment of Marines as their case report group rather than a single individual was intended and more appropriate for analysis.   Their goal was not narrative emotional power, but a mixed-methods analysis that may carry weight with a command considering program adoption beyond the bounds of the short case study.  In this, researchers affiliated with the Mind-Fitness Training Institute have been highly effective.   Early findings indicate an affirmative answer to the specific question of whether yoga-based mindfulness training can promote stress resilience in a very specific population, at a very critical juncture.   In order to enhance the validity of their conclusions, researchers used triangulation to answer their questions in more than one way.  Methods included participant observation, individual interviews, and a battery of self-reported questionnaires aimed to assess perceived stress and personal outlook.  The results showed increases in positive outlook and mindfulness skill sets and commensurate decreases in perceived stress.  Researchers observed strong adoption and adherence in some participants, and the scores of those participants rose in correlation with the hours logged in practice (Teng et al, 2013).   
Other researchers have followed the path of the Mind-Fitness team and spent time attempting to validate specific interventions for the military community incorporate mindfulness practices.  A 2011 RAND analysis commissioned by the Office of the Secretary of Defense conducted a systematic evaluation of existing programs in different branches of service.  A noted finding of the study was that few programs currently being delivered in piecemeal fashion have any formal evaluation plan in place, though almost all those interviewed saw the need for longitudinal studies of the effectiveness of their programs (Coughlin, 2012; Foran, Adler, McGurk, & Bliese, 2012).
Research Takes Years: Who Treats Wounded Warriors Using Yoga Today?
A major opportunity to validate mindfulness programs in military and veteran settings lies in the non-profit community.  Interestingly, there is much being done to bring yoga to veterans all over the country today on a volunteer basis.  Perhaps this stems from the yogic notion of seva, or service.  Many yoga practitioners believe strongly that service to others is a central component of living a yogic lifestyle.  
The major players in the treatment of veterans and Wounded Warriors (outside the standard of care they currently receive through the Veteran�s Hospitals) are not only standard government health agencies, but are instead pilot companies, nonprofit volunteers, and philanthropists.  The work they are doing contributes to an interested base of medical consumers, as veterans participating in these programs become interested and educated consumers of mindfulness-based health interventions.  Validating, formalizing, and effectively funding the work these adjunct groups are currently doing is a work in progress, but taking inventory of current efforts may light the way for later dissemination of programs on a large, DOD-wide scale.  
Mindfulness proponents love to share the practices, and many well-intentioned yoga and meditation teachers have sought ways to deliver their services to the military population.  When couched in terms of non-profit or volunteer service delivered in ancillary fashion, teacher positionality is not of paramount importance.  Organizations like Exalted Warrior and Warriors at Ease work to bring adaptive wellness and mindfulness opportunities to veterans and active duty military.  Anyone can be trained to sensitively offer mindfulness training to the military community, and that is a laudable service.  However, when we discuss program interventions designed to be implemented within military settings for the specific goal of enhancing mission readiness and enabling post-incident resilience, remembering the message delivery mandates of warrior culture is key.  The military is a very insular community bound together by shared hardship and experience.   Cynicism from the soldiers and Marines undergoing any program administered by outsiders, potentially speaking a language of partial-knowledge, would invariably color any outcomes (Malmin, 2013).  Something as simple as using acronyms incorrectly would buttress existing feelings of �us-against-them� held by many members of the military.  Research and program efforts in the training environment must be participatory and peer-led whenever possible.  As has been demonstrated successfully in recovery communities, peer mentoring and leadership provides the interaction, camaraderie, and instructor credibility required to sell an intervention to potentially recalcitrant participants in very specific, insular, or marginalized communities  (Gosan & Dustman, 2003).  
A participatory framework would involve both the researcher and the participant-leaders in the cultivation of mindfulness programs.   Instead of simply externally deciding on a format to be packaged and delivered, participants can be brought into the fold as a mindfulness program is being conceptualized.   This helps with program palatability and language use.   Participants learn at a much deeper level when involved in the process.  Understanding clearly the history, background, and literature on mindfulness could result in an increased sense of investment and self-efficacy, which inevitably promotes adherence to the program (Greden, 2010).  As the old adage about teaching a man to fish promises, community-based participatory research (CBPR) provides a challenging opportunity to yield real, lasting behavioral change through program designs that truly speak to end users.  
Case studies of existing programs provide the foundation upon which savvy programmers must build, and health promotion professionals working to prevent and treat mental health problems like depression and stress illness must understand the confluence of warrior culture and mental health issues in the veteran community.  While the research literature does not yet address this confluence issue directly, it contains ample evidence to support the development of a culturally-informed mindfulness training protocol.  This protocol would be best implemented in participatory fashion in the training environment, rather than in treatment settings.  Veterans often reject patient identities, which creates a major barrier to care for mental health in this population.   To combat suicide rates and promote military and veteran mental health, a new approach is required, one that embraces peer-education and speaks to the participatory, hard-working ethos of military culture.  Mindfulness-based programming has potential to meet these needs, and may provide a blueprint for success in working with this population.  

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