Exercise is medicine for mental health in military

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1 Exercise is medicine for mental health in military veterans: A qualitative commentary Nick Caddick1, Brett Smith2 1 Veterans and Families Institute, Anglia Ruskin University, Chelmsford Campus, Bishop Hall Lane, Chelmsford, CM1 1SQ 2 School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT.

Citation: Caddick, N., & Smith, B. (2017). Exercise is medicine for mental health in military veterans: a qualitative commentary. Qualitative Research in Sport, Exercise and Health, DOI: 10.1080/2159676X.2017.1333033

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Abstract Different approaches to treatment for mental health problems in military veterans continue to attract research attention. In addition to the NICE-approved treatments for post-traumatic stress disorder such as trauma-focused cognitive behavioural therapy and eye-movement desensitisation and reprocessing, a number of novel and innovative approaches have recently been developed. One such approach is encapsulated under the emerging paradigm of `exercise as/is medicine'. Following recent calls to strengthen the evidence base for new and emerging mental health treatments for veterans, this paper presents a commentary on current evidence in support of `exercise as medicine' derived from qualitative research studies. It is concluded that qualitative research has made a significant contribution to the emerging evidence base for exercise-based interventions. This evidence base can be used to inform current debates about quality assurance in the area of veterans' mental healthcare and to underpin quality provision for service users. Qualitative research also has a significant future contribution to make toward improving the evaluation of novel treatment approaches, generating more impactful research, and increasing the applicability of research findings in `exercise as/is medicine'. The paper closes with some critical reflections on the role of exercise-based interventions as a means of helping veterans improve their mental health.

Keywords: Exercise; Medicine; Veterans; Mental Health; PTSD; Qualitative Research

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Exercise is medicine for mental health in military veterans: A qualitative commentary `Exercise as/is medicine' has become increasingly prominent over the past decade as a philosophy and approach for treating mental health problems in military veterans1. This trend toward exercise in veterans' mental healthcare has attracted growing research attention in the form of both qualitative and quantitative studies exploring the impact of exercise on veterans' mental health. Most of the research has focused on the effects of exercise for veterans experiencing post-traumatic stress disorder (PTSD); a severe and often debilitating psychological response to traumatic incidents (e.g., Whitworth & Ciccolo, 2016). Several systematic reviews have collated evidence in support of exercise as a treatment for PTSD in the general population (Rosenbaum et al., 2015), and among veterans specifically (Caddick & Smith, 2014; Whitworth & Ciccolo, 2016). Some studies have also examined the role of exercise in promoting psycho-social elements of recovery among veterans with traumatic injuries and disabilities (e.g., Brittain & Green, 2012; Burke & Utley, 2013; Shirazipour et al., 2017)2.

In this article, we provide a commentary on the current state of knowledge in the field of mental health, exercise and military veterans. A focus on veterans within the wider `exercise is medicine' movement is warranted given the specific challenges (e.g., combat trauma, transition from military to civilian lifestyle, stigma of addressing mental health problems in the military) faced by many in this cohort (Cooper et al., 2017). The adoption of a sports-based model of recovery in the related area of military trauma rehabilitation (see, e.g., Messinger 2010; and promoted more widely via the Invictus Games) further highlights

1 We use the term `veterans' (as per popular understandings of the term) to refer to former service personnel, whilst also recognising that many currently serving military personnel utilise exercise as a means of dealing with mental health concerns. (For a technical discussion of the term `veteran' and its different meanings and limitations, see Burdett et al. (2012) and Dandeker et al., 2006). 2 Whilst important in its own right, this research will not be reviewed within this paper which focuses on exercise as a form of treatment for mental health problems such as PTSD.

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the current relevance of exercise, sport and physical activity for addressing military and veteran mental health.

The article is divided into four main sections. First, we review the contribution that qualitative research has made to the evidence base in support of using exercise as `medicine' for military veterans. In the second section, this evidence base is then situated in the context of current debates about quality assurance in veterans' mental healthcare and the requirement for evidence-based treatments. Here we comment on the role of exercise in augmenting the care veterans receive through traditional clinical pathways, and on the part played by an expanding network of military charities offering exercise-based interventions. In the third section, this article discusses the future contribution that qualitative research can make toward developing the research agenda concerning exercise as medicine and veterans' mental health research more generally. We conclude with some critical reflections on the promotion of exercise as medicine, including whether the alignment of exercise with `medicine' is likely to support, or alternatively, to undermine veterans' engagement with it as an approach to bettering their mental health.

Qualitative contributions to understanding "exercise is medicine"

Qualitative researchers have been at the forefront of an emerging body of work exploring the potential of exercise as treatment for mental health in military veterans. This is perhaps due to the capacity of qualitative research to obtain rich and detailed accounts of a topic that has emerged relatively recently and to `open up' a new area of social scientific study. Whilst not wishing to discount the achievements of quantitative research in contributing to the growing evidence base (e.g., Lundberg et al., 2011; Rogers, Mallinson & Peppers, 2014; Whitworth & Ciccolo, 2016), it is clear that a significant body of qualitative work has begun to develop in

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support of exercise in the treatment of mental health problems among veterans (e.g., Caddick, Phoenix & Smith, 2015; Caddick, Smith & Phoenix, 2015a, 2015b; Carless, 2014; Carless & Douglas, 2016; Carless, Peacock, McKenna & Cooke, 2013; Carless, Sparkes, Douglas & Cooke, 2014; Douglas & Carless, 2015; Dustin, Bricker, Arave & Wall, 2011; Hawkins, Cory & Crowe, 2011; Mowatt & Bennett, 2011; Otter & Currie, 2004). This research has focused on a variety of forms of exercise, sport and/or physical activity, and has revealed numerous ways in which these activities can improve veterans' mental health and can play a crucial role in treatment for PTSD and other mental health problems. This research also builds on an established body of qualitative work which documents the positive effects of exercise, sport, and physical activity for people experiencing serious mental illness (e.g., Carless & Douglas, 2010a; Faulkner & Biddle, 2001, 2004; Hefferon et al., 2013).

While the qualitative research in this area has not tended to use the term `exercise is medicine' explicitly, the common thread uniting this body of work is certainly its focus on the capacity of exercise and/or sport and physical activity to improve the mental health of military veterans experiencing PTSD or other mental health problems. In keeping with the theme of this special issue, we use the term `exercise' throughout this paper to refer to a number of activities that may also include sport, physical activity, and active forms of recreation. While we recognise there may be important distinctions between various types of activity (e.g., competitive vs. recreational sport, `structured' exercise performed for health reasons vs. `unstructured' games or recreational activities conducted primarily for pleasure), we have chosen for reasons of consistency to refer to `exercise'. In addition, we will use the phrase `exercise-based interventions' to describe the programs or services at the heart of the research we focus on in this paper. Such interventions are typically charity or community-run programs, or services delivered on an ongoing basis, with some form of (usually groupbased) exercise or physical activity as the basis of mental health provision. These programs

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and charities (e.g., Surf Action, Help for Heroes, the Invictus Games, the Battle Back program) have been at the forefront of the growing use of exercise-based interventions for veterans' mental health.

A number of positive psychological outcomes have been identified by qualitative research examining the impact of `exercise as medicine'. First is the capacity of exercise to reduce the clinical symptoms associated with PTSD. Consistent with the findings of a recent meta-analysis which demonstrated that physical activity can significantly reduce PTSD symptoms (Rosenbaum et al., 2015), qualitative research has revealed that various forms of exercise can reduce the symptoms of re-experiencing, avoidance and numbing, and hyperarousal associated with PTSD (Dustin et al., 2011, kayaking), reduce anger levels and improve mental alertness and sleep quality (Dustin et al., 2011; Mowatt & Bennett, 2011, fly fishing; Otter & Currie, 2004, aerobic exercise), and provide a feeling of respite from the exhausting daily cycle of PTSD symptoms (Caddick et al., 2015a, surfing). These qualitative findings are not couched in the language of clinical or statistical significance, but instead demonstrate ? through veterans' own personal testimonies ? the meaningful difference that exercise can make to their experiences of PTSD.

In addition to these symptom-focused findings, qualitative researchers have examined the positive contribution that exercise can make to veterans' lives, including how it might enable them to live purposeful and meaningful lives despite the presence of symptoms. Adopting what Hawkins, Townsend and Garst (2016) describe as a strengths-based approach, these findings illustrate the ways in which exercise can add to life ? in the form of positive experiences ? rather than simply what it might take away in the form of problems (Caddick & Smith, 2014; Carless & Douglas, 2010a). For example, Carless et al. (2013) described how participating in an adventure training and sports camp (`Battle Back') helped veterans to restore a sense of purpose in life, and reconnected them with other people and with activities

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