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The Implementation of a Mindfulness-Oriented Retreat Intervention for Rural Women Veterans

  • Nichole A. Murray-SwankEmail author
  • Barbara M. Dausch
  • Aaron B. Murray-Swank



Despite significant advances in the study of mindfulness-based interventions, research on the accessibility, acceptability, and effectiveness of varied implementation platforms is lacking, particularly among rural populations. In this study, we examined the preliminary effectiveness of a retreat-based, mindfulness-oriented intervention for rural, women veterans.


Sixty-six women veterans from rural locales participated in 3-day retreats and completed measures of psychological distress, PTSD symptoms, and mindfulness before the intervention (time 1), after the retreats (time 2), at 1-month (time 3), and 3 months post-intervention (time 4).


Repeated measures ANOVAs revealed statistically significant decreases in global psychological distress, depression, anxiety, and somatization, and significant increases in four facets mindfulness (i.e., observing, acting with awareness, nonjudging, and nonreactivity) at time 2. The participants showed sustained increases in acting with awareness, nonjudging, and nonreactivity at both follow-ups with small effect sizes. At times 3 and 4, participants displayed sustained decreases in PTSD symptoms and depression (ds = .21–.44). Significant interactions demonstrated that those with probable PTSD exhibited the largest changes in symptoms, and sustained changes in PTSD (d = .59) and depression (d = .81) at time 4. Qualitative results revealed the salience of group factors including universality and support; clinician conditions of warmth, availability, and genuineness; retreat-specific elements such as time away and condensed therapeutic care; and programmatic components including mindfulness and yoga.


Retreat-based, mindfulness-oriented programs show promise as an effective alternative for underserved, rural women veterans. The implementation advantages and challenges, particularly among those with PTSD, are discussed.


Rural women veterans Mindfulness Retreat-based intervention Implementation PTSD 


Author Contributions

NMS: Designed and executed the study, implemented the interventions, analyzed the data, and wrote the paper. BD: Obtained grant funding, designed and executed the study, implemented the interventions, wrote part of the method section, created tables, and collaborated in the editing of the final manuscript. AMS: Reviewed prior research literature, wrote part of the introduction, and collaborated in the writing and editing of the final manuscript.

Funding Information

This research was funded in part by the U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Rural Health grant awarded to Barbara M. Dausch, PhD (N19-FY14Q1-S2-P01019).

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures used were in accordance with the ethical standards of and approved by the Colorado Multiple Institutional Review Board (COMIRB) and the VA Office of Research and Development.

Informed Consent

Informed consent was obtained from all participants in this study.


  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.CrossRefGoogle Scholar
  2. Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report measures to explore facets of mindfulness. Assessment, 13(1), 27–45. Scholar
  3. Baer, R. A., Smith, G. T., Lykins, E., Button, D., Krietemeyer, J., Sauer, S., et al. (2008). Construct validity of the five facet mindfulness questionnaire in meditating and nonmeditating samples. Assessment, 15(3), 329–342. Scholar
  4. Bean-Mayberry, B., Yano, E. M., Washington, D. L., Goldzweig, C., Batuman, F., Huang, C., . . . Shekelle, P. G. (2011). Systematic review of women Veterans’ health: update on successes and gaps. Women’s Health Issues, 21(4, Supplement), S84–S97. Scholar
  5. Bernard, H., Burlingame, G., Flores, P., Greene, L., Joyce, A., Kobos, J. C … & Feirman, D. (2008). Clinical practice guidelines for group psychotherapy. International Journal of Group Psychotherapy, 58(4), 455–542. Scholar
  6. Bisson, J. I., Roberts, N. P., Andrew, M., Cooper, R., & Lewis, C. (2013). Psychological therapies for chronic post- traumatic stress disorder (PTSD) in adults. Cochrane Database of Systematic Reviews, 2013(12).
  7. Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The Posttraumatic Stress Disorder Checklist for DSM-5 (PCL-5): development and initial psychometric evaluation. Journal of Traumatic Stress, 28(6), 489–498. Scholar
  8. Bobrow, J., Cook, E., Knowles, C., & Vieten, C. (2013). Coming all the way home: integrative community care for those who serve. Psychological Services, 10(2), 137–144. Scholar
  9. Bovin, M. J., Marx, B. P., Weathers, F. W., Gallagher, M. W., Rodriguez, P., Schnurr, P. P., & Keane, T. M. (2016). Psychometric properties of the PTSD checklist for Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (PCL-5) in Veterans. Psychological Assessment, 28(11), 1379–1391. Scholar
  10. Brooks, E., Dailey, N., Bair, B., & Shore, J. (2014). Rural women Veterans demographic report: defining VA users’ health and health care access in rural areas. The Journal of Rural Health, 30(2), 146–152. Scholar
  11. Brooks, E., Dailey, N. K., Bair, B. D., & Shore, J. H. (2016). Listening to the patient: women Veterans’ insights about health care needs, access, and quality in rural areas. Military Medicine, 181(9), 976–981. Scholar
  12. Bryan, C. J., & Morrow, C. E. (2011). Circumventing mental health stigma by embracing the warrior culture: lessons learned from the Defender’s Edge program. Professional Psychology: Research and Practice, 42(1), 16–23. Scholar
  13. Cantrell, C., Valley-Gray, S., & Cash, R. E. (2012). Suicide in rural areas: risk factors and prevention. In K. B. Smalley, J. C. Warren, & J. Rainer (Eds.), Rural mental health: issues, policies, and best practices (pp. 213–228). New York: Springer.Google Scholar
  14. Coeytaux, R. R., McDuffie, J., Goode, A., Cassel, S., Porter, W. D., Sharma, P., ... & Williams J. J. (2014). Evidence map of yoga for high-impact conditions affecting Veterans. VA Evidence-based Synthesis Project #09–010. Washington, DC: Department of Veteran Affairs (US).Google Scholar
  15. Cordasco, K. M., Mengeling, M. A., Yano, E. M., & Washington, D. L. (2016). Health and health care access of rural women Veterans: findings from the national survey of women Veterans. Journal of Rural Health, 32(4), 397–406. Scholar
  16. Cramer, H., Lauche, R., Anheyer, D., Pilkington, K., de Manincor, M., Dobos, G., & Ward, L. (2018). Yoga for anxiety: a systematic review and meta-analysis of randomized controlled trials. Depression and Anxiety, 35(9), 830–843. Scholar
  17. Derogatis, L. R. (2001). Brief Symptom Inventory 18 (BSI-18): administration, scoring and procedures manual. Minneapolis: NCS Pearson Incorporated.Google Scholar
  18. Dutton, M. A. (2015). Mindfulness-based stress reduction for underserved trauma populations. In V. M. Follette, J. Briere, D. Rozelle, J. W. Hopper, & D. I. Rome (Eds.), Mindfulness-oriented interventions for trauma: integrating contemplative practices (pp. 243–256). New York: Guilford Publications.Google Scholar
  19. Engle, J. L., & Follette, V. M. (2015). Mindfulness and valued action: an acceptance and commitment therapy approach to working with trauma survivors. In V. M. Follette, J. Briere, D. Rozelle, J. W. Hopper, & D. I. Rome (Eds.), Mindfulness-oriented interventions for trauma: integrating contemplative practices (pp. 61–74). New York, NY: Guilford Publications.Google Scholar
  20. Frayne S.M, Phibbs C. S., Saechao F., Maisel N. C., Friedman S. A., Finlay A., … Haskell S. (2014). Sourcebook: Women Veterans in the Veterans Health Administration. Volume 3. Sociodemographics, utilization, costs of care, and health profile. Washington DC: Women’s Health Evaluation Initiative, Women’s Health Services, Department of Veterans Affairs.Google Scholar
  21. Friedman, S. A., Frayne, S. M., Berg, E., Hamilton, A. B., Washington, D. L., Saechao, F., … Phibbs, C. S. (2015). Travel time and attrition from VHA care among women Veterans: How far is too far? Medical Care, 53(4 0 1), S15–S22. CrossRefGoogle Scholar
  22. Gard, T., Noggle, J. J., Park, C. L., Vago, D. R., & Wilson, A. (2014). Potential self-regulatory mechanisms of yoga for psychological health. Frontiers in Human Neuroscience, 8(770), 1–20. Scholar
  23. Goldzweig, C. L., Balekian, T. M., Rolon, C., Yano, E. M., & Shekelle, P. G. (2006). The state of women Veterans’ health research. Journal of General Internal Medicine, 21(S3), S82–S92. Scholar
  24. Gray, J. S. (2011). Rural mental health research white paper. Grand Forks, ND: University of North Dakota.Google Scholar
  25. Hacker, T., Stone, P., & MacBeth, A. (2016). Acceptance and commitment therapy—do we know enough? Cumulative and sequential meta-analyses of randomized controlled trials. Journal of Affective Disorders, 190, 551–565. Scholar
  26. Hanh, T. N. (2009). Happiness: essential mindfulness practices. Berkley, CA: Parallax Press.Google Scholar
  27. Hanley, A. W., Abell, N., Osborn, D. S., Roehrig, A. D., & Canto, A. I. (2016). Mind the gaps: are conclusions about mindfulness entirely conclusive? Journal of Counseling & Development., 94(1), 103–113. Scholar
  28. Hasson-Ohayon, I., Roe, D., & Kravetz, S. (2006). A qualitative approach to the evaluation of psychosocial interventions for persons with severe mental illness. Psychological Services, 3(4), 262–273.CrossRefGoogle Scholar
  29. Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2011). Acceptance and commitment therapy: the process and practice of mindful change (2nd ed.). New York: Guilford Press.Google Scholar
  30. Hermann, B. A., Meyer, E. C., Schnurr, P. P., Batten, S. V., & Walser, R. D. (2016). Acceptance and commitment therapy for co-occurring PTSD and substance use: a manual development study. Journal of Contextual Behavioral Science, 5(4), 225–234. Scholar
  31. Jasbi, M., Sadeghi Bahmani, D., Karami, G., Omidbeygi, M., Peyravi, M., Panahi, A., et al. (2018). Influence of adjuvant mindfulness-based cognitive therapy (MBCT) on symptoms of post-traumatic stress disorder (PTSD) in veterans—results from a randomized control study. Cognitive Behaviour Therapy, 47(5), 431–446. Scholar
  32. Kaplan, M. S., McFarland, B. H., & Huguet, N. (2009). Firearm suicide among veterans in the general population: findings from the national violent death reporting system. Journal of Trauma and Acute Care Surgery, 67(3), 503–507. Scholar
  33. Karlin, B. E., & Cross, G. (2014). From the laboratory to the therapy room: national dissemination and implementation of evidence-based psychotherapies in the US Department of Veterans Affairs Health Care System. American Psychologist, 69(1), 19–33. Scholar
  34. Kearney, D. J., McDermott, K., Malte, C., Martinez, M., & Simpson, T. L. (2013). Effects of participation in a mindfulness program for veterans with posttraumatic stress disorder: a randomized controlled pilot study. Journal of Clinical Psychology, 69(1), 14–17. Scholar
  35. Kimerling, R., Gima, K., Smith, M. W., Street, A., & Frayne, S. (2007). The veterans health administration and military sexual trauma. American Journal of Public Health, 97(12), 2160–2166. Scholar
  36. King, A. P., Erickson, T. M., Giardino, N. D., Favorite, T., Rauch, S. M., Robinson, E., et al. (2013). A pilot study of group mindfulness-based cognitive therapy (MBCT) for combat veterans with posttraumatic stress disorder (PTSD). Depression and Anxiety, 30, 638–645. Scholar
  37. Kummar, A. S. (2018). Mindfulness and fear extinction: a brief review of its current neuropsychological literature and possible implications for posttraumatic stress disorder. Psychological Reports, 121(5), 792–814. Scholar
  38. Larson, J. E., Corrigan, P. W., & Cothran, T. P. (2012). The impact of mental health stigma on clients from rural settings. In K. B. Smalley, J. C. Warren, & J. Rainer (Eds.), Rural mental health: issues, policies, and best practices (pp. 49–64). New York, NY: Springer.Google Scholar
  39. Magyari, T. (2015). Teaching mindfulness-based stress reduction and mindfulness to women with complex trauma. In V. M. Follette, J. Briere, D. Rozelle, J. W. Hopper, & D. I. Rome (Eds.), Mindfulness-oriented interventions for trauma: integrating contemplative practices (pp. 140–156). NY: Guilford Press.Google Scholar
  40. Markova, D. (2000). I will not die an unlived life: reclaiming purpose and passion. Berkley, CA: Conari Press.Google Scholar
  41. Martinez, M. E., Kearney, D. J., Simpson, T., Felleman, B. I., Benardi, N., & Sayre, G. (2015). Challenges to enrollment and participation in mindfulness-based stress reduction among veterans: a qualitative study. Journal of Alternative and Complementary Medicine, 21(7), 409–421. Scholar
  42. McCarthy, J. F., Blow, F. C., Ignacio, R. V., Ilgen, M. A., Austin, K. L., & Valenstein, M. (2012). Suicide among patients in the Veterans Affairs health system: rural-urban differences in rates, risks, and methods. American Journal of Public Health, 102(S1), S111–S117. Scholar
  43. McFarland, B. H., Kaplan, M. S., & Huguet, N. (2010). Self-inflicted deaths among women with US military service: a hidden epidemic? Psychiatric Services, 61(12), 1177. Scholar
  44. Miller, R. C. (2015). The iRest program for healing PTSD. Oakland, CA: New Harbinger Publications.Google Scholar
  45. Mitchell, K. S., Dick, A. M., DiMartino, D. M., Smith, B. N., Niles, B., Koenen, K. C., & Street, A. (2014). A pilot study of a randomized controlled trial of yoga as an intervention for PTSD symptoms in women. Journal of Traumatic Stress, 27(2), 121–128. Scholar
  46. Mohatt, D. F., Bradley, M. M., Adams, S. J., & Morris, C. D. (2006). Mental health and rural America: 1994–2005. Department of Health and Human Services, Health Resources and Services Administration: U. S Retrieved from Retrieved April 26, 2018.Google Scholar
  47. Monk, J. K., Ogolsky, B. G., & Bruner, V. (2016). Veteran couples integrative intensive retreat model: An intervention for military veterans and their relational partners. Journal of Couple & Relationship Therapy, 15(2), 158–176. Scholar
  48. Moore, M., Brown, D., Money, N & Bates, M. (2011). Mind-body skills for regulating the autonomic nervous system. Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, Version 2.Google Scholar
  49. Morland, L. A., Raab, M., Mackintosh, M. A., Rosen, C. S., Dismuke, C. E., Greene, C. J., & Frueh, B. C. (2013). Telemedicine: a cost-reducing means of delivering psychotherapy to rural combat veterans with PTSD. Telemedicine and e-Health, 19(10), 754–759. Scholar
  50. Morland, L. A., Mackintosh, M. A., Greene, C. J., Rosen, C. S., Chard, K. M., Resick, P., & Frueh, B. C. (2015). Cognitive processing therapy for posttraumatic stress disorder delivered to rural veterans via telemental health: a randomized noninferiority clinical trial. The Journal of Clinical Psychiatry, 75, 470–476. Scholar
  51. Murray-Swank, N. A., Dausch, B. M., & Ehrnstrom, C. (2018). The mental health status and barriers to seeking care in rural women Veterans. The Journal of Rural Mental Health, 4(2), 102–115. Scholar
  52. Niles, B. L., Klunk-Gillis, J., Ryngala, D. J., Silberbogen, A. K., Paysnick, A., & Wolf, E. J. (2012). Comparing mindfulness and psychoeducation treatments for combat-related PTSD using a telehealth approach. Psychological Trauma Theory Research Practice and Policy, 4(5), 538–547. Scholar
  53. Pence, P., Katz, L., Huffman, C., & Cojucar, G. (2014). Delivering integrative restoration-yoga nidra meditation (iRest®) to women with sexual trauma at a veteran’s medical center: a pilot study. International Journal of Yoga Therapy, 24(1), 53–62.CrossRefGoogle Scholar
  54. Polusny, M. A., Erbes, C. R., Thuras, P., Moran, A., Lamberty, G. J., Collins, R. C., et al. (2015). Mindfulness-based stress reduction for posttraumatic stress disorder among Veterans: a randomized clinical trial. JAMA, 314(5), 456–465. Scholar
  55. Powers, M. B., Vörding, M. B. Z. V. S., & Emmelkamp, P. M. (2009). Acceptance and commitment therapy: a meta-analytic review. Psychotherapy and Psychosomatics, 78(2), 73–80. Scholar
  56. Riddle, J. R., Smith, T. C., Smith, B., Corbeil, T. E., Engel, C. C., Wells, T. S., et al. (2007). Millennium cohort: the 2001-2003 baseline prevalence of mental disorders in the U.S. military. Journal of Clinical Epidemiology, 60(2), 192–201. Scholar
  57. Roe, D., Hasson-Ohayon, I., Salyers, M., & Kravetz, S. (2009). A one-year follow-up of illness management and recovery: clients’ accounts of its impact and uniqueness. Psychiatric Rehabilitation Journal, 32(4), 285–291. Scholar
  58. Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95–103. Scholar
  59. Tiet, Q. Q., Leyva, Y. E., Blau, K., Turchik, J. A., & Rosen, C. S. (2015). Military sexual assault, gender, and PTSD treatment outcomes of US Veterans. Journal of Traumatic Stress, 28(2), 92–101. Scholar
  60. U.S. Department of Veterans Affairs. (2008). Uniform mental health services in VA medical centers and clinics (VHA Handbook 1160.01). Washington, DC: Author Amended Nov 2015.Google Scholar
  61. U.S. Department of Veterans Affairs, Office of Rural Health. (2015). Office of Rural Health annual report. Retrieved from Retrieved June 8, 2018.
  62. U.S. Department of Veterans Affairs, Office of Rural Health. (2018). Office of Rural Health programs. Retrieved from Retrieved June 8, 2018.
  63. U.S. Department of Veterans Affairs, Office of Suicide Prevention. (2016). Suicide among Veterans and other Amercians 2001–2014. Retrieved from Retrieved June 8, 2018.
  64. van der Kolk, B. A., Stone, L., West, J., Rhodes, A., Emerson, D., Suvak, M., & Spinazzola, J. (2014). Yoga as an adjunctive treatment for posttraumatic stress disorder: a randomized controlled trial. Journal of Clinical Psychiatry, 75(6), e559–e565. Scholar
  65. Visted, E., Vøllestad, J., Nielsen, M. B., & Nielsen, G. H. (2015). The impact of group-based mindfulness training on self-reported mindfulness: a systematic review and meta-analysis. Mindfulness, 6(3), 501–522. Scholar
  66. Vujanovic, A. A., Niles, B., Pietrefesa, A., Schmertz, S. K., & Potter, C. M. (2013). Mindfulness in the treatment of posttraumatic stress disorder among military veterans. Spirituality in Clinical Practice, 1(S), 15–25. Scholar
  67. Waelde, L. C. (2015). Mindfulness and meditation for trauma-related dissociation. In V. M. Follette, J. Briere, D. Rozelle, J. W. Hopper, & D. I. Rome (Eds.), Mindfulness-oriented interventions for trauma: integrating contemplative practices (pp. 301–313). New York, NY: Guilford Publications.Google Scholar
  68. Wahbeh, H., Goodrich, E., Goy, E., & Oken, B. S. (2016). Mechanistic pathways of mindfulness meditation in combat veterans with posttraumatic stress disorder. Journal of Clinical Psychology, 72(4), 365–383. Scholar
  69. Walser, R. D., Garvert, D. W., Karlin, B. E., Trockel, M., Ryu, D. M., & Taylor, C. B. (2015). Effectiveness of acceptance and commitment therapy in treating depression and suicidal ideation in Veterans. Behavior Research and Therapy, 74, 25–31. Scholar
  70. Weathers, F. W., Litz, B. T., Keane, T. M., Palmieri, P. A., Marx, B. P., & Schnurr, P. P. (2013). The PTSD Checklist for DSM-5 (PCL-5). Scale available from the National Center for PTSD at
  71. Wortmann, J. H., Jordan, A. H., Weathers, F. W., Resick, P. A., Dondanville, K. A., Hall-Clark, B., et al. (2016). Psychometric analysis of the PTSD Checklist-5 (PCL-5) among treatment-seeking military service members. Psychological Assessment, 28(11), 1392–1403. Scholar
  72. Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). NY: Basic Books.Google Scholar

Copyright information

© This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply 2019

Authors and Affiliations

  • Nichole A. Murray-Swank
    • 1
    Email author
  • Barbara M. Dausch
    • 1
  • Aaron B. Murray-Swank
    • 1
  1. 1.VA Eastern Colorado Health Care SystemRocky Mountain Regional VAMCAuroraUSA

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