Veterans with mental conditions, substance abuse disorder help researchers find answers
July 9, 2021
By Mike Richman
VA Research Communications
Veteran with PTSD, depression finds relief through mindfulness training
Dr. William Marchand is an avid recreational sailor. To him, the scenery, wind, and water are calming and compatible with mindfulness.
Mindfulness involves focusing on the present moment, while calmly acknowledging and accepting one's feelings, thoughts, and bodily sensations. Walking, hiking, meditation, and yoga can help someone achieve a state of mindfulness—as can any other type of sport or recreational activity—if one is focused on the present.
So an idea dawned on Marchand, a psychiatrist at the VA Salt Lake City Health Care System. Understanding that many Veterans with mental conditions and substance use disorders do not experience full remission from conventional treatments or engage in such therapies at all, he and VA colleagues embarked on testing a recreational program that would encourage participation by offering an enjoyable experience, while imparting a therapeutic benefit.
His choice: mindfulness-based therapeutic sailing (MBTS). “There isn’t a rule that says treatment can’t be fun,” he reasons.`
Bringing one back to the present moment
Marchand has led three pilot studies thus far, including one with nature exposure through recreational sailing and another with nature exposure through sailing combined with mindfulness training. The latter teaches one to have a non-judgmental awareness of the present and to differentiate that from autopilot thinking, or thinking instinctively, about the past and the future, according to Marchand.
“The practice involves being aware of that autopilot thinking and bringing one back to the present moment,” he says. “That’s primarily what we wanted as the take home message about mindfulness, something that people could grasp in a short period of time and could start using.”
Marchand’s most recent research was based on what he and his colleagues learned from the first two pilot studies: The concept appeared to be feasible and warranted further evaluation, and the sessions should include only sailing and not classroom-only sessions. The study included mindfulness training and was aimed at establishing a version of MBTS that would be ready for a rigorous controlled study with a large number of participants. The findings appeared in the journal Military Medicine in February 2021.
The study included 25 Veterans, all but two of whom were men (see sidebar). Each participant had at least one mental health condition or substance use disorder, and more than 90% had two or more conditions. With help from the Park City Sailing Association in Utah, the Veterans engaged in three sailing sessions of at least an hour each at the Jordanelle Reservoir State Park in Utah.
The researchers used a physical activity enjoyment scale to determine how much the participants liked the program. Scores indicated that most of the participants enjoyed the sailing, and that it was potentially linked to a decline in substance use treatment services. But the latter finding, Marchand cautions, is a correlation and not a cause and effect. He says it’s unclear how MBTS is related to less need for substance abuse treatment.
“The sailing possibly helped participants decrease substance use, and thus less treatment was needed,” Marchand says. “But more rigorous studies will be needed to further explore this finding.” Findings support results from prior studyThe results must be considered preliminary, according to Marchand and his team. “However, these findings corroborate results from a previous pilot study and indicate that MBTS holds promise as a complementary [program] that could result in enhanced treatment engagement and-or outcomes for the population studied,” the researchers write. “A randomized controlled trial of MBTS is warranted. Further, the model of a three-session [program] combining mindfulness training with nature exposure could be adapted for other types of nature exposure, such as hiking, snowshoeing, or other complementary [therapies], including equine-assisted activities and therapies.”
Marchand is confident that MBTS can improve treatment engagement or response among Veterans in conventional programs, similar to the potential of other complementary therapies, such as yoga, tai chi, or meditation. However, he would not recommend MBTS as a stand-alone treatment for a mental health condition because of its limited evidence base. A conventional treatment, such as medication or one of the trauma-focused psychotherapies VA uses to treat patients with PTSD—cognitive processing therapy or prolonged exposure—must be used first or in parallel with a complementary therapy, such as MBTS, he notes. “Over time and with lots of research, many things once considered complementary develop as stand-along treatments,” he says. “But recreational sailing would most likely remain a complementary intervention long-term.”
Based on the post-sailing questionnaire, researchers in Marchand’s most recent study also concluded that MBTS is linked to increases in psychological flexibility and mindfulness. Psychological flexibility, he says, is the ability to respond to situations in a manner that helps the person and is also consistent with his or her personal values.
“One way of thinking about it is the level of rigidity in one’s thinking versus the ability to be adaptive and perhaps most importantly to be able to engage in flexible behaviors,” he says. “A good example is that when we are upset, we tend to respond in an emotional way. So a Veteran has an argument with his or her spouse and feels upset and angry and tends to respond the way they’ve always responded in habitual behavior patterns that often aren’t very helpful. With psychological flexibility, one can better take stock and say, `Hmmm, this is what I always do, but it doesn’t work very well. Maybe I need to try something different.’”
The researchers didn’t measure PTSD-specific outcomes, for example, by using a PTSD symptom scale. “Increases in mindfulness and psychological flexibility would be expected to be beneficial for PTSD, but that must be explored in future studies,” he says.Nearly 100% of participants attended all of the sessionsOne goal of developing the MBTS program was to increase treatment participation. Marchand was surprised by the level of engagement, with 96% of the participants attending all of the sessions. That was an “excellent result” that strongly supports the use of MBTS from an engagement in treatment standpoint, he says. “This was primarily a proof of concept study, and our ability to assess outcomes was limited due to the small sample size. That said, outcome data were promising, but clearly more rigorous studies are needed with much larger sample sizes,” he says.
Participation was up, he says, mainly because all of the sessions in the study included sailing. All of this begs the following questions: How practical is MBTS as a long-term therapy for Veterans experiencing mental and substance abuse disorders? And how many Veterans can VA help with this type of therapy?
“That is difficult to answer until we do more rigorous studies that can assess cost benefit data to determine if [MBTS] would be cost-effective to implement at other VA facilities,” Marchand says. “Also, the motivation and ability to implement a program like this will vary from one VA site to another. So even if MBTS is shown to be beneficial and cost-effective in larger studies, it is impossible to know how widely it will be disseminated.
“However, that said, MBTS is a model that could be implemented with community partners–like we did with the Park City Sailing Association in Utah– in many parts of the country at least during the summer months,” he adds. “Using this model at our site, we could likely serve around 100 Veterans per summer season.”
But not all VA medical centers are close to a body of water.
“That’s one of the major limitations,” Marchand says. “Part of our work has been to develop the general concept of a therapy involving recreation and nature exposure and not necessarily tie it to sailing. For example, hiking is much more accessible and also is a nature exposure. So it might be that this model could be adapted to other more accessible forms of nature exposure.”
Control groups a challenge in studies on recreational therapyMarchand says there are various ways he could carry out a randomized controlled trial on the effectiveness of a recreational therapy. One approach would be to focus on a specific population, such as Veterans with PTSD, and randomize the participants into a treatment group that includes a recreational therapy and mindfulness training, and a control group with standard treatment. He explains that controls are challenging for studies like this because it’s impossible to blind participants and the study team. The number of Veterans would likely be around 120, with 60 in each group.
“The concept is really combining a mindfulness program with something else that is healing like nature exposure and using it to engage Veterans,” he says, “because one of the real problems we have is engaging Veterans in treatment. So combining treatment with something that is often perceived as pleasurable tends to be more engaging than inviting someone to sit in a therapy office for six to eight sessions.”
Currently, Marchand’s main research focus is on equine services, or interaction with horses, and equine-assisted psychotherapy. In one of his upcoming studies, the treatment group will include equine services with no mindfulness training, and the control group will include standard treatment.
“We’ve become interested in taking this general concept and applying it to other activities, such as hiking, which is probably just as accessible and might be just as effective, and equine services,” he says. “We want to use the outcome measures from our pilot studies, as well as diagnosis specific measures, such as PTSD symptom scales. I’m not sure that we’ll necessarily continue to explore the sailing piece. Everything is speculative at this point.”
Several people have asked and so here's an account of the work done in the last 8+ years. In August 2012 I bought her and had the bow fitting recast, the main hatch rebuilt and the main hatch Turtle replaced. I replaced the head at that time also. In 2013 we focused in on her floors and interior. My father and my oldest son did a mountain of work to remove tankage and get at the main floors, nine in the center of the boat which are steel. A lot of effort went in to removing all the rust and Carlos Campos and his crew ground out what we could not. Each was treated with osphoic acid, primed and the whole space finished off with two coats of bilgecote. At this time the aluminum mast step and the chain plates were treated as well.
The deck had been replaced in 2000 with marin plywood and was in great shape but baldly needed repainting. The converting board was also in good shape except for water damage in way of the chainplates so that was removed and graving pieces ("dutchmen") were put in to seal the openings in way of the chainplates coming through the deck. We then we turned our attention to the cabin top and the cockpit. The after part of c/p coaming at the bend had split and was showing iron damage at the drifts, so we had Jody Boyle now with the NW School of Boatbuilding fabricate a replacement, beautifully scarfed in. Meantime every surface in the interior was washed and repainted or revarnish during that happy summer of grandfather and grandson working together.
By this time I took her out for a couple of sailing outings but was awfully uncomfortable with the performance of the BMW engine which was on its very last legs and even at full power could barely stem a strong ebb off yellow bluff - not great in the light airs of wintertime.. so the decision was made to reposer her and List Marine got the project and began in January 2014. These guys are wonderful. Hans and Bill are perfectionists and managed to build new engine beds from the original,, as today's engines mount higher to accommodate the typically spoon-shaped sterns in current designs. At any rate two months later and with the entire engine room repainted and three cracked frames under the engine beds braced, the project was finished and I could take her out with equanimity.
2014 was a busy year of restoration and replacement as I was keen to have her out sailing as much and as soon as possible. By this time her deck was really in need of repainting and her brightwork which was already tired when I got her was by now done screaming for attention and it was clear it would have to be taken down to bare wood. Carlos was given both projects and removed all deck fittings and lifelines, prepped and premiered the surfaces, then tented the boat and sprayed her deck. (My crew and I were anxious to race in the Master Mariners that year, but at the race the deck had only been sealed and premiered.. the foredeck was an ice rink; suffice it to say there were no headsail changes were made that day.) When that was done we proceeded to take the cabin sides cockpit coaming and well and the toe rails down to bare wood, stain them back to their original Honduran Mahogany color, and used 8 coats of Pratt & Lambert varnish to bring them up. Also in 2014 we replaced a worn down teak veneer on the cabin top with a product called Ameriteak which we've been very pleased with, and replaced the primary winches and added a snubbing winch for the Main.
I hauled her again in 2015, this time at Bay Marine, and painted the bottom and had Jeff Rutherford repair two cracked frames just forward of the cockpit, under the pilot cabin, where the turn of the bilge is extreme and due to her long cabin the boat's narrow hull is loaded up at that location. He braced those frames and we also strengthen the cabin after bulkhead, where large holes had been cut out to take the original knotmeter and depth sounder instruments but had weakened the bulkhead as a result, this doubler is as thick as the original bulkhead. Since then the boat has been sailed in typical bay summer conditions and there are no cracks or evidence of weakness in the pilot cabin area. Also during this haulout I replaced the set screws that attach the rudder post to the rudder - a stainless steel post had been installed at some point during the boat's career and set screws bored into the post from the rudder itself. The theory is sound and we bored a little deeper and tapped a little wide diameter to take a slightly larger size set screw. I replaced the cutlass bearing at that time.
2016-2018 were spent putting her to work sailing veterans aboard, and happily showing her at the Wooden Boat show and I even lived aboard her during 2017 and got to the know the boat and her ways really well. She is the most well balanced sailer you can find, a real performer upwind but loves every point of sail equally, except perhaps the beam reach. Having a tiller on a boat of her size is really terrific, and the boat will talk to you through the tiller instantly. Her main is mighty powerful and at 705 square feet of sail she will demand your attention but she will also be merciful and round up like an intelligent thoroughbred. Olin Stephens was a remarkable man.
In October 2018 I decided I had put it off long enough and needed to paint her hull. I hauled her at San Rafael boatyard and turned again to Carlos Campos who did a wonderful job on the project. He also replaced the through hull fitting for the discharge to the head at that time. During 2018 I have rechromed or re-plated just about every metal fitting, bow chocks, fairleads, the capstan, the companionway ladder fittings, it was coming close to a fetish but I made good friends with Lynne at Pilgrim Plating in San Rafael.
As the Clover Project ramped up in 2019 we switched to doing mainly upkeep on Valiant. I have installed a new VHF radio and pump assembly for the head, and bought new jib sheets. We went through a LOT of varnish in her time. She was wonderful to care for, and she always took care of us.
VALIANT, a 1962 Sparkman Stephens sloop, Design #708 from Olin Stephen. Originally known as the Rascal Class, she was built in Buenos Aires of extraordinary craftsmanship - vivaro planking copper revised onto steam bent frames of white oak. Honduras mahogany on deck and below, she is gorgeous. With 705 sq.ft. of sail area she is very fast. With a tiller instead of a wheel she is well balanced, although she WILL require your attention! Her lines are similar to the New York 32 class built in the 1930's.
Her designer, Olin James Stephens II (April 13, 1908 – September 13, 2008) was one of the most successful American yacht designers of the 20th century. Stephens' name had a long history in connection with America's Cup. He assisted W. Starling Burgess with the design of the J-Class Ranger, which won the America's Cup in 1937, defeating the Royal Yacht Squadron's Endeavour II in four races. He was the original designer of six out of seven successful 12 Metre defenders of the America's Cup between 1958 and 1980, with the exception of Weatherly in 1962. Other than Ranger, the most remarkable of his defenders was the Intrepid. She had a rudder separate from her keel to reduce wetted surface and improve steering. Stephens had previously designed separate rudders on a number of increasingly large ocean racers of the 1960s, most notably Thomas Watson's state of the art Palawan III, before using it successfully on the Intrepid in 1967. After alterations by Britton Chance, Jr., she won the America's Cup again in 1970.
Stephens also designed many off-shore and stock boats, including the Dark Harbor 20, which he designed in 1934. His brother, Roderick Stephens, was also a partner in the yacht-designing and yacht brokerage firm Sparkman & Stephens, specializing in supervision and testing of yachts designed by the firm. Olin was working in the Nevins shipyard in 1928 as a draftsman when he first met yacht broker Drake Sparkman. They together set up an office next door to Nevins in 1929. Since retiring from the company he lived in Hanover, New Hampshire, where he spent his final years writing computer programs for designing yachts. He was awarded the Herreshoff Award by the North American Yacht Racing Union in 1965 for his contributions to sailing.
Stephens was also involved in ocean-going sailboats. His yawl designs Dorade (1929) and Stormy Weather (1934), his favorite design, each won the Newport Bermuda Race and the Fastnet race several times. Both brothers were accomplished yachtsmen. They were members of the winning crews of Dorade and Ranger. Olin served as tactician and navigator, while Rod trimmed the rig and sails. In the 1960s and 1970s, Olin contributed to the luxury yacht builders Nautor Swan of Finland and Hallberg-Rassy of Sweden.
Wooden Boats for Veterans (EIN 46-4194065) a nonprofit private foundation, was founded by combat veterans and sailors dedicated to enriching veterans’ lives. We have served and we have a passion for restoring and sailing boats.
Our long-term strategy to deliver a prolonged impact to veterans includes building community in the Bay and Delta regions through wooden boat restoration projects and sail training, ultimately leading to a capstone voyage to Hawaii.
To find out how you can be involved, visit us at www.vetsboats.org or on Facebook at https://www.facebook.com/vetsboats.org/