The University of Toledo Digital Repository. The University of Toledo. Shellie Theiss The University of Toledo. Master s and Doctoral Projects

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1 The University of Toledo The University of Toledo Digital Repository Master s and Doctoral Projects Healthy Engagement in Relationships and Occupations (H.E.R.O.) : an occupation-based program development plan for veterans with posttraumatic stress disorder (PTSD) Shellie Theiss The University of Toledo Follow this and additional works at: This Capstone Project is brought to you for free and open access by The University of Toledo Digital Repository. It has been accepted for inclusion in Master s and Doctoral Projects by an authorized administrator of The University of Toledo Digital Repository. For more information, please see the repository's About page.

2 Running head: 1 Healthy Engagement in Relationships and Occupations (H.E.R.O.) An Occupation-Based Program Development Plan for Veterans with Post-Traumatic Stress Disorder (PTSD) Shellie Theiss Faculty/Site Mentor: Barbara Kopp Miller, Ph.D. Occupational Therapy Doctoral Program Department of Rehabilitation Sciences The University of Toledo May 2013 Note: This document describes a Capstone Dissemination project reflecting an individually planned experience conducted under faculty and site mentorship. The goal of the Capstone experience is to provide the occupational therapy doctoral student with a unique experience whereby he/she can

3 2 demonstrate leadership and autonomous decision-making in preparation for enhanced future practice as an occupational therapist. As such, the Capstone Dissemination is not formal research. I. Executive Summary....5 II. Introduction...6 A. Program Goal....6 B. Program Site C. Procedures Used to Assess the Need for Programming....7 D. Literature Review.. 10 E. Occupation-Based Program Need.17 F. Model of Practice G. Health Initiatives, National and International Trends...20 III. Objectives A. Program Goal..21 B. Program Objectives.. 21 IV. Marketing and Recruitment...22 A. Marketing Plan...22 B. Inclusion Criteria and N...24 C. Marketing Timeline...26 V. Programming...26 A. Schedule and Foundation of Program...26 B. Program Assessments...27 C. Documentation System.28

4 3 D. Session One of the Intervention Program E. Session Two of the Intervention Program F. Session Three of the Intervention Program..29 G. Session Four of the Intervention Program H. Session Five of the Intervention Program...32 I. Session Six of the Intervention Program...33 J. Session Seven of the Intervention Program..34 K. Session Eight of the Intervention Program.. 34 L. Session one for Significant Other Education 35 M. Care Coordination 36 N. Discharge Procedures 36 VI. Budget and Staffing.37 A. Itemized Budget 37 B. Justification of Costs.39 C. Credentials of Occupational Therapist...42 D. Potential Funding Sources 42 E. Self-Sufficiency Plan.44 VII. Program Evaluation...45 A. Outcome Evaluation for Each Objective B. Process Evaluation Procedures C. Summative Evaluation VIII. Timeline 49 A. OEF/OIF Group 49

5 4 B. Veterans of Previous Wars Group References I. Appendices. 61 Appendix A: Center for Successful Aging Organizational Chart...61 Appendix B: Semi-Structured Interview for Veterans...62 Appendix C: Needs Assessment Questionnaire for Toledo Vet Center 63 Appendix D: Survey for Wauseon PTSD Support Group: Summary 65 Appendix E: Marketing Flyer for Potential Participants...66 Appendix F: Marketing Flyer for Significant Others 67 Appendix G: Leisure Reflection Appendix H: Handout for Significant Others 69 Appendix I: Marketing flyer to Hire Occupational Therapist Appendix J: Letter of Support Appendix K: Weekly Session Evaluation..72 Appendix L: Evaluation for Significant Other Education Session 73 Appendix M: Program Evaluation for Staff at the Center for Successful Aging.74

6 5 I. Executive Summary Veterans of the United States Military are exposed to a level of traumatic events that are not experienced by the U.S. civilian population. The need for the Healthy Engagement in Relationships and Occupations (H.E.R.O.) program for veterans seeking treatment for PostTraumatic Stress Disorder (PTSD) has been established through interviews with key-stake holders, including: veterans seeking PTSD treatment, spouses of veterans with PTSD, and mental health professionals. A review of literature relevant to Post-Traumatic Stress Disorder confirms the need for occupation-based programming. The Healthy Engagement in Relationships and Occupations (H.E.R.O.) program will be developed through the Center for Successful Aging. However, this program is developed so that it can be easily transferrable to other organizations affiliated with the Center for Successful Aging. It will run five cycles of eight-week programming, with two session groups of 10 participants in each cycle. The H.E.R.O. occupation-based program has the same protocol for both session groups. The first two sessions and the last session will be held one-on-one with the occupational therapist. Sessions three through seven will be held in a group setting. The goal of the H.E.R.O. occupational therapy program is to improve the mental health quality of life for veterans that are coping with Post-Traumatic Stress Disorder PTSD by focusing on a) communication skills to enhance interpersonal relationships, b) coping strategies, and c) leisure. The goal aims to enhance interpersonal relationships to improve the level of satisfaction and interaction in areas of occupation such as social participation.

7 6 II. Introduction A. Program Goal The goal of the Healthy Engagement in Relationships and Occupations (H.E.R.O.) occupational therapy program at the Center for Successful Aging is to improve the mental health quality of life for veterans with Post-Traumatic Stress Disorder, with a focus on; a) communication skills to enhance interpersonal relationships, b) coping strategies, and c) leisure occupations. Definitions and Explanations: Post-Traumatic Stress Disorder: This is an anxiety disorder that can occur after someone has seen or experienced a traumatic event that involved the threat of injury or death. (National Center for Biotechnology Information (NCBI), 2012). Quality of Life: The mental health well-being that affects functional status. Occupation: Encompasses everything that a person does within daily living that carries meaning and purpose. Communication: The ability to convey information to others effectively Interpersonal Relationships: Interactions and connections with family and friends that someone has. Coping Strategies: The techniques used to handle difficult situations in daily life. Leisure: The use of free time for enjoyment. B. Program Site The Center for Successful Aging at the University of Toledo, located in Toledo, OH will be the site that the Healthy Engagement in Relationships and Occupations (H.E.R.O.) occupational therapy program is developed through. The H.E.R.O. occupational therapy program

8 7 can be implemented through other organizations that the Center for Successful Aging has affiliations with. The mission statement of the Center for Successful Aging at The University of Toledo is, To enhance the quality of life for older adults through collaborative education, research, and service endeavors. The Center for Successful Aging is committed to establishing programs that focus on improving the quality of life to accomplish successful aging for older individuals in northwest Ohio and lead to opportunities for collaboration with others at state, national, and international levels. This is accomplished through: education of health care professionals, scholarly activities, and the development of programs treating older persons with dignity and compassion. This program development plan will focus on Veterans of the U.S. Military who are experiencing symptoms of PTSD that are negatively affecting aspects of mental health quality of life. Dr. Barbara Kopp Miller is the Administrative Director of the Center for Successful Aging. The Assistant Administrative Director is Dr. Victoria Steiner. The occupational therapist of the H.E.R.O. program will report to the Administrative Director, Dr. Barbara Kopp Miller. If the program is developed through another organization, that organization will determine the organizational placement of the occupational therapist. See Appendix A: Center for Successful Aging Organizational Chart. C. Procedures Used to Assess the Need for Programming To determine the current needs of veterans with Post-Traumatic Stress Disorder (PTSD), Semi-structured interviews were conducted with veterans, spouses of veterans, and professionals who treat PTSD. Surveys were used to obtain information regarding occupation-based needs of veterans that have been diagnosed with PTSD. Further, a literature review was completed to assess the mental health quality of life needs of veterans.

9 8 Semi-structured interviews were held with 13 Veterans of the United States Military. The veterans interviewed served in wars from the Korean War, Vietnam War, Desert Storm, Operation Iraqi Freedom (OIF) and Operation Enduring Freedom. Six of the veterans interviewed sought or were currently seeking treatment for PTSD symptoms. Overall, the majority of veterans interviewed reported some level of family distress due to difficulty coping and/or readjusting. Several of the veterans interviewed expressed the need for helping veterans readjust socially and to improve interpersonal relationships. Difficulties with symptoms related to PTSD, regardless of diagnosis were experienced at some point by most of the veterans. Coping with triggers, including loud noises, anger, and being in groups of people was also common. A common theme among the veterans interviewed was difficulty with relationships, at some point, which the veterans attributed to military experiences. When asked if family stress was experienced due to military experiences, Veteran 2 replied I don t keep relationships because they don t understand what I have gone through and who I am. Other veterans expressed having gone through divorces or break-ups caused from trouble readjusting. See Appendix B: Semi-Structured Interview for Veterans. A questionnaire was completed by Ralph Wineland, Team Leader, from the Toledo, Ohio Vet Center. The Toledo Vet Center, and the Vet Centers nationally are funded through the Veterans Affairs. The Vet Center offers readjustment services for veterans and their spouses. Services at the Vet Center include: PTSD, Family Counseling, Military Sex Trauma, and bereavement. Mr. Wineland reported that the Toledo Vet Center Serves 350 veterans and spouses of veterans monthly. Approximately 70-80% of those veterans are seeking services for PTSD. Mr. Wineland further reported that there is an increased need for programming that

10 9 focuses on improving interpersonal relationships that are affected by PTSD. See Appendix C: Needs Assessment Questionnaire for Toledo Vet Center. The occupational therapy student met with a PTSD support group for veterans in Wauseon, Ohio. This group will be collectively referred to as the Wauseon Group Verbal consent to utilize the information obtained through the meeting was provided by all of the veterans that shared information. The Veterans in this group served in wars including: World War I, the Korean War, the Vietnam War, and the OEF/OIF war. This group is lead by Ralph Wineland, Team Leader from the Toledo Vet Center. Several of the veterans discussed the need for educating spouses/significant others about PTSD. Surveys and open-ended questions were provided to the participants in the Wauseon Group. The surveys were developed based on the information gained through the interviews with veterans and the literature review that was completed at the beginning of the needs assessment process for the H.E.R.O. program. Five responses were returned. All except for one of the respondents expressed that PTSD affects relationships with friends and family. Further, the respondents reported that enjoyment and engagement in leisure occupations was affected by symptoms of PTSD. See Appendix D: Survey for Wauseon PTSD Support Group: Summary. The occupational therapy doctoral student spent time at the Veterans of Foreign Wars (VFW) and at the Ann Arbor, Michigan VA Hospital. During that time, the occupational therapy doctoral student engaged in several discussions with veterans from various wars to gain an understanding of military culture. Veterans shared their stories regarding experiences in a theater of war. They further shared information regarding difficulties with transitioning to civilian life, including problems with anger and difficulty with relationships. Veterans from previous wars, including Vietnam frequently expressed concern for the mental health needs of veterans

11 10 returning from the OEF/OIF wars. Encouraging early intervention so OEF/OIF Veterans are not dealing with repercussions of PTSD symptoms over the span of their life was also commonly mentioned by older veterans. A younger veteran that was diagnosed with PTSD expressed wanting to engage in programming and support groups to help with coping and to increase his desire to engage in more activities, so he is not dealing with symptoms long term. D. Literature Review Post-Traumatic Stress Disorder is a form of anxiety that occurs after exposure to traumatic events where a person feels threatened or a fear of death is evoked (NCBI, 2012). The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) established three criteria categories: 1) hyper-arousal, 2) avoidance/numbing, and 3) intrusive recollections (Morrison, 2006). Hyper-sensitivity to loud and unexpected noises, angry outbursts, and hyper-vigilance are common hyper-arousal symptoms. Individuals diagnosed with PTSD often become isolated from people and reduce social interaction. Individuals coping with PTSD may become emotionally numb and avoid situations that may remind them of the traumatic event. Intrusive thoughts may come in the form of flashbacks or nightmares (Morrison, 2006). Post-Traumatic Stress Disorder can occur after traumatic events such as a natural disaster or sexual assault. A growing concern for the occurrence of PTSD in Veterans of the Military Armed Forces is presented in current literature and research. Post-Traumatic Stress Disorder has been examined in soldiers since the First World War. Military returning from World War I ( ) displayed symptoms of stress, disconnection to their surroundings, fatigue, and confusion. These observed symptoms were named shell shock (PTSD Support Services, 2012). The number of individuals diagnosed and the severity of symptoms increased substantially during World War II ( ). Treatment was not

12 11 extensive at this time because many blocked out the events as best as they could and it was not understood to be the potential cause of behaviors post-war throughout the rest of the veteran s life (PTSD Support Services, 2012). Veterans of war often deal with a variety of issues caused from the deployment to a war theater. From boot camp to discharge, a different frame of mind and way of living is developed. The focus becomes survival and tactics to win in battle. Military deployed to a theater of war are separated from family for long periods of time. During deployment, soldiers can endure constant sounds of mortar attacks and gunfire. They often witness or are a part of violent acts on others. Experiences of war can create many issues that will be cause for later concern. The trauma experienced by veterans, both mentally and physically, can lead to the development of PTSD. In 2004, it was estimated that at least one-half million veterans are currently experiencing symptoms of Post-Traumatic Stress Disorder (Magruder et al., 2004). The Veterans Administration has collected data from veterans of various wars to track the prevalence of PTSD among each cohort. Estimates are provided for veterans of Operation Enduring Freedom/Operation Iraqi Freedom, the Gulf War, and the Vietnam War. Research of the veterans from the Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) wars showed that 13.8% of the 1,398 veterans in the sample population of veterans were suffering from PTSD symptoms at the time of the study (Gradus, 2007). Forty-three percent of the randomly sampled post-9/11 veterans had positive screenings for psychological concerns including PTSD, depression, and alcohol abuse on the National PostDeployment Adjustment Survey (Elbogen et al., 2013). Twenty percent of the veterans surveyed screened positive for PTSD symptoms. Of the veterans in the sample that screened positive for PTSD symptoms, 67% report seeking mental health treatment in the past year (Elbogen et al.,

13 ). Alcohol misuse was reported in 27% of the respondents. While significant differences by gender were found for depression rates and alcohol misuse, no significant difference was found in the results for PTSD. The majority of those reporting that services were sought reported going to Veterans Administration (VA) Medical services (Elbogen et al., 2013). A study published in 2009 assessed mental health diagnoses among OEF/OIF veterans over a two-year period, focusing on prevalence of mental health diagnosis, the prevalence in distinct cohorts of OEF/OIF veterans, and comparing the prevalence from pre-iraq war to after the start of the Iraq war (Seal et al., 2009). The overall prevalence of mental health diagnoses increased roughly 30% during the time of the study. The diagnosis of PTSD increased approximately 20%, the highest increase of all mental health diagnoses. This study also suggests that younger cohorts of active duty military (under 25 years old) were almost twice as likely to receive a mental health diagnosis than active duty military personnel over 40 years old (Seal et al., 2009). However, the study showed older National Guard and reserve veterans were at higher risk for receiving a mental health diagnosis than National Guard and reserve veterans under the age of 25 (Seal et al., 2009). Regardless of active/inactive duty status, the prevalence of mental health diagnoses, including PTSD, has increased from pre-oef/oif time. The numbers of veterans returning from the wars in Iraq and Afghanistan that are diagnosed with PTSD are comparable to the number of veterans from the Vietnam War (Garske, 2011). To date, the most significant prevalence of PTSD has been found in the Vietnam Veteran population. It is estimated that 30% of all males and 27% of all female Vietnam Veterans will at some point deal with PTSD (Gradus, 2007). Magruder et al. (2004) designed a study to evaluate the prevalence of PTSD and factors affecting the severity of symptoms. A cross-sectional research design was used to compare data

14 13 at four VA clinics. The findings revealed that several factors influence the degree of PTSD symptoms experienced by veterans. The severity of symptoms was higher in the younger cohorts of veterans. Veterans with PTSD who were not working due to disability had more severe symptoms than those not working due to retirement. The study also revealed that Post-Traumatic Stress Disorder has high incidences of co-morbidity with other health issues. It affects functional status across social, physical, and emotional subscales (Magruder et al., 2004). Post-Traumatic Stress Disorder does not only affect the veteran. The consequences of PTSD reach beyond the veteran diagnosed and affect his/her family. It was suggested that interventions should include interpersonal aspects that involve participation of the veteran s spouse (Renshaw, Rodebaugh, & Rodrigues, 2010). Spouses of veterans with PTSD have an increased risk for marital stress and decreased mental health status than spouses of veterans that do not suffer from PTSD (Renshaw et al., 2010). A study focusing on Vietnam veterans spouses found that the spouses most at risk for mental health and marital issues are those that have a perception of severity of PTSD symptoms that differs from the veteran. While studies have looked at the effects of PTSD on spouses and significant others, little research has assessed the use of family therapy and/or individual mental health services for the significant other. Sherman et al., (2005) conducted a study to assess the views that cohabiting partners of veterans with combat related PTSD have regarding the importance of family and individual, partner mental health services as a part of PTSD treatment. The results of the study revealed a large portion of participants expressed family therapy (78%) and partner therapy (68%) as extremely to very important for PTSD intervention strategies (Sherman et al., 2005). Emotional numbing and avoidance are common coping strategies that develop and hinder quality of life (Garske, 2011). Thought control and avoidance coping strategies were examined

15 14 in relationship to symptom severity and the association of a probable PTSD diagnosis in a sample of veterans from the Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) Wars. Results showed that higher rates of veterans with PTSD experience maladaptive coping skills and more difficulties with thought control than veterans without PTSD (Pietrzak, Harpaz-Rotem, & Southwick, 2011). The findings of this study suggest that PTSD is correlated with negative coping skills and thought process (Pietrzak et al., 2011). Self-Punishment, social avoidance, and worry are among the maladaptive coping strategies that are common in the sample (Pietrzak et al., 2011). This suggests that the scope of treatment for veterans with PTSD should include assisting veterans in learning positive coping strategies and behaviors to reduce social avoidance. Sociocultural factors including access to health care, race, and socioeconomic status may also influence the prevalence of Post-Traumatic Stress Disorder diagnosis in the veteran population (Nayback, 2008). Without treatment for PTSD, decreases are reported regarding quality of life (Nayback, 2008). The impacts of PTSD can be severe in many aspects of life. It is important for professionals in any discipline that works with veterans to understand military culture and how it differs from civilian culture. It is also necessary for mental health professionals to understand the nature of trauma exposure and how the combination of military culture and exposure to high levels of trauma in war can create maladaptive behaviors and thoughts in the veteran when returning to civilian life. Coll, Weiss, and Yarvis (2011) provided an overview of military culture for clinicians outside the military to assist with understanding the culture and suggestions for engaging veterans in the process of treatment assessment. More research is being done to explore the mental health needs of veterans and the appropriate evidence-based treatment methods. There is no denying that PTSD and other mental

16 15 health problems are increasing among returning veterans as the current war in the Middle East continues. This creates urgency for research and effective interventions to assist in healthy readjustment into civilian life for veterans. During active duty in a combat zone, military personnel have access to mental health assessment and treatment from Combat Stress Control Teams (CSC). This inter-disciplinary team typically has a behavioral science specialist, a social worker, a psychiatric nurse officer, a psychiatrist, and an occupational therapy officer. (Coll et al., 2011). The CSC team works together to provide comprehensive intervention treatments to assist military personnel maintain mental stability, when needed. This inter-disciplinary approach was shown to be successful in war zones including Dessert Storm and has been used in the OEF/OIF theaters of war (Coll et al., 2011). It is interesting to note that while the profession of occupational therapy is represented as part of the inter-disciplinary approach to maintain and restore mental well-being in theaters of war the profession is underrepresented in mental health services for veterans of war. Occupational therapists were, at one time, an intricate part of services for veterans. Further, occupational therapy has its roots in helping veterans of war maintain and restore mental health quality of life. The occupational therapy profession began in 1917 with the purpose of working with injured soldiers returning from World War I. The founders of occupational therapy advocated for and were successful in the campaign for the U.S. Government to hire 5000 occupational rehabilitation specialists, called Reconstruction Aides, to work with the wounded soldiers returning from the war (AOTA: A Historical Perspective, 2013). Wounded veterans were involved in making goods for the public to purchase. This active participation showed positive

17 16 outcomes, both in physical and mental gains. The goal of occupational therapy is to engage individuals in occupations that have meaning and purpose to them which will, in turn, improve his/her mental and/or physical quality of life (AOTA: A Historical Perspective, 2013). The Healthy Engagement in Relationships and Occupations (H.E.R.O.) program will improve aspects related to mental health quality of life through providing the opportunity to learn through active engagement in meaningful occupations. The need for comprehensive mental health programming to help veterans of war has grown exponentially. Mental health issues due to the exposure to the trauma of war experiences is a growing is a growing concern within the U.S. Veterans population. Occupational therapy programming is not only compatible to current mental health interventions provided, it is an asset. Occupational therapists are trained to analyze the occupational needs of clients and develop interventions to assist the client to be successful in individual goals. The American Occupational Therapy Association (AOTA) explains the qualifications of occupational therapists as relevant to mental health in Specialized Knowledge and Skills in Mental Health Promotion, Prevention, and Intervention in Occupational Therapy Practice. The American Occupational Therapy Association (2010) asserted that through the use of everyday activities, occupational therapy practitioners promote mental health and support functioning in people with or at risk of experiencing a range of mental health disorders, including psychiatric, behavioral, and substance abuse. The American Occupational Therapy Association s (2010) mental health document further stated occupational therapists are educated to analyze the interaction between and among systems, contexts, persons, populations, and occupations. Therapists use this knowledge to meet the participation needs of individuals as well as others within their communities. (2010).

18 17 The symptoms of Post-Traumatic Stress Disorder can be caused from or lead to occupational deprivation or occupational imbalance, both of which have negative impacts on quality of life. Occupational therapists have a developed skill set to recognize occupational health problems and offer interventions to alleviate them through task analysis and modification. (Scaffa, Van Slyke, & Brownson, 2008). E. Occupation-Based Program Need There is a clear need for an occupation-based program to assist veterans dealing with PTSD to improve quality of life. A substantial number of veterans suffer from symptoms of PTSD. The presence of PTSD affects every aspect of a person s life. As shown through literature and the need assessment, occupational satisfaction decreases, interpersonal relationships suffer, and abnormal coping strategies are developed. The information reflected in the literature matches the responses of veterans who were currently involved in PTSD support groups as well as veterans who were not seeking treatment at the time. Problems maintaining or initiating relationships, and lack of enjoyment or participation in occupations such as leisure were both found to be common among the veterans responses. Difficulty coping with symptoms was commonly associated with the lack of enjoyment and participation in those areas. Post-Traumatic Stress Disorder can cause maladaptive Sensory processing, cognition, and emotion regulation abilities. (Champagne, Koomar, & Olsen, 2010). Such maladjustments can make it difficult for the person to Create and maintain meaningful relationships, as well as participate in self-care, home care, education, work roles, and social and leisure interests. (Champagne et al., 2010). Occupation-based programming can address these issues and assist with increasing engagement in meaningful occupations and interpersonal relationships.

19 18 Veterans with PTSD express trouble with maintaining roles and relationships. One veteran interviewed expressed the need for early intervention so veterans of the current war are not dealing with the symptoms 40 years later, like Vietnam veterans. Several veterans expressed the need for helping the veterans returning currently readjust to civilian life. Occupation-based programming can assist veterans to develop positive coping strategies and with learning ways to have healthier interpersonal relationships. The literature regarding veterans and mental health needs support the development of occupation-based programming in the area of Post-Traumatic Stress Disorder. Veterans with PTSD experience symptoms that can affect all areas of occupation and cause difficulty in role fulfillment. Veterans with PTSD are at increased risk for dysfunctional interpersonal relationships. It can also create maladaptive coping strategies and lead to reduced social participation. Developing occupation-based mental health programming for veterans experiencing PTSD symptoms can assist improve overall quality of life. To achieve the goal of the Healthy Engagement in Relationships and Occupations program, active participation of group members is necessary. To gain successful outcomes in areas of coping skills, interpersonal communication skills, and leisure satisfaction, each group member must be an active participant; both in group sessions and occupations outside of the group setting. The H.E.R.O. program will utilize a combination of self-reflection, leisure activities, and positive habit development to improve mental health quality of life. Through mental health quality of life gains, a person will become more successful in the roles he/she needs to fulfill to maintain occupational balance in life. Group members will work individually and as a group to reflect on negative behaviors that affect aspects of daily living and the level of participation in occupations with others. From reflection activities and feedback, each member

20 19 will develop a list of positive behaviors that may be successful replacements for behaviors negatively affecting daily life. The learning process will be further developed by each member through engagement in occupations with others important in his/her life outside of the program setting. The participants will have the opportunity for reflection and practice utilizing positive coping and communication skills in a natural setting. F. Model of Practice The Role Acquisition Model was developed by Anne Cronin Mosey in This model focuses on learning social roles to successfully participate in an anticipated environment. The underlying principles of the Role Acquisition Model emphasize that skills make roles possible and the involvement in roles enhance skills. The Role Acquisition Model asserts that each individual has an intrinsic need to explore and master occupations in daily living. The interpersonal skills that the individual has are important to the success of participation in roles. This model asserts that learning is influenced by the individual s inherent capacities, current assets and limitations, age, sex, interests, and past and present cultural group membership. The Role Acquisition Model organizes social roles into four categories: 1) family, 2) occupations of daily living, 3) play/leisure/recreation, and 4) work (Mosey, 1986). Participation in social roles under each category is oriented to time, where enough time is spent in each role to lead to a satisfaction and balance (Mosey, 1986). Use of the Role Acquisition Model is meant to assist clients with learning necessary task skills and interpersonal skills to be successful in role participation in social roles (Mosey, 1986). Following the principles of learning in the Role Acquisition Model, there will be an emphasis placed on active participation of group members in the H.E.R.O. program during the learning process. The process of doing leads to skill development. The information learned will

21 20 begin as a conscious process and lead to unconscious doing as skills are learned and practiced. The H.E.R.O. program will address situations in each session to develop coping and communication skills that will be practiced in naturalistic settings outside of the program (Mosey, 1986). G. Health Initiatives, National and International Trends The United States government sets forth goals and objectives for improving the health status of American citizens in an initiative called Healthy People 2020 (HealthyPeople 2020, 2012). The development of the occupation-based program for veterans and their families is relevant to the health objectives asserted by this government initiative. First, the Educational and Community-Based Program section calls for the creation of community-based programs, including those that aim to improve mental and behavioral wellness to help prevent disease and injury, improve health, and enhance quality of life. (Healthy People 2020, 2012). Healthy Engagement in Relationships and Occupations (H.E.R.O.) program addresses this governmental initiative by providing a community-based program to enhance the quality of life and improve mental health for veterans diagnosed with Post-Traumatic Stress Disorder. In Healthy People 2020, the veteran population is listed under the topic of Emerging Issues in Mental Health and Mental Disorders. This is due to the trauma, both physical and mental, experienced during their time in military service (Healthy People 2020, 2012). The Healthy Engagement in Relationships and Occupations (H.E.R.O.) program will assist veterans to learn positive coping and interpersonal skills to experience fulfilling interactions in areas of occupation. In addition to current services, this occupation-based program will assist veterans with Post-Traumatic Stress Disorder cope and interact in occupations throughout each day.

22 21 The World Health Organization (WHO) defined health as "A state of complete physical, mental and social well-being, and not merely the absence of disease. (WHO, 2013) Under this definition, the treatment and rehabilitation of people affected by mental disorders is a part of health services required to increase or maintain mental health well-being (WHO, 2013). The H.E.R.O. program will offer occupation-based rehabilitation services that seek to improve mental health well-being through teaching coping and interpersonal skills that can lead to better outcomes in occupations that are meaningful to each participant. The H.E.R.O. occupation-based program for veterans with PTSD was developed through meeting with key stakeholders, completing a literature review, and reviewing continued education courses available on the National Post-Traumatic Stress Disorder website. The review of literature is consistent with information gained through Practicum experiences. All of the information was assessed to compose the final program development plan. III. Objectives A. Program Goal The goal of the Healthy Engagement in Relationships and Occupations (H.E.R.O.) occupational therapy program at the Center for Successful Aging is to improve the mental health quality of life for veterans with Post-Traumatic Stress Disorder, with a focus on; a) communication skills to enhance interpersonal relationships, b) coping strategies, and c) leisure occupations. B. Program Objectives: Objective 1: At the conclusion of the 8 week program, 65% of the participants will have an improved sense of mental well-being as measured by the SF-36 (Ware & Sherbourne, 1992) as compared to their pre-test scores.

23 22 Objective 2: At the conclusion of the program, 65% of the participants will report an increase in their level of satisfaction experienced during leisure occupations as measured by the Leisure Satisfaction Survey (Beard, & Ragheb, 1980) compared to their pre-test scores. Objective 3: At the conclusion of the 8 week program, participants will engage in at least four new leisure occupations with family members and friends on at least four occasions and document and discuss what they enjoyed about each occupation, what they found difficult to cope with, and suggestions to help them in similar situations. Objective 4: At the conclusion of the 8 week program, 60% of the participants will report an increase of coping skills as measured by the Proactive Coping Inventory (Greenglass, Schwarzer, & Taubert, 1999) compared to their pre-test scores. Objective 5: At the conclusion of the program, participants will report an increase of interpersonal communication skills as measured by the Interpersonal Communication Survey (Bienvenu, 1970) compared to pre-test scores. IV. Marketing and Recruitment A. Marketing Plan The marketing and recruitment campaign used for the Healthy Engagement in Relationships and Occupations (H.E.R.O.) program will aim to reach the stakeholders with a variety of marketing tools. Veterans of the U.S. Military, who are seeking treatment for PTSD and their significant others will be the key stakeholders that marketing will aim to reach. The spouses or significant others of veterans are an important part of the veteran s support system. The significant others of veterans with PTSD will be offered an optional opportunity to participate in a portion of programming for education on PTSD. The Toledo, Ohio Veterans of Foreign Wars (VFW) Posts will be a primary facility for marketing. The VFW offers

24 23 membership to all veterans that have served in a foreign war. The University of Toledo, Owens College, and Lourdes University will also be primary recruitment sites. These sites provide services to assist veterans that are attending college. The marketing and recruiting strategies will include flyers and word of mouth. Social media websites can be utilized for marketing through the various VFW profiles. The goal is to market and recruit with minimal expenses. The marketing strategies used to reach U.S. Military Veterans include recruitment flyers. Copies will be given to staff at the University of Toledo, Owens College, and Lourdes University who interact with veterans who are attending college. Local VFW posts and American Legion halls throughout Lucas County in Ohio would be asked to put flyers up in common areas. The recruitment flyer will provide information about the program content, length, contact information, and location for significant others of veterans, and mental health professionals. See Appendix E: Marketing Flyer for Potential Participants. An informational flyer will be provided to veterans that are participating in the program to advertise the educational session that will be offered for the significant others of veterans that participate in the program. The significant other marketing flyer will provide the veteran and his significant other with the session date, length, and sign-up information. A topic summary will also be included. See Appendix F: Marketing Flyer for Significant Others. It would be beneficial to meet with the team members of various areas including: psychiatry, social work, occupational therapy, and physical therapy at the Toledo, Ohio and Ann Arbor, Michigan VA facilities to provide an overview of the program and its desired outcomes. The literature provided in the brochure about the H.E.R.O. program can help mental health professionals with recruiting potential participants that would benefit from the proposed program plan. Engaging in meetings and correspondence with mental health staff at the Toledo,

25 24 Ohio VA Medical Clinic and the Ann Arbor, Michigan VA Medical Center will be used to promote the H.E.R.O. program through discussion about the program, its goals, and objectives will be beneficial the success of recruiting potential participants. Allowing the mental health staff opportunities to ask questions and provide comments will further assist in the ongoing assessments of needs for programming. Utilizing public media sources can be an effective tool to reach potential participants. The University of Toledo s radio station, 88.3 FM WUT can be approached to broadcast information regarding the H.E.R.O. program. Television sources, including the television show, Northwest Ohio Journal that broadcasts on WBGU can provide a platform for the occupational therapist to reach a larger audience of potential participants. B. Inclusion Criteria and N The primary participants of the H.E.R.O. program will be U.S. Military Veterans who are currently seeking services for PTSD. This program will be open to male veterans that have experienced symptoms of PTSD for more than six months. The needs assessment and literature review did not provide enough data to assess the needs of female veterans with PTSD. Potential participants will have a desire to improve interpersonal relationships and coping strategies for symptoms of PTSD. Participants should not have severe cognitive deficits or co-morbidity with severe psychological impairments, such as schizophrenia. Mosey (1986) asserts that the Role Acquisition Model is not appropriate for individuals with those impairments. Veterans from the OEF/OIF have expressed that the dynamics and experiences of each veterans of previous wars differ in some ways due to the difference in tactics used for each war. Also, the age difference of the veterans in the OEF/OIF war and those of other war times will present different life goals and needs. Therefore, the Healthy Engagement in Relationships and

26 25 Occupations (H.E.R.O.) program will provide separate sessions for OEF/OIF Veterans and Veterans of previous wars, including Vietnam and Desert Storm, to accommodate the differences in life stages. The programming and protocol for both session groups will be the same. There will be a maximum of ten participants for each session group in each cycle of the program. The duration of the Healthy Engagement in Relationships and Occupations (H.E.R.O.) will be eight weeks. Sessions one, two, and eight will be completed on a one on one basis with the occupational therapist. The total number of participants in sessions three through seven should not exceed ten for each session group. The program will run simultaneous programming for the two session groups. They each will run five cycles per year; totaling 10 between the OEF/OIF war group and the Veterans of Previous wars group, leaving two weeks open between starting a new cycle to assess the program evaluations and consider any changes that should be implemented to the program. The total number of participants that the H.E.R.O. program could serve each year is 100; 50 OEF/OIF Veterans and 50 Veterans of previous wars. The participants of this program can be from all of the branches of the U.S. Military. There is not a set number of years served or deployment status for the program. The participants of each cycle of the program will be chosen on a first come basis. If there is interest expressed by more than ten veterans for one cycle of the program the occupational therapist will maintain records and contact the veterans, in the order interest was expressed, for recruitment in upcoming cycles or to replace drop-outs that may occur prior to the sessions beginning. This data can also be used to track the demand and interest expressed for the H.E.R.O. program each year. This can be used to assess future changes in the number of cycles offered each year to support the need better.

27 26 A complimentary educational session will be offered for significant others of veterans with PTSD. This will be one session in length for each group of veterans. The session will provide an overview of the diagnosis and symptoms of PTSD. This complimentary session will be open to significant others of the veterans that are participating in the program. It is not mandatory for participation. The total secondary participants, significant others, that the H.E.R.O. program would benefit in a program year is 100. C. Marketing Timeline Recruiting and marketing will begin three months prior to the commencement of the program to provide time for the initial recruitment. Marketing will be ongoing throughout the program year. The occupational therapist will be active in communicating with the primary sites of recruitment to ensure that there are ample supplies of flyers available for recruitment. Contact will be maintained with the VA in Toledo, Ohio and Ann Arbor, Michigan to encourage assistance with recruiting participants. V. Programming A. Schedule and Foundation of Program Veterans who register to participate in the Healthy Engagement in Relationships and Occupations (H.E.R.O.) program through the Center for Successful Aging will attend each of the weekly sessions for the eight-week duration of the program. The participants will meet individually with the occupational therapist for sessions one, two, and eight. These sessions will take approximately one and one-half hours to complete. Sessions one, two, and eight will include an interview with the occupational therapist, completion of pre-test (week one and two), and post-test (week eight) evaluations and assessments. The interview with the occupational therapist will be used to ensure that the material of each session addresses the needs regarding relaxation,

28 27 leisure, coping, and interpersonal communication skills expressed by the majority of the participants. Weeks three through seven will be held in a group setting. Each participant will be responsible for signing in each week and bringing the binder that is provided to him. The purpose for bringing the binder weekly is to maintain information received during each session and completed reflection exercises. Sessions three through seven will each be two hours in duration. They will focus on improving interpersonal skills, coping strategies, and leisure participation. According to Mosey (1986), Learning is enhanced when the individual understands what is to be learned and the reason for learning. (p. 451). Therefore, each session will begin with an overview of the content that will be discussed and the reason for the inclusion of the content. Each group member will be expected to be an active participant in the learning process to increase the learning potential. Group occupations to provide feedback and repetition of learning are included in every session. The occupational therapist will promote the use of reflection to find effective solutions to problems that affect their quality of life. By the end of the program each group member should have a binder that provides a comprehensive collection of information regarding the topics covered, including: effective coping strategies, improving interpersonal communication skills, ideas for potential leisure occupations, and techniques for relaxation. This binder will be developed through the active participation of each group member and it will be comprised of: 1) reflections and self-help tools developed by the participant through engaging in occupations, both during the program sessions and the time between each session; 2) handouts provided by the occupational therapist; and 3) suggestions gained through interaction with group members and the occupational therapist. B. Program Assessments

29 28 The assessments used for the program will include: SF-36 (Ware & Sherbourne, 1992), Leisure Satisfaction Scale (Beard, & Ragheb, 1980), Proactive Coping Inventory (Greenglass, Schwarzer, & Taubert, 1999), and the Interpersonal Communication Survey (Bienvenu, 1970). These will be completed in two 1.5 hour sessions. During the last session, participants will meet individually to complete the follow-up assessments, including: the Leisure Satisfaction Scale (Beard, & Ragheb, 1980), SF-36 (Ware & Sherbourne, 1992), Proactive Coping Inventory (Greenglass, Schwarzer, & Taubert, 1999), Interpersonal Communication Survey (Bienvenu, 1970), and a satisfaction survey regarding the program. These will take approximately 1.5 hours to complete and will be scheduled as the eighth session. Each participant will participate in three 1.5 hour, individual sessions with the occupational therapist. Each participant will also attend five 2 hour group sessions. Ultimately, each participant spends 14.5 hours in direct contact with the occupational therapist. C. Documentation System To ensure the Healthy Engagement in Relationships and Occupations (H.E.R.O.) program is following the outline proposed the occupational therapist will complete a weekly log to summarize the content covered in each session. The sign-in logs for each session will be used to complete a spreadsheet of weekly attendance of participants. Progress and concerns regarding each group member will be noted in weekly progress notes. A file will be kept for each member that will contain pre and post tests, attendance, and weekly progress notes. This information will be kept in a locked file cabinet to protect confidentiality of each participant. D. Session One of the Intervention Program Session one will be scheduled with each participant on an individual basis. During this session the occupational therapist will provide a brief overview of the program, the meeting time,

30 29 and the expectations of the participant. A semi-structured interview will then be conducted to gather information regarding the participant s needs within the topical scope covered under the program goal. After the completion of the interview the occupational therapist will explain how to fill out the SF-36 (Ware & Sherbourne, 1992). Then the participant will be given time to complete the SF-36 (Ware & Sherbourne, 1992). The participant will be given a flyer that he can provide to his significant other regarding the complimentary session to educate significant others about PTSD. An overview of the session content will be provided to the participant. The occupational therapist will allow for time for any questions that the client may have and schedule session two. The content of the next session should be discussed briefly. E. Session Two of the Intervention Program Session Two is scheduled individually and will begin with the therapist offering time to discuss any questions with the client. The remainder of the session will be used to complete the Leisure Participation Satisfaction Scale (Beard, & Ragheb, 1980), Proactive Coping Inventory (Greenglass, Schwarzer, & Taubert, 1999), and the Interpersonal Communication Survey (Bienvenu, 1970). The participant will be provided with a binder that will contain: 1) a folder, 2) notebook, and 3) two pencils. The content of the next session should be briefly discussed. The participant will be provided time to ask any questions and voice any concerns that he may have. F. Session Three of the Intervention Program Session three will be the introduction to the group sessions. It will begin by the group sitting around a large, round table. The occupational therapist will welcome the participants while passing the sign in sheet around. The occupational therapist will then ask each person to introduce himself. Each participant will be encouraged to share information such as the branch of the military service and years of service. Next, the program goal and expectations will be

31 30 reiterated and the expectations of respect for group members will be addressed. The purpose of the binder, notebook, and pencils will be explained. These are tools to help each participant evaluate and learn from various written exercises during and outside the meeting time. The second half of this session will address coping strategies that the clients currently use in stressful situations or conflict. Each participant will consider his current coping strategies, both positive and negative. Group members will be instructed to draw a line down the center of a piece of notebook paper and label the first column positive and the second column negative. Each person will list coping strategies in the column that he feels is appropriate. The occupational therapist will facilitate an open discussion for group members to share at least three coping strategies from each column. An example of when the strategy is utilized should also be given. The occupational therapist will choose an example of negative coping techniques from each participant and engage the members in providing positive behaviors that could be used instead. At the end of the session the topic of triggers that cause agitation and negative responses will be briefly reviewed. The participants will then be assigned a self-evaluation occupation to complete regarding triggers of agitation. Prior to the next session they will be expected to write down occupations or situations that caused them to become agitated or experience increased level of stress. The content of the next session should be briefly discussed. G. Session Four of the Intervention Program The session will begin with an overview of topics and structure that will be covered. Next, a summary of the previous topic regarding coping will be provided to the group members. The occupational therapist will facilitate a group conversation about the occupation of selfreflection completed over the previous week. Participants will share at least three experiences or

32 31 situations that caused them to use coping strategies. This should be done for both negative and positive behaviors elicited. The occupational therapist and group members will provide feedback to each member through a group occupation of positive suggestions to replace negative coping strategies. The occupational therapist will be prepared to provide examples of positive and negative scenarios and coping behaviors as needed. Each participant will develop a list of positive coping strategies that can be used in stressful situations. The next topic to be introduced is interpersonal relationships. The discussion will include a definition and examples of what is meant by the term interpersonal relationships. Next, the components of communication, including body language, tone of voice and facial expressions will be explained. The participants will be asked to consider their communication techniques and what they like and dislike about their current approaches to communicate. Four columns will be drawn onto a dry erase board and labeled: words, body language, tone, and expression under the heading appropriate. The same setup will be written on another white board under the heading inappropriate. Half of the members will fill in one board while the other fills items in on the other. The occupational therapist will provide examples if needed. This will lead into an individual occupation of reflecting on current communication styles used with those closest to them. The final portion of the course will address the topic of leisure. Participants will think about leisure occupations that they currently engage in, both individually and with others. Group members will also consider leisure occupations they would like to engage in. Every participant will be encouraged to participate in at least one occupation individually and one with other people each week from this session on.

33 32 The possibility of volunteering as a leisure occupation will be discussed. Information about potential volunteering opportunities will be provided. The volunteer opportunities will include those to help other veterans as well as general community organizations. Participants can share information about other volunteer possibilities that they are aware of. Before closing the session the occupational therapist will introduce the next reflection exercise to be completed prior to session seven. The group members will be required to engage in and reflect upon occupations completed with others on at least four occasions. They will document what they enjoyed about each occupation, what they found difficult to cope with, any changes they recognize they consciously made to their behavior, and suggestions to help them in future situations. H. Session Five of the Intervention Program The session will begin with an overview of the content that will be covered. The OT will reiterate interpersonal skills and communication, as discussed in the previous session. The group members will be encouraged to share information about an occupation that they completed with other people and any reflection information they feel comfortable expressing regarding the interaction. The occupational therapist and group members will offer feedback regarding what each person shares. Group members will write five triggers of agitation and then write at least 3 positive coping strategies or communication skills to counteract each agitation trigger. The group will come back together as a group to discuss what they have written. The occupational therapist will provide feedback as appropriate. Understanding the side effects and consequences of excessive stress will be addressed. Examples should be provided and the health risks should be explained. The importance of

34 33 finding ways to relax is what the discussion should lead into. The group will fill out a sheet that provides scenarios and techniques that may be viewed as relaxing. Group members will place a checkmark by the appropriate likert scale rating that represents the level of relaxation the occupations listed are perceived to be. The participants will list other occupations that they feel are relaxing leisure occupations. See Appendix G: Leisure Reflection. Further group discussion regarding the individual reflection exercise should be facilitated. To wrap up the session the occupational therapist will remind the group about engaging in occupations with others and completing the at-home reflections. I. Session Six of the Intervention Program Session six will focus on reviewing the material from the previous sessions, strategies learned through personal reflections, group participation, and planning a leisure occupation for the group to engage in during session seven. After the introduction to the session and the review of material is complete, the occupational therapist will lead the group in a guided imagery relaxation sequence. The group will discuss any strategies that they have found helpful for coping, communicating, relaxing, and/or reducing stress levels. The occupational therapist will then provide examples of situations that could trigger agitation or relate to interpersonal communication. Using examples similar to those that participants expressed having negative reactions to in earlier sessions should be used if possible. The second half of this session will involve the group members planning a leisure day occupation for session seven, the final group session. The members will decide as a group what type of food and activities they want during the second half of session seven. The occupational therapist will provide suggestions or a direction as needed. Before ending the session the

35 34 occupational therapist will remind the participants about the reflections regarding occupations completed with others. J. Session Seven of the Intervention Program The final group session in the eight week program sequence will start with the occupational therapist leading an image-based relaxation occupation. Next, group members will discuss at least one of the reflections regarding their engagement in occupations with others outside of the program. Participants will share examples of what they have tried regarding coping, relaxation, and communication techniques that they found to be helpful. Group members will sign up for a date and time to complete session eight. They will fill out a sheet that lists services that they are interested in gaining more information. Time will be given for any questions and/or comments regarding the program prior to beginning the wrap-up leisure occupation. Consideration is needed for the preparation time for the food chosen. Some food may be prepared prior to the session. The group members will help set-up the environment for food and games. The remainder of the session will be unstructured to allow the participants to utilize their communication and coping skills while enjoying themselves. The occupational therapist will close the session by congratulating the group on their hard work and progress. More time will be given for questions. K. Session Eight of the Intervention Program This session will be scheduled with each group member individually. The occupational therapist will provide an overview of the assessments that will be completed by the participant. Post-test evaluation will include: 1) Leisure Participation Satisfaction Scale (Beard, & Ragheb, 1980), 2) SF-36 (Ware & Sherbourne, 1992), 3) Proactive Coping Inventory (Greenglass,

36 35 Schwarzer, & Taubert, 1999), 4) Interpersonal Communication Survey (Bienvenu, 1970), and 5) a satisfaction survey regarding the program. The occupational therapist will allow time for each one to be completed and will explain each post-test measure prior to the participant filling it out. After the post-test measures have been completed the occupational therapist will express that even though the participant has officially completed the program, re-enrollment is available, if needed, in the future. If re-enrollment is requested the individual will be placed on the existing list of interested veterans. The occupational therapist will provide resources to each participant that reflects the information filled out in week seven regarding interest in other services throughout the community. Time will be provided for the participant to ask any follow-up questions before finalizing the session. L. Session One for Significant Others This session will be held for the significant others of veterans who are participating in the H.E.R.O. program during the third week of programming for veterans. This session will begin with the occupational therapist greeting the participants and explaining the content of the session. The participants will be offered the opportunity to introduce themselves. Handouts will be passed out to the participants regarding the definition and symptoms of PTSD. See Appendix H: Handout for Significant Others. The occupational therapist will explain the definition of PTSD and how it relates to veterans of war. An overview of understanding military cultural aspects and how they differ from typical experiences will be provided. The second half of the session will focus on the three areas of symptoms; avoidant behavior, intrusive thoughts, and hyperarousal (National Center for Biotechnology Information, 2012). This will be the main focus of content, with information given in detail. The occupational therapist will provide several examples relevant to each symptom category. The topic of partner

37 36 abuse will be discussed. The occupational therapist should not spend a large portion of time on abuse. This is in effort to not encourage stigma of PTSD. However, the increase of potential abuse should be mentioned. Suggestions of area shelter contact will be verbally provided. The most important pieces of information to provide regarding abuse are: abuse is not okay and seeking help is okay. The goal of this session is to provide basic education to significant others that may not have previous knowledge of or dealing with PTSD. Time for questions and comments will be provided throughout the delivery of content. M. Care Coordination Care coordination will be maintained by the occupational therapist during the program by meeting with staff at the Center for Successful Aging. This will be done after the third and seventh sessions to discuss the content of the sessions. Any concerns or service needs expressed by the participants during any session will be acknowledged and the occupational therapist will provide information about services that are available to assist the client. After discharge and evaluation of program s pre and post tests the occupational therapist will meet with the staff members to discuss the outcomes of the program, focusing on the effectiveness and improvements needed. N. Discharge Procedures The group members will be officially discharged from the program after the completion of the program evaluation measures in week eight. It will be explained to each member that he/she are welcome to re-enroll in the program in the future, if necessary. Contact information for the program coordinator will be provided in the binder. The programming presented is written to be user-friendly. It has provided a thorough description so any licensed occupational therapist should be able to understand the process and

38 37 philosophy used to follow out the program without additional information. An understanding of the Role Acquisition Model of Practice is a criterion needed to understand and implement the Healthy Engagement in Relationships and Occupations (H.E.R.O.) program for veterans with PTSD. To implement the Healthy Engagement in Relationships and Occupations (H.E.R.O.) occupational therapy program, the occupational therapist must have additional training in military culture and Post-Traumatic Stress Disorder. VI. Budgeting and Staffing A. Itemized Budget Personnel Position Hours per Program Salary Fringe Benefits Total Program Occupational Therapist 250 $37.83 $1, $10, $37.83 $1, $48, Total of Personnel: Meeting Space Item Description of Item Cost for space at the VFW Post Rent: 606 for the Includes meeting space Utilities 10 months per program year Total of New Costs: Quantity Cost per Month (Both session groups) Total Cost for 1 cycle of the Program $ $ Program Supplies and Equipment (New Costs) Item Description of Item Quantity Cost per Item Total Cost

39 Office Supplies Locking 3 Drawer File Cabinet Stapler, staples, paperclips, binder clips, paper, pencils, pens, three-hole punch. Folders, clipboards and file folders found at Walmart.com Locking filing cabinet with 3 drawers to maintain participant data, evaluations, and financial information pertaining to the program $ $86.99 One and one half inch binders Binders will be given to each participant and will maintain their written material 100 $1.92 $ College-ruled notebooks Notebooks will be included for each participant to write reflections and notes 100 $1.50 $ Flyers-Color Advertising material for the recruitment sites 300 $.49 $ $.10 $ $.10 $ $ $ Flyers- Black and White Black and White Copies Dry Erase Board Marketing flyers for the significant others education session Handouts, reflections and other information for the participants Quartet Melamine DryErase Board, 48"

40 39 x 72", Aluminum Frame Dry Erase Markers Expo Low Odor Dry Erase Markers, Assorted Colors 3 packs 12/pack $15.92 $47.76 Refreshments for sessions Snacks, soda, coffee, and tea for each session - - $ Food for Session Seven Each group will have a budget of $ to plan the seventh session 10 groups $ $1, Total of New Costs: Grand Total Expenditures: In-Kind Contributions Description of Cost for 1 Cycle Item Quantity Item of the program Electric and Utilities Propane for $ heating/cooling Phone/Internet Internet/fax/phone $ Rent for Rent building/space for $ the program Total of in-kind Contributions: $2, $54, Total for the Program Year $1, $ $3, $5, B. Justification of Costs Personnel The hourly rate of the occupational therapist will be $ This is the mean hourly wage in Ohio for occupational therapists (Bureau of Labor Statistics, 2012). The occupational therapist will be contracted for the entire year. The average number of hours worked per week is

41 40 anticipated to be 20. Weeks one, two, and eight will be longer hours, approximately 35 hours. This is due to the time needed to complete one-on-one sessions with all of the participants. The occupational therapist will be responsible for recruitment, marketing, and maintaining records for the program. He/she will schedule meetings with potential participants, other key stakeholders, and recruitment sites. The occupational therapist will evaluate the effectiveness of the content in the program on a continuous basis and make adjustments to programming as needed. The last two weeks of the programming year will be utilized to analyze the data collected over the year to consider any changes needed for the overall structure of the H.E.R.O. program Fringe Benefits The occupational therapist will be offered benefits outside of wages. The occupational therapist will receive $ to utilize for the reimbursement of continuing education courses that focus on mental health and the veteran population. Further, she/he will receive compensation of four hours pay for the following national holidays: New Years Day, Independence Day, Thanksgiving, and Christmas. New Cost Items The meeting space in necessary for the delivery of the program. This space at the VFW Post 606 will offer enough room to complete each session while also providing refrigeration and space for snacks and beverages. This space is close to several major highway systems, improving the convenience of travel for the participants of the H.E.R.O. program. The H.E.R.O. Program will only require the the meeting space for 10 months out of the program year because there is a 2 week period between each cycle that will not require the use of the space.

42 41 The office items listed are needed to organize and maintain program records. The binders, folders, copies of handouts, pencils, and notebooks will be assembled and distributed to the participants throughout the programming year by the occupational therapist. All of these items can be purchased at Wal-Mart for reasonable prices. These items, except for the filing cabinet, will need to be purchased for each year of the program. The flyers are being purchased to recruit participants for the program and to provide information to other stakeholders about the program. Effective marketing strategies are important to reach and assist the maximum number of veterans possible through the program. Handouts will be printed to provide as tools for the participants of the H.E.R.O program. The handouts will provide information regarding coping skills, communication, and relaxation. All of which are directly related to the content of the H.E.R.O program. Chips, pretzels, and cookies will be provided at each session as well as beverages such as soda, water, and coffee. Each group session is two hours in length, so it is likely that participants will become thirsty or desire a snack. The food budget for the seventh session will be used to host a leisure occupation that the participants plan. To plan and complete the occupation, participants will have a chance to practice communication skills and engage in leisure. Snacks and refreshments will also be provided during the significant other education session. In-Kind Contributions The Center for Successful Aging will provide in-kind contributions of office space, meeting space, gas, electric, phone, fax, and internet fees. The use of the space will be minimal. It will serve as a place for the documentation and filing systems for the H.E.R.O. program. The occupational therapist will only be in the space approximately 10 hours per week. The space and

43 42 utilities used by the H.E.R.O. program will not cause a substantial increase from the typical monthly expenses accrued by the Center for Successful Aging. C. Credentials of the Occupational Therapist The occupational therapist hired will be registered and licensed in the state of Ohio. He/she will have a minimum of one year experience in mental health. They must be proficient in administering and interpreting the assessments used in the program. Previous work history that includes management of programming is preferred. See Appendix I: Marketing Flyer to Hire occupational Therapist. Responsibilities of the occupational therapist will include maintaining all aspects of the H.E.R.O. program, including marketing, program delivery, assessments, and program evaluation. The Occupational therapist will complete additional courses to be knowledgeable in military culture and Post-Traumatic Stress Disorder. D. Potential Funding Sources The Toledo Community Foundation would be an organization to present the Healthy Engagement in Relationships and Occupations program for grant funding. This foundation provides grant funding for a variety of programs in the Northwest Ohio and Southeast Michigan area, with a particular focus on the Toledo area. In 2011, the Toledo Community Foundation granted 12 million dollars in funding for programming. One of the Toledo Community Foundation s initiatives is improving mental health. The H.E.R.O. program seeks to improve the mental health quality of life for veterans, meeting the philosophy of the Toledo Community Foundation. The amount of grants awarded varies substantially and this organization could provide the funding necessary to maintain the Healthy Engagement in Relationships and Occupations program for one year.

44 43 To apply for funding through the Toledo Community Foundation, located at 300 Madison Avenue Suite 1300, Toledo, Ohio 43604, it is necessary to complete an online application as hard copies are not accepted. Applications and all required information are due by midnight on January 15 and September 15 of the year. Decisions are made by a committee three and one half months after each deadline. Notification of award determination is provided in writing. Further information can be obtained by contacting Sarah Harrison, Senior Program Officer by phone: (419) or sarah@toledoocf.org. The Walmart Foundation is dedicated to providing funding for programming to benefit veterans. While the Healthy Engagement in Relationships and Occupations program matches well with the Walmart Foundation s initiative of providing founding for behavioral health programs for veterans and their family, However, the grant amount awarded is typically under $2, This would not be sufficient for maintaining a year of programming for the Healthy Engagement in Relationships and Occupations program. Another foundation that provides funding for programming to help veterans is the Purple Heart Service Foundation. However, the Purple Heart Service Foundation only provides grant funding for programs specific to disabled veterans. The Healthy Engagement in Relationships and Occupations program will not specifically serve disabled veterans, so a grant will not be approved by this organization. There are potential barriers to consider when applying for grants to fund the Healthy Engagement in Relationships and Occupations program. This plan is developed by an occupational therapy doctoral student. Therefore, the lack of experience on the student s behalf regarding grant writing may affect the funding received to develop the program. The number of veteran participants expected to participate per year is 100. The amount requested for

45 44 programming may seem like a substantial amount to serve 100 people; however, the success of the program will create a positive effect in the lives of many family members and friends of the veterans served each year in the Healthy Engagement in Relationships and Occupations program. The program can improve the quality of lives of many other people outside the veteran participants. Further, the number of secondary participants (significant others) that are expected to attend the education session in the year is also 100. This is an additional benefit to the program with minimal additional funds required to deliver. E. Self-Sufficiency Plan The initial year of funding for the Healthy Engagement in Relationships and Occupations occupation-based program will be provided through a grant from an agency outside of the Center for Successful Aging. After the first year, the programming and the evaluations of the programming could be presented to other facilities outside of the Center for Successful Aging. At the end the initial program year, the occupational therapist will meet with key staff at the Toledo Vet Center, the area s leading provider of readjustment services for veterans, to present the data collected through evaluation information as well as input from the participants regarding the benefits of having this occupation-based program as a part of readjustment services for veterans with PTSD. The Toledo Vet Center could then seek to gain funding through the U.S. Department of Veterans Affairs. The United States Congress allots a specified amount of monies to the Vet Centers, nationally each year. This money is overseen by the Veterans Affairs Administration. It can only be used for programming at the Vet Centers across the nation. Public access to specific funding information was not publically available. However, the potential for future funding by the government delegated funds for programming at Vet Centers has been discussed with key staff at the Toledo Vet Center. A letter of support for programming was

46 45 provided by a potential participant. See Appendix J: Letter of Support. Additional letters of support may be obtained through mental health professionals at the Toledo Vet Center and by Barbara Kopp Miller, director of the Center for Successful Aging. VII. Program Evaluation A. Outcome Evaluation Procedures for Each Objective 1. At the conclusion of the 8 week program, 65% of the participants will have an improved sense of mental well-being as measured by the SF-36 as compared to their pre-test scores. To measure this objective, the SF-36 (Ware & Sherbourne, 1992) will be used which will measure each participant s perceived quality of life. Attention will be focused on five of the seven subsets: 1) vitality, 2) physical role functioning, 3) emotional role functioning, 4) social role functioning, and 5) mental health. The post-test scores will be compared to the pre-test scores for each participant to assess the change, if any, in scores for each subset. The data for each participant in every cycle of the program will be maintained and compared to evaluate the benefit of the program for veterans over time. 2. At the conclusion of the program, 65% of the participants will report an increase in their level of satisfaction experienced during leisure occupations as measured by the Leisure Satisfaction Survey compared to their pre-test scores. This objective will be measured using the Leisure Satisfaction Survey (Beard & Ragheb, 1980). Participants will complete this assessment at the beginning of the program and at the end. The scores from the pre-test and post-test will be compared to measure any change in satisfaction of leisure occupations. Calculations will be made regarding the percentage of participants that report a positive change in satisfaction levels.

47 46 3. At the conclusion of the 8 week program, participants will engage in at least four new leisure occupations with family members and friends on at least four occasions and document and discuss what they enjoyed about each occupation, what they found difficult to cope with, and suggestions to help them in similar situations. This objective will be measured by the documentation provided to the occupational therapist that logs the occupations and coping information required. The occupational therapist will also maintain documentation of the participation in discussion regarding this goal as it occurs in the group setting. A file will be kept throughout the duration of the program to maintain anonymous data tracking of participation in program goals by group members. 4. At the conclusion of the 8 week program, 60% of the participants will report an increase of coping skills as measured by the Proactive Coping Inventory compared to their pre-test scores. The Proactive Coping Inventory (Greenglass, Schwarzer, & Taubert, 1999) will be used to measure any changes reported in coping abilities by the program participants. The results of post-test scores will be compared to the pre-test scores obtained at the beginning of the program. The findings will be documented and shared with key personnel at the Vet Center. The documentation will be analyzed at each cycle of the program within the year to ensure that the program is effective for increasing coping skills for veterans with PTSD. 5. At the conclusion of the program, participants will report an increase of interpersonal communication skills as measured by the Interpersonal Communication Survey compared to pretest scores. This objective will be measured by using the Interpersonal Communication Survey (Bienvenu, 1970). Each participant will complete this survey during session one of the program, and, again, during session eight of the program. The pre-test and post-test scores will be

48 47 compared to evaluate the positive change reported in interpersonal communication skills. This information will be documented and data for each cycle will be maintained by the occupational therapist. B. Process Evaluation Procedures The information gained through the assessments used for measuring the outcomes of each program objective will also be used to evaluate the success of the program overall. Additional information will be maintained to assess process aspects of the program. A sign-in sheet will be kept for each session in each cycle. This information will not only serve as an attendance record, it will provide data to assess the drop-out rate of participants during the program. The participation of each program member is encouraged. At the end of each group session, participants will fill out a short evaluation to provide the occupational therapist with information pertaining to the perceptions of participants regarding each program session and structure. See Appendix K: Weekly Session Evaluation. The occupational therapist will keep session notes to document any participation concerns within the group. Formative evaluations will be completed at the fourth and seventh sessions to evaluate the perceptions of group members regarding if the process of the program is fulfilling their expectations. This will be completed in survey form and turned in before ending each of the session assigned sessions. This information will be used to make necessary changes in programming to ensure that the goal of the program is being met. To assess the content of the significant other session, the participants of that session will be asked to fill out a brief evaluation. This information will be used to track the perceived amount of relevance of the content to PTSD. This will be analyzed and provide the success or the

49 48 needs for future significant other sessions. See Appendix L: Evaluation for Significant Other Education Session A meeting with key personnel, including Barbara Kopp Miller, will be held after the fourth week. Mental health professionals from the Toledo Vet Center will be invited to join. At this meeting, the occupational therapist will present a summary of programming to date. Barbara Kopp Miller and any other mental health professionals that may attend will be asked to share their thoughts and concerns regarding programming. They will be provided with a short evaluation tool to return to the occupational therapist after the eighth session. See Appendix M: Program Evaluation for Staff at the Center for Successful Aging. C. Summative Evaluation The objectives of the Healthy Engagement in Relationships and Occupations (H.E.R.O.) program will be measured by the assessments discussed. The data collected from each assessment tool will then be analyzed to evaluate the effectiveness of the program. This information will also be compared across cycles in the program to analyze the success of the programming over a year. The perceptions of the key stakeholders will be assessed at the end of each cycle in the program, in addition to the formative evaluations. A summative evaluation tool will be provided to the key staff members after the fourth session. The staff will be asked to fill out the form after the seventh session and return it to the occupational therapist at the end of the eighth session. The H.E.R.O. occupation-based program is developed to compliment the current standards of evidence-based treatment as established by the U.S. Department of Veterans Affairs as presented through continued education courses available on the National Post-Traumatic Stress Disorder website. This website provides courses to assist clinicians in understanding

50 49 guidelines established for PTSD treatment at VA Centers nationally. The courses available on this website can be utilized as learning resources for the occupational therapist. VIII. Timeline A. OEF/OIF Group Task Conduct a Needs Assessment 1 2 Meet with Staff Make programming changes Prepare advertisement information Purchase general office supplies needed Purchase supplies needed for participant packets Print handouts, reflection exercises, reflection directions, and relaxation techniques Communicate with recruitment sites Marketing flyer for significant others Contact the potential participants as interest is expressed Advertising: flyers Conduct initial evaluations: Implement weekly sessions Conduct formative evaluations: 4 Weeks 5 6 Conduct final evaluations: Conduct summative evaluations Assess formative evaluations Assess summative evaluations

51 50 Task Week Conduct a Needs Assessment Meet with Staff Make programming changes Prepare advertisement information Purchase general office supplies needed Purchase supplies needed for participant packets Print handouts, reflection exercises, reflection directions, and relaxation techniques Communicate with recruitment sites Contact the potential participants as interest is expressed Advertising: flyers Marketing flyer for significant others Conduct initial evaluations: Implement weekly sessions Conduct formative evaluations: Conduct final evaluations: Conduct summative evaluations Assess formative evaluations Assess summative evaluations Task Meet with Staff Make programming changes 24 Weeks

52 Prepare advertisement information Purchase general office supplies needed Purchase supplies needed for participant packets Print handouts, reflection exercises, reflection directions, and relaxation techniques Communicate with recruitment sites Advertising: flyers Marketing flyer for significant others Contact the potential participants as interest is expressed Conduct initial evaluations: 51 Implement weekly sessions Conduct formative evaluations: Conduct final evaluations: Conduct summative evaluations Assess formative evaluations Assess summative evaluations Task 31 Meet with Staff Make programming changes Weeks Prepare advertisement information Purchase general office supplies needed Purchase supplies needed for participant packets

53 Print handouts, reflection exercises, reflection directions, and relaxation techniques Communicate with recruitment sites Advertising: flyers Marketing flyer for significant others Contact the potential participants as interest is expressed Conduct initial evaluations: 52 Implement weekly sessions Conduct formative evaluations: Conduct final evaluations: Conduct summative evaluations Assess formative evaluations Assess summative evaluations Task Meet with staff Make programming changes Prepare advertisement information Purchase general office supplies needed Purchase supplies needed for participant packets Print handouts, reflection exercises, reflection directions, and relaxation techniques Communicate with recruitment sites Advertising: flyers Marketing flyer for significant others Weeks

54 Contact the potential participants as interest is expressed Conduct initial evaluations: 53 Implement weekly sessions Conduct formative evaluations: Conduct final evaluations: Conduct summative evaluations Assess formative evaluations Assess summative evaluations B. Veterans of Previous Wars Group Task Conduct a Needs Assessment 1 Meet with Staff Make programming changes Prepare advertisement information Purchase general office supplies needed Purchase supplies needed for participant packets Print handouts, reflection exercises, reflection directions, and relaxation techniques Communicate with recruitment sites Marketing flyer for significant others Contact the potential participants as interest is expressed Advertising: flyers Conduct initial evaluations: Weeks

55 Implement weekly sessions 54 Conduct formative evaluations: Conduct final evaluations: Conduct summative evaluations Assess formative evaluations Assess summative evaluations Task Week Conduct a Needs Assessment Meet with Staff Make programming changes Prepare advertisement information Purchase general office supplies needed Purchase supplies needed for participant packets Print handouts, reflection exercises, reflection directions, and relaxation techniques Communicate with recruitment sites Contact the potential participants as interest is expressed Advertising: flyers Marketing flyer for significant others Conduct initial evaluations: Implement weekly sessions Conduct formative evaluations: Conduct final evaluations: Conduct summative evaluations

56 Assess formative evaluations Assess summative evaluations 55 Task Meet with Staff Make programming changes Prepare advertisement information Purchase general office supplies needed Purchase supplies needed for participant packets Print handouts, reflection exercises, reflection directions, and relaxation techniques Communicate with recruitment sites Advertising: flyers Marketing flyer for significant others Contact the potential participants as interest is expressed Conduct initial evaluations: 24 Weeks Implement weekly sessions Conduct formative evaluations: Conduct final evaluations: Conduct summative evaluations Assess formative evaluations Assess summative evaluations Task Weeks

57 Meet with Staff 56 Make programming changes Prepare advertisement information Purchase general office supplies needed Purchase supplies needed for participant packets Print handouts, reflection exercises, reflection directions, and relaxation techniques Communicate with recruitment sites Advertising: flyers Marketing flyer for significant others Contact the potential participants as interest is expressed Conduct initial evaluations: Implement weekly sessions Conduct formative evaluations: Conduct final evaluations: Conduct summative evaluations Assess formative evaluations Assess summative evaluations Task Meet with staff Make programming changes Prepare advertisement information Purchase general office supplies needed Purchase supplies needed for participant packets Weeks

58 Print handouts, reflection exercises, reflection directions, and relaxation techniques Communicate with recruitment sites Advertising: flyers Marketing flyer for significant others Contact the potential participants as interest is expressed Conduct initial evaluations: Implement weekly sessions Conduct formative evaluations: Conduct final evaluations: Conduct summative evaluations Assess formative evaluations Assess summative evaluations 57 R e fe r e n c e s AOTA: A Historical Perspective (2013). The American Occupational Therapy Association. Retrieved from: Beard, J. G., & Ragheb, M. G. (1980). Measuring leisure satisfaction. Journal of Leisure Research, 12 (1), Bienvenu, M. J. (1970). Interpersonal Communication Inventory.

59 58 Champagne, T., Koomar, J., & Olsen, L. (2010). Occupational Therapy s role with PostTraumatic Stress Disorder. The American Occupational Therapy Association. Retrieved from: Coll, J. E., Weiss, E.L., & Yarvis, J.S. (2011). No one leaves unchanged: Insights for civilian mental health care professionals into the military experience and culture. Social Work in Healthcare, 50(7), pp doi: / Elbogen, E.B., Wagner, H.R., Johnson, S.C., Kinneer, P., Kang, H., Vasterling, J.,. Beckham, J. (2013). Are Iraq and Afghanistan Veterans using mental health services? New data from a national random-sample survey. Psychiatric Services (64, pp ). doi: /appi.ps Garske, G. G. (2011). Military-related PTSD: A focus on the Symptomatology and Treatment Approaches. Journal of Rehabilitation, 77(4), doi: /s Gradus, J.L., (2007). Epidemiology of PTSD. Veterans Administration. Retrieved from: Greenglass, E., Schwarzer, R., & Taubert, S (1999). The Proactive Coping Inventory (PCI): A multidimensional research instrument. Magruder, K. M., Frueh, B., Knapp, R. G., Johnson, M. R., Vaughan III, J. A., Carson, T., &... Hebert, R. (2004). PTSD Symptoms, Demographic Characteristics, and Functional Status Among Veterans Treated in VA Primary Care Clinics. Journal of Traumatic Stress, 17(4), pp doi: /B:JOTS c8. Mental Health (2013). World Health Organization. Retrieved from:

60 59 Mental Health and Mental Disorders (2012). Healthy People Retrieved from: Morrison, J., (2006). DSM-IV made easy: The clinicians guide to diagnosis. (3rd ed., pp ) Guilford:New York, New York. Mosey, A. C. (1986). Role Acquisition: An acquisitional frame of reference. Psychosocial components of occupational therapy, pp New York, New York: Raven. Nayback, A. (2008). Health disparities in military veterans with PTSD: influential sociocultural factors. Journal of Psychosocial Nursing & Mental Health Services, 46(6), pp doi: / Occupational Outlook Handbook (2012). Bureau of Labor Statistics. Retrieved from: Pietrzak, R. H., Harpaz-Rotem, I., & Southwick, S.M. (2011). Cognitive-behavioral coping strategies associated with combat-related PTSD in treatment-seeking OEF-OIF Veterans. Psychiatry Research, 189 (2), 2011, p doi: /j.psychres Post-Traumatic Stress Disorder (2012). National Center for Biotechnology Information, U.S. National Library of Medicine. Retrieved from: Renshaw, K.D., Rodebaugh, T.L., & Rodrigues, C. S. (2010). Psychological and marital distress in spouses of Vietnam Veterans: Importance of spouses' perceptions. Journal of Anxiety Disorders, 24(7), pp doi: /j.janxdis Seal, K.H., Metzler, T.J., Gima, K.S., Bertenthal, D., Maguen, S., Marmar, C.R. (2009). Trends and Risk Factors for Mental Health Diagnoses Among Iraq and Afghanistan Veterans

61 60 Using Department of Veterans Affairs Health Care, American Journal of Public Health, 99(9), pp doi: /AJPH Specialized Knowledge and Skills in Mental Health Promotion, Prevention, and Intervention in Occupational Therapy Practice (2010). American Occupational Therapy Association, 64, pp Scaffa, M., Van Slyke, N., & Brownson, C.A. (2008). Occupational Therapy Services in the Promotion of Health and the Prevention of Disease and Disability. American Occupational Therapy Association, 62, pp doi: /ajot Sherman, M.D., Sautter, F., Lyons, J.A., Manguno-Mire, G.M., Han,., Perry, D., Sullivan, G. (2005). Mental health needs of cohabiting partners of Vietnam Veterans with combat- related PTSD. Psychiatric Services, 56 (9), pp doi: /appi.ps The Evolution of Post Traumatic Stress Disorder (2012). PTSD Support Services. Retrieved from: Ware, J. E., & Sherbourne, C.D., (1992). The MOS 36-item short-form health survey (SF36) conceptual framework and item selection. Medical Care, 30,

62 Appendix A Organization Chart Center for Successful Aging Dr. Barbara Kopp Miller Administrative Director Dr. Victoria Steiner Assistant Administrative Director Occupational Therapist 61

63 Appendix B Semi-Structured Interview: Veterans 1. What branch did you serve in? 2. How long were you enlisted? 3. Were you deployed to a theater of war? 4. Tell me about you experiences during your enlistment? 5. Did you have difficulty transitioning home? If so, what do you feel you had trouble with? 6. Have you experienced any family stress due to military experiences? 7. Have you ever experienced things like flashbacks, increased anxiousness with loud noises, avoiding situations, anger, aggression related to your deployment or stateside military experiences? 8. Have you ever sought treatment for or felt like you may have PTSD related symptoms? 9. Do you find it easy or challenging to participate in leisure activities? 10. What types of activity-based programming do you feel would benefit veterans? 62

64 63 Appendix C Needs Assessment Questionnaire for Toledo Vet Center 1. What services do veterans seek at this Vet Center? Individual counseling, group counseling, marital and family counseling, bereavement counseling, Medical referrals, assistance with VA benefits, employment counseling, alcohol and drug assessment and referral, community resources, military sexual trauma counseling, community education. 2. On average, how many people does this Vet Center serve per month? 350 Veterans and spouses 3. What percentage of veterans served at this Vet Center seek services for PTSD? Approximately 70-80% 4. What type of programs/services are currently offered for PTSD at this Vet Center? Individual and group counseling using evidence-based therapy. i.e. cognitive and/or behavioral therapy, prolonged exposure therapy. 5. Are interpersonal relationships difficult for veterans with PTSD? Very much so due to transition, avoidance, and isolation issues 6. What services can community-based programming provide to assist with improving quality of life for veterans diagnosed with PTSD? Spouse/family education Employment, human services assistance Church services and programs Veteran courts i.e. justice outreach Recreational opportunities

65 64 7. How would you prioritize the list from question 6? Employment, human services assistance Spouse/family education Recreational opportunities Church services and programs Veteran courts i.e. justice outreach 8. What are the basic demographics of the veterans that seek services? 70% Vietnam Era 29% Iraq, Afghanistan, Persian Gulf, and Desert Storm 1% Korean, WW II 9. Do you have any other information that you feel is important for me to know to develop the most effective program plan for veterans? Connect with veterans, gain their trust Follow through on what you say and promise

66 65 Appendix D Survey for Wauseon PTSD Support Group: Summary Strongly Agree Somewhat Agree Symptoms of PTSD can lead to problems in relationships with loved ones IIII Educating family members about PTSD is important IIII I Symptoms of PTSD affect motivation to participate in activities IIII I Symptoms of PTSD make it difficult to relax III I Symptoms of PTSD lead to less participation/enjoyment in leisure IIII I Neutral Somewhat Disagree Strongly Disagree I I 1. In your opinion, what areas of life does symptoms of PTSD affect the most? Family Work Friends Dealing with people, you never let others in Avoidance of serious relationships Support from spouse is very important Social-Have to be on guard all the time Family Interaction 2. What symptoms of PTSD are most difficult for you? Being alone-regardless of who or how many are around Anger, can t forget Sleep-Bad dreams, flashbacks Flashbacks Managing pressure, stress, temper 3. What topics/activities do you feel community programming should include to be the most useful for veterans with PTSD? Vet Center To accept them as is

67 To understand the symptoms and what to look for in people with PTSD 66

68 67 Appendix E Marketing Flyer for Potential Participants A program for Veterans coping with Post-Traumatic Stress Disorder The symptoms of Post-Traumatic Stress Disorder can affect all aspects of life, including enjoyment of daily activities and engaging in interpersonal relationships. The H.E.R.O. program is for Veterans diagnosed with PTSD that are interested in learning tools to improve: Interpersonal relationships Engagement in leisure occupations Coping Strategies This 8-week program is facilitated by a licensed occupational therapist and is open to veterans seeking assistance for PTSD Contact the Program Coordinator for further information regarding this program (419)

69 68 Appendix F Marketing Flyer for Significant Others Attention Spouses/Significant Others of Veterans with PTSD Are you interested in learning more about Post-Traumatic Stress Disorder? The H.E.R.O. program offers an educational session for spouses/significant others Offering an overview of the diagnosis of PTSD Understanding symptoms Facilitated by a Licensed Occupational Therapist Refreshments provided Join us on: Wednesday, May 7, :30-8:00pm Location: VFW Post W. Laskey Toledo, OH Please contact the program coordinator at: (419) to register for this free class

70 69 Appendix G Leisure Reflection Activity Taking a walk Breathing exercises Playing a sport Working in the yard Taking a nap Guided imagery Listening to music Time with a loved one Cooking Doing a craft Yoga Getting a massage Watching TV Playing cards Fishing/hunting Very Relaxing Somewhat Relaxing Neutral Not relaxing at all List activities/techniques that help you relax.

71 Appendix H Handout for Significant Others Post-Traumatic Stress Disorder Post-traumatic stress disorder is a type of anxiety disorder. It can occur after you've seen or experienced a traumatic event that involved the threat of injury or death. Symptoms 1. "Reliving" the event, which disturbs day-to-day activity Flashback episodes, where the event seems to be happening again and again Repeated upsetting memories of the event Repeated nightmares of the event Strong, uncomfortable reactions to situations that remind you of the event 2. Avoidance Emotional "numbing," or feeling as though you don't care about anything Feeling detached Being unable to remember important aspects of the trauma Having a lack of interest in normal activities Showing less of your moods Avoiding places, people, or thoughts that remind you of the event Feeling like you have no future 3. Arousal Difficulty concentrating Startling easily Having an exaggerated response to things that startle you Feeling more aware (hypervigilance) Feeling irritable or having outbursts of anger Having trouble falling or staying asleep Resource: Post-Traumatic Stress Disorder (2013). MedlinePlus. Retrieved from: 70

72 Appendix I Marketing Flyer to Hire Occupational Therapist Occupational Therapist Position Available The Center for Successful Aging is seeking a licensed and registered Occupational therapist to carry out an occupation-based program for veterans dealing with PTSD. Responsibilities: Conduct 10 eight-week sessions (2 per week), including pre and post test evaluations Developing the schedule for programming Meeting with potential participants Monthly reports on program evaluations Maintain program marketing Requirements: Licensed by the State of Ohio Registered with NBCOT Minimum of one year in a mental health setting Training in PTSD services Additional training in military culture will be required Contact: Barbara Kopp Miller Phone: (419) Address: 2801 W. Bancroft St. Toledo, OH A person starts to live when he can live outside himself Albert Einstein 71