FY 2009 Quality of Life Grant

Why QOL?Why QOL?• Serious problem not only affecting residents of

Broward County but nationwide providing Broward County but nationwide providing opportunity for project expansion and external funding

Community Partner• Broward County Commission Elderly and

Veterans Services DivisionStephen Ferrante DirectorStephen Ferrante, Director

Dr. Elda Kanzki-Veloso Wendy Thomson, MSN, Dr. Elda Kanzki Veloso (FSEHS)Angela Yehl (FSEHS, CPS)D Ro Che ail Vice

Wendy Thomson, MSN, RN (HPD)Dr. Tom Kennedy (FSEHS)Dr. Ron Chenail, Vice

President for Institutional Effectiveness (SHSS)

(FSEHS)Rivka Spiro, M.A (FSEHS)

Dr. Timothy Scala (FSEHS)Dr. Barbara Garcia-Lavin Dr. Barbara Garcia Lavin (FSEHS)Dr. Tommie Boyd (SHSS)

Operation Iraqi Operation Enduring Operation Iraqi Freedom (OIF)• 2003-Present

Operation Enduring Freedom (OEF)• 2001-Present

It has been suggested that approximately It has been suggested that approximately one in six servicemen and women returning from deployment in Iraq will be returning from deployment in Iraq will be in need of mental health services as a result of their experiences (Robinson result of their experiences (Robinson, 2004).

Several potential consequences to Several potential consequences to combat exposure, including :• posttraumatic stress disorder (PTSD)• posttraumatic stress disorder (PTSD)• depression • substance abusesubstance abuse• health problems/Traumatic Brain Injury (Hoge et

al., 2004)

Those with untreated PTSD are further at risk forThose with untreated PTSD are further at risk foralcohol and substance abusedomestic violenceunemploymentunemploymenthomelessnessincarceration suicidehealth problems

StatisticsStatistics

CBS investigation found 6 256 veteran CBS investigation found 6,256 veteran suicides in 2005 (Keteyian, 2007)

New York Times (2008) reported 121 OEF/OIF veterans charged with murder OEF/OIF veterans charged with murder upon return from deployment

360 degree battle space360 degree battle space• Compared to linear battle field in previous

conflictsconflicts

Improvised Explosive Devices (IED)p p ( )

Multiple Deploymentsp p y

What does this mean for returning What does this mean for returning ldi ?ldi ?soldiers?soldiers?

360 degree battlespace results in maintained 360 degree battlespace results in maintained heightened level of arousal creating sustained high anxiety and hypervigilance outside of g y yp gcombat

IEDs- highest number of amputees returning since the Civil War

Frequent and lengthy deployments take their toll not only on the soldier but family members toll not only on the soldier but family members and friends, as well

VIDEOVIDEOVIDEOVIDEO

Alive Day Memories: Home From IraqAlive Day Memories: Home From Iraq

Impact on FamilyImpact on Family

Over 700 000 children with at least one Over 700,000 children with at least one parent deployed (Rutledge, 2007)

Instantly becomes one-parent household

Anxiety and depression in children and spouse of deployed serviceman/womanspouse of deployed serviceman/woman

Ambiguous LossAmbiguous Loss• Family member returns- is there but not there

Domestic ViolenceDomestic Violence

According to DeAngelis (2008) domestic According to DeAngelis (2008), domestic violence is up to three times more likely to occur in veterans with PTSD than to occur in veterans with PTSD than among those without the disorder.

Over 33% of Vietnam veterans diagnosed with PTSD engaged in intimate partner with PTSD engaged in intimate partner violence over a one year period

Ba ie to Acce i Se iceBarriers to Accessing Services

Stigma associated with mental illness Stigma associated with mental illness and concern regarding how the soldier/marine would be perceived soldier/marine would be perceived among peers and superiors was identified as the primary barrier to identified as the primary barrier to provision of needed mental health services to military servicemen and services to military servicemen and women (Hoge et al., 2004)

Programmatic NeedsProgrammatic NeedsThe Department of Defense (DOD) has adopted several The Department of Defense (DOD) has adopted several programs to assist with adjustment following deployment, such as:

C t C• Courage to Care• Military One Source• Project DE-STRESS (Delivery of Self Training and Education for

Stressful Situations)Stressful Situations)

These efforts are helpful for individuals who actively k th i t h h t t b seek these services out; however, what appears to be

missing is a centralized proactive program to facilitate patient to provider care (Robinson, 2004).

Objective Objective • Alleviate the negative impact mental health

issues of returning veterans have on 3 levelsissues of returning veterans have on 3 levels1. individual2. family3. community

• We will aim to achieve this objective through provision of a “holistic” treatment program provision of a holistic treatment program.

Holistic Treatment ProgramHolistic Treatment Program• Intensive case management (Broward County

Commission Elderly and Veterans Services Commission Elderly and Veterans Services Division)- 1 hour every two weeks

• Individual therapy (FSEHS)-1 hour/weekpy ( )• Family/marital therapy (SHSS) 1 hour/week• Group therapy (HPD/FSEHS)- 1 hour every two

weeks

The holistic program will also include the use of a The holistic program will also include the use of a peer mentor to provide guidance and support, in order to reduce stigma and encourage the participant to access needed services.

Intervention SelectionIntervention Selection

The International Society for Traumatic The International Society for Traumatic Stress Studies (ISTSS) recently issued new practice guidelines for the treatment new practice guidelines for the treatment of PTSD, which the Veterans Administration/Department of Defense Administration/Department of Defense (VA/DoD) has adopted.

Intervention SelectionIntervention Selection

Several interventions were given a grade Several interventions were given a grade of “A“ through “E” based on the amount of empirical data to support them as of empirical data to support them as proven to be effective in the treatment of PTSD (i e a treatment is given a grade of PTSD (i.e., a treatment is given a grade of “A” if it has a high degree of support based on research outcomes) based on research outcomes) (DeAngelis, 2008).

Individual TherapyIndividual Therapy

Three such interventions which have Three such interventions which have received a grade of “A” by the ISTSS will be utilized in the current study be utilized in the current study. • Cognitive Therapy, • Exposure Therapy and Exposure Therapy, and • Stress Inoculation Therapy

Family TherapyFamily Therapy

Family/marital therapy will be provided Family/marital therapy will be provided to address marital and/or family issues which may arise as a result of the client’s which may arise as a result of the client s mental illness and/or the stressors associated with the repeated or associated with the repeated or prolonged deployment of a family membermember.

Family TherapyFamily Therapy

Significant reductions in domestic Significant reductions in domestic violence recidivism have been shown with individual couple therapy with individual couple therapy intervention (Stith, Rosen, McCollum, and Thomsen 2004)Thomsen, 2004)

Brief Strategic Family TherapyBrief Strategic Family Therapy

Family is part of a larger social systemFamily is part of a larger social system

Focus on relationships within the family Focus on relationships within the family, as well as within contextual framework (i e school work neighbors etc ) and (i.e., school, work, neighbors,etc.) and how these contribute to the development or maintenance of problemor maintenance of problem

Brief Strategic Family TherapyBrief Strategic Family Therapy

Among the most widely used empirically Among the most widely used empirically supported treatments of child and adolescent behavior problems and adolescent behavior problems, and substance abuse (Santisteban et al., 2006)

Group TherapyGroup Therapy

Group therapy will also be provided as a Group therapy will also be provided as a means of engaging other servicemen and women to provide support and and women to provide support and encouragement through the often difficult adjustment of returning to civilian life adjustment of returning to civilian life, and will encompass:• Employability• Employability• Social Skills• Community EngagementCommunity Engagement

Hi h Fid lit H P ti t Si l tHigh Fidelity Human Patient Simulators

Full body computer controlled Full body computer controlled mannequin that simulates real life experiences environments and experiences, environments, and situations.For healthcare providers allows one to For healthcare providers, allows one to experience situations considered too high risk to engage inhigh risk to engage in.Simulation allows participants to practice and debrief situations in a safe and debrief situations in a safe environment while doing no harm to real

The National Academy Institute of Medicine& Joint Commission on Accreditation of Healthcare & Joint Commission on Accreditation of Healthcare

Organizations

“… the American public questions whether quality health care can be delivered under the existing health care system”(Greiner & Knebel 2003 p existing health care system (Greiner & Knebel, 2003, p. 19)

To Err is Human and Crossing the Quality Chasmalso encourage the development of new also encourage the development of new educational strategies to improve patient safety. (Kohn, Corrigan, & Donaldson, 2000) (Committee on Quality Health Care in America: Institute of Medicine [IOM], 2001) Care in America: Institute of Medicine [IOM], 2001)

Public policy white paper stated healthcare must adopt simulation as means of researching patient safety and outcomes (2005)safety and outcomes (2005).

History of SimulationHistory of SimulationSimulation has an impressive track Simulation has an impressive track recordUtilized extensively in aviation, defense, y , ,maritime, and the nuclear energy industries • Chess probably represents one of the earliest

attempts at war gaming • The real modern roots of simulation can be • The real modern roots of simulation can be

found in the aviation industryCaptain Sully!

Simulated EnvironmentsSimulated Environments

How Does Human Patient Si l i Fi ?Simulation Fit?

There is nothing in the literature found There is nothing in the literature found utilizing simulators within a therapeutic environment environment. However, used in various military training exercises (i e The Combat Trauma exercises (i.e., The Combat Trauma Patient System (CTPS)The clients can interact with the simulator The clients can interact with the simulator as if it is a real person, real time.Reduces the personnel needed to Reduces the personnel needed to interact with the client.

AssessmentsAssessmentsAssessmentsAssessmentsThe instruments that will be administered

f llare as follows:• Detailed Assessment of Posttraumatic Stress

(DAPS) (DAPS), • Family Environment Scale (FES)• Family Environment Scale: Children’s Version Family Environment Scale: Children s Version,

and• Quality of Life Inventory (QOLI)

AssessmentsAssessmentsAn interview will also be used to investigate h h ldi i h i how the soldiers experience a therapeutic holistic program.

The participants will be administered each instrument prior to the intervention, during the p , gmid-point of the intervention, and post-intervention to track symptom reduction and program efficacy, via improvement in each participant‘s overall quality of life.

• (1) How do returning soldiers experience a (1) How do returning soldiers experience a holistic therapeutic program?

• (2) What intrapersonal, interpersonal, familial, demographic, and military service factors influence their experience of the factors influence their experience of the holistic therapeutic program?

• (3) Will the holistic therapeutic program affect participants’ level of psychological

l f il f i i d symptomatology, family functioning, and quality of life?

Participant RecruitmentParticipant Recruitment

Convenient sampling will be used to Convenient sampling will be used to target 10 veterans between the ages of 18 40 years of age who have served 18-40 years of age who have served during OIF and OEF for participation in the program the program. The participants will be recruited through referrals from the Broward through referrals from the Broward County Commission Elderly and Veterans Services DivisionServices Division

• A mixed-methods approach will be A mixed methods approach will be used to investigate how the returning soldiers experience a g pholistic therapeutic program consisting of the services delineated

babove.

The goal of this research project is to gather rich The goal of this research project is to gather rich descriptions and a depth of understanding of the soldier’s experiences of the holistic therapeutic program.p og a

Quantitative (Dr. James Pann)

Q lit ti (D R Ch il)Qualitative (Dr. Ron Chenail)

QuantitativeQuantitativeIn order to determine if the participants experience In order to determine if the participants experience any changes on the outcome variables (see Research Question 3) a series of repeated measures ANOVA’s

ill be tili ed to dete i e if the e i a cha e o the will be utilized to determine if there is a change on the outcome variables from pretest to mid-intervention to posttest.

If the assumptions of their statistical test are not satisfied (probably due to the small sample size) then satisfied (probably due to the small sample size) then an appropriate non-parametric test will be utilized.

QualitativeQualitative

A phenomenological approach will be A phenomenological approach will be used to analyze this data, which is the most effective method for this particular most effective method for this particular study. A phenomenological approach examines A phenomenological approach examines life experiences, provides richness to a study and allows one to hear the voice of study, and allows one to hear the voice of the subjects (Creswell, 1998)

QualitativeQualitativeThe Colaizzi (1973) method will be used to The Colaizzi (1973) method will be used to analyze the data by reading participant descriptions; extracting significant statements; p g gformulating meaning based on these statements; clustering any emerging themes, labeling them, and then exhausting them; formulating descriptions, structuring them, and then attaching them to meaning; and validating then attaching them to meaning; and validating the findings.

Ensuring TrustworthinessEnsuring Trustworthiness

Several approaches will be employed to Several approaches will be employed to ensure trustworthiness including the audio taping and transcribing of all audio taping and transcribing of all qualitative interviews.

Ensuring TrustworthinessEnsuring TrustworthinessFirst, one graduate student will conduct the interview.First, one graduate student will conduct the interview.Second, two additional graduate students will read the transcription and extract themes.Thi d the t a c i tio ill be checked a ai t the Third, the transcriptions will be checked against the initial recorder for accuracy. Fourth, themes will be compared with the initial interpretation.Fifth, the PI and Co-PI will review the themes that were extracted along with the transcript and give feedback extracted along with the transcript and give feedback on how to organize the categories. Finally, themes will be presented to participants for verification and accuracy of data (Creswell 1998)accuracy of data (Creswell, 1998).

Berger, T. J. (2006, February 13). Post Traumatic Stress Disorder (PTSD) and T t t St t t f th d f Vi t V t f A i Treatment. Statement for the record of Vietnam Veterans of America. Presented before the Subcommittee on PTSD Gulf War & Stress: Health Project, at the Institute of Medicine of the National Academy of Science, Washington, DC.Colaizzi P (1973) Reflection and research in psychology: A Colaizzi, P. (1973). Reflection and research in psychology: A phenomenological study of learning. Dubuque, IA: Rendall/Hunt Publishing.DeAngelis, T. (2008, January). PTSD treatments grow in evidence, effectiveness: Several psychological interventions help to significantly reduce post-traumatic stress disorder symptoms, say new guidelines. Monitor on Psychology, 39(1), 40-43.DeAngelis T (2008 January) Helping families cope with PTSD: DeAngelis, T. (2008, January). Helping families cope with PTSD: Psychologists study ways to address PTSD in the context of relationships. Monitor on Psychology, 39(1), 44-45.Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006, March 1). Mental health problems use of mental health services and attrition from military health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of the American Medical Association, Vol. 295(9), 1023-1032.

Hoge, C. W., Castro, C. A., Messer, S. C., McGurk, D., Cottling, D. I., & Koffman, R. L. (2004 July 1) Combat duty in Iraq and Afghanistan mental health problems and (2004, July 1). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. The New England Journal of Medicine, Vol. 351(1), 13-22.Keteyian, A. (2007, November 13). The veteran suicide “epidemic.” CBS News. Retrieved from http://www.cbsnews.com/stories/2007/11/13/cbsnews_investigates/main3496470.shtmlshtmlRobinson, S. L. (2004, September 14). Hidden toll of the war in Iraq: Mental health and the military. Presented at the Center for American Progress, Washington, DC. Retrieved March 8, 2008, from www.americanprogress.orgSantisteban, D. A., Suarez-Morales, L., Robbins, M. S., Szapocznik, J. (2006). Brief Strategic Family Therapy: Lessons Learned in Efficacy Research and Challenges to Strategic Family Therapy: Lessons Learned in Efficacy Research and Challenges to Blending Research and Practice. Family Process, 45(2) 259-271. Stith., S. M., Rosen, K. H., McCollum, E. E., & Thomsen, C. J. (2004, July). Treating intimate partner violence within intact couple relationships: Outcomes of multi-couple versus individual couple therapy. Journal of Marital and Family Therapy, Vol. couple versus individual couple therapy. Journal of Marital and Family Therapy, Vol. 30(3), 305-318.