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Introduction

Life skills training can be helpful for individuals that need improvement in interpersonal skills, community reintegration, and taking responsibility for their own wellness (Gibson, D’Amico, Jaffe, & Arbesman, 2011). Life skills training often allows for a functional and successful approach for the specific skill that was integrated. Veterans with PTSD can fall into an avoidance coping style when faced with daily tasks in the broad environment which cause them frustration (Anticevic, Kardum, & Britvic, 2011). Additionally, veterans with PTSD may need help dealing with crowds and excessive stimuli that is experienced during grocery shopping. According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association, 2013) PTSD diagnostic criteria can include:

• Irritable behavior and angry outbursts
• Persistent negative emotional state
• Hypervigilance
• Estrangement from others
• Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world

Theory

The PEO model focuses on the interaction of three components: person, environment, and occupation, which are used to assess an individual’s occupational functioning. The components are thought of as parts of a venn diagram, where the three parts interact to determine an individual’s occupational performance. The person aspect believes individuals are unique, assume multiple roles, and focuses on the behavior of the person (Law et al., 1996). The environment aspect is the context where the occupational performance will take place, unique to the perspective of the person, and constantly provides cues and demands for appropriate behavior from the person (Law et al., 1996). Lastly, the occupation aspect involves meaningful tasks and activities that are determined by the person in the following areas: self-care, leisure, and productivity (Law et al., 1996). A good fit is determined by the interaction and amount of overlap between the three components (Law et al., 1996). For example, the ability to perform daily tasks such as grocery shopping, requires effective social communication skills in a complex environment. Occupational therapists need to identify barriers and maximize the fit within the three components to increase client participation.

Evidence

There is a growing body of literature suggesting the benefits of skills training among veterans. Research has shown that using specific skills training techniques such as, mindfulness, distress tolerance, and dialectical behavior techniques provide veterans with the necessary tools to be successful not only in the community but in other aspects of life (Denckla, Bailey, Jackson, Tatarakis, & Chen, 2015). In addition, skills training have been identified as a useful tool to address specific long-term outcomes such as social community reintegration (Pugh et al., 2017).

Case Study

Samuel is a 28-year old veteran of the army national guard. As a combat medic on patrol in Afghanistan his convoy encountered an improvised explosive device (IED). Due to this traumatic event Samuel experienced a TBI and now suffers from PTSD. Unfortunately, Samuel often gets easily frustrated and angry when dealing with people. His inability to interact in a socially acceptable way with others is causing him disruptions in his activities of daily living and instrumental activities of daily living, specifically emphasized was grocery shopping.  Samuel has participated in PTSD support groups at the local VA in the past but is seeking help to be successful in his everyday activities.

Intervention Plan

Problem Statement  

Samuel is unable to participate in grocery shopping due to his inability to regulate his frustration and angry outbursts in public places.

Long Term goals

1. Samuel will be able to shop for groceries using 2 self-selected strategies to decrease frustration in public places in 4 weeks.
2. Client will be able to independently go grocery shopping while having 2 social interactions at the grocery store without irritable outbursts in 4 weeks.

Short term goals

1. Client will be able to tolerate being in the grocery store for 5 minutes with 2 verbal cues to redirect irritable outburst in 2 weeks to improve grocery shopping.
2. Client will identify 2 self-selected strategies to decrease irritable outbursts in 2 weeks to be able to go grocery shopping.
3. Client will be able to talk to 1 person for 20 seconds without getting frustrated to be able to go grocery shopping in 2 weeks.

Intervention format  

Individual

Setting

Samuel will meet with the occupational therapist individually at the outpatient clinic for 40 minutes 1x week.

Supplies

Stopwatch, pen, notebook pad

Agenda

• Meet with Samuel / develop rapport / form a partnership (5 min)
• Gather client centered information on perceived barriers to efficient grocery shopping, to identify strategies he wants to use (15 min)
  •  Potential open-ended questions
    • How do you feel when you go into your grocery store?
    • Why do you think you feel that way?
    • What kind of strategy do you think would help you reduce these symptoms?
• Practice one of his identified strategies (15 min)
  • Role play with therapist (grocery store scenario, external stimuli distractors included)
  • Allow him to describe his emotions (fluctuations, triggers)
  • Encourage him to note the changes in his mood while incorporating his strategy
• Provide summary / feedback on the session  (5 min)
  •  Reflect on how he feels about his strategy
  • Overview of treatment session

Documentation

S: Client reports that he becomes overwhelmed and frustrated in the grocery store due to the people, commotion, and noise. Client states that he often has an outburst when people try to talk to him.

O: Client participated in a 40 minute individual session that focused on identifying perceived barriers to grocery shopping and identifying a self selected coping strategy. Client explained his negative emotions about people and public places. The client reported he does not like dealing with people because it always leads to frustration causing him to make a scene. The client recognized his heightened emotions regarding grocery stores and decided on a strategy that would help reduce his discomfort and outbursts. The client was able to role-play a grocery store scenario with the therapist using his strategy and required 2 verbal cues regarding his emotions and one 2-minute break to reduce his heightened emotions. The therapist demonstrated an appropriate social interaction to show the client an alternate approach for the scenario.

A: Client displays insight into his emotional response while grocery shopping. Client was able to recognize his own strengths and weaknesses to identify a strategy that would work for him. His PTSD has seemed to interfere with his ability to socially interact causing him to use an avoidance coping strategy when dealing with grocery shopping. It was evident during the role-play scenario that the client needs to identify further strategies to incorporate so that he is able to participate in daily activities with less negative encounters. Client would benefit from creating a triggers worksheet to identify further strategies for regulating his emotions while grocery shopping. Biofeedback may allow the client to recognize when the symptoms are surfacing and how to reduce the physiological response.

P: Client should continue attending 40-minute OT session’s 4x a month to improve his social skills ability for daily activities. Next treatment session the client will engage in biofeedback training using muscle tension, heart rate, and blood pressure as indicators to improve his strategies for reducing frustration and angry outbursts.

References

Anticevic, V., Kardum, G., & Britvic, D. (2011). War Veterans’ Quality Of Life: The Impact Of Lifetime Traumatic Experiences, Psychological And Physical Health-Related Characteristics. Drustvena Istrazivanja, 20(4), 1101-1118. Retrieved from http//ezproxy.fiu.edu/login?url=https://search-:proquest-com.ezproxy.fiu.edu/docview    /92039423?accountid=10901

Denckla, C. A., Bailey, R., Jackson, C., Tatarakis, J., & Chen, C. K. (2015). A novel adaptation of distress tolerance skills training among military veterans: Outcomes in suicide-related events. Cognitive and Behavioral Practice, 22, 450-457.doi:10.1016/j.cbpra.2014.04.001

Gibson, R. W., D’Amico, M., Jaffe, L., & Arbesman, M. (2011). Occupational therapy interventions for recovery in the areas of community integration and normative life roles for adults with serious mental illness: A systematic review. The American Journal of Occupational Therapy, 65(3), 247-56. Retrieved from http://ezproxy.fiu.edu/login?url=https://search-proquest-com.ezproxy.fiu.edu/docview/866308708?accountid=10901

Law, M., Cooper, B,. Strong, S., Stewart, D., Rigby, P. & Letts, L. 1996. The Person-Environment-Occupation Model: A transactive approach to occupational performance. Canadian Journal of Occupational Therapy. 63(1):9-23.

Pugh, M. J., Swan, A. A., Carlson, K. F., Jaramillo, C. A., Eapen, B. C., Dillahunt-Aspillaga, C., . . . Grafman, J. H. (2017). Original research: Traumatic brain injury severity, comorbidity, social support, family functioning, and community reintegration among veterans of the afghanistan and iraq wars. Archives of Physical Medicine and            Rehabilitation, doi:10.1016/j.apmr.2017.05.021

Trauma- and stressor-related disorders. (2013). Diagnostic and statistical manual of mental disorders () American Psychiatric Association.doi:10.1176/appi.books.9780890425596.dsm07