OT 501: Reflective Analysis on the Rehabilitation of American Veterans The University of Scranton
Reflective Analysis Part II 2 Past By the late 1960s occupational therapy (OT) was establishing a new trend of thought as it developed its new identity as a profession. At this time there was a shift from rehabilitation and disability program expansion to advocating for disability rights. Sheltered workshops, community-based rehabilitation, independent living, halfway houses, homebound programs, outpatient clinics, follow up programs, and new mechanical interventions began a new movement in the treatment of physical dysfunction (Moore, 1967; Zasler, Katz, Zafonte, & Arciniegas, 2013). The passage of legislation for rehabilitation provided funding in order to aid and expand OT in community-based rehabilitation. Whether it was in the schools, homes, neighborhood, hospitals, or businesses, OT was helping the individual functionally exist in his environment. However, soldiers returning home from fighting in the Vietnam War were grossly overlooked (Finn, 1971; Moore). By the 1970s as the war came to an end, soldiers homecoming was less than joyful because of Americas disapproval of the war. They were antagonized, rioted against, or simply ignored (Figley, 1978). Despite OT advances for people with physical disabilities, little progress was made to meet the needs of Vietnam veterans (Padilla, 2005). Although the Vietnam War made its mark on the history of disability rehabilitation through the use of more advanced technology, many survivors with traumatic brain injury (TBI) went unrecognized and untreated (Zasler et al., 2013). TBI was extremely prevalent in this population. Neurological treatment was given to wounded soldiers within hours of the trauma, which increased chances of survival and the need for rehabilitation services upon returning home (Carey, Sacco, & Merkler, 1982). America was a divided nation. Internal conflict between military and civilian values took precedence over the veterans basic human needs. According to Hitt (1990) American values Reflective Analysis Part II 3 include democracy, justice, human rights, equality, freedom, responsibility, reason, diversity of opinion, quality of life, and world peace (pp. 18). Throughout history, America has engaged in warfare in order to sustain these values for the American people, however many of these values were not upheld during the Vietnam War. In previous wars, American soldiers were welcomed back as heroes due to their voluntary service defending freedom, equality, and justice for the people. Although the act of fighting for ones country remains honorable, soldiers who were forced into fighting the war due to a large and involuntary draft, lacked courage and enthusiasm. Those who wanted to be part of the war believed more in the goals of the confrontation they faced, whereas those who were drafted involuntarily did not necessarily believe in the cause as highly. This division of attitudes created conflicting values of democracy within the United States (Greene, 1989). According to Abraham Maslow, there are several basic needs that are common to all people (Hitt, 1990). However at this time, Americas values did not strive to fulfill physiological, security, belongingness, and self-esteem needs of the veterans. Many physiological needs were ignored due to lack of proper healthcare and rehabilitation (Greene, 1989). Riots and negative attitudes of the American people compromised security needs and providing veterans with unsuitable community reintegration overlooked belongingness needs. Self-esteem needs were disregarded due to the negative portrayal of the war through the media. (Greene; Hitt). This ignorance towards the needs of military personnel proved unethical and hindered the soldiers functional transition home from the war and their adjustments to new roles and routines (Figley, 1978). Due to the culture at this time, the negative mentality towards veterans created a rift in both Americas medical and political ethical systems. This negative mentality set the stage for the use of social contract ethics, as described by Hitt (1990) where social norms created the Reflective Analysis Part II 4 formation of American morals rather than the values the nation was founded upon. The disregard of these American values led to lack of appropriate care for the returning military personnel. Both physical and psychosocial needs were left unmet, resulting in high rates of homelessness, suicide, psychiatric symptoms, poor adjustment to home life, unemployment, and drug abuse (Figley; Zasler et al., 2013). Without proper treatment, these negative values, ethics, and consequences became lifelong battles for returning veterans (Glantz, 2009). Present
Recognition of persisting problems of veterans, especially TBI and Post-Traumatic Stress Disorder (which was not formally diagnosed until the 1980s), has been earlier and more complete in the current war Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) than it was with the Vietnam War (Pillar, 2012). With the combination of TBI and PTSD, known as the signature injury of the war, rehabilitation advanced to a more holistic and community-based treatment specifically for the care of veterans (American Occupational Therapy Association, 2013). From 2000 through 2013 the OEF/OIF wars have resulted from 280,734 diagnosed TBIs and even more have gone undiagnosed (Defense and Veterans Brain Injury Center, 2013). The ultimate achievement of OT for this population is to offer veterans hope and skills for occupational freedom (Platch & Sells, 2013). In order to not let history repeat itself, America has gone back to its roots in valuing human rights, justice, equality, and quality of life. This has been done through the creation of many foundations and administrations aimed directly at caring for returning veterans who may have been wounded physically or mentally during combat. Administrations such as the Wounded Warrior Project and Warrior Transition Units have been established to help promote and/or maintain optimal occupational performance. These administrations are founded upon life skills Reflective Analysis Part II 5 programs to support the service members integration to civilian life, which had been greatly overlooked after the Vietnam War (Erickson, 2008). In addition to the creation of foundations and administrations, new research is being conducted in order to provide evidence-based treatment to clients to ensure best possible treatment. This research covers a broad spectrum of approaches, which ranges from animal assisted therapy (AAT) to cognitive approaches to treatment (Beck et al., 2012; Vanderploeg et al., 2008). The Army Medical Department and the Office of the Surgeon General established the Proponency for Rehabilitation and Reintegration (PR&R) to advance best practices, policy, advocacy, and research (Radomski, Davidson, Voydetich, & Erickson, 2009). The Army OT program has also been established to provide proper training and education to occupational therapists to facilitate treatment to American soldiers all over the world (Johnson, 2013). The incongruence to the American values of the Vietnam era and subsequent consequences forced America to shift its view of the healthcare of veterans. In doing so, several acts were instilled such as Veterans Health Care Facilities Capital Improvement Act of 2011, The VOW to Hire Heroes Act, and The Veterans Opportunity to Work Act, to support returning soldiers reintegration into their communities and civilian lives. Through this new legislation, veterans are starting to receive proper healthcare and education/training to increase functional independence and quality of life (House Committee on Veterans' Affiars, 2013). OT has played a key role in the rehabilitation of wounded warriors, especially those living with a TBI. The VA currently employs 750 occupational therapists whom are equipped with unique and ideal qualifications needed to address complex functional issues that returning veterans are facing (Hofmann, 2008). Home health programs, outpatient facilities, and inpatient acute care units are just a few of the settings in which occupational therapists now treat returning Reflective Analysis Part II 6 veterans with TBI. However, it has become apparent in recent years that mental health needs of veterans may not be receiving the OT they could benefit from due to lack of funding. Fortunately, the American Occupational Therapy Association (AOTA) is aware of this issue and has recently recommended that the House Committee of Veterans Affair conduct a hearing on the rehabilitation and reintegration of veterans. AOTA also suggested collaboration with the VA and the Department of Defense (DoD) to help with a smooth transition home from active duty for those living with a TBI (Hofmann, 2008). The overarching goal of occupational therapy for military personnel is to use strategies to help them recover, compensate, or adapt so they can reengage with activities that are necessary for their daily life (American Occupational Therapy Association, 2009, pp. 469). However, providing care to nearly 1.5 million Americans currently serving in the military and the 22.7 million veterans remains a challenge. The VAs mission, along with The Affordable Care Act, is to serve Veterans by providing the highest quality health care available anywhere in the world Americas Veterans deserve nothing less (U.S. Department of Veteran Affairs, 2013). Unfortunately current research has found that the military is failing to diagnose, treat, and document brain injuries in veterans and insurance programs are not covering effective rehabilitation for brain injuries. Veterans receive health benefits from the VA but access to those services remains a challenge (American Occupational Therapy Association, 2013; Mojtabai, Rosenheck, Wyatt, & Susser, 2003; National Public Radio & ProPublica, 2011). This current situation brings about Hitts societal dilemmas, quality vs. price. Veterans have every right to have a sense of entitlement when going to the VA to receive the benefits they have earned. However, these benefits are not easily accessed or obtainable when they are most needed (Glantz, 2009). American service men made a bargain when they signed up. They Reflective Analysis Part II 7 agreed to go fight for America anywhere in the world as long as their Congress and Commander in Chief deemed it necessary for the sake of the nation. In return, the government agreed to take care of their wounds both on the battlefield and when they got home (Glantz, pp. 138). This is not only a societal dilemma, but also an organizational dilemma between customers vs. owners. Owners want to ensure financial return on their investments whereas customers are more concerned about the availability and quality of the product and services (Hitt, 1990). Although the VAs intentions to provide these services are rooted in American values such as justice, human rights, equality, and quality of life for all people, there is still a great need to ensure that all military personnel are receiving benefits and services as needed (Glantz). Future According to AOTAs Centennial Vision We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society's occupational needs" (American Occupational Therapy Association, 2007, pp. 613). In order to do so, efforts must be increased to meet the occupational needs of returning veterans. In accordance with occupational therapys core values of altruism, equality, freedom, justice, dignity, truth, and prudence, occupational therapists must continue to support foundations such as the Wounded Warrior Project and Warrior Transition Units and continue to establish programs to support the occupational well-being of military personnel (Peloquin, 2007). One of the biggest challenges for OT and the rehabilitation of veterans include insufficient funding. AOTAs road to the Centennial Vision addresses advocating to ensure funding for veteran care and increasing Congress awareness of residual effects of war. In order to do so, AOTA leaders must continue to meet with VA officials to support OTs role in the functional rehabilitation of veterans. Reflective Analysis Part II 8 Although there has been an increased awareness of returning veterans needs since the Vietnam War, there is still room for improvement. In order to be congruent with AOTAs Centennial Vision, more research and collaboration between AOTA, VA, and DoD must take place. There is potential growth for the successful rehabilitation of soldiers both in the United States and internationally. Rehabilitation must become more accessible to soldiers returning home and on the battlefield. OT must continue to advocate for the need of their services when treating military personnel. Occupational therapists must plan and provide interventions on the basis of the service member's unique set of circumstances, goals, and functional performance problems especially when treating TBI. Although more research must be conducted in order to address OTs role in treating veterans who have sustained a TBI, areas including client education, vision, cognition, emotional well-being, and the reintegration of life tasks and roles are recognized as the domain of OT when treating this population (Radomski et al., 2009). Potential challenges still exist due to a lack of financial resources making it essential for leaders in the OT field to advocate for funding. In order to truly encompass the American values of human rights, justice, equality, and quality of life, insurance policies must put the basic human needs of returning veterans above financial rewards. In doing so, OT will play a key role in helping soldiers reintegrate into their community and support health and well-being through the participation in meaningful occupations. Due to OTs extensive background in both cognitive and physical rehabilitation, there is a huge potential for the future of this domain. Occupational therapists must continue to provide treatment, based on OTs core values, both domestic and abroad to soldiers who volunteer their services for the good of America to reduce residual consequences of war that hinder the reintegration and participation of meaningful activities. Reflective Analysis Part II 9 References
American Occupational Therapy Association. (2013). Veteran and wounded warrior care. Retrieved from http://www.aota.org/en/Practice/Rehabilitation-Disability/Emerging- Niche/Veteran.aspx American Occupational Therapy Association. (2009). AOTAs societal statement on combat- related posttraumatic stress. American Journal of Occupational Therapy, 63, 469-470. American Occupational Therapy Association. (2007). AOTAs Centennial Vision and executive summary. American Journal of Occupational Therapy, 61(6), 613-614. Beck, C., Gonzales, F., Sells, C., Jones, C., Reer, T., Wasilewski, S., & Zhu, Y. (2012). The effects of animal-assisted therapy on wounded warriors in an occupational therapy life skills program. United States Army Medical Department Journal, 38- 44. Carey, M., Sacco, W., Merkler, J. (1982). An analysis of fatal and non-fatal head wounds incurred during combat in Vietnam by U.S. forces. Acta Chirurgica Scandinavica Supplementum. 508, 351356. Defense and Veterans Brain Injury Center. (2013). DOD worldwide numbers for TBI. Retrieved from http://www.dvbic.org/dod-worldwide-numbers-tbi Erickson, M. (2008). The role of occupational therapy in warrior transition units. United States Army Medical Department Journal, 21-24. Figley, C. (1978). Stress disorders among Vietnam veterans. New York: Brunner-Routledge. Finn, G. (1971). Occupational therapists in prevention programs. In R. Padilla (Ed.), A Professional Legacy (2nd ed.). Bethesda, MD: American Occupational Therapy Association.
Reflective Analysis Part II 10 Glantz, A. (2009). The war comes home. Los Angeles: University of California Press. Greene, B. (1989). Homecoming: When the soldiers returned from Vietnam. New York: G. P. Putnam's Sons. Hitt, W. (1990). Ethics and leadership putting theory into practice. Columbus OH: Battelle Memorial Institute. Hofmann, A. (2008). Veterans affairs. OT Practice, 12-15. House Committee on Veterans' Affairs. (2013). Legislation. Retrieved from www.veterans.house.gov/legislation-page Johnson, E. (2013). Army OT. Retrieved from http://armyotguy.com/armyOTguy.com/Army_OT.html Mojtabai R., Rosenheck R. A, Wyatt R. J., & Susser, E. S. (2003). Use of VA aftercare following military discharge among patients with serious mental disorders. Psychiatric Services, 54(3), 383388. Moore, J. (1967). Changing methods in the treatment of physical dysfunction. American Journal of Occupational Therapy , 21(1), 18-28. National Public Radio & ProPublica. (2011). Brain wars: How the military is failing its wounded. Retrieved May 12, 2011, fromhttp://www.npr.org/series/127402851/brain- wars-how-the-military-is-failing-its-wounded Padilla, R. (2005). A professional legacy. (2nd ed., pp. 171-176). Bethesda, MD: American Occupational Therapy Association. Peloquin, S.M. (2007). A reconsideration of occupational therapys core values. American Journal of Occupational Therapy, 61(4),474-478. Pillar, R. (2012). The visible and invisible effects of war. National Interest. Reflective Analysis Part II 11 Plach, H., & Sells, C. (2013). Occupational performance needs of young veterans. American Journal of Occupational Therapy, 66(1), 73-81. Radomski, M. V., Davidson, L., Voydetich, D., & Erickson. M. W. (2009). Occupational therapy for service members with mild traumatic brain injury. American Journal of Occupational Therapy, 64, 646655. U.S. Department of Veteran Affairs. (2013). The Affordable Care Act, VA, and you. Retrieved from http://www.va.gov/health/aca/EnrolledVeterans.asp Vanderploeg, R., Schwab, K., Walker, W., Fraser, J., Sigford, B., Curtiss, G., Salazar, A., & Warden, D. (2008). Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and veterans brain injury center randomized controlled trial of two rehabilitation approaches. Archives of Physical Medicine and Rehabilitation, 89(12), 22272238. Zasler, N., Katz, K., Zafonte, R., & Arciniegas, D. (2013). Brain injury medicine: Principles and practice. (2nd ed.). New York: Demos Medical Publishing.