Question 1

Which aspect of military service directly impacts daily life occupations, habits, roles, and routines?
A) Community reintegration
B) Civilian life
C) Deployment
D) Mental health intervention

Accepted Answer

Returning from extended deployments or transitioning to live outside military installations requires Veterans and their families to adapt and reintegrate into their new communities. Reintegration into the civilian community post-deployment can be a complex, lengthy, and nonlinear adjustment process involving changes in life relationships and responsibilities. In the rehabilitation literature, community integration refers to "being part of the mainstream of family and community life, discharging normal roles and responsibilities, and being an active and contributing member of one's social groups and of society as a whole" (Dijkers, 1998, p. 1). Community (re)integration (CR) as it relates to Veterans refers to "returning to participation in home, social and community living after deployment and, in many cases, after injury" (Hawkins, McGuire, Linder, & Britt, 2015, p. 527), and being "happily situated, productively occupied, and effectively supported in the community" (McColl, Davies, Carlson, Johnston, & Minnes, 2001, p. 429). Deployment refers to the movement of military personnel and equipment into places where they can be used when needed. The focus of this chapter is on military service members who were deployed and are returning from war zones in the Middle East. However, many of the topics covered in the chapter could easily be applied to Veterans who served in other conflicts.

Question 2

Veterans 65 and older often receive reimbursable health care through which program?
A) Medicare
B) Medicaid
C) Medicare supplement
D) Tricare

Accepted Answer

Military cultural competence is essential to caring for the biopsychosocial needs of military and Veteran populations (Meyer, Writer, & Brim, 2016). Veterans continue to be seen in many sectors of the health-care system, including both Veterans Health Administration (VHA) and non-VHA facilities. According to the U.S. Census Bureau (n.d.), Veterans experience a disparity in health-care coverage based on age and employment status. For example, in 2016, about one-half of Veterans received medical coverage through Medicare because they were 65 years or older. The other half of Veterans of working age (19-64) were covered by employer-sponsored, TRICARE, direct purchase, or Medicaid insurances, with 5.5% of Veterans remaining uninsured.

Question 3

Eligibility for health care services for a Veteran is based upon which of the following factors?
A) Type of service
B) Division of the military
C) Number of deployments
D) If disability was acquired during military service

Accepted Answer

Health care for Veterans is not guaranteed by military service alone. Eligibility and health-care benefits requirements vary by whether or not the Veteran's disability is related to military service (service connection), as well as period of service, employment status, and income.

Question 4

The largest demographic of Veterans in today's society served in which war era?
A) World War I
B) World War II
C) Gulf War
D) Vietnam War

Accepted Answer

Gulf War-era (1990-present) Veterans now comprise the largest demographic of the Veteran population, accounting for nearly 7.2 million of the 20 million Veterans. According to the U.S. Department of Veterans Affairs (VA) (2018a), the total Veteran population is predicted to decrease from 20 million in 2017 to 13.6 million in 2037. As these trends emerge, Veteran culture may be impacted by generational differences and race and ethnicity, as well as the geographical locations where service members reside. For example, Veterans from underrepresented groups are predicted to increase from 23.3% percent of the total Veteran population in 2017 to 32.8% in 2037, as the proportion of white Veterans declines. Additionally, 50% of Veterans live within 10 states, with the largest concentration residing in the West and South (VA, 2018a). Understanding the nuances of Veteran culture should better inform community health promotion programming, resulting in improved health outcomes.

Question 5

The most common health issue for Veterans from the wars in Iraq and Afghanistan is:
A) Traumatic brain injury
B) Chronic pain
C) Posttraumatic stress disorder
D) Polytrauma

Accepted Answer

Compared to other conflicts, recent advances in battlefield medicine and protective armor have improved the ability of OIF/OEF Veterans to survive common mechanisms of injury, including small-arms fire and explosive munitions (e.g., blasts from improvised explosive devices [IEDs]). Although lives have been saved, polytrauma, defined as "two or more injuries to physical regions or organ systems one of which may be life threatening, resulting in physical, cognitive, psychological, or psychosocial impairments and functional disability" have become the signature injuries of the wars in Iraq and Afghanistan (VA, n.d., para. 2). The "polytrauma triad" of mild traumatic brain injury (mTBI), chronic pain, and posttraumatic stress disorder (PTSD) have proven to be a difficult diagnostic and therapeutic challenge for the current medical system (Cifu et al., 2014). To address these challenges, the VHA Polytrauma System of Care has been established to provide an integrated network of specialized rehabilitation programs dedicated to serving Veterans and service members with both combat- and civilian-related traumatic brain injury (TBI) and polytrauma.

Question 6

A factor associated with chronic pain in the Veteran population is:
A) Smoking
B) Chronic headache
C) Balance problems
D) Visual disturbances

Accepted Answer

According to the Institute of Medicine (2011), 25% of the U.S. population experiences chronic pain; however, 50% of Veterans are affected by chronic pain. The prevalence of moderate to severe chronic pain in the Veteran population is approximately 27%. Chronic pain is defined as "ongoing or recurrent pain, lasting beyond the usual course of acute illness or injury or more than 3 to 6 months, and which adversely affects the individual's wellbeing" (American Chronic Pain Association, n.d., para. 1). Chronic pain is pain without biological value that has persisted past the expected time for tissue healing. Of the types of chronic pain, musculoskeletal (61%) and back pain (24%) have the highest prevalence in VA primary care settings. Factors associated with chronic pain in both Veteran and civilian populations are lower levels of education, smoking, and emotional distress (Van Den Kerkhof, Carley, Hopman, Ross-White, & Harrison, 2014).

Question 7

The most common mental health diagnosis for active-duty service members is:
A) Posttraumatic stress disorder
B) Depression
C) Anxiety
D) Insomnia

Accepted Answer

According to the Defense Health Agency, the prevalence of active-duty service members (ADSM) diagnosed with any mental health condition varies by military force (i.e., Army, Navy, Air Force, Marines), and has increased from 2005 to 2012, with a reported decline from 2013 to 2016. For example, the peak point prevalence for ADSM was 30% in 2013. The most common diagnoses across all services include anxiety disorders (5%), depressive disorders (7%), insomnia (5%), and PTSD (2.5%). Other diagnoses related to alcohol and substance abuse ranged from 0% to -1.5% (Crum-Cianflone, Powell, LeardMann, Russell, & Boyko, 2016).

Question 8

Mr. Edwards is 29-year-old male who recently returned from a deployment after sustaining a hand injury from an explosive device. He lost two of his fellow soldiers during the incident. His hand rehabilitation is making progress but he reports being really tired, not sleeping well, and some irritability. Mr. Edwards is most likely experiencing a physical manifestation of what?
A) Grief
B) Challenges with community reintegration
C) Anxiety
D) Insomnia

Accepted Answer

In a study by Toblin et al. (2012), infantry brigade soldiers experiencing combat-related grief were at least 2.4 times more likely to experience negative health outcomes as those who reported no difficulty with grief. The top five physical health symptoms reported by those having difficulty coping with grief were: fatigue (58.1%), sleep problems (55.4%), musculoskeletal pain (49.7%), back pain (41.3%), and headaches (32.7%). Other symptoms associated with grief included feeling easily annoyed or irritated (62.3%), concentration problems (37.3%), and memory problems (24.0%). Toblin et al. (2012) indicated it was the emotional reaction of grief, rather than the actual experience of loss, that was associated with diminished physical health.

Question 9

Moral injury, a state of inner conflict and turmoil that often precipitates feelings of shame, guilt, grief, anxiety, anger, and remorse, can often be confused with:
A) Grief
B) PTSD
C) Anxiety
D) Insomnia

Accepted Answer

According to Litz et al. (2009), moral injury is a consequence of "perpetrating, failing to prevent, bearing witness to acts that transgress deeply held moral beliefs and expectations" (p. 695). Acts that may precipitate moral injury include incidents causing harm to civilians during war, friendly fire deaths, military sexual assaults, and betrayals by leadership. Moral injury is a "broad clinical concept that exists in the intersection of multiple emotional, cognitive and social pathways" (Farnsworth, Drescher, Nieuwsma, Walser, & Currier, 2014, p. 258). It is a state of inner conflict and turmoil that often precipitates feelings of shame, guilt, grief, anxiety, anger, and remorse. Other reactions include purposelessness and alienation from self and others. Behavioral manifestations of moral injury may include self-harm, social withdrawal, substance abuse, and social instability. Although moral injury and PTSD have some common characteristics, "each has unique components that make them separable consequences of war" (Maguen & Litz, 2012, para. 6). PTSD is emotionally characterized by fear, while moral injury is emotionally characterized by shame. Moral injury can co-occur with depression and substance use disorder, as well as in the absence of active PTSD symptoms (Farnsworth et al., 2014).

Question 10

Mary is 32-year-old Veteran who was an officer in the military. She has been successful in her community reintegration. Which of the following is a protective factor for community re-integration?
A) Length of deployment
B) Age at discharge
C) College degree
D) Length of service

Accepted Answer

Of the Veterans who have served since September 2001, 43% report having had a military-related experience that was emotionally traumatic, and nearly half of these Veterans say they have suffered from posttraumatic stress as a result. Veterans who reported a relatively easy transition were more likely to be commissioned officers, have a college degree, and attend religious services a least once a week. Variables that appear to have no effect on ease of transition were race/ethnicity, length of service, age at discharge, and number of deployments (Morin, 2011).

Question 11

Joe is a 31-year-old who has decided to transition out of the military due to the birth of his daughter. Joe is experiencing which type of transition?
A) Anticipated transition
B) Unanticipated transition
C) Non-event transition
D) Deployment

Accepted Answer

Transitions are turning points between two periods of relative stability. Transitions are life events or nonevents that require changes in relationships, assumptions, roles, and/or routines. Transitions provide unique challenges, and opportunities for growth, adaptation, and transformation. They are frequently stressful even when freely chosen and deemed desirable. Moving through a transition requires relinquishing aspects of the self and former roles and learning new skills and developing a new identity. Multiple transitions can occur simultaneously, and often do. Transitions can be normative, anticipated, and expected, or unpredictable, unanticipated, and unexpected (Anderson, Goodman, & Schlossberg, 2012).
Anticipated transitions are typically normative, meaning they predictably occur during the life course, and the vast majority of people experience them. Anticipated transitions are often self-initiated and planned; there is usually time to prepare. Examples of anticipated transitions are graduation, marriage, starting a job, the birth of a child, and retirement. Unanticipated transitions are non-normative, have a low probability of occurrence, and often involve crises. Unanticipated transitions are outside of one's control and offer little or no opportunity to prepare. Unanticipated transitions may occur at the individual, family, community, or societal level. Examples of unanticipated transitions are divorce, the premature death of a spouse, the death of a child, natural and technological disasters, being laid off or fired from a job, war, and terrorism.
Nonevent transitions are expected or hoped-for events that did not occur. These nonevent transitions also alter a person's life and require change and adaptation. The four types of nonevents are personal, ripple, resultant, and delayed. Personal nonevents are those individual aspirations that are not realized-for example, never marrying or having a baby or not being promoted. Ripple nonevents are personal nonevents of people close to us that require us to change or adapt-for example, a spouse not receiving a promotion at work. Resultant nonevents are the result of some event that occurs that causes an aspiration or expectation to remain unfulfilled. The event itself has a beginning and an end, but the nonevent lasts a lifetime-for example, not graduating from college because of an acquired brain injury due to an automobile crash. Delayed nonevents are those events that do not happen at the expected or desired time but are still hoped for and aspired to. The demarcation of when a dream delayed becomes a nonevent is idiosyncratic (Anderson et al., 2012).

Question 12

Kathryn is a 28-year-old who just transitioned out of military life. She reports feeling more connected to her military friends than her family. This experience, common to Veterans, often occurs because of:
A) Difficulty finding work
B) PTSD symptoms
C) Substance abuse
D) Changes in family life during deployment

Accepted Answer

Veterans may experience a return to civilian life and culture as alien, as many aspects of civilian life no longer feel normal to them. This is due to the reality that the Veteran, the family, and the home environment have changed while the service member was deployed. Veterans may feel disconnected from family and friends who have not shared the deployment experience. This is one reason they may gravitate toward and spend more time with military "buddies" than with family members (Sayer et al., 2011). Feelings of alienation increase the likelihood of engaging in risky behaviors that hinder reintegration and diminish well-being. Frequently, Veterans and their family members experience a mismatch between their expectations and reality when the person returns home. Adjustment requires time, patience, and the establishment of a "new normal" that satisfies the needs of the Veteran and the family (Ahern et al., 2015).

Question 13

Most military personnel are:
A) Single
B) Married
C) Married with children
D) Divorced

Accepted Answer

The U.S. Department of Defense (2016) estimates that nearly 35% of military personnel are married with children, 16% are married without children, and more than 6% are single parents. Every member of the family can be significantly affected by the prolonged separations associated with combat deployments, creating strain when the service member returns home (Cogan, 2014). Although many military couples and families eagerly await a joyful reunion upon return from deployment, the transition and reintegration into family life is challenging for the family as well as the Veteran. Relationship distress and emotional turmoil are not uncommon during the 6 months following a return from a tour of duty (Knobloch & Theiss, 2012). In a study of 250 individuals, half of whom were in the military and half of whom were partners of service members (not necessarily matched couples), participants identified several ways their relationships had changed after deployment. These changes are listed in Box 21-1 (Knobloch & Theiss, 2012). Role changes affect both male and female Veterans. However, upon returning home, women Veterans face the civilian expectation of "traditional" caregiver female gender roles. In the military, women often work in job positions that would typically be considered male domains in the civilian world, thus making reintegration more challenging.

Question 14

The most common change in a partner relationship after a deployment is:
A) Divorce
B) Separation
C) Heightened conflict
D) Problems reconnecting

Accepted Answer

10 Categories of Relationship Change (% of thematic units in qualitative data)
Relationship is stronger (18%)
Value the relationship more (14.7%)
Problems reconnecting (11.8%)
Difficulty communicating (10.9%)
Increased autonomy (10.4%)
Changes in finances and employment (9.5%)
Changes in sexual behavior (7.6%)
Problems reintegrating the service member into daily life (5.7%)
Heightened conflict (5.7%)
Separation or divorce (5.7%)
Data from "Experiences of U.S. Military Couples During the Post-Deployment Transition: Applying the Relational Turbulence Model," by L. K. Knobloch and J. A. Theiss, 2012, Journal of Social and Personal Relationships, 29(4), 430-434.

Question 15

An occupation typically limited during military deployment that can cause occupational deprivation is:
A) Leisure
B) ADLs
C) Social participation
D) Education

Accepted Answer

During deployment, a service member's daily occupations are dictated by the exigencies of military operations. Long work hours, with little discretionary time, are typical of most military deployments. Furthermore, the range of leisure pursuits and the opportunities to engage in them are also typically limited during deployment. Upon returning home, service members have a greater opportunity to select occupations that are meaningful to them and to create their own daily routines. With the absence of structured time, which had been driven by military operation, returning Veterans are now expected to choose, schedule, and engage in self-care, work, and leisure occupations that are personally meaningful. Both during and following deployment, unmet occupational needs can lead to occupational deprivation, imbalance, and/or disruption. Occupational disruption "occurs when a person's normal pattern of occupational engagement is disrupted due to significant life events" (Whiteford, 2000, p. 201). Occupational disruptions are typically temporary and can occur due to a variety of situations-for example, moving to a new military base, changing job positions, losing a comrade, or transitioning to civilian life.

Question 16

In the 4S model of transitions, personal assets necessary for successful transition and deficits or liabilities serving as roadblocks to transition fit into which aspect of the model?
A) Situation
B) Self
C) Support
D) Strategies

Accepted Answer

Self, the second S in the model, can be described in terms of resources, or personal assets necessary for successful transition, and deficits, or liabilities serving as roadblocks to transition. Psychological status varies among student Veterans and may hinder the transition process (Shiavone & Gentry, 2014). In a study of two university campuses in the southeastern United States, 56.9% of a sample of 538 student Veterans identified as having at least one mental health problem. Deficits in help-seeking behavior may also negatively affect the transitioning process. Of the one-third of student Veterans having a mental health problem requiring treatment, only one-third participated in an adequate number of treatment sessions to receive any benefit (Currier, McDermott, & McCormick, 2017). An additional liability is the emotional and psychological trauma experienced in combat, often leading to insomnia and difficulty managing relationships. Despite these challenges, student Veterans possess many assets to assist the transitioning process. Global awareness, maturity, and self-discipline can serve to open new opportunities with other student groups across campus, while modeling behaviors necessary for academic success (Shiavone & Gentry, 2014).

Question 17

Mr. Elliott is a 27-year-old who has posttraumatic stress disorder. The most common theoretical approach in occupational therapy in the United States used for intervention with an individual like Mr. Elliott is:
A) The Canadian Model of Occupational Performance and Engagement
B) The Recovery Model
C) The Model of Human Occupation
D) Occupational Adaptation

Accepted Answer

In a Delphi study conducted by Gerardi (2017), Canadian occupational therapists ranked theories that could be used for intervention with Veterans with PTSD. The theoretical framework that was most highly supported for this purpose was the Canadian Model Of Occupational Performance and Engagement (CMOP-E). Other theories identified included the Recovery Model and the Model of Human Occupation (MOHO). In an earlier study conducted with occupational therapists in the United States, the MOHO was the most highly ranked theoretical framework for potential use as part of a manualized occupational therapy intervention for clients with PTSD (Gerardi, 2016).

Question 18

An appropriate assessment for occupational therapy for a Veteran transitioning to civilian life focused on community engagement is:
A) COPM
B) Community Integration Questionnaire
C) Modified Interest Checklist
D) Occupational Questionnaire

Accepted Answer

In addition to mental health, cognitive, and occupation-based assessments, evaluation of community integration is an important component of overall well-being and quality of life. From an occupational therapy perspective, community reintegration is a dynamic adaptation process that facilitates participation in culturally appropriate and personally meaningful roles, and full engagement in community life. An assessment that may be useful in working with Veterans is the Community Integration Questionnaire (CIQ). The CIQ consists of 15 questions and 3 subscales (i.e., home integration, social integration, and productivity outside of the home). The questions are designed to ascertain if the person performs a certain activity alone or with another person. The higher the score, the greater the integration into the community. Although the assessment was originally developed for use with clients with head injuries, it can be adapted for other populations (Dijkers, 2000).

Question 19

A significant environmental barrier to community reintegration for Veterans is:
A) Inadequate transportation
B) Lack of financial assistance
C) Negative attitudes of civilians
D) No environmental barriers exist

Accepted Answer

Successful community reintegration is not simply a matter of individual function, but also the readiness of a community to embrace Veterans and their needs. Contextual factors--physical, social, and attitudinal--can have a profound effect on degree and ease of community reintegration for Veterans. It is therefore necessary to conduct a community assessment to identify the resources and barriers the environment presents to the Veteran who is trying to adjust to civilian life. Environmental barriers may include, but are not limited to, negative attitudes of civilians, a lack of available services and assistance, physical and structural obstructions, and policy limitations (Resnick et al., 2012).

Question 20

In community reintegration for Veterans, social support can act as a(n):
A) Inhibitor
B) Facilitator
C) Neither
D) Both

Accepted Answer

It was determined that two elements directly influenced CR-personal factors (i.e., self-efficacy, motivation) and social support (i.e., family, friends, and peers). Personal factors that acted as facilitators of CR included participants' sense of self-efficacy, motivation to be productive, and ability to self-regulate and set goals. Social support and connections with others acted as both barriers and facilitators of CR. Spouses and children often facilitated the Veterans' participation in community activities. Connecting with Veteran peers provided an opportunity to regain a sense of personal identity as part of the military family. However, social support, or lack thereof, could also be an inhibiting factor or barrier to CR. Negative attitudes, misconceptions, and stigma related to military service and/or the physical and psychological injuries sustained by the Veterans made CR more difficult (Hawkins et al., 2015).

Quiz 21: Community Reintegration Services for Military Veterans Introduction

Which aspect of military service directly impacts daily life occupations, habits, roles, and routines?

Veterans 65 and older often receive reimbursable health care through which program?

Eligibility for health care services for a Veteran is based upon which of the following factors?

The largest demographic of Veterans in today's society served in which war era?

The most common health issue for Veterans from the wars in Iraq and Afghanistan is:

A factor associated with chronic pain in the Veteran population is:

The most common mental health diagnosis for active-duty service members is:

Moral injury, a state of inner conflict and turmoil that often precipitates feelings of shame, guilt, grief, anxiety, anger, and remorse, can often be confused with:

Mary is 32-year-old Veteran who was an officer in the military. She has been successful in her community reintegration. Which of the following is a protective factor for community re-integration?

Joe is a 31-year-old who has decided to transition out of the military due to the birth of his daughter. Joe is experiencing which type of transition?

Kathryn is a 28-year-old who just transitioned out of military life. She reports feeling more connected to her military friends than her family. This experience, common to Veterans, often occurs because of:

Most military personnel are:

The most common change in a partner relationship after a deployment is:

An occupation typically limited during military deployment that can cause occupational deprivation is:

In the 4S model of transitions, personal assets necessary for successful transition and deficits or liabilities serving as roadblocks to transition fit into which aspect of the model?

Mr. Elliott is a 27-year-old who has posttraumatic stress disorder. The most common theoretical approach in occupational therapy in the United States used for intervention with an individual like Mr. Elliott is:

An appropriate assessment for occupational therapy for a Veteran transitioning to civilian life focused on community engagement is:

A significant environmental barrier to community reintegration for Veterans is:

In community reintegration for Veterans, social support can act as a(n) :