801.activity programming in mental health speedling ... · principles of quality of life, and honor...

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Therapeutic Recreation

Barbara Speedling Quality of Life SpecialistACHCA – March 2019

Activity Programming in Mental Health

Disclosure of Commercial Interests

I have no commercial interests to disclose.

What is Quality of Life?

• Subjective, multidimensional, encompassing positive and negative features of life.

• A dynamic condition that responds to life events

http://www.forbes.com/sites/iese/2013/09/04/quality-of-life-everyone-wants-it-but-what-is-it/

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NEW FEDERAL REGULATIONSFINAL RULE, PHASE 2 (11/28/17)

F675§ 483.24 Quality of lifeQuality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care.

NEW FEDERAL REGULATIONSFINAL RULE, PHASE 2 (11/28/17)

F675§ 483.24 Quality of life

INTENT

The intent of this requirement is to specify the facility’s responsibility to create and sustain an environment that humanizes and individualizes each resident’s quality of life by:

• Ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and

• Ensuring that the care and services provided are person-centered, and honor and support each resident’s preferences, choices, values and beliefs.

F675 §483.24 Quality of life(11/28/17)

Definition: “Quality of Life”

• An individual’s “sense of well-being, level of satisfaction with life and feeling of self-worth and self-esteem.

• For nursing home residents, this includes a basic sense of satisfaction with oneself, the environment, the care received, the accomplishments of desired goals, and control over one’s life.”

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Quality of Life Concerns in Long Term Care

• Many facilities try to avoid admitting residents with complicated psychosocial issues;

• Staff is often unprepared to care appropriately for residents with dementia, mental illness, addictions or psychosocial challenges

SYSTEM FAILURES

• Diagnosis is not always known at the time of admission screening or condition is misdiagnosed as simply dementia

• Staff education and training in caring for the mentally ill is lacking; care of residents with dementia is weak in many environments

• Staff lack basic understanding of symptoms and how this impacts all aspects of function

• Assessment procedures often fail to distinguish symptoms from behaviors

SYSTEM FAILURES

• Assessments often fail to identify the antecedents to behavior

• Communication between disciplines is weak in tracking behavioral patterns

• Care teams are weak in practicing behavior modification

• Medication is the often the preferred intervention

• Little consideration is given to how boredom and a lack of meaningful activity impact behavior and function

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The Woodstock GenerationTHEN NOW

Drug Abuse and Mental Health Issues

A 2011 study by the Substance Abuse and Mental Health Services Administration found:

• Baby Boomers who came of age in the ‘60s and ‘70s when drug experimentation was pervasive, are far more likely to use illicit drugs;

• Among adults 50-59, current illicit drug use increased to 6.3 percent in 2011 from 2.7 percent in 2002;

• The most commonly abused drugs were opiates, cocaine and marijuana.

Drug Abuse and Mental Health Issues

2010: An estimated six to eight million older Americans – almost 20 % of the elderly population – had one or more substance abuse or mental health disorders.2030: Adults 65 and older is projected to increase to 73 million from 40 million between 2010 and 2030.

http://newoldage.blogs.nytimes.com/2013/04/29/a-rising-tide-of-mental-distress/

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Increased Numbers of Disabled Young Adults

• The number of children and young adults with disabilities is increasing.

• Life-saving and life-prolonging medical care and new technologies have increased the survival of seriously ill younger people.

• These children, teens and young adults will need long-term care to assist them in their homes or in nursing homes and residential facilities.

LTC Panel Report 2009

Social Groups

1.Are you selective about choosing friends?

2.How do you choose a seat at a gathering where you don’t know many people?

SOCIAL REACTIONS

Have you ever:• Declined an invitation because you didn’t know

anyone else who would be attending or because you learned someone you didn’t like would be there?

• Moved from your original seat because of the behavior of someone else at the table?

• Left a gathering or program because you found it wasn’t as interesting as you’d thought it would be or because another guest arrived wearing your dress?

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Cultural Facts to Consider

CHINAHealth and Wellness: Countless Chinese people, especially the middle-aged and elderly, have developed the habit of exercising each morning to improve their health.

The Importance of Face: The concept of 'face' roughly translates as honor', good reputation or respect. There are four types of Face:

1) Diu-mian-zi: this is when one's actions or deeds have been exposed to people.2) Gei-mian-zi: involves the giving of face to others through showing respect.3) Liu-mian-zi: this is developed by avoiding mistakes and showing wisdom in action.4) Jiang-mian-zi: this is when face is increased through others, i.e. someone complementing you to an associate.

It is critical you avoid losing Face or causing the loss of Face at all times.

Cultural Facts to Consider

CHINA

•Learn to use chopsticks.

•Wait to be told where to sit. The guest of honor will be given a seat facing the door.

•You should try everything that is offered to you.

•Never eat the last piece from the serving tray.

•Be observant to other peoples' needs.

•Chopsticks should be returned to the chopstick rest after every few bites and when you drink or stop to speak.

•Do not put bones in your bowl. Place them on the table or in a special bowl for that purpose.

•Hold the rice bowl close to your mouth while eating.

•Do not be offended if a Chinese person makes slurping or belching sounds; it merely indicates that they are enjoying their food.

•There are no strict rules about finishing all the food in your bowl.

Is Your Family Dysfunctional?

The Nature of Relationships• Assessing personalities, office politics, and respect issues.• What sort of first impression does your organization make?• What resources or support systems does your organization foster

to improve relationships?

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Common Triggers to Altercations and Discontent

Commingling of Non-demented And Demented Residents

NOISE

Wandering Residents

Yelling or Calling Out

Unresolved Disputes

F699Trauma-Informed care

§483.25(m) Trauma-informed care

The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents’ experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

§483.25(m) will be implemented beginning November 28, 2019 (Phase 3)

What is Trauma-Informed Care?

Trauma-Informed Care understands and considers the pervasive nature of trauma and

promotes environments of healing and recovery rather than practices and services that may

inadvertently re-traumatize.

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NEW FEDERAL REGULATIONSFinal Rule, Phase 2 (11/28/17)

F742

Treatment and Services for Mental/Psychosocial Concerns:

§483.40(b) Based on the comprehensive assessment of a resident, the facility must ensure that—

§483.40(b)(1)A resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being;


“Mental and psychosocial adjustment difficulty” refers to the development of emotional and/or behavioral symptoms in response to an identifiable stressor(s) that has not been the resident’s typical response to stressors in the past or an inability to adjust to stressors as evidenced by chronic emotional and/or behavioral symptoms.

(Adapted from Diagnostic and Statistical Manual of Mental Disorders - Fifth edition. 2013, American Psychiatric Association.).


INTENT §483.40(b) & §483.40(b)(1)

• The intent of this regulation is to ensure that a resident who upon admission, was assessed and displayed or was diagnosed with a mental or psychosocial adjustment difficulty or a history of trauma and/or post-traumatic stress disorder (PTSD), receives the appropriate treatment and services to correct the initial assessed problem or to attain the highest practicable mental and psychosocial well-being.

• Residents who were admitted to the nursing home with a mental or psychosocial adjustment difficulty, or who have a history of trauma and/or PTSD, must receive appropriate person-centered and individualized treatment and services to meet their assessed needs.

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KEY ELEMENTS OF NONCOMPLIANCE §483.40(b) & §483.40(b)(1)

To cite facility deficient practice at F742, the surveyor’s investigation will generally show that the failed to:

• Assess the resident’s expressions or indications of distress to determine if services were needed;

• Provide services and individualized care approaches that address the assessed needs of the resident and are within the scope of the resources in the facility assessment;

• Develop an individualized care plan that addresses the assessed emotional and psychosocial needs of the resident;

• Assure that staff consistently implement the care approaches delineated in the care plan;

• Monitor and provide ongoing assessment as to whether the care approaches are meeting the emotional and psychosocial needs of the resident; or

• Review and revise care plans that have not been effective and/or when the resident has a change in condition and accurately document all of these actions in the resident’s medical record.

AssessmentWhen, Where, and How…

When…

• Consolidate the interview process among disciplines to minimize repetition;

• Allow the primary CNA the first hour to become acquainted and begin the care profile;

• Plan to interview the resident several times over the first 30 days to get an accurate picture of cognition and skills;

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Where…

Whenever possible, conduct the interview somewhere other than the resident’s bedroom.

How…

• Identify and address all sensory needs;

• Avoid question and answer sessions – have a conversation;

• Know who you’re talking to;– Dementia: Do you work?

– Mental Disorders: Listen and observe patterns.

– Addictions: Explore the history – how did it start?

Assessment

• Impact of neurodegenerative disease, mental disorders, and stress on behavioral health and social functioning;

• Assessment of symptoms and behavioral triggers;

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The Dementia Epidemic

• Alzheimer’s disease is the most common form of dementia;

• Every 66 seconds someone in the U.S. is diagnosed with Alzheimer’s disease;

• Increasing numbers of younger, physically able residents; and

• Incidence of dual-diagnosis (i.e TBI, mental disorders) is increasing.

THE GLOBAL DETERIORATION

SCALE

Assessing The Degree Of Dementia

Communication

Apraxia of SpeechAgnosia

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Vision

Perception - MotionDepth - Color

Evaluate Existing Medications

• Consider the following issues:– Drug induced cognitive impairment

• Anticholinergic Load

– Medication induced electrolyte disturbance

– Recent medication additions that may alter metabolism of a drug that the person has been taking for a while

– Withdrawal reaction to a recently discontinued medication

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What to Ask

Significant social/personality information:

• How do you feel about being in large groups of people?

• Are there any specific things that turn you off about other people?

• How do you express yourself when you are angry, frustrated or upset?

• What things do you do to comfort yourself at times when you feel this way?

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What to Ask

• Dislikes with regard to other people

• How do you feel about needing help with your personal care?

• Things the resident finds stressful

• Resident’s feelings about noise and sharing living space

• Things the resident finds comforting

• Current life goals and aspirations How do you feel about needing help with your personal care? How do you feel about needing help

Case Study - Helga

Description:

• 86 year-old woman with diagnoses of Alzheimer’s disease, anxiety, high blood pressure, and Type 2 diabetes.

Behavior:

• Described by staff as alert but confused with respect to time, place, and situation, Helga often resists care related to Activities of Daily Living (ADL). She sometimes yells or strikes out at the staff. Cries uncontrollably when her husband leaves to go home after visiting.

Case Study - Helga

Situation:

Before admission, Helga’s husband was caring for her at home with the help of a home health care worker. As her illness progressed, her memory loss worsened and she began to wander away from their home. She was admitted to the facility when her husband felt he could no longer care for her safely at home.

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Case Study - Helga

Social History

• Married more than 60 years; mother of two.

• Elementary school teacher

• Polish decent – identifies strongly with her heritage

• Catholic – says her rosary daily

• Met with her teaching colleagues monthly for dinner after she retired.

Case Study - Helga

Interventions:

• Socialization – talking/reminiscing with other retired teachers

• Engagement - reading aloud to others

• Heritage – providing Polish memorabilia, making Pierogi

• Faith – sitting quietly with her in the chapel mid-afternoon when Sundowning occurs

• Recollection – providing photographs to help stimulate memories of life and family

Dementia Assessment Resources and Tools

• Alzheimer’s Association: www.alz.org

• Pioneer Network: www.pioneernetwork.org

Tools: Sometimes used in addition to the MDS 3.0, Section C – Cognition

– Global Deterioration Scale

– Dementia Screening Indicator (Barnes, et al.)

– Geriatric Depression Scale

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Watching TV(2 hours and 47

minutes)

Socializing and communicating

(41 minutes)

Relaxing and thinking(17 minutes)

Participating in sports, exercise, recreation

(18 minutes)

Reading (19 minutes)

Total leisure andsports time =

4 hours and 59 minutes

Playing games; using computer for leisure

(25 minutes)

Other leisure activities(12 minutes)

NOTE: Data include all persons age 15 and over. Data include all days of the week and are annual averages for 2015.

Leisure time on an average day

SOURCE: Bureau of Labor Statistics, American Time Use Survey

Activities for a New Age

• Diversify therapeutic activity offerings to include education, self-help, and support programs;

• Collaborate with community addiction services;

• Promote positive self-esteem through meaningful socialization and therapeutic activity;

• Collaborate with community vocational services organizations in discharge planning;

• Foster opportunities for volunteerism.

Creative, Artistic, and Expressive Therapies for PTSD

A number of non-traditional creative/expressive therapies has demonstrated at least preliminary

effectiveness in reducing PTSD symptoms, reducing the severity of depression (which often accompanies PTSD), and/or improving quality of

life.

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• Expressive Writing: is a brief intervention that instructs individuals to write about their deepest thoughts and feelings about a stressful event without regard to the structure of the writing

• Dance and Body Movement Therapies: propose that one’s negative, emotion-laden experiences are represented in the body in the form of tension and pain.

• Art Therapy: involves residents using some medium (e.g., painting, drawing, collage) to represent their feelings or emotions related to their trauma;

• Music Therapy: engages residents to use music in a variety of ways (e.g., playing music, beating a drum, listening to and sharing songs) to encourage emotional expression in a non-threatening environment.


• Drama Therapy: creates safe, playful environments where patients are able to act out anxieties or conflicts due to their trauma

• Nature Therapy: involves a set of related activities that utilize a mix of relaxation and creative approaches involving nature.

• Mindfulness Therapies: focus primarily on observing one’s internal and external states and accepting one’s past experiences, so as to better tolerate the distress associated with trauma reminders

Source: Creative, Artistic, and Expressive Therapies for PTSD

By Joshua Smyth, PhD and Jeremy Nobel, MD, MPH

PTSD ASSESSMENT RESOURCES AND TOOLS

• US Department of Veteran’s Affairs: National Center for PTSD:– https://www.ptsd.va.gov/professional/assessment/scree

ns/index.asp• Primary Care PTSD Screen for DSM-5 (PC-PTSD-5)• Trauma Screening Questionnaire (TSQ)

• American Psychological Association: – https://www.apa.org/ptsd-guideline/assessment/index

• Structured Clinical Interview; PTSD Module (SCID PTSD Module)

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Enhancing Activities

• Education and training of recreation and nursing staff in the application of “meaningful” activity

• Conducting comprehensive admission interviews and including family and friends of the resident

• Utilizing information gleaned through MDS 3.0 interview process

Enhancing Activities

• Emphasizing individualized activities over groups

• Applying technology to reach the greatest numbers

• Involving residents in program planning

• Expanding community access and involvement

F645Defining Mental Disorder

(A) A schizophrenic, mood, paranoid, panic or other severe anxiety disorder; somatoform disorder; personality disorder; other psychotic disorder; or another mental disorder that may lead to a chronic disability; but

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F645Defining Mental Disorder

(B) Not a primary diagnosis of dementia, including Alzheimer's disease or a related disorder, or a non-primary diagnosis of dementia unless the primary diagnosis is a major mental disorder as defined in paragraph (b)(1)(i)(A) of this section.

LIFE SKILLS PROGRAMMING: CHRONIC MENTAL HEALTH

• Life skills programs encourages independent living and enhances quality of life.

• Life skills often have several components: – Communication and talking;

– Financial awareness and money management; domestic tasks (such as cooking, washing‐ up dishes, hoovering, doing the laundry and running a home); and

– Personal self‐care (such as washing, bathing, cleaning teeth, shaving, combing hair and getting dressed).


• Other life skills include training on:– Coping with stress

– Shopping for and eating healthy food,

– Knowing the time,

– Taking medication,

– Improving social skills,

– Using transport; and

– Forward planning

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Rehabilitation or getting better is slow, complex and difficult.

• There are many ways of engaging with people during this process, including: – Creative therapies (art, drama, music, poetry, education, dancing,

singing);

– Life skills (as described above);

– Work‐based therapy to enhance employment; and

– Recreational activities (such as group walks, swimming, sport, reading, writing a diary, watching television, going to parties, events and day trips).

Mental Health Resources

• National Institute of Mental Health:

– https://www.nimh.nih.gov

• The Mayo Clinic – Mental Health

– https://www.mayoclinic.org

• The SAMHSA-HRSA Center for Integrated Health

Solutions (CIHS) :

– https://www.integration.samhsa.gov

PROGRAMMING TO ADDRESS ADDICTIONS/SUBSTANCE ABUSE

Group Therapy is used to guide clients through the process of gaining insight about themselves, others, and the world around them.

• Through the group dynamic, residents foster hope and examine core issues that exacerbate their addictive disorders.

• They also work to develop their communication skills and learn to engage in fun, healthy social experiences.

• The group dynamic encourages honest feedback and facilitates bonding between individuals with shared experiences.

• Clients weigh in on the issues of others in order to offer suggestions or provide outside perspectives, broadening the individual’s understanding of the conflict.

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Substance Use/Addiction Resources

• National Institute on Alcohol Abuse and Alcoholism:

– https://www.niaaa.nih.gov/

• World Health Organization: Management of Substance Abuse

– https://www.who.int/substance_abuse/publications/alcohol/en/

• The SAMHSA-HRSA Center for Integrated Health Solutions

(CIHS) :

– https://www.integration.samhsa.gov

Social and Cognitive Engagement

Additional studies suggest that other modifiable factors, such as remaining mentally and socially active, may support brain health and possibly reduce the risk of Alzheimer’s and other dementias.

http://www.alz.org/downloads/facts_figures_2013.pdf

Benefit of Conversation

University of Exeter:

"One Social Hour a Week in Dementia Care Improves Lives and Saves Money: Person-centered activities combined with just one hour a week of social interaction can improve quality of life and reduce agitation for people with dementia living in care homes, while saving money."

ScienceDaily, 16 July 2017

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Procedural Memory

• A part of the long-term memory that is responsible for knowing how to do things, also known as motor skills.

• Procedural memory stores information on how to perform certain procedures, such as walking, talking and riding a bike.

• Delving into something in your procedural memory does not involve conscious thought.

http://www.livescience.com/43595-procedural-memory.html#sthash.sgerS8rA.dpuf

Different Types of Memory

• Procedural memory is a subset of implicit memory, sometimes referred to as unconscious memory or automatic memory.

• Implicit memory uses past experiences to remember things without thinking about them.

• It differs from declarative memory, or explicitmemory, which consists of facts and events that can be explicitly stored and consciously recalled or "declared."

http://www.livescience.com/43595-procedural-memory.html#sthash.7EIT4BV1.dpuf

Examples Of Tasks Dependent Upon Procedural Memory

• Playing piano

• Skiing

• Ice skating

• Playing baseball

• Swimming

• Driving a car

• Riding a bike

• Climbing stair

http://www.livescience.com/43595-procedural-memory.html#sthash.sgerS8rA.dpuf

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Procedural Memory

By providing effective environmental cues to prompt this memory system,

rehabilitation specialists are able to facilitate relearning of familiar, meaningful,

procedural skills necessary for daily functioning.

http://cirrie.buffalo.edu/encyclopedia/en/article/28/

Cognition and Memory

“There is an increased risk of cognitive decline for individuals whose engagement in cognitive activities decreases over time…increases in cognitive activity from baseline are associated with better than expected cognitive performance.”

Mitchell, Meghan B., et al, “Cognitively Stimulating Activities: Effects on Cognition across Four Studies with up to 21 Years of Longitudinal Data”, Hindawi Publishing Corporation, Journal of Aging Research, Volume 2012, Article ID 461592


“The motor component of a task is believed to make it more memorable, as it enriches the encoding experience and often involves the manipulation of concrete objects. There is further evidence that people with dementia are able to maintain or relearn activities of daily living (e.g. setting the table, preparing a meal) with appropriate environmental support and active regular practice.”

Pachana, Nancy, “Memory and Communication Support in Dementia: Research-Based Strategies For Caregivers” Cambridge Univ Press: Jan 1, 2011

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“The planning and performance of complex or multi-step tasks can be effectively supported by breaking tasks into individual sub-components or steps, giving instructions one at a time, and using short simple sentences.”

(Small and Gutman,2002; Bourgeois and Hickey, 2009)

The Impact Of Music OnMEMORY AND LANGUAGE

Researchers have found that “musical training has a profound impact on other skills including speech and language, memory and attention, and even the ability to convey emotions vocally.

S.L.Baker, “Music Benefits the Brain Research Reveals, circa 2010,”

NaturalNews.com, http://www.naturalnews.com/029324_music_brain.html

For people with cognitive and memory deficits, medical research shows us that music affects the brain in ways that can promote language and understanding beyond the spoken word. New research also shows that music has a significant impact on reducing depression and agitation in people with dementia.

Laird Harrison, “Music Therapy May Help Dementia Patients Especially,”

Caring for the Ages, Vol.12, No.7 (July 2011): 1

Music and Memory

AGE DOB PRIME AGE RANGE FOR

MAKING MEMORIES

16 - 30 years

90 1924 1940-1954

80 1934 1950-1964

70 1944 1960-1974

60 1954 1970-1984

50 1964 1980-1994

40 1974 1990-2004

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Non-Pharmacologic Intervention

Redefining What is Meaningful

What is Activity?

• A personal encounter • Naturally offered by the environment • Daily housekeeping routines• Self-care activities• Planned scheduled events• Spontaneous activities

Non-pharmacological Interventions • Increasing the amount of resident

exercise;

• Reducing underlying causes of distressed behavior such as boredom and pain;

• Individualized bowel regimen to prevent or reduce constipation and the use of medications;

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Non-pharmacological Interventions • Improving sleep hygiene;

• Accommodating the resident’s behavior and needs by supporting and encouraging activities reminiscent of lifelong work or activity patterns;

• Using massage, hot/warm or cold compresses to address a resident’s pain or discomfort; and

• Enhancing the dining experience.

Improving the Dining Experience

Bernie

Patriot

Actor

Grandpa

“I used to cry because I didn’t have new shoes,

until I met the man with no feet.”

Painter

Musician

Gardener

Conductor

IDENTITY BOARDS

Husband

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Personalized ActivityExample #1

• Facts: Middle-aged woman, brain injured, comatose, vent dependent: known to collect butterflies, loved the smell of lilacs in the spring, enjoyed music by the Beatles. – Activity intervention: butterfly mural painted on the

ceiling tiles over the resident’s bed; aroma of fresh lilacs used in room; Beatles music on as scheduled (not to be played continuously and variety is maintained).


• Facts: 93 y/o man with moderate dementia: He says that he would go fishing on his boat, that he loves being on the water and the smell of the sea. He says he feels free and peaceful when he’s fishing, especially if he goes out alone. His family fills in the details of where he fished and about his boat because these are details he no longer remembers.


• Facts: 78 y/o alert, oriented woman who was admitted for short term rehab, but was unable to return home due to lack of ambulation/AD L support: owned a successful real estate firm until two years ago when she sold the business and retired; is known to be smart, strong, persuasive and aggressive in getting what she wants; loves all things cultured – the ballet, the opera, the annual fundraising gala for Lincoln Center. Says that she loves being in the city, loves the “pulse” of New York. Expresses frustration over being “pinned down” as she perceives it. Sees herself as intellectually superior to her peers.

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“Sheltered Workshops"

“Sheltered Workshops"A facility or program, either for outpatients or for residents of an institution, that provides vocational experience in a controlled working environment. • For residents with dementia the workshop also offers

the opportunity to find comfort in doing familiar tasks.

• For the non-traditional resident who plans to return to the community, the workshop provides an opportunity education, life skills programming, and helps prepare the resident for community reintegration.

JOURNALING

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Chronological Photo Displays

101 ACTIVITIESANYONE CAN DO

1. Listen to music2. Make homemade lemonade3. Count trading cards4. Clip Coupons5. Sort poker chips6. Rake leaves7. Write a poem together8. Make a fresh fruit salad…

Source: Alzheimer’s Association Web Site – www.alz.org

Combining ADL, Leisure and Therapeutic Activity

The simplest way to begin improving the manner in which meaningful activity is made available to residents is by redefining what “meaningful” is.

Find ways to turn ADL activity into activity that occurs between leisure and therapeutic groups. Consider all the disciplines that could contribute real and valuable programming to the day. There may be more resources than you think.

There are hundreds of tasks that make up a person’s daily routine. Evaluate what already happens in your environment with regard to common sense ADL and leisure tasks.

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Barbara SpeedlingQuality of Life Specialist917.754.6282Bspeedling@aol.comwww.innovationsforqualityliving.com

Creating Meaningful, Satisfying Lives One Person at a Time

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801.activity programming in mental health speedling ... · principles of quality of life, and honor...

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