A small-scale study exploring the efficacy of scale modelling as an open intervention for military veterans with mental health conditions

Abstract

Introduction:

Medical discharges due to mental health conditions have steadily increased within the British Armed Forces since 2007, with post-traumatic stress disorder (PTSD) cited for 41% of these. Mental health conditions can adversely impact engagement in activities of daily living. Research has shown that meaningful activity has benefits for mental well-being and engagement in this population.

Aims:

This small-scale study aimed to determine whether scale modelling had a measurable impact on veteran well-being and to describe how the results of this study may inform future occupational therapy research with veterans.

Method:

This was a retrospective quantitative design using the Short Warwick and Edinburgh Mental Wellbeing Scale to gather pre- and post-engagement data from veterans attending scale-modelling groups.

Results:

N = 12. There was a positive difference between pre- and post-engagement in scale modelling, p < 0.05, and effect size 0.61 within a limited participant pool. The Model-of-Human-Occupation and the Occupational Perspective of Health framework demonstrated that participants who found meaning and value in an activity were most likely to benefit from it.

Conclusion:

This study suggests that scale modelling enables health, well-being and independence for veterans if found meaningful by them. This is a limited-size study contributing to an under-researched area, opening pathways for further research with this participant group.

Keywords

Post-traumatic stress disorder model of human occupation veteran(s)scale modelling mental health

Introduction

Between 2017 and 2022, there were an average of four medical discharges a day from the British Armed Forces, with mental health and post-traumatic stress disorder (PTSD) contributing to over half of those (Ministry of Defence, 2022). The military is particularly susceptible to developing PTSD (National Institute for Health and Care Excellence (NICE), 2018), with 37% of all mental health discharges from the army, 26% from the navy and 21% from the Royal Air Force being attributed to PTSD in 2022 (Ministry of Defence, 2022).

Contrary to public perception, PTSD among military veterans does not always result from combat, as per a review of the literature by the Cochrane Library (Sijbrandij et al., 2013). It has been demonstrated that post-discharge the transition from the military to civilian life is specifically noted as a contributing factor to PTSD in its own right (Carra, 2023; Sijbrandij et al., 2013; Vaughan-Horrocks, 2021).

The economic impact on the individual and wider society can be greater than other mental health conditions, partly due to the ineffectiveness of self-management (Ross, 2018). Veterans with PTSD may experience a high incidence of social dysfunction and sleep disturbance (Murphy, 2019).

The stigma associated with mental health is one of the biggest acknowledged barriers for veterans seeking support (Association, 2015), and may have contributed to high suicide rates in the UK veteran population (Ministry of Defence, 2021). It can take on average 13 years to ask for assistance (NICE, 2018; Preston, 2019). Services to support individuals exist but are under-subscribed with 60% of veterans indicating that the care they receive is either inadequate or non-existent (Help for Heroes, 2019).

The military provides standardised healthcare, but discharged British veterans must follow the National Health Service’s (NHS) paths, which vary greatly geographically. The Transition, Intervention and Liaison Service, an NHS programme for veterans that offers specialist complex mental health care, observes that take-up is not proportional to the number of current veterans.

Occupational therapy

Occupational therapy has militaristic roots through World War I hospitals and recognises that psychological trauma and physical disability should be treated equally (American Occupational Therapy Association, 2015). Occupational therapy has since reinforced its role in psychiatric treatment for military mental health, although there is a dearth of guidance in existing regulations and recommendations. The American Occupational Therapy Association (AOTA) suggests, however, that the emphasis should be on engagement, participation and working with meaningful occupations (American Occupational Therapy Association (AOTA), 2015).

Occupational therapy has long been affiliated with military mental health due to the life-long negative impact PTSD can have on engagement in occupation (Carra, 2023). Organisations working with veterans utilise occupational therapy, focusing on sleep hygiene, sensory work and assistance with everyday activities (Help for Heroes, 2019). Identifying a strong emphasis on finding purpose and worth in activity, much of this work is grounded in engagement in occupation, both for leisure and self-care (Dowling, 2019).

Scale modelling

Scale modelling involves creating a three-dimensional piece of work that is an accurate or recognisable replica of an existing concept (Pollard, 2016). According to Carter (2014), kits of historical and modern military vehicles are the most widely used, although many other options are available. Scale modelling is currently being used in organisations that work with veteran’s mental health. Models for Heroes, in particular, provide group modelling sessions and supplies model kits to serving members and veterans (Childs, 2023).

The structure of Models for Heroes sessions allows veterans to work on their models in a group setting. Sessions can last approximately 2–4 hours, at locations across the United Kingdom (UK). During the nationwide lockdown period which took place from March 2020, the groups were run virtually.

The positive effects of this occupation on group members’ mental health are demonstrated in the testimonies given to Models for Heroes. Improvements in family relationships, motivation to engage in further support, support for anxiety and better anger control are just a few examples (Childs, 2023).

It is this sample of testimonials that served as inspiration for this research study. The purpose of this was to determine whether there was a measurable increase in well-being from participating in these sessions and if so to begin providing an evidence base for this to be more widely used as an occupational therapy intervention with military veterans in the UK.

Literature review

A literature search was carried out in 2020 across the databases: CINAHL, PubMed, SAGE Journals, Science, Direct, EBSCO Host, Cochrane Library and SCOPUS. In total, 483 studies were identified with keywords ‘occupational therapy’, ‘scale modelling’, ‘veteran’, ‘PTSD’, ‘post-traumatic stress disorder’, ‘mental health’, ‘craft’(s)’, ‘arts and crafts’, ‘art therapy’ and ‘intervention’. After applying exclusion criteria (see Table 1) and removing duplicates, this was narrowed down to 81 studies. This review was repeated with the same criteria in early 2023 and a further two studies (Carra 2023; Vaughan-Horrocks, 2021) were added.

Table 1.

Exclusion and inclusion criteria for the literature review.

Inclusion	Exclusion
Quantitative, qualitative and mixed-method studies. Literature reviews.	Studies or reviews not written in English.
Participants who are serving military members or military veterans. Participants with mental health conditions.	Studies or reviews focusing on PTSD in children. Letters, editorials, newspaper articles, opinion pieces and blogs.
Works between 2000 and 2023 unless considered seminal work.
Works including armed forces and veterans from beyond the British Isles.

The results were a combination of research studies, literature reviews and reports. There was limited research into the specific area of interest (scale modelling with military/veterans) – occupational therapy specific or otherwise – thus, the search was broadened to encompass additional related domains (art therapy, arts and crafts, etc.) that could nevertheless contribute to the justification for this study.

Crafting

Occupational therapy utilises the therapeutic use of art and crafting to allow self-expression and a sense of control (Lloyd, 2007; Pöllänen, 2009). Creative pursuits offer choices to those who cannot or do not wish to partake in more physical activities like sports (Burt, 2012). The ownership of self-chosen activity, the physicality of working with the hands and creating something out of nothing has been raised through a number of sources as the key reasons for having a positive effect on mental health (Blomdahl, 2016; Burt, 2011; Lloyd, 2007; Pöllänen, 2009). It is suggested that the purpose of an activity – rather than the action itself – has an impact on well-being (Blomdahl, 2016). Scale modelling has been referred to as a therapeutic art, with a focus on developing skills, establishing identity and enhancing wellness through its use as an occupation (Pollard, 2016). The scarcity of work specifically related to the military or veterans and crafting occupations necessitated further extension into areas that encompassed these communities including art therapy, sports and outdoor activities.

Art therapy

Although art therapy is a specialised psychotherapy, occupational therapists also use art as an intervention (Preston, 2019). With emphasis on the creativity and enjoyment found in the activity, art has been shown to benefit self-expression as a meaningful occupation with health and well-being advantages for veterans (Preston, 2019).

Having control over the creation of something can help military veterans who feel a loss of control due to their PTSD symptoms (Lobban, 2019). Immersion in a project is seen to quiet intrusive thoughts and decrease the impact of PTSD symptoms (Schouten, 2019).

Physical pursuits

Research has shown that non-creative contexts such as sports, physical exercise and archaeology can also be meaningful for military veterans (Caddick, 2014; Carless 2013; Everill, 2019; Ley, 2017; Nimenko, 2014; Peacock 2019). Whilst these occupations do not directly tie into scale modelling, it is still important to include the benefits of finding meaning in an activity, regardless of what the occupation is.

Flow

Flow is a state of consciousness attained when a task’s challenge is appropriate for a person’s degree of expertise, creating an optimal sense of positive mental well-being and self-confidence (Burt, 2011; Csikszentmihalyi, 2008; Pöllänen, 2009). The mental health benefits of entering a state of flow are significant (Ley, 2017), including lowering barriers to participation and fostering a pleasant sense of well-being through diversion, relaxation and loss of outer awareness (Burt, 2011).

Flow has been explored in terms of occupational engagement and occupational performance and is a potent tool for engaging clients (Reid, 2011). Flow can be a rewarding state of being for an activity.

Meaningful activity

Despite the wide range of activities included here, it is seen that the engagement in meaningful activity, not the activity itself, is providing a beneficial impact. Since finding meaning in occupation is known to be necessary for achieving a state of flow (Csikszentmihalyi, 2008), an occupation that is meaningful can reward with a feeling of flow, encouraging further participation (Carra, 2023; Ley, 2017). The idea of discovering identity within a task is thought to contribute to said task having significance (Carra, 2023; Peacock, 2019). Although there is a scarcity of literature pertaining to scale modelling, it has been shown through limited personal testimonials that participants who find value and meaning in scale modelling appear to see a beneficial impact on their PTSD and mental health symptoms (Childs, 2023).

Methods

This study began as a mixed-methods approach by including qualitative semi-structured interviews face to face. As of March 2020, the COVID-19 pandemic determined that face-to-face interviews would not be appropriate and the study was truncated to include only the quantitative methods.

Ethical consent was granted by the College of Health and Life Sciences Research Ethics Committee at Brunel University in February 2020. Participants were recruited through the non-profit organisation, Models for Heroes. With permission from the Chair of Models for Heroes, the individual groups were approached by email explaining the purpose of the study and inviting participation. Potential participants who responded and met the inclusion criteria (Table 2) were sent a participant information sheet, consent form and questionnaire by email. Recruitment continued throughout the study to ensure a maximum number of respondents. The recruitment was expanded to include social media after the first nation-wide UK lockdown of 2020 caused the in-person modelling groups to close and the group emails were no longer monitored. Given the retrospective design of this study, sampling could not be truly randomised.

Table 2.

Participant inclusion and exclusion criteria to be included within the study.

Inclusion criteria	Exclusion criteria
A veteran of His Majesty’s Armed Forces; Royal Air Force, British Army, Royal Navy, Royal Marines	Veterans only, no serving membersArmed forces veterans only, not including family members or emergency services
18+ years old
Participation in scale modelling as an occupation at the time of study	Participants must not be participating in other mental health studies or trials at the time of the study
No requirement for a formal mental health diagnosis – but will be asked to report if a diagnosis existsDischarge does not need to be due to mental health	Veterans of British Armed Forces only, other armed forces not accepted (NOTE: a participant may be a member of the British Armed Forces, but not a British citizen, in which case they are still eligible)
	Participants must provide written consent for all parts of the study to participate

Of the research papers appraised for the literature review, the most common format for conducting research with military veterans regarding their mental health has been the utilisation of outcome measures with follow-up interviews (Carless, 2013; Everill, 2020; Peacock, 2019). Given that veterans reported a wide variety of mental health conditions, an outcome measure with a broad application was preferred. One of the most versatile outcome measures with this client group as per the literature review was the Short Warwick and Edinburgh Mental Well-Being Scale (SWEMWBS) (Putz, 2012; Scotland, 2006). This was in line with research studies which utilised it pre-intervention and post to determine whether there was an improvement in mental well-being (Everill, 2020; Maheswaran, 2012; Peacock, 2019).

Permission to use this tool was gained prior to the start of the study from the authors. The SWEMWBS has been shown to be valid within English-speaking ethnic minority groups (Taggart, 2015) which is an important consideration given the multinational makeup of the British Armed Forces (Ministry of Defence, 2022). It has high face validity and content validity (Tennant, 2007) and the responsiveness of the measure is shown to be independent of the sample size the of population and the type of intervention and is considered responsive enough to detect changes within a person or population (Maheswaran, 2012). For this study, the scale was used retrospectively.

The Warwick and Edinburgh Mental Well-Being Scale has two formats, either of 14 items or 7. In this case, the seven-item scale (SWEMWEBS) was used, to minimise the attention and focus required of each respondent given they were being asked to complete it twice in one sitting.

This seven-item check-box inventory comprises seven statements regarding feelings and thoughts that require the user to mark on a numerical scale whether they agree that the statement applies to them. The minimum score of SWEMWBS is 7 (low mental well-being) and the maximum is 35 (high mental well-being) with the population norm considered to be 23.61 (Ng Fat et al., 2017).

No modifications were made to the questionnaire itself although demographic questions were asked: name, age, military unit, the presence of mental health diagnosis, suspected undiagnosed mental health condition and length of time engaging in scale modelling. Respondents were required to fill in the SWEMWBS twice within the supplied questionnaire: retrospectively regarding their mental well-being before engaging with scale modelling as an activity, and post having engaged in the activity.

Suggested minimum number of respondents was 30 for statistical significance (Taggart, 2015). Transformation of the raw scores of the SWEMWBS was completed with a conversion table provided by the authors (Stewart-Brown, 2009). Given the risk of missing the threshold for statistically significant returns of quantitative data, the SWEMWBs were also particularly well informed as low results are still useful for suggesting patterns and informing future research (Taggart, 2015; Tennant, 2007).

Demographics

Whilst the inclusion criteria did not demand a mental health diagnosis, the demographics asked for clarification. Undiagnosed but suspected conditions were included due to the known difficulties this population faces in seeking a diagnosis (NICE, 2018). In all, 10 respondents reported a PTSD diagnosis, one cited other mental health conditions and one declined to answer.

In all, 11 participants identified as male and one as female, with no officers taking part. The length of time participating in scale modelling varied from under a year to up to 40 years.

Results

In total, 13 questionnaires were returned. Of these, one was discounted due to missing the SWEMWBS survey. One form was returned with a missing data point in the ‘before’ section of the SWEMWBS table. This is considered Missing at Random data and was handled according to the guidance computationally built into the SWEMWBS calculation tool.

The scoring tool and appropriate statistics were followed as laid out by the owners of the tool (Taggart, 2015). Due to the small sample size, the data were not normally distributed and a paired t-test could not be used. A Wilcoxon signed-rank test was therefore appropriate (Taggart, 2015).

The mean well-being score before engaging in the occupation was 14.39 ± 1.94 (low) and after was 23.83 ± 1.56 (moderate) which is 0.2 above the population norm. Pre-engagement, 92% of respondents retrospectively reported a well-being score of low, and 8% had moderate scores at baseline. Post-engagement, it was seen that 42% of respondents had a score ranked as low, and 58% were moderate. In all, 11 respondents showed an increase in well-being, and one had no change. The Wilcoxon signed-rank test showed that p = 0.00338. Being less than 0.05, it can be stated that there was a significant positive increase in well-being from baseline (pre-engagement) to post-engagement, although this is only within this small sample size.

The effect size was calculated as r = 0.61, which suggests that the positive change in well-being status was moderate. This is shown with the descriptive statistics of the Wilcoxon signed-rank test in Table 3.

Table 3.

Descriptive statistics taken from the Wilcoxon signed-rank results demonstrate the change in well-being between pre- and post-engagement scores.

	Before engagement in an activityn = 12	After an engagement in an activityn = 12	Change
% Low well-being	92	42
% Moderate well-being	8	58
% High well-being	0	0
Mean score	14.4 ± 1.94	24 ± 1.56	9.44
Standard deviation	5.6	4.5	5.0
Wilcoxon signed-rank test p value				p = 0.00338
Effect size R = Z√N				0.61
Respondents with a meaningful positive change (change score >7.7) %				8 (66.7%)
Respondents with a meaningful negative change (%)				0 (0.0%)

A p value of <0.05 is considered significant.

Discussion

The meaning and value ascribed by participants to an activity and how it affects them as they take part in it can have a positive impact on mental well-being (Caddick, 2014; Hammell, 2017). The outcomes of this concept and study have been explored both through the Model of Human Occupation (MOHO; Kielhofner, 2008) and the framework of Doing, Being, Becoming, Belonging (Wilcock, 1998).

Data collection for this study began in March 2020, shortly before the World Health Organization declared the COVID-19 outbreak to be a pandemic. It would be difficult to quantify the true effect the COVID-19 pandemic had on this study but it would be reasonable to suggest there were fewer participants willing to engage. This may have been a factor in the small sample size.

The mental health of 11 out of the 12 respondents improved following participation in scale modelling. One respondent’s mental health remained unchanged. There was a weak, non-significant correlation between the amount of time spent on scale modelling and the improvement in mental health.

Although the results of statistical analysis imply an improvement in well-being after participation, due to sample size this can only be inferred. However, it is a promising line of enquiry and continues to add to the conversation. The following conclusions can therefore only be tentative in nature without further investigation.

Application of the MOHO

Sociology models of care are common for veteran health care but there is no specific model for occupational therapy with the military or military veterans. The MOHO has been utilised instead (Dowling, 2019; Gerardi, 1996). To produce performance and action, the MOHO takes into account the motivation to engage in meaningful occupation in an environmental context (Kielhofner, 2008).

As per Kielhofner (2008), the subsystems of MOHO comprise Volition, Habituation and Performance Capacity, all within an Environmental context. Volition is the organisation of an individual’s chosen behaviours (Kielhofner, 2008). Increased participation in a meaningful activity can increase the volition to engage in occupation (Dowling, 2019; Carra, 2023). Habituation encompasses routine and behavioural patterns that are acquired through activity and occupation which can lead to an overall positive impact on well-being (Kielhofner, 2008). Performance capacity is the ability of a person to manage a situation (Dowling, 2019). MOHO suggests that a person’s ability to manage a task or situation is directly linked to their ability or capacity to perform said action and how the skills they possess can support the engagement (Dowling, 2019). These subsystems interact continuously in a feedback loop that includes input from an occupation, output to that occupation and ongoing processing to make the necessary adjustments in the context of the environment (Kielhofner, 2008).

The effects of PTSD symptoms on a person’s volition, engagement and occupational performance are significant (Brownlow, 2018). MOHO has been used in occupational therapy work to better define how a veteran’s volition, habituation and general performance in activities in which they try to participate can be impacted by a diagnosis of PTSD (Dowling, 2019; Gerardi, 1996).

Volition

Given that PTSD can detrimentally impact a person’s engagement in their occupation (AOTA, 2015), the findings in this study could imply that by increased participation in scale modelling and the resulting improvement in mental well-being, PTSD symptoms may have improved for the participants. The findings indicate that within this study increasing participation in a meaningful activity could boost volition to engage in occupation.

Habituation

Given the behavioural components of this subsystem and its connection to utilising behaviour to control the environment (Gerardi, 1996), it is reasonable to assume that the length of time a respondent has been participating in scale modelling and the progression of their well-being will be correlated. Whilst the outcomes do not necessarily support this theory, it is important to acknowledge that the nature of this study did not focus on the measurement of this complex and detailed phenomenon.

Within habituation, there is a focus on the concept of mastering one’s behavioural patterns and changing roles (Gerardi, 1996). It could be argued that when a chosen activity – scale modelling – becomes more ingrained in a routine and behavioural patterns begin to revolve around that routine, the participant’s general attitude to other situations may also change. It is possible that micro decisions during the modelling process can be used to slowly change behavioural patterns and increase a wider ability to take ownership and make decisions in other matters.

Performance capacity

Role and identity are linked to performance capacity. There is a strong link between task performance and an individual’s decision-making capacities within an environmental context (Dowling, 2019). The positive change seen in these results regarding decision-making suggests that the decision-making found within the occupation of scale modelling is transferable for these particular participants. Prolonged physical or mental injury can cause uncertainty and negative feelings (Ross, 2018). PTSD symptoms can include hyperarousal and avoidance, which, in turn, may lead to concentration problems (NICE, 2018). The results suggest that performing a meaningful occupation, in this case scale modelling, could potentially lessen these symptoms.

Many of these suppositions were seen in the literature review. It has been observed that participating in an activity that is meaningful to the participants improves mental well-being across a range of activities (Caddick, 2014; Carra, 2023; Ley, 2017; Nimenko, 2014; Schouten, 2019). It has also been previously highlighted in the literature how skill mastery and confidence are related, particularly when linked to flow and increasing well-being (Csikszentmihalyi, 2008; Lloyd, 2007; Pöllänen, 2009).

Doing, being, becoming and belonging

The Occupational Perspective of Health framework, which identifies the concepts of doing, being, becoming and belonging (Hitch, 2014; Wilcock, 1998), is a useful lens to view the results and guide occupational understanding. It supports the engagement of a person in meaningful activity, and suggests why such participation is beneficial for health and well-being.

Four dynamically interactive dimensions – doing, being, becoming and belonging – are used to conceptualise participation in meaningful activity (Ennals, 2016). Doing is action and purpose; being is the connection between a person and their activity of choice; becoming is development and transformation via purposeful activity; and belonging describes the complex relationships intertwined within occupation (Hitch, 2014; Wilcock, 1998). This framework supports the engagement of a person in meaningful occupation, and suggests why such participation is beneficial for health and well-being (Hitch, 2014).

It has been stated that developing a feeling of being in an occupational role can be accomplished through doing, or engaging in a chosen occupation (Hitch, 2014). By building this self-perception as an occupational being, it is argued that an individual’s quality of life may be improved and their mental well-being increased (Hitch, 2014).

The results are in line with this claim since the respondents’ reported mental wellness apparently improved as a result of their involvement in the scale modelling. Through doing (engagement in activity), the respondents were attending to their occupational needs by being, developing their role as a scale modeller and belonging and thus moving forward into their futures and becoming (Hitch, 2014; Wilcock, 1998). This suggests that the act of doing for these participants leads to the therapeutic change seen in the responses.

Previous research has seen that doing, being, becoming and belonging can all be expressed and enhanced through crafting occupations (Pöllänen, 2020). However, the chosen occupation needs to be meaningful and relevant to the individual to have such an effect (Pöllänen, 2020). Additionally, it has been suggested that a person’s occupation and occupational experience are closely related, with experience coming directly from engaging in a chosen occupation (Kuo, 2011).

Connection to flow

The literature review highlighted that finding meaning in the occupation, rather than the occupation itself, is what allows an activity to be beneficial to veterans (Everill, 2019). The individual would need to find the occupation valuable to them personally for it to have therapeutic benefit (Persson, 2001). Equally, the concept of flow was integral across a wide range of otherwise unrelated activities (Everill, 2019; Ley, 2017; Lobban, 2019; Peacock, 2019; Pöllänen, 2020).

According to the results of the literature study, experiencing flow can promote mental well-being. If this is true, it may help to explain why scale-modelling involvement has resulted in an increase in mental well-being within this study. Whilst a disruption in life through illness and/or injury can reduce an individual’s capacity to relate to the meaning and value of occupations (Persson, 2001), the experience of flow itself can be its own reward, building motivation to continue engaging. Scale-modelling participation in this instance has led to an improvement in mental well-being for these participants, and finding flow in a new occupation can bring about new meaning and a new role (Reid, 2011), allowing individual ownership over their own happiness (Csikszentmihalyi, 2008).

Implications for future occupational therapy work

This small-scale study is suggestive that improvement in well-being can occur for veterans who find meaning and enjoyment in participating in scale-modelling groups. The intervention appears to take only a short period of time to begin producing positive effects, which implies that it could work in a variety of settings.

Given that these results are currently only indicative but not conclusive of the benefits of this intervention, a larger-scale study could build on this initial data. A significantly larger number of participants would allow for better-defined statistical analysis, results with greater significance and build a stronger case for occupational therapists to use scale modelling as an intervention for veterans with mental health conditions.

Limitations of the study

This was a small-scale study with a limited participant pool. As a result, the conclusions are only speculative in nature and would benefit from further research. Extrapolation from a short dataset was necessary because the intended number of participants for this investigation was not obtained. Despite a promising positive outcome, it is less statistically significant as a result.

The impact of COVID-19 can also not be ignored. Although the effects cannot be predicted, the announcement of the first UK lockdown coincided with the start of this study, which likely affected participant engagement in the research.

Given that this is a novel area of research, there is a distinct lack of literature on scale modelling and veterans with PTSD and mental health conditions in particular, as well as on occupational therapy in veteran mental health as a whole. The literature review could only include papers in English. Additionally, because the participants were recruited from a UK charity, it exclusively included members of the British military forces.

Veterans with mental health conditions and scale modelling are not unique to the UK. Therefore, if a larger study were to find a positive correlation between participation in the activity and improvement in mental health, it may very likely apply to countries outside of the UK as well. The addition of qualitative data in further research could also strengthen the understanding of the therapeutic value found in this activity.

As a final point, this study did not address the type of models being made. A large proportion of the models were military vehicles, which was not considered within the scope of this work. This could be an interesting avenue to expand upon, with an opportunity for joint working with psychology to explore the impacts of role identity and using scale modelling as a way of facing trauma head-on.

Summary and conclusion

The results of this study imply that scale modelling may be advantageous for veterans with PTSD and mental health conditions if it is an activity they find meaningful. This study utilised the MOHO (Kielhofner, 2008) and the framework of Doing, Being, Becoming, Belonging (Wilcock, 1998) to explore the results through an occupational lens.

Further work will be required, on a much larger scale, to gain significant results. Nevertheless, despite the conclusions being tentative in nature, this study adds to the conversation of occupational therapy in veterans with PTSD and mental health conditions whilst exploring a novel intervention on a small scale.

Key findings

Engaging in meaningful activity can help dampen PTSD symptoms and scale modelling may have a positive impact on military veterans mental well-being if meaningful.

This study opens up the exploration of scale modelling as a novel occupational therapy intervention for veteran mental health.

Further research with larger participant numbers is required to gain significant results.

What this study has added

This study suggests that scale modelling may have some benefits for veterans with PTSD and mental health conditions who find meaning in the activity. These findings, while adding to the conversation, are nonetheless limited and call for more extensive research.

Footnotes

Acknowledgements

With thanks to Models for Heroes for agreeing to participate in this research.

Research ethics

Approval granted 13/02/2020 reference number: 18945-SS-Dec/2019- 22820-1.

Consent

Informed consent was obtained from all participants in written format. All required information was provided to participants.

Patient and public involvement data

During the development, progress and reporting of the submitted research, patient and public involvement in the research was included in the conduct of the research through participant responses.

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors confirm that there is no conflict of interest.

Funding

The author(s) declared no financial support for the research, authorship, and/or publication of this article.

Contributorship

CL conceived the study, completed the literature review, gained ethical approval, patient recruitment, data collection and data analysis. DE supervised the above. CL wrote the first draft of the manuscript, and DE reviewed and edited the manuscript in its original form as a Masters dissertation. CL has written all further drafts for publication.

ORCID iD

Ceri Lawrence

References

American Occupational Therapy Association (AOTA) (2015) Occupational Therapy’s Role with Post-Traumatic Stress Disorder. Washington DC: American Occupational Therapy Association.

Blomdahl

Gunnarsson

Guregård

, et al. (2016) Art therapy for patients with depression: Expert opinions on its main aspects for clinical practice. Journal of Mental Health 25: 527–535.

Brownlow

Zitnik

McLean

, et al. (2018) The influence of deployment stress and life stress on post-traumatic stress disorder (PTSD) diagnosis among military personnel. Journal of Psychiatric Research 103: 26–32.

Burt

Atkinson

(2012) The relationship between quilting and wellbeing. Journal of Public Health 34: 54–59.

Caddick

Smith

(2014) The impact of sport and physical activity on the well-being of combat veterans: A systematic review. Psychology of Sport and Exercise 15: 9–18.

Carless

Peacock

McKenna

, et al. (2013) Psychosocial outcomes of an inclusive adapted sport and adventurous training course for military personnel. Disability and Rehabilitation 35: 2081–2088.

Carra

Curtin

Fortune

, et al. (2023) Rural former service members participate in meaningful occupations to ‘fill the void ’after military service. Australian Occupational Therapy Journal 70: 341–353.

Carter

Gibbs

Harrop

(2014) Drafting an army: The playful pastime of Warhammer 40,000. Games and Culture 9: 122–147.

Childs

(2023) Models for Heroes. Available at: https://modelsforheroes.co.uk/who-are-you/ourstory (accessed 4 February 2023).

10.

Csikszentmihalyi

(2008) Flow: The Psychology of Optimal Experience. 1st edn. New York: Harper.

11.

Dowling

(2019) Barriers to Veterans Accessing Services: A Study of the Benefits of using an Occupational Therapy Approach to Enhance Participation. Herefordshire: The Royal British Legion.

12.

Ennals

Fortune

Williams

, et al. (2016) Shifting occupational identity: Doing, being, becoming and belonging in the academy. Higher Education Research & Development 35: 433–446.

13.

Everill

Bennett

Burnell

(2019) Dig in: Archaeology as a vehicle for improved wellbeing, and the recovery/rehabilitation of military personnel and veterans. Antiquity 94: 212–227.

14.

Gerardi

(1996) The management of battle fatigues soldiers: An occupational therapy model. Military Medicine 161: 483–488.

15.

Hammell

(2017) Opportunities for well-being: The right to occupational engagement. Canadian Journal of Occupational Therapy 84: 209–222.

16.

Help for Heroes (2019) Improving Medical Discharge Process. Downton: Downton: Help for Heroes.

17.

Hitch

Pépin

Stagnitti

(2014) In the footsteps of Wilcock, part one: The evolution of doing, being, becoming, and belonging. And In the footsteps of Wilcock, part two: The interdependent nature of doing, being, becoming, and belonging. Occupational Therapy in Health Care 28: 231–246.

18.

Kielhofner

(2008) A Model of Human Occupation: Theory and Application. Baltimore, MD: Lippincott Williams & Wilkins.

19.

Kuo

(2011) A transactional view: Occupation as a means to create experiences that matter. Journal of Occupational Science 18: 131–138.

20.

Ley

Krammer

Lippert

, et al. (2017) Exploring flow in sport and exercise therapy with war and torture survivors. Mental Health and Physical Activity 12: 83–93.

21.

Lloyd

Wong

Petchkovsky

(2007) Art and recovery in mental health: A qualitative investigation. British Journal of Occupational Therapy 70: 207–214.

22.

Lobban

Murphy

(2019) Understanding the role art therapy can take in treating veterans with chronic post-traumatic stress disorder. The Arts in Psychotherapy 62: 37–44.

23.

Maheswaran

Weich

Powell

, et al. (2012) Evaluating the responsiveness of the Warwick Edinburgh Mental Well-Being Scale (WEMWBS): Group and individual level analysis. Health and Quality of Life Outcomes 10: 1–8.

24.

Ministry of Defence (2021) Suicides in the UK regular armed forces: Annual summary and trends over time. London: Ministry of Defence.

25.

Ministry of Defence (2022) Defence People Mental Health and Wellbeing Strategy 2017-2022. London: Ministry of Defence.

26.

Murphy

Ross

Busuttil

, et al. (2019) A latent profile analysis of PTSD symptoms among UK treatment seeking veterans. European Journal of Psychotraumatology 10: 1558706.

27.

National Institute for Health and Care Excellence (NICE) (2018) Post-Traumatic Stress Disorder. London: National Institute for Health and Care Excellence.

28.

Ng Fat

Scholes

Boniface

, et al. (2017) Evaluating and establishing national norms for mental wellbeing using the short Warwick–Edinburgh Mental Well-being Scale (SWEMWBS): Findings from the Health Survey for England. Quality of Life Research 26: 1129–1144.

29.

Nimenko

Simpson

(2014) Rear Operations Group medicine: A pilot study of psychological decompression in a Rear Operations Group during Operation HERRICK 14. BMJ Military Health 160: 295–297.

30.

Peacock

McKenna

Carless

, et al. (2019) Outcomes from a one-week adapted sport and adapted adventure recovery programme for military personnel. Sports 7: 135.

31.

Persson

Erlandsson

Eklund

, et al. (2001) Value dimensions, meaning, and complexity in human occupation-a tentative structure for analysis. Scandinavian Journal of Occupational Therapy 8: 7–18.

32.

Pöllänen

(2009) Craft as context in therapeutic change. The Indian Journal of Occupational Therapy 41: 43–47.

33.

Pöllänen

Weissmann-Hanski

(2020) Hand-made well-being: Textile crafts as a source of eudemonic well-being. Journal of Leisure Research 51: 348–365.

34.

Pollard

Carver

(2016) Building model trains and planes: An autoethnographic investigation of a human occupation. Journal of Occupational Science 23: 168–180.

35.

Preston

(2019) Assessing the potential use of art therapy in the United Kingdom Ministry of Defence Department of Community Mental Health. International Journal of Art Therapy 24: 151–157.

36.

Putz

O’Hara

Taggart

, et al. (2012) Using WEMWBS to Measure the Impact of Your Work on Mental Wellbeing: A Practice-Based User Guide. Warwick: NHS Coventry.

37.

Ross

Murphy

Armour

, 2018. A network analysis of DSM-5 posttraumatic stress disorder and functional impairment in UK treatment-seeking veterans. Journal of Anxiety Disorders 57: 7–15.

38.

Reid

(2011) Mindfulness and flow in occupational engagement: Presence in doing. Canadian Journal of Occupational Therapy 78: 50–56.

39.

Schouten

van Hooren

Knipscheer

, et al. (2019) Trauma-focused art therapy in the treatment of posttraumatic stress disorder: A pilot study. Journal of Trauma & Dissociation 20: 114–130.

40.

Sijbrandij

Reitsma

Roberts

, et al. (2013) Self-report screening instruments for post-traumatic stress disorder (PTSD) in survivors of traumatic experiences. Cochrane Database of Systematic Reviews 6.

41.

Stewart-Brown

Tennant

, et al. (2009) Internal construct validity of the Warwick-Edinburgh mental well-being scale (WEMWBS): A Rasch analysis using data from the Scottish health education population survey. Health and Quality of Life Outcomes 7: 1–8.

42.

Tennant

Hiller

Fishwick

et al. (2007) The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): development and UK validation. Health Qual Life Outcomes 5: 63. DOI: 10.1186/1477-7525-5-63

43.

Taggart

Stewart-Brown

Parkinson

(2015) WEMWEBS User Guide V.2. Edinburgh: The University of Warwick.

44.

Vaughan-Horrocks

Reagon

Seymour

(2021) The experiences of veterans with mental health problems participating in an occupational therapy and resilience workshop intervention: an exploratory study. British Journal of Occupational Therapy 84: 531–540.

45.

Wilcock

(1998) Reflections on doing, being and becoming. Canadian Journal of Occupational Therapy 65: 248–256.