Peer Outcomes Protocol (POP): Questionnaire

Peer Outcomes Protocol (POP): Questionnaire
Campbell‚ Cook‚ Jonikas‚ & Einspahr‚ K. 2004
Quality of Life Scale (Lehman‚ 1988)‚ Social Acceptance Scale (Campbell & Schraiber‚ 1989)‚ Health Survey (Ware‚ Kosinski‚ & Keller‚ 1996)‚ Quality of Life Scale (Lehman‚ 1988)‚ Coercion Scale (Campbell‚ Wieselthier‚ Einspahr‚ & Evenson in Campbell et al.2004)
Demographics Module (Interview)
1. What is your gender? 1=Male‚ 2=Female
2. What is your date of birth? ______ month ______ day ______ year
3. Are you of Spanish or Hispanic origin? Please tell me the group or groups that represent your national origin or ancestry. [Circle all that apply]
[Hand respondent response card 1]
·         No‚ not Spanish/Hispanic
·         Yes‚ Mexican‚ Mexican-American‚ Chicano
·         Yes‚ Puerto Rican
·         Yes‚ Cuban
·         Yes‚ other Spanish/Hispanic
·         Please specify
What ethnicity do you consider yourself to be? Please tell me the group or groups which represent your race. [Circle all that apply]
[Hand respondent response card 2]
·         White
·         Black or African American
·         American Indian/Native American
·         Eskimo
·         Aleut
·         Asian or Pacific Islander (API) (including East Indian)
If Asian or API Ask:
·         Chinese
·         Japanese
·         Filipino
·         Asian Indian
·         Hawaiian
·         Samoan
·         Korean
·         Guamanian
·         Vietnamese
·         Other API
·         Please specify ________________________
·         Other race
·         Please specify
4. In what country were you born?
·         United States‚ including Puerto Rico [Skip to Question 7]
·         Other [Continue to Question 6]
·         Please specify ______________________________
5. In what year did you come to the U.S. to stay?
(If came to stay more than once‚ ask): In what year did you come to the U.S. to stay the last time? ______ (Year)
6. Is English your primary language?
·         Yes [Skip to Question 9]
·         No
7. What is your primary language? ____________________
8. What is your current marital status?
[Hand respondent response card 3]
·         Now married [Skip to Question 11]
·         Widowed
·         Divorced
·         Separated
·         Never married
9. Are you living in a committed relationship‚ but not married? By committed relationship‚ I mean sharing your life and housing with a partner?
·         Yes
·         No
10. Which of the following describes your sexual orientation?
Interviewer: Read list to respondent and circle category of response.
·         Heterosexual. By heterosexual‚ I mean‚ “straight”
·         Gay male
·         Lesbian female
·         Bisexual. by “bisexual‚” I mean both straight and lesbian or gay.
11. (If female): How many children have you given birth to?
(If male): How many children have you fathered?
Interviewer: If none‚ write “0”.
______ (number of children)
12. How many children under the age of 18 live with you at least four days per week?
Interviewer: If none‚ write “0” and skip to Question 15.
______(number of children)
13. Are you a single parent? By “single parent‚” I mean that you are the only adult living in the household and all other people who live with you are under the age of 18.
·         Yes
·         No
14. Are you a veteran? By “veteran‚” I mean‚ did you serve in the armed forces?
·         Yes
·         No
15. Do you have a physical and/or sensory disability? By “physical or sensory disability‚” I mean one that is not caused by a psychiatric disability.
·         Yes
·         No
16. What is the highest grade in school that you have completed?
[Hand respondent response card 4]
·         No formal schooling
·         Up to 8th grade
·         Some high school
·         High school diploma/GED
·         Some college or post-high school training
·         2-year Associate degree
·         4-year college degree
·         Post-college graduate training
17. In the past 30 days‚ have you had any financial support from the following sources? [Read the list to the respondent and circle all that apply]
[Hand respondent response card 5]
·         Earned income
·         Social Security Benefits (SSA)
·         Social Security Disability Income (SSDI)
·         Supplemental Security Income (SSI)
·         Armed Service connected disability payments
·         Other Social Welfare benefits-‎-‎-‎-state or county (TANF‚ Aid to Families with Dependent Children)
·         Vocational program (Comprehensive Employment and Training Act (CETA)‚ Vocational Rehabilitation‚ sheltered workshop‚ Goodwill)
·         Unemployment compensation
·         Retirement‚ investment or savings income
·         Rent supplements (including HUD‚ section 8 certificates‚ living programs receiving public support)
·         Alimony or child support
·         Food stamps
·         Family and/or spouse contribution
·         Other sources(s):
·         Please Specify:
18. How much money did you receive during the past 30 days from all of these sources?
19. What was your total personal income last year? $________________
20. On the average‚ how much money do you have to spend on yourself each month‚ not counting money for room and meals? $________________
*****************************
Service Use Module (Interview)
Now I would like to ask you a few questions related to your status as a mental health consumer/survivor.
1. Have you been diagnosed with a major mental illness?
·         Yes [Continue to Question 2]
·         No [Skip to Question 3]
·         Not sure [Continue to Question 2]
2. What have you been told is your psychiatric diagnosis? From the list‚ please pick all diagnoses that you have been told‚ or tell me any other diagnosis that may not be on the list.
Interviewer: Read question and instruction and circle all the categories that apply or write in exactly what the respondent says.
[Hand respondent response card 6]
·         Schizophrenia
·         Schizoaffective Disorder
·         Manic Depression‚ Bipolar‚ or Affective Disorder
·         Major Depression
·         Anxiety Disorder (such as Panic Disorder‚ Obsessive Compulsive Disorder‚ etc.)
·         Dissociative Disorder (such as Multiple Personality‚ Dissociative Amnesia‚ etc.)
·         Personality Disorder
·         Substance Abuse
·         Other
·         Please Specify __________________________________________
3. Are you currently taking any psychiatric medications?
·         Yes
·         No [Skip to Question 5]
4. In the past 30 days‚ have you been bothered by any side effects from the psychiatric medications you have taken?
[Hand respondent response card 7]
No side effects‚ Mild side effects‚ Moderate side effects‚ Severe side effects
5. Have you had any problems associated with alcohol use in your lifetime?
·         Yes
·         No
6. Have you had any problems associated with drug use in your lifetime?
·         Yes
·         No
7. Were you ever physically abused as a child?
·         Yes
·         No
8. Were you ever sexually abused as a child?
·         Yes
·         No
9. Have you ever been hospitalized for psychiatric reasons?
·         Yes
·         No [Skip to Question 13]
10. How old were you at your first psychiatric hospitalization? ______ (years of age at first hospitalization)
11. About how many times have you been hospitalized for psychiatric reasons in your lifetime? ________ (number of psychiatric hospitalizations)
12. About how many times have you been hospitalized for psychiatric reasons during the past 12 months? ________ (number of psychiatric hospitalizations)
Next‚ I would like to know about some of the services you have used in the past.
13. How long have you been attending this peer support program? If you can‚ please tell me the date of when you first started coming here.
_____ Month _____ Day(approximate)  _____ Year [Code as MM/DD/YYYY]
14. During a typical week‚ how often do you attend this peer support program?
[Hand respondent response card 8]
Almost every Day‚ 2 or more times a week‚ About once a week‚ About once a month‚ A few times a year
15. I have a list of services that are available in the community. For each one please tell me if you have received the service in the past 30 days. If you have‚ tell me if you received the service at this peer support program‚ somewhere else‚ or here and somewhere else.
Interviewer: Read list to the respondent and circle all that apply.
[Hand respondent response card 9]
Community Services: 1= At Peer Program‚ 2= Outside of Peer Program‚ 3= At Peer Program & Elsewhere
·         Self-Help Group‚ such as AA‚ NA‚ DMDA‚ a sexual abuse survivors group 1‚ 2‚ 3
·         Medication management by a psychiatrist or doctor 1‚ 2‚ 3
·         Therapy 1‚ 2‚ 3
·         Counseling 1‚ 2‚ 3
·         Case Management 1‚ 2‚ 3
·         Crisis Hotline 1‚ 2‚ 3
·         Crisis Intervention Service 1‚ 2‚ 3
·         Supervised or Supported Living Program 1‚ 2‚ 3
·         dr‎op-In Center 1‚ 2‚ 3
·         Homeless Shelter 1‚ 2‚ 3
·         Domestic Violence Shelter/Program 1‚ 2‚ 3
·         Legal Aid 1‚ 2‚ 3
·         Job Training or Vocational Program 1‚ 2‚ 3
·         Partial or day hospitalization services 1‚ 2‚ 3
·         Services for alcohol use or abuse problems 1‚ 2‚ 3
·         Services for drug use or abuse problems 1‚ 2‚ 3
·         Alternative therapy or treatment‚ such as body massage‚ herbs/homeopathic 1‚ 2‚ 3
·         Other‚ describe: 1‚ 2‚ 3
In this section‚ I would like to know about recent psychiatric problems and hospitalizations you may have had‚ and about you experiences with peer support during these times. This information is strictly confidential.
16. Have you had any significant emotional difficulties in the past six months?
·         Yes
·         No [SKIP to Question 24]
17. Do you feel that this program helped prevent these difficulties from turning into a psychiatric crisis during the past 6 months?
·         Yes
·         No
18. Do you feel that this program helped you stay out of the hospital during the past 6 months?
·         Yes
·         No [SKIP to Question 24]
I’d like to read a list of ways this program might have helped you stay out of the hospital. As I read each one‚ tell me whether it was true or false for you:
1=True‚ 2= False
19. Did the program help you stay out of the hospital by offering you another place to stay? 1‚ 2
20. Did the program help you stay out of the hospital by providing support whenever you needed it? 1‚ 2
21. Did the program help you stay out of the hospital by giving you someone to talk to? 1‚ 2
22. Did the program help you stay out of the hospital by helping you cope with symptoms? 1‚ 2
23. Did the program help you stay out of the hospital by involving other people in your life? 1‚ 2
Next‚ I’d like to ask you about any recent hospitalizations you may have had.
24. In the past 6 months‚ have you been hospitalized for psychiatric problems?
·         Yes
·         No [SKIP to Next Module]
25. In the past 6 months‚ how many times were you in a psychiatric hospital?
·         [If none write "0"]
·         __________ # of times
26. In the past 6 months‚ how many of your hospitalizations were involuntary? __________ # of times
27. In the past 6 months‚ approximately how many total days were you hospitalized for psychiatric reasons? __________ # of days
28. Were you in this program at the time of your most recent hospitalization?
·         Yes [Continue to Question 29]
·         No [Skip to Next Module]
I’d like to know how much you agree or disagree with the following statements about this most recent hospitalization.
[Hand respondent response card 10]
1= Disagree‚ 2= Somewhat Disagree‚ 3= Somewhat Agree‚ 4= Agree
29. People from this program supported me while I was in the hospital. 1‚ 2‚ 3‚ 4
30. People from this program ignored me while I was in the hospital. 1‚ 2‚ 3‚ 4
31. People from this program visited me while I was in the hospital. *** 1‚ 2‚ 3‚ 4
32. People from this program made me feel like a failure for being in the hospital. *** 1‚ 2‚ 3‚ 4
*******************************
Employment Module
In this section‚ I would like to ask about your work activities.
1. Are you currently working for pay?
·         Yes
·         No [Skip to Question 6]
2. How many hours per week do you work? _________(number of hours)
3. Some people have more than one paid job. How many paid jobs do you have? _________ (number of jobs)
4. What is your current hourly wage? Pick the highest hourly wage if you have more than one job. _________ (dollars per hour)
5. Does your job offer health insurance to you?
·         Yes [Skip to Question 9]
·         No [Skip to Question 9]
[Interviewer: Ask question and circle response]: 1= Yes‚ 2= No
6. Are you currently interested in working? 1‚ 2
7. Have you been looking for work during the last 4 weeks? 1‚ 2
8. Do you remain at home to care for others? 1‚ 2
9. Have you attended school or a training program in the past 6 months? 1‚ 2
10. Are you retired? 1‚ 2
11. Do you do any volunteer work or any other kind of work for which you are not paid? 1‚ 2
Employment Satisfaction Scale
Now I would like to ask you about how you feel about work‚ whether or not you are employed.
Please tell me how much you agree or disagree with the following statements.
Interviewer: Show respondent card‚ read the instruction and question‚ and circle number of response.
[Hand respondent response card 11]
1=Disagree‚ 2= Somewhat Disagree‚ Somewhat Agree‚ 4= Agree
12. In general‚ I am satisfied with my employment status right now. 1‚ 2‚ 3‚ 4
13. If I am ha‎ving emotional problems‚ I am able to put them aside when I work. 1‚ 2‚ 3‚ 4
14. I know how to get a job. 1‚ 2‚ 3‚ 4
15. I know how to keep a job once I am hired. 1‚ 2‚ 3‚ 4
16. This peer support program has helped me to improve my work situation. 1‚ 2‚ 3‚ 4
17. I feel comfortable talking to people in this program about losing SSI or SSDI as a result of returning to work. 1‚ 2‚ 3‚ 4
18. I feel comfortable talking to people in this program about losing Medicaid or Medicare as a result of returning to work. 1‚ 2‚ 3‚ 4
19. This program inspires me to believe that meaningful work is possible for me. 1‚ 2‚ 3‚ 4
20. This program does not have enough resources to help program members find jobs. 1‚ 2‚ 3‚ 4
21. This program does not have enough resources to help program members keep jobs. 1‚ 2‚ 3‚ 4
22. I am comfortable discussing work issues with my peers in this program. 1‚ 2‚ 3‚ 4
Interviewer: If respondent is not working‚ ask:
23. I am not working‚ but I would like to be working. 1‚ 2‚ 3‚ 4
Interviewer: If respondent is working‚ ask:
24. I am working at a job that I want. 1‚ 2‚ 3‚ 4
*****************************
Community Life Module
I would like to ask some questions about your housing situation and community life.
1. Where do you currently live?
[Hand respondent response card 12]
·         Apartment‚ condo‚ house‚ or trailer
·         Transitional living center or half-way house [SKIP to Question 3]
·         Group home/board and care [SKIP to Question 3]
·         Shelter [SKIP to Question 3]
·         Hotel or Motel [SKIP to Question 3]
·         Street [SKIP to Question 3]
·         Other [SKIP to Question 3]
·         Please Specify _______________________________
2. Is this apartment‚ condo‚ house‚ or trailer ….
·         Rented for cash?
·         Occupied without payment of cash rent?
·         Owned by you with a mortgage or loan?
·         Owned by you free and clear (without a mortgage)?
3. Who currently lives in your residence with you? [Circle all that apply]
[Hand respondent response card 13]
·         Parents
·         Spouse or partner
·         Friends
·         Other peers
·         Minor children
·         Adult children
·         No one (respondent lives alone)
·         Other
·         Please Specify _____________________________________
4. Do you receive any help in managing your money?
·         Yes
·         No [SKIP to Question 6]
5. From whom do you receive help? [Circle all that apply]
[Hand respondent response card 14]
·         People at this peer program
·         Staff from another program
·         Family
·         Friends
·         Spouse or Partner
·         Other
·         Please Specify _____________________________________
6. Do you receive any help with cooking?
·         Yes
·         No [SKIP to Question 8]
7. From whom do you receive help? [Circle all that apply]
[Hand respondent back response card 14]
·         People at this peer program
·         Staff from another program
·         Family
·         Friends
·         Spouse or Partner
·         Other
·         Please Specify _____________________________________
8. Do you receive any help with housekeeping?
·         Yes
·         No [SKIP to Question 10]
9. From whom do you receive help? [Circle all that apply]
[Hand respondent back response card 14]
·         People at this peer program
·         Staff from another program
·         Family
·         Friends
·         Spouse or Partner
·         Other
·         Please Specify _____________________________________
Now I would like to ask you about how you feel about your current living situation and the neighborhood in which you live. Please tell me how much you agree or disagree with the following statements.
[Hand respondent response card 15]
1=Disagree‚ 2= Somewhat Disagree‚ 3= Somewhat Agree‚ 4= Agree
10. In general‚ I am satisfied with the neighborhood in which I live. 1‚ 2‚ 3‚ 4
11. I live in this neighborhood because I want to. 1‚ 2‚ 3‚ 4
12. I live in this kind of housing because I want to. 1‚ 2‚ 3‚ 4
13. I am involved in neighborhood activities‚ such as volunteer work‚ religious groups‚ sports‚ or recreation activities‚ that are not related to being a mental health consumer. 1‚ 2‚ 3‚ 4
14. I feel rejected by people in my neighborhood because I am diagnosed with mental illness. *** 1‚ 2‚ 3‚ 4
15. I feel this program helps people find better housing. 1‚ 2‚ 3‚ 4
Quality of Life Scale (A. Lehman)
In this section‚ I would like to know about the people in your life and how you feel about your social relationships.
[Hand respondent response card 16]
1= Not at all‚ 2= Once‚ 3= 2-3 times‚ 4= 4-6 times‚ 5= Once a day or more
16. During the past 7 days‚ how often did you spend time with friends or family in recreational activities? This does not include mental health system sponsored activities or activities at the peer support program. 1‚ 2‚ 3‚ 4‚ 5
17. How often did you spend time alone in recreational activities during the past 7 days? 1‚ 2‚ 3‚ 4‚ 5
18. During the past 7 days‚ how often did you go to clubs‚ church‚ or other meetings in your community? This does not include mental health system sponsored activities or activities at the peer support program. 1‚ 2‚ 3‚ 4‚ 5
19. During the past 7 days‚ how often did you spend time with friends in recreational activities at this peer support program? 1‚ 2‚ 3‚ 4‚ 5
Interviewer: Show respondent card‚ read the questions‚ and circle number of response.
[Hand respondent response card 17]
1= Not at all‚ 2= Less than once a month‚ 3= At least once a month‚ 4= At least once a week‚ 5= At least once a day
20. About how often do you visit with someone who does not live with you? 1‚ 2‚ 3‚ 4‚ 5
21. About how often do you telephone someone who does not live with you? 1‚ 2‚ 3‚ 4‚ 5
22. About how often do you do something with another person that you planned ahead of time? 1‚ 2‚ 3‚ 4‚ 5
23. About how often do you spend time with someone you consider more than a friend‚ like a boyfriend or girlfriend? 1‚ 2‚ 3‚ 4‚ 5
Now I would like to know how you feel about the things you do with other people. Please look at this card. This is called the Delighted-Terrible Scale. The scale goes from terrible which is the lowest ranking of 1‚ to delighted‚ which is the highest ranking of 7. There are also points 2 through 6 with descriptions about them. For the next three questions‚ please tell me what on the scale best describes how you feel.
24. How do you feel about the things you do with other people?
[Hand respondent response card 18]
1= Terrible‚ 2= Unhappy‚ 3= Mostly Dissatisfied‚ 4= Mixed‚ 5= Mostly Satisfied‚ 6= Pleased‚ 7= Delighted
25. How do you feel about the amount of time you spend with other people? 1‚ 2‚ 3‚ 4‚ 5‚ 6‚ 7
26. How do you feel about the people you see socially? 1‚ 2‚ 3‚ 4‚ 5‚ 6‚ 7
Social Satisfaction Scale
The following section is about your social relationships. Please tell me how much you agree or disagree with the following statements.
[Hand respondent response card 19]
1= Disagree‚ 2= Somewhat Disagree‚ 3= Somewhat Agree‚ 4= Agree
27. The social relationships that I have with neighbors are what I want them to be. 1‚ 2‚ 3‚ 4
28. The social relationships that I have with my family members are what I want them to be. 1‚ 2‚ 3‚ 4
29. The social relationships that I have with my friends are what I want them to be. 1‚ 2‚ 3‚ 4
30. The social relationships that I have with my peers in this program are what I want them to be. 1‚ 2‚ 3‚ 4
31. I often feel lonely. *** 1‚ 2‚ 3‚ 4
32. I lack intimacy in my everyday life. *** 1‚ 2‚ 3‚ 4
Discrimination Scale
In the next set of questions‚ I am going to ask you about discrimination. Discrimination means that you are denied your rights to freedom of speech‚ or equal access‚ or equal opportunity because you are of a particular gender‚ or race‚ or sexual orientation‚ or have a mental or physical disability.
33. Have you ever experienced discrimination in this program?
·         Yes
·         No
Now I’d like you to tell me how much you agree or disagree with the following statements.
[Hand respondent back response card 19]
1= Disagree‚ 2= Somewhat Disagree‚ 3= Somewhat Agree‚ 4= Agree
34. I know what to do if I experience discrimination from staff at this program. 1‚ 2‚ 3‚ 4
35. I know what to do if I experience discrimination in the workplace. 1‚ 2‚ 3‚ 4
36. I know what to do if I experience discrimination from my landlord. 1‚ 2‚ 3‚ 4
Crime Demographics
Now I am going to ask a few questions about crime and violence in your life.
37. Have you been the victim of a violent crime‚ such as assault‚ robbery‚ rape‚ or abuse‚ in the past six months‚ whether it was reported or not reported?
·         Yes
·         No
38. Have you been a victim of a nonviolent crime‚ such as theft‚ in the past six months‚ whether it was reported or not reported?
·         Yes
·         No
39. Have you been arrested in the past six months?
·         Yes
·         No
40. Have you been in jail or prison in the past six months?
·         Yes
·         No
Interviewer: For the next two questions‚ read the question‚ and check the response. If the respondent is experiencing physical or sexual abuse as reported in Q41 and Q42‚ stop the interview and (1) give the person a list of the local services and support groups‚ and (2) ask the respondent if they need assistance in making contact with a service or support group‚ then (3) proceed with the interview.
41. Are you experiencing physical abuse in your life?
·         Yes [See above instruction]
·         No
42. Are you experiencing sexual abuse in your life?
·         Yes [See above instruction]
·         No
Social Acceptance Scale ( J. Campbell & R. Schriaberl)
[Hand respondent response card 20]
43. How often do people treat you differently when they know you have a mentaldiagnosis or have received mental healthservices? 1= Most of the Time‚ 2= Sometimes‚ 3= Seldom or Rarely‚ 4= Never‚ 5= No Opinion
As an individual who has received mental health services‚ how often do you think others . . .
[Hand respondent response card 21]
1= All of the time‚ 2= Most of the time‚ 3=Sometimes‚ 4=Seldom‚ 5=Never‚ 6= No Opinion
44. …feel or treat you like you are violent or dangerous. 1‚ 2‚ 3‚ 4‚ 5‚ 6
45. ... feel you are a child or treat you like a child?” 1‚ 2‚ 3‚ 4‚ 5‚ 6
46. …feel or treat you like you are unpredictable? 1‚ 2‚ 3‚ 4‚ 5‚ 6
47. ....think that you do not know what is in your own best interests? 1‚ 2‚ 3‚ 4‚ 5‚ 6
48. ....think or treat you like you are incapable of caring for children? 1‚ 2‚ 3‚ 4‚ 5‚ 6
49. ....think or treat you like you are incapable of holding a job? 1‚ 2‚ 3‚ 4‚ 5‚ 6
50. …feel or treat you like you are incapable of ha‎ving a satisfying relationship with another man or woman? 1‚ 2‚ 3‚ 4‚ 5‚ 6
*****************
Quality of Life Module
SF-12 Health Survey (J. Ware)
Now I would like to ask you a few questions about your health. If you are unsure about how to answer‚ please give the best answer you can.
1. In general‚ would you say your health is
[Hand respondent response card 22]
5= excellent‚ 4= very good‚ 3= good‚ 2= fair‚ 1=poor
The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so‚ how much?
2. Moderate activities‚ such as moving a table‚ pushing a vacuum cleaner‚ bowling‚ or playing golf.
[Hand respondent response card 23]
1= Yes‚ limited a lot‚ 2= Yes‚ limited a little‚ 3= No‚ not limited at all
3. Climbing several flights of stairs.
[Hand respondent back response card 23]
1= Yes‚ limited a lot‚ 2= Yes‚ limited a little‚ 3= No‚ not limited at all
During the past 4 weeks‚ have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
4. Accomplished less than you would like
·         Yes
·         No
5. Were limited in the kind of work or other activities
·         Yes
·         No
During the past 4 weeks have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems‚ such as feeling depressed or anxious?
6. Accomplished less than you would like
·         Yes
·         No
7. Didn’t do work or other activities as carefully as usual
·         Yes
·         No
8. During the past 4 weeks‚ how much did pain interfere with your normal work‚ including both work outside the home and housework?
[Hand respondent response card 24]
5= Not at all‚ 4= A little bit‚ 3= Moderately‚ 2= Quite a bit‚ 1= Extremely
These questions are about how you feel and how things have been with you during the past 4 weeks. For each question‚ please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks
[Hand respondent response card 25]
6=All of the time‚ 5= Most of the time‚ 4= A good bit of the time‚ 3= Some of the time‚ 2= A little of the time‚ 1= None of the time
9. Have you felt calm and peaceful?* 6‚ 5‚ 4‚ 3‚ 2‚ 1
10. Did you have a lot of energy? *** 6‚ 5‚ 4‚ 3‚ 2‚ 1
11. Have you felt downhearted and blue? *** 6‚ 5‚ 4‚ 3‚ 2‚ 1
12. During the past 4 weeks‚ how much of the time has your physical health or emotional problems interfered with your social activities‚ like visiting with friends‚ relatives‚ etc.?
[Hand respondent response card 26]
5= All of the time‚ 4=Most of the time‚ 3= Some of the time‚ 2= A little of the time‚
1= None of the Time
Quality of Life Scale (A. Lehman)
In this next section‚ I would like to know how you feel about the quality of your life. For the next question‚ I will use the Delighted-Terrible Scale.
[Hand respondent response card 27]
Please look at this card. The scale goes from terrible which is the lowest ranking of 1‚ to delighted‚ which is the highest ranking of 7. There are also points 2 through 6 with descriptions below them. Please tell me what on the scale best describes how you feel.
13. How do you feel about your life in general?
1= Terrible‚ 2= Unhappy‚ 3= Mostly Dissatisfied‚ 4= Mixed‚ 5= Mostly Satisfied‚ 6= Pleased‚ 7= Delighted
Subjective Quality of Life
Now I am going to make a series of statements about how you view your life right now. Please tell me how much you agree or disagree with the statement.
[Hand respondent response card 28]
1=Disagree‚ 2= Somewhat Disagree‚ 3= Somewhat Agree‚ 4= Agree
14. In general‚ I am satisfied with my physical health. 1‚ 2‚ 3‚ 4
15. In general‚ I am satisfied with my emotional health. 1‚ 2‚ 3‚ 4
16. In general‚ I am satisfied with how things are going in my life. 1‚ 2‚ 3‚ 4
17. I often do things that are enjoyable. 1‚ 2‚ 3‚ 4
18. I am hopeful about the conditions of my life in general. 1‚ 2‚ 3‚ 4
19. Currently I have sufficient resources to live on‚ such as adequate housing‚ clothing‚ and food. 1‚ 2‚ 3‚ 4
20. I worry about not ha‎ving sufficient resources to live on in the future. 1‚ 2‚ 3‚ 4
21. I have things to do each day that give meaning to my life. 1‚ 2‚ 3‚ 4
Program Quality of Life
Now‚ I would like to know what impact participating in this program has on your life. I’m going to read a series of statements and ask you how much you agree or disagree with each one.
[Hand respondent response card 28]
1=Disagree‚ 2= Somewhat Disagree‚ 3= Somewhat Agree‚ 4= Agree
Disagree Somewhat
22. This program helps me to improve the quality of my life. 1‚ 2‚ 3‚ 4
23. This program helps me to do things that are enjoyable. 1‚ 2‚ 3‚ 4
24. This program helps me to be hopeful about the conditions of my life. 1‚ 2‚ 3‚ 4
25. This program helps me to worry less about ha‎ving sufficient resources to live on in the future. 1‚ 2‚ 3‚ 4
26. This program helps to protect my basic human rights. 1‚ 2‚ 3‚ 4
27. This program helps protect my rights as a mental health consumer. 1‚ 2‚ 3‚ 4
28. This program helps me to have meaningful activities in my life 1‚ 2‚ 3‚ 4
****************
Well-Being Module
Personhood and Empowerment Scale
Next‚ I would like to know about your sense of identity and self-esteem. Please tell me how much you agree or disagree with the following statements.
[Hand respondent response card 29]
1=Disagree‚ 2= Somewhat Disagree‚ 3= Somewhat Agree‚ 4= Agree
1. In general‚ I am satisfied with who I am as a person. 1‚ 2‚ 3‚ 4
2. I feel that I get the respect that I deserve from important people in my life. 1‚ 2‚ 3‚ 4
3. I am comfortable asking people to take me seriously. 1‚ 2‚ 3‚ 4
4. I feel that my opinions count. 1‚ 2‚ 3‚ 4
5. I feel that I can trust my own decisions. 1‚ 2‚ 3‚ 4
6. I feel that I have contributions to make in life. 1‚ 2‚ 3‚ 4
7. This program enables me to make contributions in life. 1‚ 2‚ 3‚ 4
8. This program helps me to believe that personal growth in my life is possible. 1‚ 2‚ 3‚ 4
9. This program helps me get respect from important people in my life. 1‚ 2‚ 3‚ 4
10. Being with members at this program helps me to have personal power. 1‚ 2‚ 3‚ 4
11. I take an active role in decisions about my mental health services. 1‚ 2‚ 3‚ 4
12. I have control over my daily routine. 1‚ 2‚ 3‚ 4
13. I can change the things about my life that are important to me. 1‚ 2‚ 3‚ 4
14. I am becoming self-sufficient in my life. 1‚ 2‚ 3‚ 4
15. I am knowledgeable about mental health issues. 1‚ 2‚ 3‚ 4
16. This program helps me have more choices in my life. 1‚ 2‚ 3‚ 4
17. This program inspired me to believe that I can live independently. 1‚ 2‚ 3‚ 4
18. This program helps me make positive changes in my life. 1‚ 2‚ 3‚ 4
19. This program helps me have an active role in decisions about my mental health services. 1‚ 2‚ 3‚ 4
20. This program helps me to have control over my daily routine. 1‚ 2‚ 3‚ 4
21. This program helps me make needed changes in the things that are important to me. 1‚ 2‚ 3‚ 4
22. This program helps me become self-sufficient in my life. 1‚ 2‚ 3‚ 4
23. I feel that I can change things about this program if I want to. 1‚ 2‚ 3‚ 4
24. I feel that I am involved in the planning for the future of this program. 1‚ 2‚ 3‚ 4
Recovery Scale
I would like to know how you are doing in your efforts to heal and recover from mental illness‚ be empowered‚ and build an identity for yourself. Please tell me how much you agree or disagree with the following statements about recovery.
[Hand respondent scale card 29].
1=Disagree‚ 2= Somewhat Disagree‚ 3= Somewhat Agree‚ 4= Agree
25. In general‚ I am satisfied with my progress towards recovery from mental illness. 1‚ 2‚ 3‚ 4
26. I usually know if I am beginning to have a psychiatric problem. 1‚ 2‚ 3‚ 4
27. If I have a psychiatric problem‚ usually I can do something about it before it becomes severe. 1‚ 2‚ 3‚ 4
28. I have hope that I will recover from mental illness. 1‚ 2‚ 3‚ 4
29. I understand what recovery involves for me. 1‚ 2‚ 3‚ 4
30. I believe that personal growth in my life is possible. 1‚ 2‚ 3‚ 4
31. I am making positive changes in my life. 1‚ 2‚ 3‚ 4
32. I usually can handle life’s ups and downs. 1‚ 2‚ 3‚ 4
33. If I am ha‎ving emotional problems‚ usually I can cope. 1‚ 2‚ 3‚ 4
34. In general‚ I am satisfied with the kinds of choices I can make in my life. 1‚ 2‚ 3‚ 4
35. This program gives me hope that I will recover from mental illness. 1‚ 2‚ 3‚ 4
36. This program helps me cope if I have psychiatric problems. 1‚ 2‚ 3‚ 4
37. This program helps me to understand what recovery involves for me. 1‚ 2‚ 3‚ 4
****************
Program Satisfaction Module
 
In this last section of the survey‚ I would like your opinion of this peer support program. Please tell me how much you agree or disagree with the following statements.
[Hand respondent response card 30].
1=Disagree‚ 2= Somewhat Disagree‚ 3= Somewhat Agree‚ 4= Agree
Note: (R) = reverse code
1. Overall‚ I am satisfied with this peer support program. 1‚ 2‚ 3‚ 4
2. I am satisfied with the peer program facilities‚ such as the condition and layout of the rooms and building. 1‚ 2‚ 3‚ 4
3. I do not feel physically safe when I am at this program. *** (R) 4‚ 3‚ 2‚ 1
4. Overall‚ the program services are useful to me. 1‚ 2‚ 3‚ 4
5. This program is helpful to me regarding my employment needs‚ such as choosing or keeping a job. 1‚ 2‚ 3‚ 4
6. This program is helpful to me regarding my housing needs‚ such as finding a place to live that I like. 1‚ 2‚ 3‚ 4
7. This program is helpful to me regarding my educational needs‚ such as finishing a degree‚ or getting into a training program. 1‚ 2‚ 3‚ 4
8. This program is helpful to me regarding my recreational needs‚ such as being involved in a hobby‚ playing games‚ or watching movies. 1‚ 2‚ 3‚ 4
9. This program is helpful to me regarding my transportation needs‚ such as helping me get to this program. 1‚ 2‚ 3‚ 4
10. At this program I get the kind of information that I need. 1‚ 2‚ 3‚ 4
11. At this program I get information when I need it. 1‚ 2‚ 3‚ 4
12. In general‚ I feel that program staff actively promote my human rights. By human rights‚ I mean my rights to freedom of speech or access to legal representation‚ or my rights as a mental health consumer. 1‚ 2‚ 3‚ 4
13. I feel program staff are respectful of my racial or ethnic background. 1‚ 2‚ 3‚ 4
14. I feel program members are respectful of my racial or ethnic background. 1‚ 2‚ 3‚ 4
15. I feel program staff are respectful of my sexual orientation. 1‚ 2‚ 3‚ 4
16. I feel program members are respectful of my sexual orientation. 1‚ 2‚ 3‚ 4
17. I feel program staff are respectful of my gender. 1‚ 2‚ 3‚ 4
18. I feel program members are respectful of my gender. 1‚ 2‚ 3‚ 4
19. I feel program staff respect my wishes regarding the confidentiality of my personal information. 1‚ 2‚ 3‚ 4
20. In general‚ program staff are competent. 1‚ 2‚ 3‚ 4
21. I feel that program staff ignore my individual problems. *** (R) 4‚ 3‚ 2‚ 1
22. I feel safe talking about personal matters with program staff. 1‚ 2‚ 3‚ 4
23. In general‚ members and staff do not get along with each other at this program. (R) 4‚ 3‚ 2‚ 1
24. In general‚ members at this program are considerate. 1‚ 2‚ 3‚ 4
25. I would recommend this program to other mental health consumers. 1‚ 2‚ 3‚ 4
26. I am able to accept criticism about myself from program staff. 1‚ 2‚ 3‚ 4
27. I feel that program staff are able to see me as a person who has strengths 1‚ 2‚ 3‚ 4
28. I feel that there are few power struggles between members and program staff in this program. (R) 4‚ 3‚ 2‚ 1
29. I feel that program staff focus on my real‚ concrete needs. 1‚ 2‚ 3‚ 4
30. I feel comfortable voicing my positive opinions of this program. 1‚ 2‚ 3‚ 4
31. I feel comfortable voicing my negative opinions of this program. 1‚ 2‚ 3‚ 4
32. This program helps me become knowledgeable about mental health issues.1‚ 2‚ 3‚ 4
33. This peer support program is making a positive difference in how I feel about myself as a person. 1‚ 2‚ 3‚ 4
34. This program helps me cope if I have an emotional crisis. 1‚ 2‚ 3‚ 4
35. This program helps me become self-sufficient in my life. 1‚ 2‚ 3‚ 4
36. Participation at this peer support program is making a positive difference in my social life. 1‚ 2‚ 3‚ 4
37. I feel comfortable socializing with members of this peer support program. 1‚ 2‚ 3‚ 4
38. I feel that I do not have to hide my diagnosis of mental illness from members of this program. 1‚ 2‚ 3‚ 4
39. I can turn to program members at this peer support program if I need help in doing things‚ such as moving‚ getting a ride‚ baby sitting‚ or organizing a party for someone. 1‚ 2‚ 3‚ 4
40. I get the emotional support that I need from members in this program. 1‚ 2‚ 3‚ 4
Coercion Scale (J. Campbell; V. Wieselthier; K. Einspahr‚ & R. Evenson)
The following items relate to your experience of coercion within the mental health programs you attend. Please indicate how often you feel this way.
[Hand respondent response card 31]
1= Always‚ 2= Most of the Time‚ 3= Some of the Time‚ 4= Rarely‚ 5= Never
41. I feel pressured by staff to do what they want me to do. 1‚ 2‚ 3‚ 4‚ 5
42. I feel like staff will get back at me if I do not do what they want me to do. 1‚ 2‚ 3‚ 4‚ 5
43. I have to butter up to staff to get what I want. 1‚ 2‚ 3‚ 4‚ 5
44. I have to butter up to staff to get what I need. 1‚ 2‚ 3‚ 4‚ 5
45. I have to do something staff wants to get something I want. 1‚ 2‚ 3‚ 4‚ 5
46. Staff threatens me with the loss of my housing. 1‚ 2‚ 3‚ 4‚ 5
47. Staff threatens me with the loss of my spending money. 1‚ 2‚ 3‚ 4‚ 5
48. Staff threatens me with hospitalization. 1‚ 2‚ 3‚ 4‚ 5
49. Staff threatens to make me take medication I do not want. 1‚ 2‚ 3‚ 4‚ 5
50. Staff threatens me in other ways. 1‚ 2‚ 3‚ 4‚ 5
****************
Conclusion
Thank you very much for completing this questionnaire. Your input is very important in developing the final questionnaire. We want to make it as useful to peer support programs as possible.
1. We’ve covered a lot of ground‚ are there any thoughts or issues that you’d like to talk about?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
[INTERVIEWER: Record the time here that the interview ends and remember to record the end time on the cover page.]
End Time ____________
Scale (Internal Consistency ‚ Two week Test-Retest)
Employment Satisfaction (alpha= .71‚ r= .47)‚
Community Satisfaction (alpha= .72‚ r= .73)
Social Satisfaction (alpha= .76‚ r= .54)
Social Acceptance (alpha .93‚ r= .66)
Health (alpha .85‚ r= .88)
Quality of Life (alpha .74‚ r= .63)
Personhood (alpha .83‚ r= .73)
Empowerment (alpha .89‚ r= .63)
Recovery (alpha .86‚ r= .61)
Program Quality of Life (alpha .88‚ r= .72)
Program Satisfaction (alpha .95‚ r= .78)
Felt Coercion (alpha .83‚ r= .85)
This instrument can be found at: https://www.power2u.org/downloads/pn-55.pdf

Campbell‚ J.‚ Cook‚ J.‚ Jonikas‚ J.‚ & Einspahr‚ K. (2004a). Peer outcomes protocol questionnaire. Chicago‚ IL: University of Illinois at Chicago. Campbell‚ J.‚ Cook‚ J.‚ Jonikas‚ J.‚ & Einspahr‚ K. (2004b). Peer outcomes protocol (POP): Administration manual. Chicago‚ IL: University of Illinois at Chicago.

Campbell‚ J.‚ Einspahr‚ K.‚ Evenson‚ R.‚ & Adkins‚ R. (2004). Peer outcomes protocol (POP): Psychometric properties of the POP. Chicago‚ IL: University of Illinois at Chicago.

Cambell‚ J. and Schraiber‚ R. (1989). The Well-Being Project: Mental health clients speak for themselves. Sacramento‚ CA: California Department of Mental Health.