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Journal of Human Behavior in the Social Environment

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Trauma informed care with military populations

Joseph R. Herzog, James D. Whitworth & Diane L. Scott

To cite this article: Joseph R. Herzog, James D. Whitworth & Diane L. Scott (2020) Trauma informed care with military populations, Journal of Human Behavior in the Social Environment, 30:3, 265-278, DOI: 10.1080/10911359.2019.1679693

To link to this article: https://doi.org/10.1080/10911359.2019.1679693

Published online: 09 Dec 2019.

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Trauma informed care with military populations Joseph R. Herzoga, James D. Whitworthb, and Diane L. Scotta

aDepartment of Social Work, University of West Florida, Pensacola, Florida, USA; bSchool of Social Work, University of Central Florida, Orlando, Florida, USA

ABSTRACT Many of the most challenging issues military members and their families are facing are trauma related. Agencies and treatment providers work- ing with military members and their families should be able to recognize and respond to symptoms based on a trauma informed care perspec- tive. This article describes frequent trauma responses found in this population and how to assess these reactions. It explores and endorses a Trauma-informed care treatment framework for understanding and intervening with military-connected clients that centrally emphasizes

individual, family, and systems strengths, adaptation, and resiliency and that is built on the five essential care principles of safety, trust- worthiness, choice, collaboration, and empowerment. The article further highlights research-supported, adjunctive, and alternative trauma- informed clinical interventions for members, veterans, and their families along with providing guidance on how to adjust these approaches for these clients.

KEYWORDS Veterans; mental health; military; trauma-informed care; military families

Introduction

The impact of trauma in the lives of individuals is of increasing focus for treatment providers and social service agencies. Individuals and families often present with many different types of trauma, this is especially true for military populations. Without a framework of trauma-informed care, mental health symptoms may be misinterpreted. Furthermore, agencies and mental health providers without a knowledge base of trauma- informed care may re-traumatize their clients or exacerbate the client’s current symptoms (Dinnen, Kane, & Cook, 2014; Guarino, Beach, & Clervil, 2014). To better serve indivi- duals and families with trauma histories, agencies and mental health providers should take a Trauma-informed care (TIC) approach to working with military populations. Trauma- informed care can be conceptualized as the contextual framework in which trauma- impacted individuals are treated. The Substance Abuse and Mental Health Services Administration (SAMHSA, 2014a, p.9) describes four key assumptions of TIC for orga- nizations or systems. The first assumption is the basic realization that trauma impacts individuals, families, groups, organizations, and communities. The second assumption is the need to recognize the signs and symptoms of trauma. The third assumption is a trauma-informed response to functioning. The last assumption is the resistance of re-traumatizing clients.

CONTACT Joseph R. Herzog [email protected] University of West Florida, Orlando, FL

JOURNAL OF HUMAN BEHAVIOR IN THE SOCIAL ENVIRONMENT 2020, VOL. 30, NO. 3, 265–278 https://doi.org/10.1080/10911359.2019.1679693

© 2019 Taylor & Francis Group LLC

Substance Abuse and Mental Health Services Administration (SAMHSA, 2014a) concep- tualizes trauma as having three components including an event containing actual or threa- tened extreme psychological or physical harm, the experience of these events, and the lasting effects of the event. Trauma is further described in the DSM-5 (American Psychiatric Association, 2013) for individuals who are both directly and indirectly impacted by a traumatic event. The direct impact of trauma includes individuals experiencing or witnes- sing a traumatic event. Those indirectly impacted by a traumatic event include individuals who have either learned of a traumatic event that has impacted a close friend or family member, or for those who have repeated or extreme exposure to the details of a traumatic situation. Symptoms of trauma in the DSM-5 include the following categories: intrusion, avoidance, negative mood and cognitive alterations, arousal and reactivity. Veteran exposure to trauma has been associated with mental health diagnosis such as PTSD, depression, and substance abuse (Tanielan, Batka, & Meredith, 2017), and with status such as homelessness and justice involvement (Dinnen et al., 2014; Greenberg, Rosenheck, & Desai, 2007; Guarino et al., 2014; Saxton et al., 2001).

Literature review/theory

Military connected spouses and family members may not be directly involved in the service mission of their active duty or veteran, but they are frequently impacted by it both directly and indirectly through the military connected member and military lifestyle (Scott, Whitworth, & Herzog, 2017). A key factor in how the family and military member cope with their experiences and possible related trauma are their existing coping skills and resiliency. Many of the military members, veterans, and their families emerge from some of their adverse experiences with new skills, increased autonomy and growth as they build upon their existing strengths. Clinicians can help to support and foster resiliency in individuals and families with good coping skills by helping them to stay prepared. However, for those military connected individuals whose prior trauma and repeated trauma may overwhelm them and negatively impact aspects of their functioning, clinicians should consider a trauma informed approach.

Military trauma response

Military members and veterans are at a higher risk than the overall U.S. population who experience trauma-related responses such as acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) (U.S. Department of Veterans Affairs, 2019). PTSD continues to be one of the most frequent mental health conditions experienced by military veterans (Kok, Herrell, Thomas, & Hoge, 2012; Seal, Bertenthal, Miner, Sen, & Marmar, 2007; U.S. Department of Veterans Affairs, 2019). Most researchers estimate that between 13.5% and 30% of veterans experience some level of PTSD symptoms depending on the service era, conflict(s) involved in their military service and the type of trauma that they experienced (Eber et al., 2013; U.S. Department of Veterans Affairs, 2018). Furthermore, veterans receiving care at the Veterans Administration have reported military sexual trauma at rates of over 35 percent for women and over 2 percent for men (Valdez et al., 2011).

Military members and veterans can be exposed to traumatic experiences such as being in combat, witnessing other service members die or be severely injured, handling the

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bodies of deceased service members, treating medically injured patients, experiencing military sexual trauma, or being present in a dangerous deployment setting. These experiences can be perceived as highly traumatic (triggering) events that meet the first criterion required for being diagnosed with ASD or PTSD as “exposure to actual or threatened death, serious injury, or sexual violation.” (American Psychiatric Association, 2013, p. 271). Military members can understandably perceive these events as threats to their survival and physical integrity not only for themselves but also for those that they care about or feel responsible for. When confronted with any one of these threats, the human stress reaction in military members begins with activating the sympathetic response in their autonomic nervous system (ANS) which is more commonly known as the “Flight vs. Fight vs. Freeze response” or the “Alarm Stage.” This response can help the member address and defend themselves from the actual or perceived threat (Scott et al., 2017). Exposure to such threats can affect the member’s long-term capacity to control the ANS response to future perceived threats (Kelly, Boyd, Valente, & Czekanski, 2014). Repeated and more extreme activation of the ANS can persist long after the threat event has passed making the member hyper-responsive to future threatening situations leading to development of ASD or PTSD (Kelly et al., 2014; Sherin & Nemeroff, 2011). ASD and PTSD symptoms consist of reexperiencing, avoidance, negative thoughts or feelings, and arousal/reactivity (American Psychiatric Association, 2013). ASD is consid- ered to be the appropriate diagnosis for individuals experiencing these symptoms during the first 30 days after the traumatic event(s) with PTSD being the diagnosis for those with these responses after that time frame (American Psychiatric Association, 2013). Military members and veterans with PTSD will frequently experience more elevated ANS responses compared to civilians with trauma exposure (Park et al., 2017; Seal et al., 2007). They are at risk for having problems in their primary relationships, suicide, difficulties with employment, medical problems and legal difficulties, (Gates et al., 2012; Kok et al., 2012; Koven, 2016). Military members and veterans with military-related PTSD frequently describe missing the elevated ANS arousal feelings that became their “new normal” during deployments with some of them pursuing risk taking behaviors as a way of maintaining higher levels of autonomic arousal (Hoge, 2011). Some military members and veterans are attracted to or desire to return to deployment settings where they felt more comfortable in their persistently elevated ANS state. Many also experience extreme feelings of guilt, grief, and shame with some believing they could have done more to deal with deployment-related stress or prevent harm to other military members or themselves (Cunningham, Davis, Wilson, & Resick, 2018).

Trauma symptoms can impact not only the service member or veteran but also their family members. This often takes the form of secondary trauma. Secondary traumatic stress are the stress symptoms that may develop in close friends and family members of someone who has experienced a traumatic event. Research indicates evidence of secondary trauma in children (Del Valle & Avelo, 1996; Herzog, Everson, & Whitworth, 2011; Rosenheck & Nathan, 1985), adolescents (Herzog, Flemming, Ferdik, & Durkin, 2016), and spouses (Dekel, Solomon, & Bleich, 2005; Dirkzwager, Bramsen, Ader, & van der Ploeg, 2005). Therapists and agencies working with military populations should be aware of the secondary impact trauma has on families.

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Assessment

The starting point when assessing for trauma is to determine if an individual has been exposed to a traumatic situation. The Brief Trauma Questionnaire (BTQ) (Schnurr, Vielhauer, Weathers, & Findler, 1999) does just that in assessing a client’s exposure to a traumatic incident through 10 self-reported items. The BTQ can be utilized to determine if a person meets criterion A from the DSM-5. Another scale that measures traumatic exposure is the Life Events Checklist for DSM-5 (Weathers et al., 2013). This 17-item scale is more encompassing than the BTQ, however it does not report a score for exposure. The Life Stressor Checklist – Revised (LSC-R) (Wolfe, Kimerling, Brown, Chestman, & Levin, 1996) is a 30 item scale with 5 sub-items for each item. The LCS-R contains questions about age at both the beginning and ending of the traumatic event, feelings of help- lessness, and if they believed they might be harmed during the incident. Rather than general traumatic situations, the Combat Exposure Scale (Keane et al., 1989) specifically measures a person’s traumatic experiences in combat. It is a 7-item scale that categorizes a person’s exposure to combat on a scale from light to moderate to heavy.

Once it has been determined that an individual has been exposed to a traumatic event, then there are a number of scales to determine the psychological consequences of this event. One such instrument often used with trauma survivors is the PTSD Checklist for DSM-5 (PCL-5) (Wortmann et al., 2016). This is a 20 item self-report scale that can be used for screening, making a provisional diagnosis, or monitoring changes in PTSD symptoms. The PCL-5 has a cut-point score of 33 suggesting probable PTSD. The Clinician-Administered PTSD Scale for DSM-5 (CAP-5) (Weathers et al., 2018) can be used to further determine PTSD levels. To administer this scale the clinician interviews the client using a set of manualized questions to determine PTSD severity including onset, distress, and impact of symptoms. This scale can take over 40 minutes to complete.

PTSD is not the only psychological outcome for trauma survivors. It is not uncommon for trauma survivors to also experience anxiety, depression and other psychological symptoms. One way to more fully assess mental health is to use the Adult Behavior Checklist (ABCL) (Achenbach & Rescorla, 2003). The ABCL can be used to determine adaptive functioning and problems for adults between the ages of 18 and 59. It broadly gauges internal and external functioning as well as substance use. The ABCL contains 118 items and there is a monetary cost for the scale. While the ABCL measures anxiety and depression, there are also several shorter scales for measuring depression and anxiety that may be a result of a traumatic experience. One of the more established measures is the Hamilton Depression Rating Scale (HAM-D) (Hamilton, 1960). The HAM-D is scored based on 17 items and indicates the severity of depression in an individual. A still shorter depression scale is the Patient Health Questionnaire – 9 (PHQ-9) (Kroenke, Spitzer, & Williams, 2001). The PHQ-9 is a nine-item scale that measure the severity of depression and can aid in the diagnosis of depression.

When conducting an assessment with a veteran or their family, it is important to remember that they may have experienced trauma before, during, and after military service. One measure that assesses childhood trauma is the Adverse Childhood Experiences questionnaire (Felitti et al., 1998). This questionnaire is composed of 10 items that measures abuse, neglect, and household dysfunction in childhood. Having multiple adverse childhood experiences (ACEs) has been associated with poorer health

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and mental health outcomes (Hughes et al., 2017). Furthermore, there is evidence that that service members who experience multiple types of ACEs are at increased risk for PTSD (LeardMann, Smith, & Ryan, 2010).

One scale to measure these symptoms in close friends or family members of trauma survivors is the Secondary Trauma Questionnaire (Motta, Kefer, Hertz, & Hafeez, 1999). This 20-item scale was developed to measure secondary trauma symptoms in non- clinician populations. Motta et al. further developed this tool in the Secondary Trauma Scale (STS) (Motta, Chirichella, Maus, & Lombardo, 2004). The STS is an 18-item scale and gives a cutoff score of 45 to indicate emotional distress. These scales should not be confused with the Secondary Traumatic Stress Scale (Bride, Yegidis, & Figley, 2004) which is aimed at measuring symptoms in helping professionals.

The Traumatic Events Screening Inventory for Children (TES-C) (Ippen et al., 2002) measures children’s experiences of traumatic events. It is 24 items in length and is written on a 5th grade level. It can also be given as a semi-structured interview. Another helpful scale to use with children who may have experienced trauma is the Trauma Play Scale (TPS) (Findling, Bratton, & Henson, 2006). This TPS is able to discriminate children who have experienced trauma from those who have not (Myers, Bratton, & Hagen, 2011). TPS is tool based on the observation of children’s play therapy sessions and is composed of intense play, repetitive play, play disruptions, and avoidant play behavior domains.

Treatment

Formulating a TIC treatment framework

TIC treatment responses are part of an overall framework of understanding and helping those impacted by trauma that emphasizes individual, family, and systems strengths, adaptation, and resiliency over deficits, maladaptation, or pathology (Substance Abuse and Mental Health Services Administration [SAMHSA], 2014b). TIC treatments encom- pass the last two of the Four R’s of Trauma-Informed Care: respond appropriately and resilience through skill-building (Elliott, Bjelajac, Fallot, Markoff, & Reed, 2005). They include specific clinical interventions for military members, veterans, and their families who present with ASD or PTSD. These treatment responses are more frequently being framed as trauma-specific services that are part of a broader TIC agenda where entire organizations address their culture, structure, values, and operations based on a new understanding of how trauma impacts military-connected populations (DeCandia, Guarino, & Clervil, 2014; Guarino et al., 2014).

Providing TIC interventions to these clients in any setting initially requires providers and their staff member to be aware and sensitive to how they interact with their clients throughout their interactions not just during clinical sessions (Currier, Stefurak, Carroll, & Shatto, 2017). This comprises providing military-connected clients with privacy for completing intake and assessment forms that ask them to describe their mental health needs or trauma history and removing undue noise sounds or noise from the clinical setting (Currier et al., 2017; SAMHSA, 2014b). Allowing these clients to choose where they want to sit before/during sessions is another way to adjust clinical practice for these clients.

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Providers of clinical interventions for trauma-impacted military-connected clients can deliver their treatments with five essential TIC care principles in mind: (1) safety, (2) trustworthiness, (3) choice, (4), collaboration, and (5) empowerment (Bloom & Farragher, 2013; Currier et al., 2017). They can help create a treatment environment where veterans and military member perceive that they are physically and emotional safe by employing rather simple logistical and procedural practices. Some of these practices include getting the client’s consent for nearly every intervention process but especially before doing anything that might unnecessarily trigger a threat response such as closing doors in therapy settings, doing relaxation exercises that entails closing their eyes, and avoiding paperwork that requires them to repeatedly recount traumatic events (Bloom & Farragher, 2013; Currier et al., 2017; SAMHSA, 2014b). Providers can help foster the trustworthiness of military-connected clients by first acknowledging that such trust needs to be earned. They can help build this trust through actions they take throughout the entirety of the client’s intervention experience such as using clear/transparent/honest communication, avoiding standardized “one size fits all” treatment goals, and vague-sounding treatment language that can frustrate these clients (SAMHSA, 2014b). Choice and collaboration can be fostered in treatment by knowing their client’s personal preferences, understanding their military cultural perceptions and expectations, and modifying standardized research- based interventions based on the client’s current emotional abilities and readiness (Currier et al., 2017). Such clinical judgment is needed for all clients, but may be particularly indicated for veterans and military members who feel that they need to stay in some state of ANS arousal to be prepared for future deployments or job requirements. Treatment providers can empower these clients by encouraging them to advocate for themselves with multiple systems, but especially in advocating for their benefits and services from the Veterans Administration (Currier et al., 2017).

Role of psychoeducation

Military members, veterans, and their families will often not understand the true sources and etiology of the trauma symptoms that they are experiencing. They may blame themselves, others, and triggering settings, or see themselves as weak/flawed for the difficulties that they are experiencing. Conducting appropriately timed psychoeducation that explains the client’s responses as part of the ANS can greatly help these clients understand the connections between their traumatic experience(s) and these symptoms which can sometimes be quite transformative and healing (Machtinger, Cuca, Khanna, Rose, & Kimberg, 2015; Whitworth, 2016). When this psychoeducation is done in a military-culturally-sensitive, human-centered, and relationship-focused manner it has been found to help these clients building resiliency as they respond to their trauma experience(s) (Whitworth, 2016).

Evidence-based treatments

Two cognitive-behavioral interventions, prolonged exposure (PE) and cognitive proces- sing therapy (CPT) have each been extensively examined for use with military connected clients with PTSD (Department of Veterans Affairs, 2010; Karlin et al., 2010; Peterson, Foa, & Riggs, 2011; Schnurr et al., 2007; SAMHSA, 2014b). Eye movement desensitization

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reprocessing (EMDR) has also been found to be quite helpful for treating PTSD with these clients (Russell, Lipke, & Figley, 2011). PE, CPT, and EMDR have all been endorsed and promoted by both the VA and the Department of Defense (DoD) for treating trauma conditions present in military members and veterans (Department of Veterans Affairs, 2010). Even though these evidence-based treatments can be potentially quite helpful for military-connected clients with trauma, they should only be initiated by trained and experienced clinicians and only when the client is ready for such interventions. Clients with imminent threat of suicidal or homicidal behavior, serious self-injurious behavior, existing psychosis, or current high risk of being assaulted need to have these issues addressed first and should be stabilized before consideration of these interventions (Department of Veterans Affairs, 2010; Foa, Hembree, & Rothbaum, 2007).

PE treatment is grounded in emotional processing theory that assumes individuals who have experienced trauma need to emotionally process their traumatic experience(s) in order to reduce their trauma-related responses/symptoms (Foa et al., 2007). Such proces- sing can take place somewhat naturally for some as they address the trauma by talking with supportive others, repeatedly thinking about the trauma, and accepting that they and those they care about are safe and are no longer in the presence of threat(s). PE seeks to help those who are not able to process the trauma though more natural means by helping them confront or expose themselves to these experiences and other triggering situations through in vivo and imaginal exposure. All participants in PE, CPT, and EMDR are first provided with psychoeducation to begin to normalize what they are experiencing by helping them understand how trauma has impacted their ANS and their subsequent functioning. PE participants are taught and practice relaxation breathing and mindfulness exercises as they learn to monitor and manage their level of ANS arousal/distress by recurrently using the Systematic Units of Distress Scale (SUDS) (Peterson et al., 2011). In vivo exposure requires the client to directly expose themselves to settings and people that they have been fearfully avoiding. Imaginal exposure comprises of the client repeatedly recounting what they remember about their traumatic event(s) (Peterson et al., 2011).

CPT also incorporates some exposure therapy components, but it most centrally requires clients to addresses avoidance by helping them confront common trauma-related cognitive distortions (Monson et al., 2006; Resick & Schnicke, 1992). For military members and veterans with PTSD this involves them addressing and exploring the altering of commonly experienced deployment and post-deployment cognitive distortions by working with the clinician to review, question, and replace thoughts with functional and fact-based ways of thinking. The client can then potentially better comprehend the meaning of the traumatic event(s) through this process (Williams, Galovski, Kattar, & Resick, 2011).

EMDR can be an effective alternative research-based treatment for clients who are having extreme difficulty thinking or talking about their traumatic event(s) (Bisson & Andrew, 2007; Shapiro, 2009). This approach also encompasses some exposure and cognitive processing aspects. However, it most centrally comprises the client doing saccadic eye movements as they recall and focus on their traumatic event(s). These eye movements are rapid intermittent eye actions that can occur when the eyes fix on one point after another (Russell et al., 2011).

Other trauma-focused treatments that have been found to have solid efficacy for use with military and veteran populations with PTSD include specific cognitive behavioral therapies for PTSD, Brief Eclectic Psychotherapy (BEP), Narrative Exposure Therapy

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(NET), and written narrative exposure (Department of Veterans Affairs, 2010). Stress inoculation therapy (SIT), person-centered therapy (PCT) and interpersonal therapy (IPT) are each recommended as viable treatment options for clients who decline or do not have access to trauma-focused approaches (Department of Veterans Affairs, 2010). These clients may also consider concurrently or alternatively being treated with pharmacother- apy as directed by their medical provider.

Alternative and adjunctive treatments

Half or more of veterans and military members who would benefit from the research- based trauma treatments described above either resist starting these interventions or they stop participating them after a few sessions (DeViva et al., 2016; Goetter et al., 2015; Hoge et al., 2015). Alleged explanations for this opposition include the frequency and number of sessions required, veteran or military member avoidance in addressing their traumatic event(s), poor relationships with available mental health providers, perceived stigma when asking for help, and a desire to not be seen as “weak” by requesting help (Fragedakis & Toriello, 2014; Hoge et al., 2015; Hoyt & Candy, 2011). Alternative and adjunctive treatment approaches have emerged as ways to engage and help these clients. These approaches include but are not limited to: mind-body practices, acupuncture, mindful- ness, meditation, relaxation, yoga, animal-assisted therapies (i.e., equine therapy and service dog training), music/drama/art therapy, physical fitness–related therapies, prayer/meditation, recreational therapy and progressive muscle relaxation (Department of Veterans Affairs, 2010). Even though there is much interest in many of these approaches, currently there is only initial research efficacy to support some of them (Department of Veterans Affairs, 2010).

Family-focused treatments/interventions

As described earlier, the spouses, partners, and children of veterans and military members who have PTSD can frequently experience secondary traumatic symptoms. Despite the important implications of these difficulties, family-focused interventions have only slowly been endorsed or utilized within the VA or DoD treatment settings (MacDermid Wadsworth et al., 2013). Of the treatment approaches that have been most researched and endorsed, emotionally focused couples therapy (EFT), Families Overcoming Under Stress (FOCUS) and solution-focused therapy (SFT) have emerged as highly promising ways to support and treat family systems impacted by military-related trauma (Everson & Figley, 2010; Lester et al., 2016, 2011; Saltzman, Lester, Milburn, Woodward, & Stein, 2016; Weiss, Coll, Gerbauer, Smiley, & Carillo, 2010; Weissman et al., 2018).

EFT could be particularly well-suited for military couples dealing with the impacts of PTSD because it addresses and seeks to rebuild the relationship bond between partners (Everson & Figley, 2010; Weissman et al., 2018). This approach is based on Bowlby’s attachment theory and the subsequent premise that the single greatest predictor of the ability to recover from human trauma is the ability to derive comfort from another human being (Bowlby, 1969; Weissman et al., 2018). It addresses the negative interaction style that often happens in military-connected relationships impacted by trauma where one partner, usually the one with primary PTSD, is avoiding emotional connection while the

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other is pursuing beliefs that their partner has stopped caring for them. The EFT therapist works within the relationship dynamic by fostering therapeutic encounters to help the partners emotionally reconnect and to help them reframe the negative interactional cycle as a normative response to very abnormal traumatic experiences (Everson & Figley, 2010).

FOCUS is a family-centered narrative-focused intervention designed and researched specifically for military and veteran families that builds on several primary concepts of attachment theory and EFT (Lester et al., 2011). FOCUS was developed by researchers and practitioners at the University of California, Los Angeles and Harvard Medical School and has been implemented online and at U.S. military installations throughout the world (Lester et al., 2011). It initially includes psychoeducation for the family system about the impacts of deployments and trauma along with teaching family members to use emotional regulation skills, goal setting, and joint problem solving skills (Lester et al., 2011). A core component of FOCUS centers on helping partners and/or families members to suppor- tively and sensitively communicate about how military deployments and traumatic experi- ences have affected them individually and as a family. To the degree that that they are able, each family member provides their own narrative story about these experiences and their impacts which are placed on a timeline. These narrative stories are then shared in planned and structured family sessions usually with the aid of a facilitator (Lester et al., 2011). Analysis of longitudinal program evaluation data from FOCUS indicate that this approach can help reduce psychological health risk symptoms and increase indicators of resilience in children participating in these programs (Lester et al., 2016). Parents who were feeling distressed due to the impacts of military experiences electively sustained their participa- tion in FOCUS programs and they reported reduced distress along with improvements in resilient family processes (Saltzman et al., 2016).

SFT with military and veteran families emphasizes systemic, family, and individual resilience and strengths. It seeks to help partners and family members redefine their current difficulties to find solutions as opposed to focusing on current and past problems. SFT therapists seek to help family members focus on what is working in the relationships. This treatment approach may be expressly helpful for partners and families who are having trouble benefiting from more traditional couple or family approaches and it may be more consistent with military cultural values that emphasize achieving positive out- comes versus extended processes (Tews-Kozlowski, 2012). SFT therapists work with the family or partner system to help them formulate collaborative concrete and often small goals that reflect specific tangible needs that they want to meet and what they would like their relationships to become. They also pay special attention to small or simple solutions that emerge from the family along with exceptions to the presenting problems. Some SFT therapists have successfully employed the use of genograms to help military or veterans families identify these exceptions and solutions (Weiss et al., 2010).

An effective way to treat children and adolescents who have experienced crisis and trauma is through play therapy (Webb, 2015). Play is the central component of play therapy and is used both for assessment and treatment. Play therapy can be used with children, adolescents, or adults individually, in dyads, families, or in groups. Play therapy can be either directed or non-directed. Typically, play therapists have a dedicated kit consisting of manipulatives, art supplies, a sand tray, as well as other play items. Play therapists working with military families and children should have military related items such as airplanes, helicopters, trucks, ships, and items related to

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military life. Filial play therapy has been suggested for use with military families (Herzog, Everson, & Taylor, 2015). Packman, Paone, LeBeauf, Smaby, & Lepkowski (2006). One such evidenced based filial play therapy intervention to use with military families is Child Parent Relationship Therapy (CPRT) (Landreth & Bratton, 2006). CPRT consists of 10 group and structured play therapy sessions that teach basic child-centered play therapy skills. This intervention was found to increase a sense of proactive parenting efficacy while decrease emotional and behavioral concerns (Jensen-Hart, Christensen, Dutka, & Leishman, 2012).

Conclusion

Military members, veterans, and their families can experience primary and secondary trauma responses due to a number of real and potential threats. Practitioners who engage with, treat, and support military populations can optimally help these clients by first understanding the primary factors underlying military trauma responses for this popula- tion. This article describes valid and reliable and tools to use for identifying and assessing potential trauma responses with military-connected clients. It endorses and defines the formulation of a TIC treatment framework for helping those impacted by trauma which highlights individual, family, and systems strengths, adaptation, and resiliency and that is built on the five essential TIC care principles of safety, trustworthiness, choice, collabora- tion, and empowerment. Specific research-supported, adjunctive, and alternative clinical interventions are also outlined along with guidance on how to adjust these approaches for military members, veterans, and their families.

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