6210 Week 3 Discussion 1 & 2
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6210WeekFamily-focusedinterventionsandresourcesforveteransandtheirfamilies.pdf
Family-Focused Interventions and Resources for Veterans and Their Families
Michelle D. Sherman University of Minnesota–Twin Cities
Jessica L. Larsen Lukin Center for Psychotherapy, Hoboken, New Jersey
Accelerated by the decreasing military presence in Iraq and Afghanistan, many military members are currently transitioning out of active duty into civilian life. Many of these new veterans have recently experienced combat deployment(s), and some are struggling with the aftermath of combat exposure, separation from family, and reintegration stressors. These challenges often follow these military families as they enter the civilian world, a time with its own major life changes vocationally, socially, and interpersonally. Although numerous resources have been developed to assist service members during their transition to the civilian world, relatively fewer exist for partners, children, and broader family systems. Family psychoeducation is a nonpathologizing, strengths-focused model of care that has documented benefits in the arena of mental illness. This article describes some manualized family psychoeducational programs and online and phone-based resources that may be useful to veteran families during this time of change. The programs and resources described herein are all available for free, primarily online. Because of a wide variety of barriers and limitations for family based care in the Veterans Affairs health care system, veteran families are and will continue to seek mental health care in public sector settings. Community providers can enhance their military culture competence by familiarizing themselves with these resources and drawing upon them in working with transitioning military families.
Keywords: family psychoeducation, veterans, military, transition, interventions
Increasing numbers of military members are transitioning out of active duty service into civilian life. These transitions are largely due to a 2016 Pentagon initiative to reduce the size of the military in response to a decreased presence in Iraq and Afghanistan (Tice, 2016), as well as normal changeover in an all-volunteer force. Military members and families face a variety of challenges when exiting the military, from meeting basic housing and welfare needs to securing employment and health care. Although all military personnel receive a standard transition assistance program, the needs of military family members, including partners and children, are often not formally addressed by the military during the tran- sition period. This article focuses on the unique challenges that families face during the transition from the military and explains how civilian providers are well situated to meet these needs. After describing four provider trainings to strengthen knowledge about military culture, we summarize four manualized interventions and six phone-based/online resources that providers can employ in working with transitioning veterans and their families.
Military to Civilian Life Transition
The transition from the military into civilian life poses signifi- cant and predictable challenges for military families. Research directed on this time period is largely underdeveloped, and has primarily focused on the experience of military members during reintegration following combat deployments. Military members face challenges in numerous domains following their return from military deployments, including mental health, social and role functioning, relationship functioning and family life, spirituality, physical health, and financial well-being (Sherman, Larsen, & Borden, 2015). Despite what is known about reintegration chal- lenges, there is growing recognition of the need to better under- stand family challenges as they leave the military, a time period that can overlap with reintegration, but is often a distinct and separate time frame. Two independent reviews have articulated the possible needs of families transitioning out of the military (Insti- tute of Medicine, 2010; Søndergaard et al., 2015), highlighting interpersonal, psychosocial, and vocational challenges that fami- lies face during the transition.
Prior to focusing on family issues related to the transition from the military to civilian roles, it is important to acknowledge that many new veterans have recently experienced deployment(s) to Iraq and/or Afghanistan; the psychosocial and interpersonal issues during the reintegration process after combat deployments have been well documented. Deployment to Iraq and Afghanistan has been associated with increases in rates of posttraumatic stress disorder (PTSD; Fulton et al., 2015), depression (Bonde et al., 2016), substance abuse (Jacobson et al., 2008), and risk-taking behaviors (Adler, Britt, Castro, McGurk, & Bliese, 2011). Deploy-
Michelle D. Sherman, Department of Family Medicine and Community Health, University of Minnesota–Twin Cities; Jessica L. Larsen, Lukin Center for Psychotherapy, Hoboken, New Jersey.
Correspondence concerning this article should be addressed to Michelle D. Sherman, Department of Family Medicine and Community Health, University of Minnesota–Twin Cities, 420 Delaware Street SE, MMC 381, Minneapolis, MN 55455. E-mail: [email protected]
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Psychological Services © 2018 American Psychological Association 2018, Vol. 15, No. 2, 146 –153 1541-1559/18/$12.00 http://dx.doi.org/10.1037/ser0000174
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ments have been shown to have a cascade effect on the family members. Research on active duty military families has shown that war deployments have been associated with increased mental health problems in partners (Mansfield et al., 2010), child emo- tional and behavioral problems (Chartrand, Frank, White, & Shope, 2008; Mansfield et al., 2011), alcohol use (Lipari, Forsyth, Bose, Kroutil, & Lane, 2016), child maltreatment (Rentz et al., 2007), intimate partner violence (Taft et al., 2009), and marital instability (Cohen & Segal, 2009). Further, there is a strong link between PTSD symptoms and relationship distress in military couples (Campbell & Renshaw, 2013). In particular, PTSD symp- toms are associated with poorer communication, lower intimacy, and frequent parenting disagreements for service members and partners (Dekel & Monson, 2010). Importantly, the sequelae of mental health problems associated with combat deployments often follow post-911 military families as they enter the civilian world (Sayer et al., 2010).
The transition out of the military poses several of its own unique challenges which contribute to overall family stress and likely compound preexisting issues. Military life affords many tangible family benefits, including access to stable income, housing, em- ployment, and basic necessities. Programs to protect families from financial distress, such as emergency relief loans, are available to active duty families who encounter unexpected hardships. Despite programs to assist veterans in making the military to civilian transition, such as the Transition Assistance Program (Faurer, Rogers-Brodersen, & Bailie, 2014), many veterans struggle as they make the transition and lose access to these and many other military specific resources (Schnurr, Lunney, Sengupta, & Spiro, 2005). A loss of stable income may pose financial problems for families (Tsai, Pietrzak, & Rosenheck, 2013; Widome, Jensen, Bangerter, & Fu, 2015). In addition to basic needs, social needs may also be negatively impacted during the transition. As families move away from the supportive military social networks to pursue civilian employment or education, the adjustments to the new environment can be difficult (Elliott, Gonzalez, & Larsen, 2011). Mental health challenges can also arise after separation from active military service as families adjust their identities to being civilians (Orazem et al., 2016).
Military partners face their own unique vocational challenges during a service member’s transition out of the military. Military service itself has been shown to limit spouses’ employment (His- nanick & Little, 2015), likely due to the demands of military life, frequent moves, and increased domestic demands during deploy- ments. As families transition out of the military, transition support services are focused primarily on service members directly, and fewer supports are available for military spouses (Sherman, Hawkey, et al., 2015). Further, military spouses lose access to health care and childcare resources as the family makes the tran- sition. Together, these challenges likely contribute to significant family stress during the military to civilian transition. In sum, while research has historically focused on the needs of military service personnel during the military to civilian life transition, it is clear that military families also experience stress associated with the shift from the protections inherent in military life to the civilian community.
Given the challenges military families face during this transi- tion, community providers are well situated to be a vital support for military spouses, partners, and children as they leave the military for civilian communities. To facilitate this process, it is important for providers to familiarize themselves with military culture. Several organizations, including the Department of Vet- erans Affairs, the Department of Defense, and the National Child Traumatic Stress Network, have developed tools for community providers to orient them to the special needs of military members (see Table 1). A recent compilation of military culture trainings and resources is available online (Gunty et al., 2016), but several tools that are especially focused on military families include:
The Department of Veterans Affairs Community Provider Toolkit
Recognizing the important role that community providers have in helping veterans, the Community Provider Toolkit links com- munity providers with relevant information and resources to foster veterans’ health and well-being. Information on screening for military service, handouts and trainings about military culture, and
Table 1 Military Culture Trainings and Resources for Providers
Name Description Website
The Department of Veterans Affairs Community Provider Toolkit
Website with handouts and information on trainings about military culture, veteran behavioral health, and wellness
www.mentalhealth.va.gov/communityproviders/
National Child Traumatic Stress Network’s (NCTSN) After Service Pamphlet
Pamphlet with information about the family experience of leaving the military, assessment considerations for clinicians, and family-based resources
www.nctsn.org/sites/default/files/assets/pdfs/veterans_families_final.pdf
VA Working With Couples Training
Free, 5-module online training that teaches clinicians basic skills in working with veteran couples
www.vacouplestherapy.org
Military Child Education Coalition’s Supporting Veterans’ Children Though Transitions
Day-long training for professionals who work with military children regarding challenges associated with family transitions
www.militarychild.org/professionals/supporting-veterans-children-through-transitions
Note. VA � Veterans Affairs.
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147INTERVENTIONS AND RESOURCES FOR VETERAN FAMILIES
trainings focused on behavioral health and wellness are available at http://www.mentalhealth.va.gov/communityproviders/.
National Child Traumatic Stress Network’s (NCTSN) After Service Pamphlet
NCTSN provides a useful pamphlet on military transition for families and children. The pamphlet includes a brief overview of the challenges of transition from military service, key assessment considerations for military families, and links to resources to help military families. The pamphlet is available at http://www.nctsn .org/sites/default/files/assets/pdfs/veterans_families_final.pdf.
Veterans Affairs Working With Couples Training
One particularly relevant resource is a free five-module online training created by Michelle Sherman and Michael Kauth. Funded by the Veterans Affairs (VA) South Central Mental Illness Re- search, Education and Clinical Center (MIRECC), the Working with Couples training teaches clinicians basic skills in working with veteran couples. Modules address communication problems, anger and conflict, mental illness, trauma, and reintegration into the family after deployment. This training is helpful for both VA and non-VA providers who work with veterans and their partners/ spouses. The free training is available at www.vacouplestherapy .org.
Military Child Education Coalition’s Supporting Veterans’ Children Though Transitions
The Military Child Education Coalition is a worldwide non- profit organization that provides services for military youth and parents and professional development opportunities for educa- tors and others who care for military youth. Their newest day-long professional training, Supporting Veterans’ Children though Transitions (http://www.militarychild.org/professionals/ supporting-veterans-children-through-transitions), specifically tar- gets the challenges associated with leaving the military.
Rationale for Family-Level Focus in Care
The Department of Defense and VA systems have created numerous programs to assist military personnel during the transi- tion period, but these large governmental bodies cannot bear the responsibility for the large scope of needs and issues across the broad range of geographic locations and diverse communities to which veterans and their families transition. The array of diverse programs to support military families is immense including, but not limited to, state and community-based organizations, large businesses, American Red Cross, Boys and Girls Club, 4-H pro- grams, colleges and universities, faith-based organizations, phil- anthropic groups, professional sports teams (e.g., Boston Red Sox), nonprofit groups, private foundations, and many more.
Although many of the programs focus on the service member/ veteran, some focus their supports to spouses/partners, offering resources in domains of employment, education, relocation, and mental health issues (Kuhl et al., 2015). Although separate pro- grams for each member of the family are important, the focus of this review is helping the entire family unit more broadly. Al-
though a few isolated family based models exist such as the Unified Behavioral Health Center for Military Veterans and Their Families in Long Island that provides services to all members of veteran families in an integrated-care facility, most programs do not take the larger family perspective in developing services.
The importance and benefits of engaging families in care of mental health concerns have been documented for decades (e.g., Leff, Kuipers, Berkowitz, & Sturgeon, 1985). One approach to working with families, family psychoeducation, holds consider- able potential for supporting military families as they transition to the civilian world. At its core, family psychoeducation values family members as collaborative team members in the treatment plan, offers education and support regarding psychiatric symptoms and their management, and teaches skills in communication, problem-solving, and stress management. Family psychoeducation has been included as a core component of psychosocial rehabili- tation and the recovery movement, with measurable benefits for clients, family members, and intimate relationships (Lucksted, McFarlane, Downing, & Dixon, 2012). Practice guidelines for some serious mental illnesses recommend family psychoeducation as a central component of comprehensive treatment. In sum, fam- ily psychoeducational models can be economical, feasible, effec- tive, and acceptable to families; as reviewed in detail subsequently, these approaches have the potential to be engaging and relevant for military families as they transition out of the military.
Psychoeducational Programs and Resources Focused on Military Families
Numerous programs and resources have been developed in the military and private sector to support military/veteran families across their military careers and beyond. The following two sec- tions describe several manualized programs and online resources that practitioners can use to support transitioning families; the programs and resources and corresponding websites are listed in Tables 2 and 3.
Manualized Programs
Programs vary in focus, intensity, target population, duration, local availability, and evidence base. In an attempt to make this review most helpful to practitioners supporting families during and shortly after the transition period, we used the following selection criteria for programs: (a) curriculum is readily available (online or published work), (b) program is not specifically focused on deployment-related stress and/or reintegration, and (c) program is not traditional psychotherapy. These criteria exclude some valu- able programs such as FOCUS (Families OverComing Under Stress) Family Resilience Training which is offered at limited locations and whose curriculum is not publicly available (Lester et al., 2012); ADAPT: After Deployment: Adaptive Parenting Tools (Gewirtz, Pinna, Hanson, & Brockberg, 2014); American Red Cross military family classes (http://www.redcross.org/about-us/ our-work/military-families) that focus on deployment, and more traditional couples therapy models for PTSD such as Cognitive- Behavioral Conjoint Therapy for PTSD (Monson & Fredman, 2012) and Structured Approach Therapy (Sautter, Glynn, Cretu, Senturk, & Vaught, 2015). The focus herein is on easily accessible family psychoeducational models that go beyond deficits to build- ing resilience and strengths.
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Four family psychoeducational programs met our inclusion cri- teria, three of which are facilitated by a mental health professional and one which is peer led. For each program, we describe program structure, logistics, available data, and websites for curricula and further information.
Support and Family Education (SAFE) Program. The SAFE Program (Sherman, 2003, 2006) is an 18-session manual- ized family education program to educate and support adults who care about a veteran living with mental illness or PTSD. It has been identified as a best practice in the VA health care system, and has been implemented in military and private sector settings across the county.
The program was originally created in 1999 at the Oklahoma City VA Medical Center with funding from the South Central
Mental Illness Education and Clinical Center and is in its third edition. Ninety-minute workshops are provided on a monthly basis and participants can attend whenever they wish. Each workshop has three sections: (a) group discussion/peer support, (b) a didactic presentation, and (c) a question and answer period with a psychi- atrist. Each session has a specific topic, such as “PTSD and Its Impact on the Family,” “Creating a Low-Stress Environment and Minimizing Crises,” and “Limit Setting and Boundaries with Fam- ily Members.” Detailed session outlines include ready-to-present text reviewing basic information on the session’s topic, group activities (e.g., role plays), discussion questions, suggested video clips, and session handouts.
Program evaluation efforts revealed very high levels of satis- faction, with families especially appreciated the opportunity to talk
Table 2 Manualized Family Education Curricula
Name Description Website
Support and Family Education (SAFE) Programa
18-session program for adults who care about someone living with mental illness or PTSD
www.ouhsc.edu/SAFEProgram
Operation Enduring Families (OEF) Five-session program for OEF/OIF veterans and family members focusing on post-deployment issues
www.ouhsc.edu/OEF
Reaching Out to Educate and Assist Healthy, Caring Families (REACH) Programa
Three-phase multi-family group program for veterans and their family members dealing with PTSD
www.ouhsc.edu/REACHProgram
NAMI’s Project Homefront Six-session peer-led program for adults whose veteran has experienced deployment and has a mental health condition
www.nami.org/Find-Support/NAMI-Programs/NAMI-Homefront
Note. PTSD � posttraumatic stress disorder; OIF � Operation Iraqi Freedom; NAMI � National Alliance on Mental Illness. a Has program evaluation data.
Table 3 Online and Phone Resources for Veteran Families
Name Description Website
Coaching Into Care Free phone-based coaching for veterans and family members to encourage help-seeking and connect families with local resources
www.mirecc.va.gov/coaching
PTSD Family Coach Smartphone App
Smartphone App with information about PTSD, self-care, communication tips, and counseling
Free download on iTunes
Make the Connection Website with brief videos of over 400 veterans and family members sharing their experiences with mental health problems
http://maketheconnection.net/
Sesame Street’s Transition Programa
Free, online, 12-module interactive program that supports military parents with young children as they leave the military
www.sesamestreet.org/toolkits/veterans
Parenting for Veterans and Service Members (Corresponding App is Parenting2Go)
Free, online 6-module interactive course and mobile app to help military parents, especially surrounding reintegrating after deployment
www.veterantraining.va.gov/parenting/
Veteran’s Guide to Talking With Kids About PTSD
Interactive pamphlet for veteran parents living with PTSD to educate and empower them in their role as parent
www.mirecc.va.gov/VISN16/docs/Talking_with_Kids_about_PTSD.pdf
Note. PTSD � posttraumatic stress disorder. a Has program evaluation data.
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149INTERVENTIONS AND RESOURCES FOR VETERAN FAMILIES
to other families, to feel appreciated by VA providers, and to have the opportunity to ask doctors questions about PTSD/mental ill- ness. In addition, significant positive correlations emerged be- tween the number of SAFE sessions attended and family members’ understanding of PTSD/mental illness, awareness of VA re- sources, decreased levels of caregiver distress (Sherman, 2006).
The detailed therapist manual and participant workbook are available for free download at www.ouhsc.edu/SAFEProgram. This website includes an Implementation Toolkit to support pro- fessionals who wish to offer the SAFE Program. Importantly, mental health providers and family members may find the hand- outs and general information in the SAFE Program useful even if not participating in the group-based program as written. For ex- ample, handouts such as “PTSD and its Impact on the Family” or “What can I do when my family member is depressed” can stand alone and may be useful for providers and clients.
Of note, the SAFE Program was adapted to meet the needs of families of Iraq and Afghanistan wars in a briefer family education program titled Operation Enduring Families (Bowling, Doerman, & Sherman, 2011). This five-session program includes sessions on family relationships, communication and intimacy, anger, PTSD, and depression. A sixth optional session focuses on traumatic brain injury. The entire manual and participant workbook are available for free at www.ouhsc.edu/OEF. Although anecdotal feedback from participants has been positive, formal evaluation of Operation Enduring Families has yet to be conducted.
Reaching out to Educate and Assist Caring, Healthy Fami- lies (REACH) Program. The REACH Program (Reaching out to Educate and Assist Caring, Healthy Families) is an adaptation of the evidence-based multifamily group model (McFarlane, 2002) for a VA setting and for veterans living with PTSD and mood disorders (Sherman, Fischer, Sorocco, & McFarlane, 2009).
REACH has three phases, beginning with four single-family sessions focused on rapport building and goal setting. Phase II consists of six weekly 90-minute sessions for cohorts of 4 to 6 veterans and their families. Session topics include problem- solving, psychoeducation about symptom management, communi- cation, managing symptoms of depression, stress management, and anger/conflict resolution. Each of the Phase II sessions includes time with veteran/family dyads together, and separate break-out groups for veterans and family members. In Phase III, veterans/ families attend six monthly multifamily groups to support main- tenance of gains.
Longitudinal research of the REACH program has found high levels of attendance, retention, and participant satisfaction (Sher- man et al., 2009). Research with 100 veterans with PTSD and their partners showed significant improvements over time on levels of empowerment, family problem solving and communication, rela- tionship satisfaction, social support, symptom status, knowledge of PTSD, self-efficacy in coping with PTSD, and quality of life (Fischer, Sherman, Owen, & Han, 2013). Family members showed similar statistically significant improvements on most measures. Changes over time in individual participants’ relationship satisfac- tion, social support, symptom status, and quality of life were attributable to changes in program-targeted knowledge and skill. Similar positive findings emerged among a cohort of veterans living with mood disorders and their partners who participated in the REACH program (Sherman, Fischer, Owen, Lu, & Han, 2015).
The entire therapist manual and participant workbook are avail- able for free download: www.ouhsc.edu/REACHProgram. The detailed online manual includes specific didactic scripts, suggested interactive exercises, handouts, and homework activities. This website also describes a specific motivational-interviewing style engagement procedure for how to encourage veteran families to participate in REACH.
Of note, the multifamily group model has also been used in the VA system with veterans living with traumatic brain injury and their family members. Preliminary outcomes show this as a feasi- ble and acceptable model, warranting additional research (Perlick et al., 2013).
National Alliance on Mental Illness (NAMI)’s Project Homefront program. Project Homefront is a free, six-session family education program for adults who care about a military member who has experienced deployment and has a mental health condition. Classes are facilitated by volunteer, military-connected family members, and are offered in several states across the country. Sessions focus on problem solving, effective communi- cation, self-care, connecting with resources, and understanding PTSD and mental illness. This course is adapted from NAMI’s popular Family to Family course which has documented positive outcomes for family members of adults living with mental illness, including decreased burden and increased empowerment (Dixon et al., 2004). Evaluation of the Project Homefront program is cur- rently underway, and an online format is being developed. Infor- mation about this program including currently available groups is available online at http://www.nami.org/Find-Support/NAMI- Programs/NAMI-Homefront.
Phone and Online Resources for Veteran Families
A large number of websites, services, and programs have been developed for veteran families, and it is beyond the scope of this review to describe all of them. We selected a variety of resources that span modality and focus, all of which are being commonly used in the VA system and are easily accessible to community providers and families. The first four focus on veterans and family members broadly, whereas the latter three target issues related to parenting. The first two resources are telephone-based, whereas the others in the list are online resources.
Coaching Into Care (http://www.mirecc.va.gov/coaching/). Coaching Into Care is a free telephone-based service for adults who care about a veteran who may benefit from mental health services. Family members and friends can call the toll free number (888-823- 7458) between 8 AM and 8 PM, Monday through Friday and have a free consultation with a social worker or psychologist. Coaching sessions typically last 10 to 30 minutes, and callers can have follow-up ses- sions if desired. Coaches work with callers to explore veterans’ ambivalence and fears about reaching out for help, drawing upon motivational interviewing techniques. Coaches can connect callers with resources anywhere in the country, and help families navigate oftentimes overwhelming, confusing health care systems.
PTSD Family Coach Smartphone App (https://www.ptsd .va.gov/public/materials/apps/ptsdfamilycoach.asp). The Nat- ional Center for PTSD and the Department of Defense’s National Center for Telehealth and Technology have created a plethora of free mobile apps to support veterans managing mental health issues. Apps provide information and support on skills such as deep breathing,
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imagery, mindfulness, and behavioral activation. One popular app titled PTSD Coach has a companion app for families, PTSD Family Coach, both of which are available for free download in iTunes. PTSD Family Coach provides information about PTSD, support on coping with a loved one with PTSD, self-care suggestions, and information about counseling for couples/families managing PTSD. A clinical trial examining the feasibility, acceptability, and effectiveness of this app is currently underway.
Make the Connection (http://maketheconnection.net/). Created by the U.S. Department of Veterans Affairs, the Make the Connection website includes videos of over 400 veterans and family members sharing their experiences in managing mental health problems. Site visitors can select videos most relevant to their situations, sorting by gender, war era, military branch, topic, and more. The videos describe a wide array of topics, and convey messages of empowerment, hope, and recovery for the entire family. A special section of the website focuses on transi- tioning out of the military (http://maketheconnection.net/events/ transitioning-from-service).
Sesame Street’s Transition Program (http://www.sesame street.org/toolkits/veterans). Sesame Street Workshop has cre- ated a free, online Adventure Campaign to support families with young children as they leave the military. The program consists of 12 modules delivered by e-mail, each of which includes a newsletter, a video link for parents and children to view together, and a fun challenge with a small prize. Module themes include communication, making new friends, connecting as a family, and maintaining a positive attitude through change. Although the program acknowl- edges the challenges faced by all family members with leaving the military, it also celebrates families’ strength and resilience, helping them consider this time as an adventure. A randomized control trial of 200 transitioning active duty and veteran families found very high levels of parental satisfaction, a positive impact on caregivers’ self- efficacy in helping themselves and their children cope effectively with the transition, and reductions in overall child emotional and behav- ioral problems, including levels of hyperactivity/inattention (Sher- man, Monn, Bowers, Larsen, & Gewirtz, 2017).
Parenting for Veterans and Service Members (http://www .veterantraining.va.gov/parenting/). Created as a joint effort between the VA system and the Department of Defense, Parenting for Veterans and Service Members is a free online six-module parenting course. It includes practical information, interactive ex- ercises, and handouts for military parents across the following topics: Reconnecting with your child after deployment, positive parent– child communication, helping children deal with challeng- ing behaviors and emotions, positive approaches to discipline, managing stress as a parent, and parenting with physical and emotional challenges. The website also features powerful videos of military families sharing their feelings and experiences.
Much of the content of this website was used for a smartphone application called the Parenting2Go Mobile App which is free at the Apple store. The app includes support in coping with parenting stressors, tips on effective communication, and stress management exercises.
Veteran’s Guide to Talking With Kids About PTSD (http:// www.mirecc.va.gov/VISN16/docs/Talking_with_Kids_about_ PTSD.pdf). This 25-page interactive pamphlet for veteran par- ents is a source of reflection and empowerment in parenting with PTSD. The pamphlet can be used independently by veterans,
included as part of individual or group therapy, or integrated into a psychoeducational class or workshop. The guide is interactive, filled with activities such as a pros and cons list about sharing with children. The pamphlet not only addresses family challenges; it also empowers veterans to identify and focus on their strengths as parents as well as their children’s strengths. Sample sections of the pamphlet include the following: What Do You Enjoy About Par- enting? How Can PTSD Affect Families? Should I Tell My Kids About PTSD? What Should I Do If I Get Upset When Talking With My Kids About PTSD? How Do I Deal With Questions My Child Asks?
Content for this pamphlet is based on a three-site, mixed meth- ods research conducted by the authors and funded by the VA South Central MIRECC. Focus groups and key informant interviews explored veterans’ perceptions of the impact of PTSD and their parenting and children, as well as parent– child communication about parental PTSD (Sherman, Gress Smith, Straits-Troster, Larsen, & Gewirtz, 2016; Sherman, Larsen, Straits-Troster, Erbes, & Tassey, 2015). Selected quotations from veterans in this re- search are included in the pamphlet which lends credibility and poignancy to the messages.
Conclusion
Military families reside in every large community across the country, attend public schools and universities, bring their kids to the same orthodontists, play in the same parks, and work in the same businesses as civilian families. Military families often bring a sense of civic pride and commitment to our country, and civilians owe them respect and appreciation for their sacrifices. Although military families have had extra supports and buffers while in the military, they may have also faced challenges and trauma that are unparalleled in the civilian sector. At this time of transition, military families simultaneously lose access to supportive pro- grams and services as they engage in major life changes that often call for increased needs for support. Many families will manage the transition well, drawing upon natural supports of family, friends, religious/spiritual groups, and peer networks. However, some veterans, partners, and children will struggle with the tran- sition and will benefit from more formal mental health treatment.
Although some of the programs and resources described herein have promising evaluation data, much more rigorous research is needed to examine the short and long-term impacts of these programs. This call for strong evaluation of family programs for Iraqi and Afghanistan veteran has been made for over a decade (Johnson et al., 2007), but high-quality research is expensive and time-intensive and obtaining funding can be difficult. Dedication of resources to evaluate and strengthen family based resources is vital to developing a robust array of evidence-based services for families.
Although some veterans have access to health care in the VA system, data from a nationally representative sample of veterans showed that fewer than 20% of veterans use VA as their primary source of health care (Wisco et al., 2014). In addition, most VAs do not provide individual services for nonveteran family members or for children. For these reasons, it is important for community providers to familiarize themselves with military culture and avail- able resources.
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151INTERVENTIONS AND RESOURCES FOR VETERAN FAMILIES
Thus, veteran families are and will continue to seek mental health care in public sector settings. It is essential that civilian providers seeking to work with this population familiarize them- selves with the military culture. Military families can quickly discern when providers do not comprehend their distinct culture, and they will go elsewhere if they do not feel understood. Mental health providers can seek out trainings as described herein, and explore family psychoeducation as a model for care. Although many of the family curricula described herein were created in the VA system, they can and should be used in the private sector. Almost all of these resources are available for free download online, and the curricula have clear implementation guides to assist programs in the start-up phase. Civilian providers can also gain credibility by empowering their veteran families with reputable online and phone-based resources as adjunctive supports. Veteran families do not expect civilian providers to know every military abbreviation or policy, but they deserve a provider who is knowl- edgeable, open to learn, concerned about the entire family, respect- ful of military culture, and appreciative of the family’s service.
References
Adler, A. B., Britt, T. W., Castro, C. A., McGurk, D., & Bliese, P. D. (2011). Effect of transition home from combat on risk-taking and health- related behaviors. Journal of Traumatic Stress, 24, 381–389. http://dx .doi.org/10.1002/jts.20665
Bonde, J. P., Utzon-Frank, N., Bertelsen, M., Borritz, M., Eller, N. H., Nordentoft, M., . . . Rugulies, R. (2016). Risk of depressive disorder following disasters and military deployment: Systematic review with meta-analysis. The British Journal of Psychiatry, 208, 330 –336. http:// dx.doi.org/10.1192/bjp.bp.114.157859
Bowling, U. B., Doerman, A. L., & Sherman, M. D. (2011). Operation enduring families: Support and education for returning Iraq and Af- ghanistan veterans and their families (2nd ed.). South Central Mental Illness Research, Education and Clinical Center.
Campbell, S. B., & Renshaw, K. D. (2013). PTSD symptoms, disclosure, and relationship distress: Explorations of mediation and associations over time. Journal of Anxiety Disorders, 27, 494 –502. http://dx.doi.org/ 10.1016/j.janxdis.2013.06.007
Chartrand, M. M., Frank, D. A., White, L. F., & Shope, T. R. (2008). Effect of parents’ wartime deployment on the behavior of young children in military families. Archives of Pediatrics & Adolescent Medicine, 162, 1009 –1014. http://dx.doi.org/10.1001/archpedi.162.11.1009
Cohen, J., & Segal, M. W. (2009). Veterans, the Vietnam era, and marital dissolution. Armed Forces and Society, 36, 19 –37. http://dx.doi.org/10 .1177/0095327X09332146
Dekel, R., & Monson, C. M. (2010). Military-related post-traumatic stress disorder and family relations: Current knowledge and future directions. Aggression and Violent Behavior, 15, 303–309. http://dx.doi.org/10 .1016/j.avb.2010.03.001
Dixon, L., Lucksted, A., Stewart, B., Burland, J., Brown, C. H., Postrado, L., . . . Hoffman, M. (2004). Outcomes of the peer-taught 12-week family-to-family education program for severe mental illness. Acta Psy- chiatrica Scandinavica, 109, 207–215. http://dx.doi.org/10.1046/j.0001- 690X.2003.00242.x
Elliott, M., Gonzalez, C., & Larsen, B. (2011). US military veterans transition to college: Combat, PTSD, and alienation on campus. Journal of Student Affairs Research and Practice, 48, 279 –296. http://dx.doi .org/10.2202/1949-6605.6293
Faurer, J., Rogers-Brodersen, A., & Bailie, P. (2014). Managing the re- employment of military veterans through the Transition Assistance Program (TAP). Journal of Business & Economics Research, 12, 55. http://dx.doi.org/10.19030/jber.v12i1.8378
Fischer, E. P., Sherman, M. D., Owen, R., & Han, X. (2013). Outcomes of participation in the REACH multifamily group program for Veterans with PTSD and their families. Professional Psychology, Research and Practice, 44, 127–134. http://dx.doi.org/10.1037/a0032024
Fulton, J. J., Calhoun, P. S., Wagner, H. R., Schry, A. R., Hair, L. P., Feeling, N., . . . Beckham, J. C. (2015). The prevalence of posttraumatic stress disorder in Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans: A meta-analysis. Journal of Anxiety Disorders, 31, 98 –107. http://dx.doi.org/10.1016/j.janxdis.2015.02.003
Gewirtz, A. H., Pinna, K. L., Hanson, S. K., & Brockberg, D. (2014). Promoting parenting to support reintegrating military families: After deployment, adaptive parenting tools. Psychological Services, 11, 31– 40. http://dx.doi.org/10.1037/a0034134
Gunty, A., Richmond, A., Williams, R., Otto, M., & Borden, L. M. (2016). Military culture. Report submitted to the U. S. Department of Defense. Retrieved online https://reachmilitaryfamilies.umn.edu/sites/default/ files/rdoc/Military%20Culture%202016.04.29.pdf
Hisnanick, J. J., & Little, R. D. (2015). ‘Honey I love you, but’ . . . investigating the causes of the earnings penalty of being a tied-migrant military spouse. Armed Forces and Society, 41, 413– 439. http://dx.doi .org/10.1177/0095327X13512620
Institute of Medicine. (2010). Returning home from Iraq and Afghanistan: Preliminary Assessment of readjustment needs of veterans, service mem- bers, and their families. Washington, DC: National Academies Press.
Jacobson, I. G., Ryan, M. A., Hooper, T. I., Smith, T. C., Amoroso, P. J., Boyko, E. J., . . . Bell, N. S. (2008). Alcohol use and alcohol-related problems before and after military combat deployment. Journal of the American Medical Association, 300, 663– 675. http://dx.doi.org/10 .1001/jama.300.6.663
Johnson, S. J., Sherman, M. D., Hoffman, J. S., James, L. C., Johnson, P. L., Lochman, J. E., . . . Palomares, R. S. (2007). The psychological needs of U.S. military service members and their families: A preliminary report. American Psychological Association Presidential Task Force on Military Deployment Services for Youth, Families and Service Mem- bers. Retrieved from http://www.ptsd.ne.gov/publications/military- deployment-task-force-report.pdf
Kuhl, M., Rudi, J., Westerhof, L., Sherman, M., Bommarito, R., Steinham, D., . . . Borden, L. (2015). Supports for military spouses as active duty service members transition out of the military. Retrieved from https:// pdfs.semanticscholar.org/4b82/795d691dea02ceeb7fcb1000fd5fd 15a8eef.pdf
Leff, J., Kuipers, L., Berkowitz, R., & Sturgeon, D. (1985). A controlled trial of social intervention in the families of schizophrenic patients: Two-year follow-up. The British Journal of Psychiatry, 146, 594 – 600. http://dx.doi.org/10.1192/bjp.146.6.594
Lester, P., Saltzman, W. R., Woodward, K., Glover, D., Leskin, G. A., Bursch, B., . . . Beardslee, W. (2012). Evaluation of a family-centered prevention intervention for military children and families facing wartime deployments. American Journal of Public Health, 102(Suppl. 1), S84 – S54. http://dx.doi.org/10.2105/AJPH.2010.300088
Lipari, R. N., Forsyth, B., Bose, J., Kroutil, L. A., & Lane, M. E. (2016, November). Spouses and children of U.S. military personnel: Substance use and mental health profile from the 2015 National Survey on Drug Use and Health. Retrieved November 15, 2016, from http://www. samhsa.gov/data
Lucksted, A., McFarlane, W., Downing, D., & Dixon, L. (2012). Recent developments in family psychoeducation as an evidence-based practice. Journal of Marital and Family Therapy, 38, 101–121. http://dx.doi.org/ 10.1111/j.1752-0606.2011.00256.x
Mansfield, A. J., Kaufman, J. S., Engel, C. C., & Gaynes, B. N. (2011). Deployment and mental health diagnoses among children of US Army personnel. Archives of Pediatrics & Adolescent Medicine, 165, 999 – 1005. http://dx.doi.org/10.1001/archpediatrics.2011.123
T hi
s do
cu m
en t
is co
py ri
gh te
d by
th e
A m
er ic
an P
sy ch
ol og
ic al
A ss
oc ia
ti on
or on
e of
it s
al li
ed pu
bl is
he rs
. T
hi s
ar ti
cl e
is in
te nd
ed so
le ly
fo r
th e
pe rs
on al
us e
of th
e in
di vi
du al
us er
an d
is no
t to
be di
ss em
in at
ed br
oa dl
y.
152 SHERMAN AND LARSEN
Mansfield, A. J., Kaufman, J. S., Marshall, S. W., Gaynes, B. N., Morris- sey, J. P., & Engel, C. C. (2010). Deployment and the use of mental health services among U.S. Army wives. The New England Journal of Medicine, 362, 101–109. http://dx.doi.org/10.1056/NEJMoa0900177
McFarlane, W. (2002). Multifamily groups in the treatment of severe psychiatric disorders. New York, NY: Guilford Press.
Monson, C. M., & Fredman, S. J. (2012). Cognitive-behavioral conjoint therapy for PTSD: Harnessing the healing power of relationships. New York, NY: Guilford Press.
Orazem, R., Frazier, P., Schnurr, P., Oleson, H., Carlson, K., & Sayer, N. (2016). Identity adjustment among Afghanistan and Iraq war veterans with reintegration difficulty. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. http://dx.doi.org/10 .1037/tra0000225
Perlick, D. A., Straits-Troster, K., Strauss, J. L., Norell, D., Tupler, L. A., Levine, B., . . . Dyck, D. G. (2013). Implementation of multifamily group treatment for veterans with traumatic brain injury. Psychiatric Services, 64, 534 –540. http://dx.doi.org/10.1176/appi.ps.001622012
Rentz, E. D., Marshall, S. W., Loomis, D., Casteel, C., Martin, S. L., & Gibbs, D. A. (2007). Effect of deployment on the occurrence of child maltreatment in military and nonmilitary families. American Journal of Epidemiology, 165, 1199 –1206. http://dx.doi.org/10.1093/aje/kwm008
Sautter, F. J., Glynn, S. M., Cretu, J. B., Senturk, D., & Vaught, A. S. (2015). Efficacy of structured approach therapy in reducing PTSD in returning veterans: A randomized clinical trial. Psychological Services, 12, 199 –212. http://dx.doi.org/10.1037/ser0000032
Sayer, N. A., Noorbaloochi, S., Frazier, P., Carlson, K., Gravely, A., & Murdoch, M. (2010). Reintegration problems and treatment interests among Iraq and Afghanistan combat veterans receiving VA medical care. Psychiatric Services, 61, 589 –597. http://dx.doi.org/10.1176/ps .2010.61.6.589
Schnurr, P. P., Lunney, C. A., Sengupta, A., & Spiro, A., III. (2005). A longitudinal study of retirement in older male veterans. Journal of Consulting and Clinical Psychology, 73, 561–566. http://dx.doi.org/10 .1037/0022-006X.73.3.561
Sherman, M. D. (2003). The S. A. F. E. Program: A family psychoeduca- tional curriculum developed in a Veterans Affairs Medical Center. Professional Psychology, Research and Practice, 34, 42– 48. http://dx .doi.org/10.1037/0735-7028.34.1.42
Sherman, M. D. (2006). Updates and five-year evaluation of the S. A. F. E. program: A family psychoeducational program for serious mental ill- ness. Community Mental Health Journal, 42, 213–219. http://dx.doi.org/ 10.1007/s10597-005-9018-3
Sherman, M. D., Fischer, E. P., Owen, R. R., Jr., Lu, L., & Han, X. (2015). Multifamily group treatment for veterans with mood disorders. Couple & Family Psychology, 4, 136 –149. http://dx.doi.org/10.1037/ cfp0000040
Sherman, M. D., Fischer, E. F., Sorocco, K., & McFarlane, W. (2009). Adapting the multifamily group model to the Veterans Affairs system: The REACH program. Professional Psychology, Research and Practice, 40, 593– 600. http://dx.doi.org/10.1037/a0016333
Sherman, M. D., Gress Smith, J. L., Straits-Troster, K., Larsen, J. L., & Gewirtz, A. (2016). Veterans’ perceptions of the impact of PTSD on their parenting and children. Psychological Services, 13, 401– 410. http://dx.doi.org/10.1037/ser0000101
Sherman, M. D., Hawkey, K. R., Smith, B., Rudi, J. H., Kuhl, M. W., Bommarito, R., & Borden, L. M. (2015). Supports for military spouses as active duty service members transition out of the military. Report submitted to the U.S. Department of Defense.
Sherman, M. D., Larsen, J., & Borden, L. M. (2015). Broadening the focus in supporting reintegrating Iraq and Afghanistan Veterans: Six key domains of functioning. Professional Psychology, Research and Prac- tice, 46, 355–365. http://dx.doi.org/10.1037/pro0000043
Sherman, M. D., Larsen, J., Straits-Troster, K., Erbes, C., & Tassey, J. (2015). Parent-child communication about parental PTSD. Journal of Family Psychology, 29, 595– 603. http://dx.doi.org/10.1037/ fam0000124
Sherman, M. D., Monn, A., Bowers, J., Larsen, J., & Gewirtz, A. (2017). Evaluation of the Sesame Street for military families: Transitions pro- grams. The Adventure Campaign. Prepared for Sesame Workshop, Min- neapolis, Minnesota.
Søndergaard, S., Robertson, K., Silfversten, E., Anderson, B., Meads, C., Schaefer, A., & Larkin, J. (2015). Families support to transition: A systematic review of the evidence. Cambridge, UK: RAND.
Taft, C. T., Weatherill, R. P., Woodward, H. E., Pinto, L. A., Watkins, L. E., Miller, M. W., & Dekel, R. (2009). Intimate partner and general aggression perpetration among combat veterans presenting to a posttrau- matic stress disorder clinic. American Journal of Orthopsychiatry, 79, 461– 468. http://dx.doi.org/10.1037/a0016657
Tice, J. (2016). Army headed for 30,000 active and reserve units in 2016. Army Times. Retrieved from https://www.armytimes.com/story/military/ capitol-hill/2015/11/19/army-headed-30000-active-and-reserve-cuts-2016/ 75870074
Tsai, J., Pietrzak, R. H., & Rosenheck, R. A. (2013). Homeless veterans who served in Iraq and Afghanistan: Gender differences, combat expo- sure, and comparisons with previous cohorts of homeless veterans. Administration and Policy in Mental Health, 40, 400 – 405. http://dx.doi .org/10.1007/s10488-012-0431-y
Widome, R., Jensen, A., Bangerter, A., & Fu, S. S. (2015). Food insecurity among veterans of the US wars in Iraq and Afghanistan. Public Health Nutrition, 18, 844 – 849. http://dx.doi.org/10.1017/S136898001400072X
Wisco, B. E., Marx, B. P., Wolf, E. J., Miller, M. W., Southwick, S. M., & Pietrzak, R. H. (2014). Posttraumatic stress disorder in the US veteran population: Results from the National Health and Resilience in Veterans Study. The Journal of Clinical Psychiatry, 75, 1338 –1346. http://dx.doi .org/10.4088/JCP.14m09328
Received December 6, 2016 Revision received May 11, 2017
Accepted May 22, 2017 �
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