SAN ANTONIO– As foreign wars wind down, and more families of military members and veterans receive care in civilian settings, an intervention used successfully on military bases to help families reduce risk of serious psychological disorders is being extended to civilian practices.
In the past decade, some 650,000 military and veteran family members have gone through Families Overcoming Under Stress, or FOCUS, a group of family-based interventions developed by a team led by psychiatrist Dr. Patricia E. Lester, director of the Nathanson Family Resilience Center at UCLA Health in Los Angeles.
Dr. Lester and her UCLA colleagues first adapted FOCUS at Marine Corps Base Camp Pendleton, San Diego, in 2006. Two years later, they implemented the program for the U.S. Navy Bureau of Medicine and Surgery at 22 Navy, Marine, Army, and Air Force installations in the United States and overseas. Now, with as many as 70% of active-duty military members living in civilian communities and about half of military-affiliated children getting health care in the civilian system, the program is being adapted to follow veterans’ families as they transition home.
The UCLA FOCUS team also is training community providers and extending technology platforms “to deliver our programs, monitor them, and put them in the hands of people where they live,” Dr. Lester said at the annual meeting of the American Academy of Child and Adolescent Psychiatry.
New research from a longitudinal observational study assessing more than 2,600 families with children who participated in the program in the United States and Japan on military bases, published recently online, shows that the intervention has been well received, with about 70% of families completing it. In addition, its positive impact on psychological health outcomes for parents and children was sustained (J Am Acad Child Adolesc Psychiatry. 2015 [doi: http://dx.doi.org/10.1016/j.jaac.2015.10.009]).
“Consistently what we’ve found is that doing a preventive educational program early on is an opportunity to engage families before they may need mental health treatment – reducing anxiety, depression, and [posttraumatic stress disorder] in adults, strengthening family functioning, and improving internalizing and externalizing symptoms in kids,” Dr. Lester said.
The latest research is based on a secondary analysis of FOCUS data collected between 2008 and 2013. Significant improvements for parental anxiety, posttraumatic stress, and depression symptoms occurred in service member and civilian parents, and child anxiety symptoms improved in boys and girls. Importantly, those reductions were maintained 6 months after the intervention ended.
Roots of intervention
The model for FOCUS derives from two civilian interventions developed over the past 15 years, one of them for families in which a parent is depressed, and another for those in which a parent is medically ill. FOCUS also incorporated elements of a third intervention used with families living in postwar Bosnia-Herzegovina and in New York City after the terrorist attacks of Sept.11, 2001.
“We know from decades of developmental literature that if a parent is not doing well in terms of depression, anxiety, or PTSD, it represents an ongoing risk for children,” Dr. Lester said. In military and veteran populations, “family approaches are critical.”
About a third of combat service members and veterans are estimated to have depression, PTSD, or a traumatic brain injury – and an emerging body of research is showing that their children are at elevated risk for social, academic, and emotional problems.
The FOCUS program, which generally lasts 8 sessions over 6-8 weeks, starts with real-time web-based screening of psychological health measures, using a set of standardized behavioral health, family adjustment, and coping assessments to assess risk and customize the intervention. “We sit down with the family; we identify their strengths and where they may be having difficulties,” Dr. Lester said.
About a quarter of the parents in Dr. Lester’s study had clinically meaningful anxiety or depression symptoms at intake, with civilian spouses reporting slightly more than military members. Also, some 31% of civilian spouses had PTSD symptoms at baseline, compared with 26% of military members – an unexpected finding, Dr. Lester said. Among children, 35% of boys and 25% of girls had social difficulties at baseline.
Location of intervention is key
Rolling FOCUS out on military installations required attention to military family culture. A voluntary program, it was implemented to service members as a form of training, rather than counseling or a mental health intervention, though part of its objective was to help to bridge gaps to mental health treatment for those who needed it.
Importantly, the intervention was delivered in community centers or retail spaces in lieu of mental health facilities on bases. “Military families may be reluctant to come for behavioral health services because of stigma or concern about their job – the same barriers we see in civilian communities but amplified, because the risks are quite concrete,” Dr. Lester said.