Building family resilience

For more than 20 years, trauma specialist Robin Gurwitch, PhD, has successfully used the evidence-based intervention known as parent-child interaction therapy to improve caregivers' parenting skills, children's behavior and parents' stress levels. The intervention is easy to learn, fun for participants, and it doesn't take long to complete, the Duke University Medical Center psychologist says. 

"I still get excited about it because positive changes happen so fast," she says. 

Given the stress that military families face, in 2009, Gurwitch reasoned they might benefit from the treatment as well. With funding from the Substance Abuse and Mental Health Services Administration and in collaboration with colleagues at several military bases, her team developed a protocol for implementing the therapy with military families. In 2013, 11 families completed the tailored treatment. 

Preliminary results show the adaptation is working: Parents' stress levels went down, their parenting skills improved, and the couples even reported greater marriage satisfaction. Their children's behavior also improved significantly. Now the team plans to implement the intervention with more than 60 military families nationwide in an expanded demonstration project.

The program is just one example of the ways psychologists are adapting resiliency treatments to help military families and couples. The programs share several features: They are evidence-based, they are often tweaked from interventions already shown to work with other populations, and they are standardized across sites, so if families move — as military families often do — they can reconnect with the program right where they left off.

An added plus? Families say they enjoy the treatment. "They show up for appointments, they do what is asked of them, and they complete their homework assignments," Gurwitch says with a grin.

The best of these interventions align with APA's and the federal government's emphasis on family well-being as a key component in ensuring the long-term health of service members, says Heather O'Beirne Kelly, PhD, APA's lead staffer for military and veterans policy.

"Family interventions are particularly important with the people who served in Iraq and Afghanistan because unlike in previous conflicts, about half have children, many of them very young," she says.

"Parenting young children and negotiating the many stressors associated with all phases of deployment can present a major challenge," she adds. "We are thrilled to see the Department of Defense collaborating with psychologists to employ empirically based programs that capitalize on military families' resilience and strengths."

Effective parent training

Parent-child interaction therapy combines coaching, practice and support to ensure that parents learn positive parenting skills.

The treatment starts with the therapist observing from behind a one-way mirror how parents and children interact in increasingly demanding situations. In one five-minute interaction, for instance, the parent is told to let the child take the lead in play; in another, the parent takes the lead while the child follows. All interactions are assessed using a coding system derived from previous research to allow therapists to monitor progress and give feedback to parents about how well they're mastering skills. 

Based on the interaction the therapist observes between the parents and child, the therapist then coaches parents in skills designed to improve the relationship and address behavioral concerns. For example, parents are coached in how to use specific praise statements to improve behaviors or follow a specific protocol to manage a child's defiant behavior.

Parents then practice the skills at home with their children for a "therapeutic dose" of five minutes a day, Gurwitch says.

Knowing that parent-child interaction therapy had been successfully adapted in families where a member had a cognitive impairment, Gurwitch and colleagues are adopting some of the same strategies for military families coping with traumatic brain injury. The team will be assessing families for PTSD symptoms. While the tailored treatment is not designed as a PTSD treatment per se, the researchers are hoping to minimize such symptoms by helping to create a calmer, more predictable, and more stable home environment for both parents and children — a hypothesis she and others will examine in future research.

"We believe parent-child interaction therapy may help to complement ongoing PTSD treatment," Gurwitch says. 

Helping families and couples connect

Another prevention and resiliency intervention that draws from successful evidence-based programs in nonmilitary populations is FOCUS, or Families OverComing Under Stress, designed for military families with children ages 3 to 18. FOCUS has been implemented at 22 major military installations nationwide and served thousands of family members to date. The researchers have adapted it for couples, families with very young children and families that include service members who are wounded, ill or injured. They also have tailored it for different service branches and groups, including the Navy Seals.

A 2012 American Journal of Public Health study of 331 families who participated in the original military FOCUS program shows it significantly improves children's behavior and family functioning and reduces anxiety and depression among all family members.

It does this by offering fun and engaging ways for family members to learn and practice key skills that support resilience and recovery in the wake of war's many challenges, says William Saltzman, PhD, a psychologist at the University of California, Los Angeles, who co-created the program with UCLA psychiatrist Patricia Lester, MD.

The original FOCUS protocol includes four core elements:

• Real-time computerized psychological health check-ins with customized feedback and referrals for all family members.
• Family-specific psychoeducation on issues such as PTSD, traumatic brain injury and the impact of stress on families and child development.
• A chance for service members and their families to reflect on their differing experiences during the service member's deployment and share them with family members. The team then helps the family take these "narrative timelines" and create a shared family narrative from them—a key feature of the intervention, Saltzman adds.
  
  "The narratives help to bridge estrangement and the misunderstandings and misattributions that can grow up across these years of deployment," he says.
• Resilience training in emotional regulation, goal setting, problem-solving, communication, and managing trauma and loss, using tools to enhance emotional awareness and communication skills. An example is the "feeling thermometer," which uses color coding to help family members talk about their emotions — green for a comfortable, "good to go" feeling, and red for such uncomfortable feelings as anger.

The newer adaptations are helping specific audiences improve their resiliency as well, research is showing. One is the couples intervention, which the UCLA team created in a partnership with Purdue University's Military Family Research Institute. Couples are important to target because by the time they come for services, they often feel overwhelmed, depressed and anxious about deployment and related stressors, Lester says.

To fit their needs, the team modified the core elements of FOCUS to address dyadic coping, marital satisfaction and marital functioning, rather than parenting. They paid extra attention to the couple's narrative timelines because military couples are separated for long periods and often lack a good understanding of what their partner's life has been like. "Having the opportunity to map that all out and look at it is really helpful for them," Lester says.

First-year data on 202 couples are promising. In a paper under review, the team finds that at six months, couples' clinical depression scores were reduced by half, while self-reported functioning as a couple rose significantly. A paper out this month in Clinical Child and Family Psychology Review describes more of these adaptations, which also include mobile applications and video teleconferencing so soldiers and families can access them from anywhere.

It's gratifying to see the way these programs make a difference in the lives of military families, says Saltzman.

"By increasing and improving the natural resilient processes in the family, it appears that all family members may benefit and better contend with ongoing stressors," he says.

Home-based coping tools

Another resiliency intervention created by University of Michigan psychologist Michelle Kees, PhD, and social worker Kate Bullard is called HomeFront Strong, designed to foster resilience in the partners of deployed service members using psychological tools and friendship support. It's one of several evidence-driven interventions under the University of Michigan's M-SPAN, or Support Programs and Networks program, tailored to military and veteran families. Data from HomeFront Strong also will be used as part of a longitudinal study looking at how service members, spouses and parents of soldiers fared during deployment and three years after. 

HomeFront Strong families are an important group to target because many personnel are in the National Guard and Reserve and lack connections with and support from military bases, Kees says. "These families can literally be living one street over from someone and not know they're military," she says.

The program — a pilot project funded by the Ethel and James Flinn Foundation, a Michigan-based philanthropy — features eight weekly classes grounded in empirically based theories and strategies relevant to deployment. Positive psychology tools can help spouses build optimism in the face of uncertainty, for instance, while cognitive behavioral strategies offer ways to expand and normalize participants' thinking, which tends to be more negative during deployment. The program also relies on aspects of dialectical behavior therapy to help participants tolerate difficult emotions, while social support can help them cope across life domains.

As with the FOCUS intervention, narrative therapy plays a part by helping participants frame their lives and situations in more meaningful ways, Kees adds. "It's all grounded in the notion that the story you tell yourself matters," she says.

The two-hour sessions include a talk, discussion time, a grounding exercise like progressive muscle relaxation or a mindfulness technique, and homework. They're designed to be fun and interactive: After a take-in dinner, participants discuss such topics as coping with their partners' deployment, dealing with challenging thoughts and regulating their emotions. Humor and sharing are encouraged.

Many women end the sessions feeling more attuned to their strengths, says Kees. "They'll say, ‘This [experience of deployment] was hard, but I learned I'm stronger than I thought I was.'"

In measures taken right after the intervention, 16 participants reported less stress and anxiety, more optimism and life satisfaction, and for parents, less parenting stress than they had before meeting with each other. They also reported a greater ability to handle stress thanks to tools such as learning how to identify negative thoughts, distressing emotions and positive social support.

And at least in this sample, their ties lasted, Kees adds. "They created a social network outside of our group, and that is incredibly powerful," she says. The team is now analyzing longer-term follow-up data.

Next on Kees's docket: program dissemination. In October, she received additional funding from the Flinn Foundation to train providers in other Michigan communities, which she will begin to do in January. University of Michigan researchers will evaluate the effort.

Kees says that working with these families opened her eyes to an admirable but poorly understood culture. "It's a volunteer military, but less than 1 percent of our population volunteers," says Kees. "So there is something very unique and honorable about that 1 percent. They sacrifice so much, and it's our obligation to serve them."

Tori DeAngelis is a writer in Syracuse, N.Y.