The FOCUS Family Resilience Program: An Innovative Family Intervention for Trauma and Loss.

This article describes the core principles and components of the FOCUS Program, a brief intervention for families contending with single or multiple trauma or loss events. It has been administered nationally to thousands of military family members since 2008 and has been implemented in a wide range of civilian community, medical, clinical, and school settings. Developed by a team from the UCLA and Harvard Medical Schools, the FOCUS Program provides a structured approach for joining with traditional and nontraditional families, crafting shared goals, and then working with parents, children, and the entire family to build communication, make meaning out of traumatic experiences, and practice specific skills that support family resilience. Through a narrative sharing process, each family member tells his or her story and constructs a timeline that graphically captures the experience and provides a platform for family discussions on points of convergence and divergence. This narrative sharing process is first done with the parents and then the children and then the family as a whole. The aim is to build perspective-taking skills and mutual understanding, to reduce distortions and misattributions, and to bridge estrangement between family members. Previous studies have confirmed that families participating in this brief program report reductions in distress and symptomatic behaviors for both parents and children and increases in child pro-social behaviors and family resilient processes.

Pathways of Risk and Resilience: Impact of a Family Resilience Program on Active-Duty Military Parents.

Over the past decade, studies into the impact of wartime deployment and related adversities on service members and their families have offered empirical support for systemic models of family functioning and a more nuanced understanding of the mechanisms by which stress and trauma reverberate across family and partner relationships. They have also advanced our understanding of the ways in which families may contribute to the resilience of children and parents contending with the stressors of serial deployments and parental physical and psychological injuries. This study is the latest in a series designed to further clarify the systemic functioning of military families and to explicate the role of resilient family processes in reducing symptoms of distress and poor adaptation among family members. Drawing upon the implementation of the Families Overcoming Under Stress (FOCUS) Family Resilience Program at 14 active-duty military installations across the United States, structural equation modeling was conducted with data from 434 marine and navy active-duty families who participated in the FOCUS program. The goal was to better understand the ways in which parental distress reverberates across military family systems and, through longitudinal path analytic modeling, determine the pathways of program impact on parental distress. The findings indicated significant cross-influence of distress between the military and civilian parents within families, families with more distressed military parents were more likely to sustain participation in the program, and reductions in distress among both military and civilian parents were significantly mediated by improvements in resilient family processes. These results are consistent with family systemic and resilient models that support preventive interventions designed to enhance family resilient processes as an important part of comprehensive services for distressed military families.

Using multidimensional grief theory to explore the effects of deployment, reintegration, and death on military youth and families.

To date, the US military has made major strides in acknowledging and therapeutically addressing trauma and post-traumatic stress disorder (PTSD) in service members and their families. However, given the nature of warfare and high rates of losses sustained by both military members (e.g., deaths of fellow unit members) and military families (e.g., loss of a young parent who served in the military), as well as the ongoing threat of loss that military families face during deployment, we propose that a similar focus on grief is also needed to properly understand and address many of the challenges encountered by bereaved service members, spouses, and children. In this article, we describe a newly developed theory of grief (multidimensional grief theory) and apply it to the task of exploring major features of military-related experiences during the phases of deployment, reintegration, and the aftermath of combat death--especially as they impact children. We also describe implications for designing preventive interventions during each phase and conclude with recommended avenues for future research. Primary aims are to illustrate: (1) the indispensable role of theory in guiding efforts to describe, explain, predict, prevent, and treat maladaptive grief in military service members, children, and families; (2) the relevance of multidimensional grief theory for addressing both losses due to physical death as well as losses brought about by extended physical separations to which military children and families are exposed during and after deployment; and (3) a focus on military-related grief as a much-needed complement to an already-established focus on military-related PTSD.

Enhancing family resilience through family narrative co-construction.

We draw upon family resilience and narrative theory to describe an evidence-based method for intervening with military families who are impacted by multiple wartime deployments and psychological, stress-related, or physical parental injuries. Conceptual models of familial resilience provide a guide for understanding the mechanics of how families respond and recover from exposure to extreme events, and underscore the role of specific family processes and interaction patterns in promoting resilient capabilities. Leading family theorists propose that the family's ability to make meaning of stressful and traumatic events and nurture protective beliefs are critical aspects of resilient adaptation. We first review general theoretical and empirical research contributions to understanding family resilience, giving special attention to the circumstances, challenges, needs, and strengths of American military families. Therapeutic narrative studies illustrate the processes through which family members acquire meaning-making capacities, and point to the essential role of parents' in facilitating discussions of stressful experiences and co-constructing coherent and meaningful narratives. This helps children to make sense of these experiences and develop capacities for emotion regulation and coping. Family-based narrative approaches provide a structured opportunity to elicit parents' and children's individual narratives, assemble divergent storylines into a shared family narrative, and thereby enhance members' capacity to make meaning of stressful experiences and adopt beliefs that support adaptation and growth. We discuss how family narratives can help to bridge intra-familial estrangements and re-engage communication and support processes that have been undermined by stress, trauma, or loss. We conclude by describing a family-based narrative intervention currently in use with thousands of military children and families across the USA.

Evaluation of a family-centered prevention intervention for military children and families facing wartime deployments.

OBJECTIVES: We evaluated the Families OverComing Under Stress program, which provides resiliency training designed to enhance family psychological health in US military families affected by combat- and deployment-related stress. METHODS: We performed a secondary analysis of Families OverComing Under Stress program evaluation data that was collected between July 2008 and February 2010 at 11 military installations in the United States and Japan. We present data at baseline for 488 unique families (742 parents and 873 children) and pre-post outcomes for 331 families. RESULTS: Family members reported high levels of satisfaction with the program and positive impact on parent-child indicators. Psychological distress levels were elevated for service members, civilian parents, and children at program entry compared with community norms. Change scores showed significant improvements across all measures for service member and civilian parents and their children (P < .001). CONCLUSIONS: Evaluation data provided preliminary support for a strength-based, trauma-informed military family prevention program to promote resiliency and mitigate the impact of wartime deployment stress.

Mechanisms of risk and resilience in military families: theoretical and empirical basis of a family-focused resilience enhancement program.

Recent studies have confirmed that repeated wartime deployment of a parent exacts a toll on military children and families and that the quality and functionality of familial relations is linked to force preservation and readiness. As a result, family-centered care has increasingly become a priority across the military health system. FOCUS (Families OverComing Under Stress), a family-centered, resilience-enhancing program developed by a team at UCLA and Harvard Schools of Medicine, is a primary initiative in this movement. In a large-scale implementation project initiated by the Bureau of Navy Medicine, FOCUS has been delivered to thousands of Navy, Marine, Navy Special Warfare, Army, and Air Force families since 2008. This article describes the theoretical and empirical foundation and rationale for FOCUS, which is rooted in a broad conception of family resilience. We review the literature on family resilience, noting that an important next step in building a clinically useful theory of family resilience is to move beyond developing broad "shopping lists" of risk indicators by proposing specific mechanisms of risk and resilience. Based on the literature, we propose five primary risk mechanisms for military families and common negative "chain reaction" pathways through which they undermine the resilience of families contending with wartime deployments and parental injury. In addition, we propose specific mechanisms that mobilize and enhance resilience in military families and that comprise central features of the FOCUS Program. We describe these resilience-enhancing mechanisms in detail, followed by a discussion of the ways in which evaluation data from the program's first 2 years of operation supports the proposed model and the specified mechanisms of action.

Unpacking trauma exposure risk factors and differential pathways of influence: predicting postwar mental distress in Bosnian adolescents.

Methods are needed for quantifying the potency and differential effects of risk factors to identify at-risk groups for theory building and intervention. Traditional methods for constructing war exposure measures are poorly suited to "unpack" differential relations between specific types of exposure and specific outcomes. This study of 881 Bosnian adolescents compared both common factor-effect indicator (using exploratory factor analysis) versus composite causal-indicator methods for "unpacking" dimensions of war exposure and their respective paths to postwar adjustment outcomes. The composite method better supported theory building and most intervention applications, showing how multitiered interventions can enhance treatment effectiveness and efficiency in war settings. Used together, the methods may unpack the elements and differential effects of "caravans" of risk and promotive factors that co-occur across development.

Multi-informant assessment of maltreated children: convergent and discriminant validity of the TSCC and TSCYC.

OBJECTIVE: This study examined the convergent and discriminant validity of two trauma symptom measures, the Trauma Symptom Checklist for Children (TSCC) [Briere, J. (1996). Trauma Symptom Checklist for Children (TSCC). Odessa, FL: Psychological Assessment Resources] and the Trauma Symptom Checklist for Young Children (TSCYC) [Briere, J. (2005). Trauma Symptom Checklist for Young Children (TSCYC). Odessa, FL: Psychological Assessment Resources]. METHODS: Children's scores on the TSCC and their caretakers' ratings on the TSCYC were analyzed in a study of 310 children presenting to one of two child abuse treatment centers. RESULTS: TSCC and TSCYC scales generally converged in their assessment of symptomatology in maltreated children. Equivalent scales measuring anxiety, depression, anger, dissociation, and sexual concerns were generally most correlated with one another. Similarly, the Posttraumatic Stress-Intrusion (PTS-I) scale of the TSCYC correlated highest with the Posttraumatic Stress (PTS) and Anxiety (ANX) scales of the TSCC, the TSCYC Posttraumatic Stress-Arousal (PTS-AR) scale was correlated with the TSCC ANX scale, and the TSCC PTS scale was most correlated with the TSCYC ANX, PTS-I, and Sexual Concerns (SC) scales. The TSCYC Posttraumatic Stress-Avoidance scale was unrelated to any TSCC scale. Discriminant function analysis revealed that the TSCC PTS scale was the best single predictor of sexual abuse-related PTSD status as identified by the TSCYC. CONCLUSIONS: The TSCC and TSCYC display moderate convergent and discriminant validity with respect to one another, despite different information sources. Nevertheless, the relatively small association between relevant TSCC and TSCYC scales indicates that different symptom informants may have different perspectives on the child's symptomatology; an outcome that may be beneficial when both measures are administered simultaneously. PRACTICE IMPLICATIONS: These results reinforce the notion that both child- and parent/caretaker report measures should be used in the evaluation of traumatized children, so that multiple sources of information can be considered simultaneously. In the current context, administration of the TSCC to the child and the TSCYC to the caretaker, when appropriate (i.e., in children 8-12 years of age) may yield more clinical information on the child's symptomatology than either measure would alone-perhaps especially in cases when one of the two respondents under- or over-reports the child's distress.

Effectiveness of a school-based group psychotherapy program for war-exposed adolescents: a randomized controlled trial.

OBJECTIVE: To evaluate the comparative effectiveness of a classroom-based psychoeducation and skills intervention (tier 1) and a school-based trauma- and grief-focused group treatment (tier 2) of a three-tiered mental health program for adolescents exposed to severe war-related trauma, traumatic bereavement, and postwar adversity. METHOD: A total of 127 war-exposed and predominantly ethnic Muslim secondary school students attending 10 schools in central Bosnia who reported severe symptoms of posttraumatic stress disorder (PTSD), depression, or maladaptive grief and significant impairment in school or relationships were randomly assigned to one of two experimental conditions. These included either an active-treatment comparison condition (tier 1), consisting of a classroom-based psychoeducation and skills intervention alone (n = 61, 66% girls, mean age 16.0 years, SD 1.13) or a treatment condition composed of both the classroom-based intervention and a 17-session manual-based group therapy intervention (tier 2), trauma and grief component therapy for adolescents (n = 66, 63% girls, mean age 15.9 years, SD 1.11). Both interventions were implemented throughout the school year. Distressed students who were excluded from the study due to acute risk for harm (n = 9) were referred for community-based mental health services (tier 3). RESULTS: Program effectiveness was measured via reductions in symptoms of PTSD, depression, and maladaptive grief assessed at pretreatment, posttreatment, and 4-month follow-up. Analysis of mean-level treatment effects showed significant pre- to posttreatment and posttreatment to 4-month follow-up reductions in PTSD and depression symptoms in both the treatment and comparison conditions. Significant pre- to posttreatment reductions in maladaptive grief reactions were found only in the treatment condition. Analyzed at the individual case level, the percentages of students in the treatment condition who reported significant (p <.05) pre- to posttreatment reductions in PTSD symptoms (58% at posttreatment, 81% at 4-month follow-up) compare favorably to those reported in controlled treatment efficacy trials, whereas the percentages who reported significant reductions in depression symptoms (23% at posttreatment, 61% at follow-up) are comparable to, or higher than, those found in community treatment settings. Lower but substantial percentages of significant symptom reduction were found for PTSD (33% at posttreatment, 48% at follow-up) and depression symptoms (13% at posttreatment; 47% at follow-up) in students in the comparison condition. The odds of significant symptom reduction were higher for PTSD symptoms at both posttreatment and 4-month follow-up and for maladaptive grief at posttreatment (no follow-up was conducted on maladaptive grief). Rates of significantly worsened cases were generally rare in both the treatment and comparison conditions. CONCLUSIONS: A three-tiered, integrative mental health program composed of schoolwide dissemination of psychoeducation and coping skills (tier 1), specialized trauma- and grief-focused intervention for severely traumatized and traumatically bereaved youths (tier 2), and referral of youths at acute risk for community-based mental health services (tier 3) constitutes an effective and efficient method for promoting adolescent recovery in postwar settings.

Developing a culturally and ecologically sound intervention program for youth exposed to war and terrorism.

This article describes the public mental health approach used to develop and implement a school-based postwar trauma/grief intervention program for adolescents in Bosnia-Herzegovina. This approach includes development of multilateral partnerships with local and ministerial stakeholders, systematic assessment that yields a detailed understanding of the specific range and severity of trauma and loss experiences, current adversities and trauma reminders among the affected population, and a training program aimed at developing the capacities of local service providers and an indigenous support infrastructure so that the intervention program may be directed and sustained by people within the communities served. Concluding comments detail an expanded conceptual framework for public mental health interventions that may be appropriate for terrorist and mass-casualty events.